Digital Health Technologies to Promote Lifestyle Change and Adherence
- 1.3k Downloads
Cardiovascular disease is the leading cause of morbidity and mortality worldwide with an estimated 17.5 million deaths annually, or 31% of all global deaths, according to the World Health Organization. The majority of these deaths are preventable by addressing lifestyle modification (i.e., smoking cessation, diet, obesity, and physical inactivity) and promoting medication adherence. At present, initiatives to develop cost-effective modalities to support self-management, lifestyle modification, and medication adherence are a leading priority. Digital health has rapidly emerged as technology with the potential to address this gap in cardiovascular disease self-management and transform the way healthcare has been traditionally delivered. However, limited evidence exists about the type of technologies available and how they differ in functionality, effectiveness, and application. We aimed to review the most important and relevant recent studies addressing health technologies to promote lifestyle change and medication adherence including text messaging, applications (“apps”), and wearable devices. The current literature indicates that digital health technologies will likely play a prominent role in future cardiovascular disease management, risk reduction, and delivery of care in both resource-rich and resource-limited settings. However, there is limited large-scale evidence to support adoption of existing interventions. Further clinical research and healthcare policy change are needed to move the promise of new digital health technologies towards reality.
KeywordsDigital health Mobile health Health tech Lifestyle change Medication adherence Cardiovascular disease
Compliance with Ethical Standards
Conflict of Interest
Numan Khan and Jane Wang report no conflicts.
Francoise A. Marvel has received research support from Apple.
Seth S. Martin has received research support from Apple. Dr. Martin has also received research support from the PJ Schafer Cardiovascular Research Fund, American Heart Association, Aetna Foundation, CASCADE FH, and Google. Dr. Martin declares being a co-inventor on a pending patent filed by Johns Hopkins University for the novel method of low-density lipoprotein cholesterol estimation. He has served as a consultant to Abbott Nutrition, Pressed Juicery, Quest Diagnostics, Sanofi/Regeneron, Amgen, and the Pew Research Center.
Human and Animal Rights and Informed Consent
This article does not contain studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 1.Poushter J. Smartphone ownership and Internet usage continues to climb in emerging economies [Internet]. Pew Res Cent. 2016. Available from: http://www.pewglobal.org/2016/02/22/smartphone-ownership-and-internet-usage-continues-to-climb-in-emerging-economies/.
- 2.Wood B. By 2020, 90% of World’s population aged over 6 will have a mobile phone: report [Internet]. Next Web. 2014 [cited 2016 Dec 6]. Available from: http://thenextweb.com/insider/2014/11/18/2020-90-worlds-population-aged-6-will-mobile-phone-report/.
- 3.Steinhubl SR, Muse ED, Topol EJ. The emerging field of mobile health. Sci Transl Med. [Internet]. 2015;7:283rv3–283rv3. Available from: http://stm.sciencemag.org/cgi/doi/10.1126/scitranslmed.aaa3487.
- 4.Smith A, Mcgeeney K, Rainie L, Keeter S. U.S. Smartphone use in 2015. Smartphone Differ. [Internet]. 2015;60. Available from: http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/.
- 5.Calugar-Pop C, Lee P. The state of the global mobile consumer, 2013 divergence deepens contents. London: Deloitte; 2013.Google Scholar
- 7.• Martin SS, Feldman DI, Blumenthal RS, Jones SR, Post WS, McKibben, RA, et al. mActive: a randomized clinical trial of an automated mHealth intervention for physical activity promotion. J Am Heart Assoc [Internet]. 2015;4:e002239. Available from: http://jaha.ahajournals.org/content/4/11/e002239.abstract. The mActive trial found that activity tracking combined with real-time, personalized text messages can significantly increase physical activity, and further affirms text messaging as an effective health behavior modifier.
- 8.• 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. Jama [Internet]. 2015;314:1255. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.10945. The randomized Tobacco, Exercise, and Diet Messages (TEXT ME) trial included 710 adults in Australia. It showed that, compared with the participants who received usual care only, those who received usual care plus four motivational texts weekly for 6 months had significant improvement in low-density lipoprotein cholesterol (LDL-C), the primary end point, as well as decreases in body-mass index (BMI) and smoking status and an increase in physical activity.
- 9.• Müssener U, Bendtsen M, Karlsson N, White IR, McCambridge J, Bendtsen P. Effectiveness of short message service text-based smoking cessation intervention among university students: a randomized clinical trial. JAMA Intern Med [Internet]. 2016;176:321–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26903176. The Nicotine Exit (NEXit) trial implemented a text messaging intervention for smoking cessation and included 1502 adults in its analysis. Eight-week prolonged abstinence from smoking and 4-week complete cessation as a result of the intervention were significant and comparable to current standard smoking cessation techniques.
- 10.Thakkar J, Kurup R, Laba T-L, Santo K, Thiagalingam A, Rodgers A, et al. Mobile telephone text messaging for medication adherence in chronic disease. JAMA Intern Med [Internet]. 2016;176:340. Available from: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2015.7667 CrossRefGoogle Scholar
- 11.Gandapur Y, Kianoush S, Kelli HM, Misra S, Urrea B, Blaha MJ, et al. The role of mHealth for improving medication adherence in patients with cardiovascular disease: a systematic review. Eur Heart J Qual Care Clin Outcomes [Internet]. 2016;qcw018. Available from: http://ehjqcco.oxfordjournals.org/lookup/doi/10.1093/ehjqcco/qcw018.
- 12.Ralf-Gordon Jahns. 500m people will be using healthcare mobile applications in 2015 [Internet]. research2guidance. 2015. Available from: http://research2guidance.com/500m-people-will-be-using-healthcare-mobile-applications-in-2015-2/.
- 13.Examples of mobile apps for which the FDA will exercise enforcement discretion [Internet]. U.S. Food Drug Adm. Available from: http://www.fda.gov/MedicalDevices/DigitalHealth/MobileMedicalApplications/ucm368744.htm.
- 14.FDA. Mobile medical applications. U.S. Deapartment Heal. Hum. Serv. Food Drug Adm. [Internet]. 2015;44. Available from: http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM263366.pdf.
- 15.U.S. Food and Drug Administration. Draft guidance medical device data systems, medical image storage devices, and medical image communications devices draft guidance for industry and food and drug administration staff. 2014;1–9. Available from: http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM401996.pdf.
- 16.R.K. R, A. K, S.P. K. Symptom-based smartphone app for detecting acute coronary syndrome: A diagnostic accuracy study [Internet]. J Am Coll Cardiol. 2016. p. 632. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed13&NEWS=N&AN=72242135.
- 17.Sardana M, Saczynski J, Esa N, Floyd K, Chon K, Chong JW, et al. Performance and usability of a novel smartphone application for atrial fibrillation detection in an ambulatory population referred for cardiac monitoring. J Am Coll Cardiol [Internet]. American College of Cardiology Foundation; 2016;67:844. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0735109716308452.
- 18.• Plante T, Urrea B, MacFarlane Z, Blumenthal R, Miller E III, Appel L, et al. Validation of the instant blood pressure smartphone app. JAMA Intern Med. 2016;176:E1–2. This study is important because it is one of the few that attempts to critically evaluate the claims of a popular smartphone app.Google Scholar
- 19.• Johnston N, Bodegard J, Jerström S, Åkesson J, Brorsson H, Alfredsson J, et al. Effects of interactive patient smartphone support app on drug adherence and lifestyle changes in myocardial infarction patients: a randomized study. Am Heart J. 2016;178:85–94. This trial conducted in Sweden found that utilizing an interactive app significantly improved drug adherence (primary outcome) at six months and showed a trend of improvement in some of the secondary outcomes such as smoking cessation, physical activity, and quality of life.Google Scholar
- 20.McConnell MV, Shcherbina A, Pavlovic A, Homburger JR, Goldfeder RL, Waggot D, et al. Feasibility of obtaining measures of lifestyle From a Smartphone App: The MyHeart Counts Cardiovascular Health Study. JAMA Cardiol. 2017;2:67–76.Google Scholar
- 21.Higgins JP. Smartphone applications for patients’ health and fitness. Am J Med [Internet]. 2015;129:11–9. Available from: http://www.sciencedirect.com/science/article/pii/S0002934315005379 CrossRefGoogle Scholar
- 22.Misra, Satish, Greg Von Portz, Iltifat Husain, Douglas Maurer, Melissa Murfin, Brian Chau and David Tseng. IMedicalApps-Reviews of Medical Apps & Healthcare Technology [Internet]. [cited 2016 Nov 20]. Available from: http://www.imedicalapps.com/.
- 24.Freak-Poli RLA, Cumpston M, Peeters A, Clemes SA. Workplace pedometer interventions for increasing physical activity. Cochrane Database Syst rev. 2013;4Google Scholar
- 25.Jakicic JM, Davis KK, Rogers RJ, King WC, Marcus MD, Helsel D, et al. Effect of wearable technology combined with a lifestyle intervention on long-term weight loss. JAMA [Internet]. 2016;316:1161. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2016.12858 CrossRefGoogle Scholar
- 26.• Finkelstein EA, Haaland BA, Bilger M, Sahasranaman A, Sloan RA, Nang EEK, et al. Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): a randomised controlled trial. Lancet Diabetes Endocrinol [Internet]. Elsevier Ltd; 2013;0:219–29. Available from: doi: 10.1016/S2213-8587(16)30284-4. TRIPPA implemented an intervention using activity trackers to increase physical activity but introduced the element of external incentive. While significant increases in physical activity were seen in the cash incentive group, these results were short-lived, which highlights the importance of intrinsic motivation.
- 27.Monroe CM. Valuable steps ahead: promoting physical activity with wearables and incentives. LANCET Diabetes Endocrinol [Internet]. Elsevier Ltd; 2016;8587:30284. Available from: doi: 10.1016/S2213-8587(16)30264-9.
- 28.• Ganesan AN, Louise J, Horsfall M, Bilsborough SA, Hendriks J, McGavigan AD, et al. International mobile-health intervention on physical activity, sitting, and weight: the Stepathlon cardiovascular health study. J Am Coll Cardiol. 2016;67:2453–63. The Stepathlon Study implemented an international (64 countries), mass-participation (69,219 subjects), and low-cost mHealth activity-tracker intervention with results that were reproducible annually for three consecutive years. Significant improvements were found in step count, exercise days, sitting duration, and weight.Google Scholar
- 29.Murakami H, Kawakami R, Nakae S, Nakata Y, Ishikawa-Takata K, Tanaka S, et al. Accuracy of wearable devices for estimating total energy expenditure. JAMA Intern. Med. [Internet]. 2016;176:E1–2. Available from: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.0152 Google Scholar
- 30.• Wang R, Blackburn G, Desai M, Phelan D, Gillinov L, Houghtaling P, et al. Accuracy of wrist-worn heart rate monitors. JAMA Cardiol. [Internet]. 2016;313:625–6. Available from: http://jamanetwork.com/journals/jamacardiology/article-abstract/2566167. This study was important as it sets a precedent for the academic community to critically evaluate and validate wearable devices that can impact patient outcomes.
- 31.Widmer RJ, Collins NM, Collins CS, West CP, Lerman LO, Lerman A. Digital health interventions for the prevention of cardiovascular disease: a systematic review and meta-analysis. Mayo Clin Proc [Internet]. 2015;90:469–80. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-84926389726&partnerID=40&md5=1206a327c626d417dfe4ccb20285f872 CrossRefGoogle Scholar
- 32.Murray E, Hekler EB, Andersson G, Collins LM, Doherty A, Hollis C, et al. Evaluating digital health interventions: key questions and approaches. Am J Prev Med [Internet]. Elsevier; 2016;51:843–51. Available from: doi: 10.1016/j.amepre.2016.06.008.
- 33.Turakhia MP, Affairs V, Alto P, Care H, Alto P, Desai SA, et al. The outlook of digital health for cardiovascular medicine challenges but also extraordinary opportunities. JAMA Cardiol. 2016;1(7):743–4. Available from: doi: 10.1001/jamacardio.2016.2661.
- 34.Varnfield M, Karunanithi M, Lee C-K, Honeyman E, Arnold D, Ding H, et al. Smartphone-based home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial. Heart [Internet]. 2014;100:1770–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24973083 CrossRefGoogle Scholar
- 35.Schoenfeld AJ, Sehgal NJ, Auerbach A. The challenges of mobile health regulation. JAMA Intern Med [Internet]. 2016;176:704–5. Available from: http://archinte.jamanetwork.com.proxy.lib.umich.edu/article.aspx?articleid=2500060 CrossRefGoogle Scholar