The Role of Text Messaging in Cardiovascular Risk Factor Optimization

  • Harry KlimisEmail author
  • Mohammad Ehsan Khan
  • Cindy Kok
  • Clara K. Chow
Ischemic Heart Disease (D Mukherjee, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Ischemic Heart Disease


Purpose of Review

Many cases of CVD may be avoidable through lowering behavioural risk factors such as smoking and physical inactivity. Mobile health (mHealth) provides a novel opportunity to deliver cardiovascular prevention programs in a format that is potentially scalable. Here, we provide an overview of text messaging-based mHealth interventions in cardiovascular prevention.

Recent Findings

Text messaging-based interventions appear effective on a range of behavioural risk factors and can effect change on multiple risk factors—e.g. smoking, weight, blood pressure—simultaneously. For many texting studies, there are challenges in interpretation as many texting interventions are part of larger complex interventions making it difficult to determine the benefits of the separate components.


Whilst there is evidence for text messaging improving cardiovascular risk factor levels in the short-term, future studies are needed to examine the durability of these effects and whether they can be translated to improvements in clinical care and outcomes.


mHealth Mobile health Cardiovascular disease Text message SMS Risk factors 



Clara K. Chow is supported by National Health and Medical Research Council Career Development Award (APP1033478) co-funded by the National Heart Foundation of Australia and Sydney Medical Foundation Chapmen Fellowship. She reports speaker fees paid to her institution from Astra Zeneca, Sanofi, Pfizer and Amgen. She is also an author of some of the literature that has been referenced in this paper.

Compliance with Ethical Standards

Conflict of Interest

Harry Klimis, Mohammad Ehsan Khan and Cindy Kok declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    World Health Organisation. Media centre: cardiovascular diseases (CVDs) 2015. Accessed 18th Feb 2016.
  2. 2.
    Australian Institute of Health and Welfare. Monitoring acute coronary syndrome using national hospital data: an information paper on trends and issues. Cat no CVD 57. Canberra: AIHW; 2011.Google Scholar
  3. 3.
    Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937–52. doi: 10.1016/S0140-6736(04)17018-9.CrossRefPubMedGoogle Scholar
  4. 4.
    World Health Organisation. Global Action Plan for the prevention and control of noncommunicable diseases 2013–2020. Geneva: WHO; 2013.Google Scholar
  5. 5.
    Bethell HJ, Evans JA, Turner SC, Lewin RJ. The rise and fall of cardiac rehabilitation in the United Kingdom since 1998. J Public Health. 2007;29:57–61. doi: 10.1093/pubmed/fdl091.CrossRefGoogle Scholar
  6. 6.
    Chamnan P, Simmons RK, Khaw KT, Wareham NJ, Griffin SJ. Estimating the population impact of screening strategies for identifying and treating people at high risk of cardiovascular disease: modelling study. BMJ. 2010;340:c1693. doi: 10.1136/bmj.c1693.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    World Health Organisation. mHealth: new horizons for health through mobile technologies: second global survey on eHealth. World Health Organization, Geneva 27, Switzerland. 2011. Accessed 15 July 2016.
  8. 8.
    Wireless F. Report: Global smartphone penetration to jump 25% in 2014, led by Asia-Pacific. Fierce Wireless. 2014. Accessed 16 July 2016.
  9. 9.
    Bastawrous A, Henning B, Livingstone I. mHealth: possibilities in a changing world. Distribution of global cell phone subscriptions. J MTM. 2013;2:22–5. doi: 10.7308/jmtm.78.CrossRefGoogle Scholar
  10. 10.••
    Burke LE, Ma J, Azar KM, Bennett GG, Peterson ED, Zheng Y, et al. Current science on consumer use of mobile health for cardiovascular disease prevention: a scientific statement from the American Heart Association. Circulation. 2015;132:1157–213. doi: 10.1161/CIR.0000000000000232. A recent comprehensive review of all RCTs on mobile health technology for modifiable cardiovascular risk factors.CrossRefPubMedGoogle Scholar
  11. 11.
    Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone short-message service. Am J Prev Med. 2009;36:165–73. doi: 10.1016/j.amepre.2008.09.040.CrossRefPubMedGoogle Scholar
  12. 12.
    Bastawrous A, Armstrong MJ. Mobile health use in low- and high-income countries: an overview of the peer-reviewed literature. J R Soc Med. 2013;106:130–42. doi: 10.1177/0141076812472620.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.•
    Siopis G, Chey T, Allman-Farinelli M. A systematic review and meta-analysis of interventions for weight management using text messaging. J Hum Nutr Diet. 2015;28 Suppl 2:1–15. doi: 10.1111/jhn.12207. A recent meta-analysis on text messaging in weight loss.CrossRefPubMedGoogle Scholar
  14. 14.
    Pew Research Center. Older adults and technology use. 2014. Accessed 20th Aug 2016.
  15. 15.
    Seidell JC, Halberstadt J. The global burden of obesity and the challenges of prevention. Ann Nutr Metab. 2015;66 Suppl 2:7–12. doi: 10.1159/000375143.CrossRefPubMedGoogle Scholar
  16. 16.
    Lajunen HR, Keski-Rahkonen A, Pulkkinen L, Rose RJ, Rissanen A, Kaprio J. Are computer and cell phone use associated with body mass index and overweight? A population study among twin adolescents. BMC Public Health. 2007;7:24. doi: 10.1186/1471-2458-7-24.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Haapala I, Barengo NC, Biggs S, Surakka L, Manninen P. Weight loss by mobile phone: a 1-year effectiveness study. Public Health Nutr. 2009;12:2382–91. doi: 10.1017/S1368980009005230.CrossRefPubMedGoogle Scholar
  18. 18.
    Napolitano MA, Hayes S, Bennett GG, Ives AK, Foster GD. Using Facebook and text messaging to deliver a weight loss program to college students. Obesity (Silver Spring). 2013;21:25–31. doi: 10.1002/oby.20232.CrossRefGoogle Scholar
  19. 19.
    Patrick K, Raab F, Adams MA, Dillon L, Zabinski M, Rock CL, et al. A text message-based intervention for weight loss: randomized controlled trial. J Med Internet Res. 2009;11, e1. doi: 10.2196/jmir.1100.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Partridge SR, McGeechan K, Hebden L, Balestracci K, Wong ATY, Denney-Wilson E, et al. Effectiveness of a mHealth lifestyle program with telephone support (TXT2BFiT) to prevent unhealthy weight gain in young adults: randomized controlled trial. JMIR mHealth uHealth. 2015;3, e66. doi: 10.2196/mhealth.4530.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Shapiro JR, Koro T, Doran N, Thompson S, Sallis JF, Calfas K, et al. Text4Diet: a randomized controlled study using text messaging for weight loss behaviors. Prev Med. 2012;55:412–7. doi: 10.1016/j.ypmed.2012.08.011.CrossRefPubMedGoogle Scholar
  22. 22.
    World Health Organisation. Media centre: physical activity. 2016. Accessed 3rd Sept 2016.
  23. 23.
    Australian Institute of Health and Welfare. National health priorities report: cardiovascular health 1998. Canberra: AIHW; 1999.Google Scholar
  24. 24.
    Hakim AA, Petrovitch H, Burchfiel CM, Ross GW, Rodriguez BL, White LR, et al. Effects of walking on mortality among nonsmoking retired men. N Engl J Med. 1998;338:94–9. doi: 10.1056/NEJM199801083380204.CrossRefPubMedGoogle Scholar
  25. 25.
    Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2014;129:S76–99. doi: 10.1161/01.cir.0000437740.48606.d1.CrossRefPubMedGoogle Scholar
  26. 26.
    Frederix I, Hansen D, Coninx K, Vandervoort P, Vandijck D, Hens N, et al. Medium-term effectiveness of a comprehensive internet-based and patient-specific telerehabilitation program with text messaging support for cardiac patients: randomized controlled trial. J Med Internet Res. 2015;17, e185. doi: 10.2196/jmir.4799.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Maddison R, Pfaeffli L, Whittaker R, Stewart R, Kerr A, Jiang Y, et al. A mobile phone intervention increases physical activity in people with cardiovascular disease: results from the HEART randomized controlled trial. Eur J Prev Cardiol. 2015;22:701–9. doi: 10.1177/2047487314535076.CrossRefPubMedGoogle Scholar
  28. 28.
    Fjeldsoe BS, Miller YD, Marshall AL. MobileMums: a randomized controlled trial of an SMS-based physical activity intervention. Ann Behav Med. 2010;39:101–11. doi: 10.1007/s12160-010-9170-z.CrossRefPubMedGoogle Scholar
  29. 29.
    Kim BH, Glanz K. Text messaging to motivate walking in older African Americans: a randomized controlled trial. Am J Prev Med. 2013;44:71–5. doi: 10.1016/j.amepre.2012.09.050.CrossRefPubMedGoogle Scholar
  30. 30.•
    Whittaker R, McRobbie H, Bullen C, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev. 2016;4, CD006611. doi: 10.1002/14651858.CD006611.pub4. A recent Cochrane review on mHealth in smoking cessation.PubMedGoogle Scholar
  31. 31.
    Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W, et al. Smoking cessation support delivered via mobile phone text messaging (txt2stop): a single-blind, randomised trial. Lancet. 2011;378:49–55. doi: 10.1016/S0140-6736(11)60701-0.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Abroms LC, Whittaker R, Free C, Mendel Van Alstyne J, Schindler-Ruwisch JM. Developing and pretesting a text messaging program for health behavior change: recommended steps. JMIR Mhealth Uhealth. 2015;3, e107. doi: 10.2196/mhealth.4917.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Rodgers A, Corbett T, Bramley D, Riddell T, Wills M, Lin RB, et al. Do u smoke after txt? Results of a randomised trial of smoking cessation using mobile phone text messaging. Tob Control. 2005;14:255–61. doi: 10.1136/tc.2005.011577.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    World Health Organisation. Global report on diabetes. Geneva: WHO; 2016.Google Scholar
  35. 35.
    Baker IDI Heart and Diabetes Institute. Diabetes: the silent pandemic and its impact on Australia. Diabetes Australia Baker IDI Heart and Diabetes Institute 2012.Google Scholar
  36. 36.
    Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA. 2006;296:427–40. doi: 10.1001/jama.296.4.427.CrossRefPubMedGoogle Scholar
  37. 37.
    Liang X, Wang Q, Yang X, Cao J, Chen J, Mo X, et al. Effect of mobile phone intervention for diabetes on glycaemic control: a meta-analysis. Diabet Med. 2011;28:455–63. doi: 10.1111/j.1464-5491.2010.03180.x.CrossRefPubMedGoogle Scholar
  38. 38.
    Shariful Islam SM, Niessen LW, Ferrari U, Ali L, Seissler J, Lechner A. Effects of mobile phone SMS to improve glycemic control among patients with type 2 diabetes in Bangladesh: a prospective, parallel-group, randomized controlled trial. Diabetes Care. 2015;38:e112–e3. doi: 10.2337/dc15-0505.CrossRefPubMedGoogle Scholar
  39. 39.•
    Arambepola C, Ricci-Cabello I, Manikavasagam P, Roberts N, French DP, Farmer A. The impact of automated brief messages promoting lifestyle changes delivered via mobile devices to people with type 2 diabetes: a systematic literature review and meta-analysis of controlled trials. J Med Internet Res. 2016;18, e86. doi: 10.2196/jmir.5425. A recent meta-analysis on text messaging in diabetes.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    World Health Organisation. Q&As on hypertension. 2015. Accessed 3rd Sept 2016.
  41. 41.
    Neumann CL, Menne J, Rieken EM, Fischer N, Weber MH, Haller H, et al. Blood pressure telemonitoring is useful to achieve blood pressure control in inadequately treated patients with arterial hypertension. J Hum Hypertens. 2011;25:732–8. doi: 10.1038/jhh.2010.119.CrossRefPubMedGoogle Scholar
  42. 42.
    Logan AG, Irvine MJ, McIsaac WJ, Tisler A, Rossos PG, Easty A, et al. Effect of home blood pressure telemonitoring with self-care support on uncontrolled systolic hypertension in diabetics. Hypertension. 2012;60:51–7. doi: 10.1161/HYPERTENSIONAHA.111.188409.CrossRefPubMedGoogle Scholar
  43. 43.
    Cottrell E, Chambers R, O’Connell P. Using simple telehealth in primary care to reduce blood pressure: a service evaluation. BMJ Open. 2012;2. doi: 10.1136/bmjopen-2012-001391.
  44. 44.
    Kiselev AR, Gridnev VI, Shvartz VA, Posnenkova OM, Dovgalevsky PY. Active ambulatory care management supported by short message services and mobile phone technology in patients with arterial hypertension. J Am Soc Hypertens. 2012;6:346–55. doi: 10.1016/j.jash.2012.08.001.CrossRefPubMedGoogle Scholar
  45. 45.•
    Bobrow K, Farmer AJ, Springer D, Shanyinde M, Yu L-M, Brennan T, et al. Mobile phone text messages to support treatment adherence in adults with high blood pressure (StAR): a single-blind, randomized trial. Circulation. 2016;133:592–600. doi: 10.1161/CIRCULATIONAHA.115.017530. A recent well constructed RCT on text messaging in blood pressure control and medication adherence.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Smith Jr SC. Current and future directions of cardiovascular risk prediction. Am J Cardiol. 2006;97:28A–32A. doi: 10.1016/j.amjcard.2005.11.013.CrossRefPubMedGoogle Scholar
  47. 47.••
    Chow CK, Redfern J, Hillis GS, Thakkar J, Santo K, Hackett ML, et al. Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: a randomized clinical trial. JAMA. 2015;314:1255–63. doi: 10.1001/jama.2015.10945. The only RCT assessing text messaging as a stand alone treatment for multiple cardiovascular risk factors.CrossRefPubMedGoogle Scholar
  48. 48.•
    Pfaeffli Dale L, Whittaker R, Jiang Y, Stewart R, Rolleston A, Maddison R. Text message and internet support for coronary heart disease self-management: results from the Text4Heart randomized controlled trial. J Med Internet Res. 2015;17, e237. doi: 10.2196/jmir.4944. An RCT assessing text messaging on multiple behavioural risk factors.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.•
    Anand SS, Samaan Z, Middleton C, Irvine J, Desai D, Schulze KM, et al. A digital health intervention to lower cardiovascular risk: a randomized clinical trial. JAMA Cardiol. 2016;1:601–6. doi: 10.1001/jamacardio.2016.1035. An important RCT assessing mHealth on overall cardiovascular risk in a primary prevention cohort, without statistically significant results.CrossRefPubMedGoogle Scholar
  50. 50.
    Ho PM, Magid DJ, Shetterly SM, Olson KL, Maddox TM, Peterson PN, et al. Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease. Am Heart J. 2008;155:772–9. doi: 10.1016/j.ahj.2007.12.011.CrossRefPubMedGoogle Scholar
  51. 51.
    World Health Organisation. Adherence to long-term therapies: evidence for action. Geneva: World Health Organisation; 2003.Google Scholar
  52. 52.
    Hamine S, Gerth-Guyette E, Faulx D, Green BB, Ginsburg AS. Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review. J Med Internet Res. 2015;17, e52. doi: 10.2196/jmir.3951.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.••
    Thakkar J, Kurup R, Laba TL, Santo K, Thiagalingam A, Rodgers A, et al. Mobile telephone text messaging for medication adherence in chronic disease: a meta-analysis. JAMA Intern Med. 2016;176:340–9. doi: 10.1001/jamainternmed.2015.7667. An important recent meta-analysis on text messaging for medication adherence.CrossRefPubMedGoogle Scholar
  54. 54.
    Yudi MB, Clark DJ, Tsang D, Jelinek M, Kalten K, Joshi S, et al. SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes [SMART-REHAB Trial]: a randomized controlled trial protocol. BMC Cardiovasc Disord. 2016;16(1):170. doi: 10.1186/s12872-016-0356-6.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Harry Klimis
    • 1
    • 2
    • 3
    Email author
  • Mohammad Ehsan Khan
    • 1
    • 2
  • Cindy Kok
    • 3
  • Clara K. Chow
    • 1
    • 2
    • 3
  1. 1.University of SydneySydneyAustralia
  2. 2.Department of CardiologyWestmead HospitalWentworthvilleAustralia
  3. 3.The George Institute for Global HealthSydneyAustralia

Personalised recommendations