Kristen M.J. Azar

Mobile applications for weight management: theory-based content analysis.

BACKGROUND The use of smartphone applications (apps) to assist with weight management is increasingly prevalent, but the quality of these apps is not well characterized. PURPOSE The goal of the study was to evaluate diet/nutrition and anthropometric tracking apps based on incorporation of features consistent with theories of behavior change. METHODS A comparative, descriptive assessment was conducted of the top-rated free apps in the Health and Fitness category available in the iTunes App Store. Health and Fitness apps (N=200) were evaluated using predetermined inclusion/exclusion criteria and categorized based on commonality in functionality, features, and developer description. Four researchers then evaluated the two most popular apps in each category using two instruments: one based on traditional behavioral theory (score range: 0-100) and the other on the Fogg Behavioral Model (score range: 0-6). Data collection and analysis occurred in November 2012. RESULTS Eligible apps (n=23) were divided into five categories: (1) diet tracking; (2) healthy cooking; (3) weight/anthropometric tracking; (4) grocery decision making; and (5) restaurant decision making. The mean behavioral theory score was 8.1 (SD=4.2); the mean persuasive technology score was 1.9 (SD=1.7). The top-rated app on both scales was Lose It! by Fitnow Inc. CONCLUSIONS All apps received low overall scores for inclusion of behavioral theory-based strategies.

Current Science on Consumer Use of Mobile Health for Cardiovascular Disease Prevention A Scientific Statement From the American Heart Association

Although mortality for cardiovascular disease (CVD) has declined for several decades, heart disease and stroke continue to be the leading causes of death, disability, and high healthcare costs. Unhealthy behaviors related to CVD risk (eg, smoking, sedentary lifestyle, and unhealthful eating habits) remain highly prevalent. The high rates of overweight, obesity, and type 2 diabetes mellitus (T2DM); the persistent presence of uncontrolled hypertension; lipid levels not at target; and the ≈18% of adults who continue to smoke cigarettes pose formidable challenges for achieving improved cardiovascular health.1,2 It is apparent that the performance of healthful behaviors related to the management of CVD risk factors has become an increasingly important facet of the prevention and management of CVD.3 In 2010, the American Heart Association (AHA) made a transformative shift in its strategic plan and added the concept of cardiovascular health.2 To operationalize this concept, the AHA targeted 4 health behaviors in the 2020 Strategic Impact Goals: reduction in smoking and weight, healthful eating, and promotion of regular physical activity. Three health indicators also were included: glucose, blood pressure (BP), and cholesterol. On the basis of the AHA Life’s Simple 7 metrics for improved cardiovascular health, 30% have not reached the target levels for lipids or BP. National Health and Nutrition Examination Survey (NHANES) data revealed that people who met ≥6 of the cardiovascular health metrics had a significantly better risk profile (hazard ratio for all-cause mortality, 0.49) compared with individuals who had achieved only 1 metric or none.2 The studies reviewed in this statement targeted these behaviors (ie, smoking, physical activity, healthful eating, and maintaining a healthful weight) and cardiovascular health indicators (ie, blood …

Racial/Ethnic Differences in Dyslipidemia Patterns

Background— No studies have comprehensively examined the prevalence of dyslipidemia, a major risk factor for cardiovascular disease, among diverse racial/ethnic minority groups. The primary aim of this study was to identify racial/ethnic differences in dyslipidemia among minorities including Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, or Vietnamese), Mexican Americans, and blacks compared with non-Hispanic whites. Methods and Results— Using a 3-year cross section (2008–2011), we identified 169 430 active primary care patients (35 years or older) from an outpatient healthcare organization in northern California. Age-standardized prevalence rates were calculated for 3 dyslipidemia subtypes: high triglycerides (fasting laboratory value ≥150 mg/dL), low levels of high-density lipoprotein cholesterol (fasting laboratory value <40 mg/dL [men] and <50 mg/dL [women]), and high levels of low-density lipoprotein cholesterol (fasting laboratory value ≥130 mg/dL or taking low-density lipoprotein–lowering agents). Odds ratios were calculated by multivariable logistic regression, with adjustment for patient characteristics (age, measured body mass index, smoking). Compared with non-Hispanic whites, every minority subgroup had an increased prevalence of high triglycerides except blacks. Most minority groups had an increased prevalence of low high-density lipoprotein cholesterol, except for Japanese and blacks. The prevalence of high low-density lipoprotein cholesterol was increased among Asian Indians, Filipinos, Japanese, and Vietnamese compared with non-Hispanic whites. Conclusions— Minority groups, except for blacks, were more likely to have high triglyceride/low high-density lipoprotein cholesterol dyslipidemia. Further research is needed to determine how racial/ethnic differences in dyslipidemia affect racial/ethnic differences in cardiovascular disease rates.

Incorporation of whole, ancient grains into a modern Asian Indian diet to reduce the burden of chronic disease

Refined carbohydrates, such as white rice and white flour, are the mainstay of the modern Asian Indian diet, and may contribute to the rising incidence of type 2 diabetes and cardiovascular disease in this population. Prior to the 1950s, whole grains such as amaranth, barley, brown rice, millet, and sorghum were more commonly used in Asian Indian cooking. These grains and other non-Indian grains such as couscous, quinoa, and spelt are nutritionally advantageous and may be culturally acceptable carbohydrate substitutes for Asian Indians. This review focuses on practical recommendations for culturally sensitive carbohydrate modification in a modern Asian Indian diet to reduce type 2 diabetes and cardiovascular disease in this population.

Racial/ethnic differences in the prevalence of proteinuric and nonproteinuric diabetic kidney disease.

OBJECTIVE To examine racial/ethnic differences in the prevalence of diabetic kidney disease (DKD), with and without proteinuria, in an outpatient health care organization. RESEARCH DESIGN AND METHODS We examined electronic health records for 15,683 persons of non-Hispanic white (NHW), Asian (Asian Indian, Chinese, and Filipino), Hispanic, and non-Hispanic black (NHB) race/ethnicity with type 2 diabetes and no prior history of kidney disease from 2008 to 2010. We directly standardized age- and sex-adjusted prevalence rates of proteinuric DKD (proteinuria with or without low estimated glomerular filtration rate [eGFR]) or nonproteinuric DKD (low eGFR alone). We calculated sex-specific odds ratios of DKD in racial/ethnic minorities (relative to NHWs) after adjustment for traditional DKD risk factors. RESULTS Racial/ethnic minorities had higher rates of proteinuric DKD than NHWs (24.8–37.9 vs. 24.8%) and lower rates of nonproteinuric DKD (6.3–9.8 vs. 11.7%). On adjusted analyses, Chinese (odds ratio 1.39 for women and 1.56 for men), Filipinos (1.57 for women and 1.85 for men), Hispanics (1.46 for women and 1.34 for men), and NHBs (1.50 for women) exhibited significantly (P < 0.01) higher odds of proteinuric DKD than NHWs. Conversely, Chinese, Hispanic, and NHB women and Hispanic men had significantly lower odds of nonproteinuric DKD than NHWs. CONCLUSIONS We found novel racial/ethnic differences in DKD among patients with type 2 diabetes. Racial/ethnic minorities were more likely to have proteinuric DKD and less likely to have nonproteinuric DKD. Future research should examine diverse DKD-related outcomes by race/ethnicity to inform targeted prevention and treatment efforts and to explore the etiology of these differences.

Festival Foods in the Immigrant Diet

Dietary acculturation for immigrant groups has largely been attributed to the “Westernization” of indigenous diets, as characterized by an increased consumption of unhealthy American foods (i.e., fast foods, hamburgers). However, acculturation and adoption of western dietary habits may not fully explain new dietary patterns among racial/ethnic minority immigrants. The immigrant diet may change in such a way that it elaborates on specific ethnic traditions in addition to the incorporation of Western food habits. In this paper, we explore the role that festival foods, those foods that were once eaten a few times a year and on special occasions, play in the regular diet of immigrants to the US. This paper will focus on the overconsumption of ethnic festival foods, which are often high in carbohydrates, animal protein, sugar and fat, as opposed to Western “junk” food, as an explanation for the increased risk of cardiometabolic disorders among new immigrant groups.

Virtual small groups for weight management: an innovative delivery mechanism for evidence-based lifestyle interventions among obese men

While group interventions for weight management have been shown to be efficacious, adherence is often low, especially among men. This pilot study seeks to test whether group interventions using web-based group video conferencing (VC) technology is effective for weight loss. We adapted a 12-week curriculum based on the Diabetes Prevention Program, and delivered this intervention to a small group of men (BMI ≥30 kg/m2), using web-based group VC. Participants were randomized to intervention (n = 32) or delayed-intervention control group (n = 32). The intervention group lost 3.5 % (95 % CI 2.1 %, 4.9 %) of their initial body weight. Difference in mean weight loss was 3.2 kg (p = 0.0002) and mean BMI decrease was 1.0 kg/m2 (p = 0.0010) between the two groups. Virtual small groups may be an effective means of allowing face-to-face group interaction, while overcoming some barriers to access.

A Fully Automated Diabetes Prevention Program, Alive-PD: Program Design and Randomized Controlled Trial Protocol

Background In the United States, 86 million adults have pre-diabetes. Evidence-based interventions that are both cost effective and widely scalable are needed to prevent diabetes. Objective Our goal was to develop a fully automated diabetes prevention program and determine its effectiveness in a randomized controlled trial. Methods Subjects with verified pre-diabetes were recruited to participate in a trial of the effectiveness of Alive-PD, a newly developed, 1-year, fully automated behavior change program delivered by email and Web. The program involves weekly tailored goal-setting, team-based and individual challenges, gamification, and other opportunities for interaction. An accompanying mobile phone app supports goal-setting and activity planning. For the trial, participants were randomized by computer algorithm to start the program immediately or after a 6-month delay. The primary outcome measures are change in HbA1c and fasting glucose from baseline to 6 months. The secondary outcome measures are change in HbA1c, glucose, lipids, body mass index (BMI), weight, waist circumference, and blood pressure at 3, 6, 9, and 12 months. Randomization and delivery of the intervention are independent of clinic staff, who are blinded to treatment assignment. Outcomes will be evaluated for the intention-to-treat and per-protocol populations. Results A total of 340 subjects with pre-diabetes were randomized to the intervention (n=164) or delayed-entry control group (n=176). Baseline characteristics were as follows: mean age 55 (SD 8.9); mean BMI 31.1 (SD 4.3); male 68.5%; mean fasting glucose 109.9 (SD 8.4) mg/dL; and mean HbA1c 5.6 (SD 0.3)%. Data collection and analysis are in progress. We hypothesize that participants in the intervention group will achieve statistically significant reductions in fasting glucose and HbA1c as compared to the control group at 6 months post baseline. Conclusions The randomized trial will provide rigorous evidence regarding the efficacy of this Web- and Internet-based program in reducing or preventing progression of glycemic markers and indirectly in preventing progression to diabetes. Trial Registration ClinicalTrials.gov NCT01479062; http://clinicaltrials.gov/show/NCT01479062 (Archived by WebCite at http://www.webcitation.org/6U8ODy1vo).

Baseline obesity status modifies effectiveness of adapted diabetes prevention program lifestyle interventions for weight management in primary care.

Objective. To examine whether baseline obesity severity modifies the effects of two different, primary care-based, technology-enhanced lifestyle interventions among overweight or obese adults with prediabetes and/or metabolic syndrome. Patients and Methods. We compared mean differences in changes from baseline to 15 months in clinical measures of general and central obesity among participants randomized to usual care alone (n = 81) or usual care plus a coach-led group (n = 79) or self-directed individual (n = 81) intervention, stratified by baseline body mass index (BMI) category. Results. Participants with baseline BMI 35+ had greater reductions in mean BMI, body weight (as percentage change), and waist circumference in the coach-led group intervention, compared to usual care and the self-directed individual intervention (P < 0.05 for all). In contrast, the self-directed intervention was more effective than usual care only among participants with baseline BMIs between 25 ≤ 35. Mean weight loss exceeded 5% in the coach-led intervention regardless of baseline BMI category, but this was achieved only among self-directed intervention participants with baseline BMIs <35. Conclusions. Baseline BMI may influence behavioral weight-loss treatment effectiveness. Researchers and clinicians should take an individuals baseline BMI into account when developing or recommending lifestyle focused treatment strategy. This trial is registered with ClinicalTrials.gov NCT00842426.

Improving diet, activity and wellness in adults at risk of diabetes: randomized controlled trial.

Objective:The purpose of this analysis is to examine the effect of an algorithm-driven online diabetes prevention program on changes in eating habits, physical activity and wellness/productivity factors.Methods:The intervention, Alive-PD, used small-step individually tailored goal setting and other features to promote changes in diet and physical activity. A 6-month randomized controlled trial was conducted among patients from a healthcare delivery system who had confirmed prediabetes (n =339). Change in weight and glycemic markers were measured in the clinic. Changes in physical activity, diet and wellness/productivity factors were self-reported. Mean age was 55 (s.d. 8.9) years, mean body mass index was 31 (s.d. 4.4) kg m−2, 68% were white and 69% were male.Results:The intervention group increased fruit/vegetable consumption by 3.71 (95% confidence interval (CI) 2.73, 4.70) times per week (effect size 0.62), and decreased refined carbohydrates by 3.77 (95% CI 3.10, 4.44) times per week both significantly (P<0.001) greater changes than in the control group. The intervention group also reported a significantly greater increase in physical activity than in the control group, effect size 0.49, P<0.001. In addition, the intervention group reported a significant increase in self-rated health, in confidence in ability to make dietary changes and in ability to accomplish tasks, and a decrease in fatigue, compared with the control group. These changes paralleled the significant treatment effects on glycemic markers and weight.Conclusions:In addition to promoting improvements in weight and glycemic markers, the Alive-PD program appears to improve eating habits and physical activity, behaviors important not just for diabetes prevention but for those with diagnosed diabetes or obesity. The improvements in wellness/productivity may derive from the diet and activity improvements, and from the satisfaction and self-efficacy of achieving goals.