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An 014100
An 014100
An 014100
ABSTRACT
The use of mobile and wireless technologies and wearable devices for improving health care processes and outcomes (mHealth) is promising
for health promotion among patients with chronic diseases such as obesity and diabetes. This study comprehensively examined published
mHealth intervention studies for obesity and diabetes treatment and management to assess their effectiveness and provide recommendations
for future research. We systematically searched PubMed for mHealth-related studies on diabetes and obesity treatment and management
published during 2000–2016. Relevant information was extracted and analyzed. Twenty-four studies met inclusion criteria and varied in terms of
sample size, ethnicity, gender, and age of the participating patients and length of follow-up. The mHealth interventions were categorized into
3 types: mobile phone text messaging, wearable or portable monitoring devices, and applications running on smartphones. Primary outcomes
included weight loss (an average loss ranging from 21.97 kg in 16 wk to 27.1 kg in 5 wk) or maintenance and blood glucose reduction (an average
decrease of glycated hemoglobin ranging from 20.4% in 10 mo to 21.9% in 12 mo); main secondary outcomes included behavior changes and
patient perceptions such as self-efficacy and acceptability of the intervention programs. More than 50% of studies reported positive effects of
interventions based on primary outcomes. The duration or length of intervention ranged from 1 wk to 24 mo. However, most studies included small
samples and short intervention periods and did not use rigorous data collection or analytic approaches. Although some studies suggest that
mHealth interventions are effective and promising, most are pilot studies or have limitations in their study designs. There is an essential need for
future studies that use larger study samples, longer intervention ($ 6 mo) and follow-up periods ($ 6 mo), and integrative and personalized innovative
mobile technologies to provide comprehensive and sustainable support for patients and health service providers. Adv Nutr 2017;8:449–62.
ã2017 American Society for Nutrition. Adv Nutr 2017;8:449–62; doi:10.3945/an.116.014100. 449
(7). It is projected that India will have 101 million patients terms of study selection, data collection, data analysis, and result reporting.
with T2D, the largest number in the world, by 2030 (8). Because of the high heterogeneity in study characteristics of the selected
studies and limited number of comparable studies and quantitative results,
Providing good health care services and preventing related quantitative meta-analysis could not be conducted in the present study.
health complications are critical for diabetic and obese pa-
tients, their families, and the society at large. Without effective Study selection
prevention and management of diabetes and obesity, patients Database and search strategy. To identify studies that have investigated the
and their families will suffer. The society will also suffer from effectiveness of mHealth intervention programs for obesity and/or diabetes
huge financial and other costs incurred during the care of treatment and management, we searched PubMed for relevant articles
published between 1 January 2000 and 31 August 2016. We limited the
those patients. However, there are many challenges in provid- search for studies published since 2000 because, although smartphones
ing good health care to obese and diabetic patients and help- originated in ;2007, some mobile devices were available and tested in
ing them control their weight and blood glucose (7, 9, 10), health promotion–related research before then. In the end, we found 24
especially in developing countries with limited health care fa- studies that met our inclusion criteria, all published after 2008 (see
cilities and professionals. Treatment of obesity and diabetes is Figure 1).
The terms we used in the PubMed search included “cell phone and over-
costly; requires long-term efforts from patients, their health weight,” “cell phone and obesity,” “cell phone and diabetes,” “smartphone
providers, and other stakeholders; and is often ineffective be- and overweight,” “smartphone and obesity,” “smartphone and diabetes,”
cause of complex factors, including many challenges that pa- “mobile phone and overweight,” “mobile phone and obesity,” “mobile
tients may face in their daily work and life. phone and diabetes,” “mHealth and overweight,” “mHealth and obesity,”
Development of lower-cost, more effective methods for “mHealth and diabetes,” “eHealth and overweight,” “eHealth and obesity,”
“eHealth,” and “diabetes.” The search was limited to studies involving ran-
treatment and self-management of obesity and diabetes is domized trials (i.e., experimental but not observational studies), human
greatly needed to reduce health care costs associated with studies, and publication in English. Search results were further screened
obesity and diabetes while at the same time improving the manually by study title, abstract, and full text based on our study inclusion
quality of care and the life of patients (11, 12). and exclusion criteria.
New advances in the use of mobile and wireless technologies
Study inclusion and exclusion criteria. Inclusion criteria that we used were
and wearable devices for improving health care processes and 1) participants in studies were diabetic or obese patients; 2) mobile devices,
outcomes (mHealth) provide promising options for low-cost, such as mobile phones and/or wearable monitoring devices, were used in
effective care (13) and health promotion for patients with the health intervention or care delivery; 3) diabetes- and obesity-related
chronic diseases such as obesity and diabetes. It can be an effec- behaviors and outcomes were evaluated, for example, whether weight
tive tool for patients by helping facilitate their interactions with changes of obese patients or glycated hemoglobin (HbA1c) changes of
diabetic patients were reported; 4) the study design was a randomized
health care providers, other patients, and family members. clinical trial (RCT) or quasi-experiment; and 5) the study was published
mHealth has no standard definition yet. For the purpose of in English.
this study, we defined mHealth as health practice or services Exclusion criteria included 1) review or commentary articles or studies
supported by mobile technologies and devices, including cell not published in English; 2) proposed interventions that only used emails,
phones, wearable devices, and sensors as well as mobile applica- web-based programs, or log books without interacting with patients and de-
livering an intervention to a mobile device; and 3) studies that involved pa-
tions running on smartphones (APPs). mHealth has been widely tients with other chronic diseases, such as cardiac disease or cancer.
adopted to help manage diseases in various domains, such as
HIV and AIDS, malaria, tuberculosis, diabetes, asthma, obesity, Data collection and analysis
and smoking (13–17). However, despite the growing number of Two coauthors and a research assistant extracted information from identi-
applications of mHealth, the effectiveness of mHealth APPs in fied studies that met inclusion criteria, including study design, subjects, na-
improving health remains inconclusive, and the evidence is scat- ture of the intervention, inclusion of control groups, and key research
results. Extracted information was reviewed by other coauthors to verify ac-
tered. A systematic examination of related mHealth studies is curacy. The methodological quality of the selected studies was assessed by
needed to guide future mHealth research and practice. using the Jadad scale (20), which has been recognized as a useful tool for
The existing literature reviews of mHealth APPs mainly fo- evaluation of RCT quality (21). Jadad scores range from 0 (very poor) to
cus on the availability of commercial applications and use for 5 (rigorous) and consist of points for randomization (randomized = 1 point;
patients (18). However, there are very few systematic reviews table of random numbers or computer-generated randomization = addi-
tional 1 point), double blindness (double blind = 1 point; use masking
regarding the current APPs and their effectiveness as mHealth such as identical placebo = additional 1 point), and follow-up (stating num-
tools for obesity and diabetes treatment and management. To bers of subjects withdrawn and the reasons for them in each group of a
fill this gap and advance our understanding of existing research study = 1 point) (22).
on mHealth in support of obesity and diabetes treatment and The research designs used in previous RCT studies were highly het-
management, we conducted a systematic review of the related erogeneous with respect to intervention durations, outcome variables,
and target populations, which prohibited quantitative analysis (i.e.,
research and assessed the effectiveness of the mHealth inter- meta-analysis). Thus, we present a narrative synthesis of the results of
ventions for obesity and diabetes treatment and management, mHealth interventions for diabetes and obesity management reported
identified gaps in the literature, and provided recommenda- by those studies.
tions for future research.
Results
Methods Main characteristics of the selected studies
This systematic literature review was conducted following the Preferred Re- Table 1 shows the main characteristics of the 24 selected
porting Items for Systematic Reviews and Meta-Analyses framework (19) in studies. Among them, 15 studies (63%) were conducted in
the United States, and the rest were conducted in 7 other self-manage their conditions; and 3) wearable or portable
countries, including Iran, Germany, South Korea, Italy, monitoring devices (WPMDs), which offer patient data
Finland, Spain, and Australia. Regarding study design, 16 collection over a wireless connection and can monitor
studies (67%) were randomized controlled trials, and patients’ physiological status. This classification is made
8 (33%) were quasi-experiments. based on several considerations including simplicity, un-
Most studies included small samples. Sample sizes of the derstandability to a nontechnical audience, and technolog-
selected studies ranged from 15 to 124 subjects/intervention ical complexity involved in interventions, but there could
or control group, with 8 studies (33%) with no groups be other ways to classify. For example, from a system per-
of >30 subjects/group, 11 studies (46%) with 30–60 spective, text messaging is an APP running on a mobile
subjects/group, and 5 studies (21%) with >60 subjects/ phone. Wearable devices are hardware and are associated
group. Two studies (8%) recruited only female subjects, with software.
whereas 22 (92%) recruited both male and female subjects Regarding tested mHealth intervention approaches,
(Table 2). about half (13 studies, 54%) used MPTM, 6 (25%) used
WPMDs, and 5 (21%) used APPs. Intervention durations
Types of mHealth interventions ranged widely from only 1 wk to 2 y, although most had a
As reported in Tables 1 and 2, based on the nature of specific short duration. Specifically, more than half (13 studies,
mHealth technologies investigated by the selected studies, 54%) had an intervention <3 mo (i.e., 12 wk), 7 (29%)
we categorized the mHealth interventions into 3 types: 1) had an intervention between 3 and 6 mo, and only 4 studies
mobile phone text messaging (MPTM), which uses text (17%) had an intervention >6 mo.
messages as the primary mode of communication between This study found that MPTM and APP were largely used
patients and health care providers; 2) an APP, which uses to facilitate behavior changes in patients with obesity or di-
smartphones to deliver patient education or help patients abetes by providing patients with knowledge and tips for
(Continued)
TABLE 1 (Continued )
453
TABLE 1 (Continued )
(Continued)
weight or blood sugar control, providing reminders about
for improving the health care processes and outcomes; LDL-C, LDL cholesterol; MPTM, mobile phone text messaging; PA, physical activity; PDA, personal digital assistant; Q-E, quasi-experiment; RCT, randomized controlled trial; SMS, short-
APP, application run on a smartphone; BP, blood pressure; BW, body weight; BUN, blood urea nitrogen; G, number of groups; HbA1c, glycated hemoglobin; ID, identifier; mHealth, use of mobile and wireless technologies and wearable devices
some activities to control them, providing social support,
Effective
Yes
No
and collecting patient physiological data, such as body
weight and amount of physical activity (PA), for self-
message service; SS, sample size; TC, total cholesterol; WC, waist circumference; WPMD, wearable or portable monitoring device; %overBMI, BMI 2 BMI at 50th percentile for age and sex/BMI at 50th percentile 3 100.
was mainly used for providing knowledge and tips on
Conclusions
Automated feedback
control of LDL-C.
type 2 diabetes.
in disease control, such as providing feedback to help
with positive behavior changes and serving as data collec-
tion platforms.
In contrast, our review suggested that WPMD were used
exclusively for data collection (patient monitoring). The in-
fructosamine (P = 0.881), and
to transmit glucose
and an automated
manager weekly
age dropout rate across all studies that reported this infor-
mation was 17.4%. Obesity intervention studies had a
higher average drop-out rate (19.6%) than those on diabetes
mHealth Intervention
interventions (13.9%).
period
10 mo
6 mo
WPMD
type
18–75
2
48
3 for diabetes).
Study IDs indicate the 1st to 24th study.
design
RCT
RCT
Reference, year
Pressman et al.
reported positive results (16, 25, 27, 28, 30, 31, 33–35), 6
Orsama et al.
(43), 2013
(44), 2014
Mean.
24
2
3
4
improvement (25, 31). Shorter-term interventions tended than that at baseline (34). Some research reported that
to get more positive results in weight-control studies than a mobile intervention reduced waist circumference by
did the longer-term interventions (Table 5). 3.0 cm (25), reduced sedentary time by 47.2 min/d (31),
For the 10 studies on mHealth interventions for dia- increased completion rate of self-registrations of diet
betes treatment and management, 5 (50%) reported sta- and PAs by nearly 20% (30), and increased light PA time
tistically significantly improved results in primary by 31 min/d and moderate-to-vigorous PA time by
outcomes or clinical biochemical analysis, such as blood 16.3 min/d (31).
glucose, HbA1c, and blood lipids (14, 39, 40, 41, 43). Among studies on diabetes, the mHealth interven-
Two WPMD intervention studies reported positive re- tions used in 5 studies resulted in decreased HbA1c
sults, but the only APP intervention appeared to have (14, 39, 40, 41, 43). The greatest percentage reduction
no effect on controlling diabetes. It is notable that behav- of HbA1c was ;1% (40), and blood glucose reduction
ior changes after receiving interventions did not reach was ;1 mmol/L (39).
statistical significance in any diabetes control studies
(Table 5). Discussion
The growing global obesity and diabetes epidemic affects
Quantitative findings. As shown in Table 6, 6 studies on both developed and developing counties, many of which
mHealth interventions for obesity management reveal sig- have limited resources to help patients fight the related
nificant body weight loss (16, 25, 27, 34, 35); the highest consequences (45, 46). At present a large number of peo-
average body weight loss was 7.1 kg (pre- and postinterven- ple worldwide suffer from the epidemic, with >40% of
tion comparison) (27); the highest proportion of weight adults being overweight or obese globally. The number
loss after receiving mobile interventions was 9.4% higher of obese and diabetic patients will continue to increase
at least in the near future. Effective and sustainable inter- Some earlier literature reviews documented the dramatic
vention programs are needed to improve patients’ health increase of mHealth use (18, 47–49). For example, there
and reduce care cost. The use of mobile and wireless tech- were >1000 commercial APPs for diabetes care in the
nologies (i.e., mHealth interventions), attributable to the Google Play Store (for Android) and 605 in the Apple App
pervasiveness and ubiquity of mobile, handheld devices, store (for iOS) in 2013 (18). Previous reviews evaluated the
to support obesity and diabetes treatment and manage- usability, feasibility, and acceptability or patient preferences
ment, including long-term care and self-management by of mHealth interventions (49, 50). However, few existing re-
patients, may transform health service delivery across the views have assessed the impact of mHealth on disease-specific
globe (13). clinical outcomes (50, 51). In addition, previous reviews
focused on certain types of mHealth tools only (e.g., mobile aspects, for example, WPTM is used to provide personal-
phone messaging applications) (47, 48, 50, 51) or focused ized guidelines for medication and lifestyle behaviors
only on specific populations, mHealth intervention methods (14), and WPMDs are used to transmit glucose, blood
(e.g., only on phone text messages), or outcomes (e.g., only pressure, and weight information to care providers to im-
on obesity or BMI) (52–54). prove care management (44).
To fill the research gaps and help guide future research, Our review results show that the effects of mHealth inter-
our systematic review evaluated the whole spectrum of ef- ventions are heterogeneous across studies, which may be
fects of mHealth interventions for obesity and diabetes partially because of the different outcomes targeted and
treatment and management. We categorized mHealth in- assessed. The selected studies assessed a wide range of health
tervention methods into 3 types, namely MPTM, APPs, outcomes, although most studies focused only on 1 or 2
and WPMDs, based on the type of information and com- outcomes. The primary and direct outcomes were weight
munication technologies used. MPTM plays an important loss, weight maintenance, and waist circumference reduc-
role in providing knowledge outreach, activity reminders, tion for obesity studies, and blood glucose and HbA1c con-
tools for social support, feedback for behavior changes trol and reduction for diabetes studies. The most important
and maintenance, and sometimes serves as an indirect secondary outcomes of both types of studies were health be-
channel for data collection and monitoring. MPTM has haviors, such as PA and diet. Some studies also assessed
been more easily and widely used than the 2 other types other clinical measurements and management actions,
of mHealth interventions because it is easy to implement, such as blood pressure, medicine dose, self-efficacy, social
but it is largely limited to patient education. APPs have support, and acceptability of mHealth (25, 28, 38, 40–42).
been playing versatile roles in interventions, whereas We found the mHealth interventions were more effective
WPMDs mainly support health-related data collection. if they targeted PA-related outcomes than other outcomes,
The subject dropout rate was higher in studies related to with 11 of 18 studies that targeted PA reporting positive
controlling overweight and obesity than those related to effects on increased PA and decreased body weight and waist
controlling diabetes (25, 29, 32, 35–37, 39, 41, 44), suggest- circumference. Second to PA interventions were the in-
ing that interventions may be more difficult to adopt and terventions targeting diet-related outcomes, with 9 of 16
less well perceived by patients with overweight and obesity studies that targeted diet outcomes reporting improved
than by diabetic patients because diabetes is likely viewed diet. Our results suggest that mHealth intervention effective-
by patients as a more severe condition than obesity. For ness is outcome-, context-, and intervention-dependent. Find-
both types of studies, incentives were important to maintain ings may vary even when similar mHealth tools are used
participants’ adherence to interventions, which highlights (e.g., MPTM or an APP) in different intervention designs
the importance of investigating the self-sustainability of and settings.
such mHealth interventions in future studies. Despite the limitations of the 24 studies, such as short
According to behavior change theories, such as the intervention durations, >50% of the studies reported
Knowledge-Attitude-Practice Model (55), the Health Be- some desirable, positive effects on obesity and diabetes
lief Model (56), Social Cognitive Theory (57), and the control based on the primary outcomes (14, 16, 25, 27,
Stages of Change Model (57), mHealth interventions 28, 30, 31, 33–35, 39–41, 43). This is encouraging for
can serve multiple functions in the self-management of future related research and interventions. Theoretically, be-
obesity or diabetes (58). Our review suggests that the ma- havior changes should precede changes in anthropometry
jority of the mHealth interventions targeted improving and laboratory examination outcomes because obesity
nutrition-related behaviors, including diet and PA, and and diabetes are lifestyle-related diseases. However, the
this was particularly true for obesity management. More- studies included in this review reported that mobile inter-
over, existing mHealth applications for diabetes treatment ventions were less effective in changing behavior than they
and management have been expanded to nonnutrition were in changing anthropometry or laboratory results
(14, 16, 25, 34, 40, 41). This finding may be attributable to the contact and coaching in addition to self-monitoring may
limitations of the published studies and the challenges of eval- be needed to achieve the desired long-term effects (54).
uating health behaviors and changes in those behaviors. For ex- Third, most of the studies were carried out in developed
ample, evaluations of PA and eating behaviors in previous countries such as the United States; therefore, the findings
studies were typically based on self-reported questionnaires may not be generalizable to developing countries. There
that included only subjective questions. There is a need for are some limitations of our study. Because of the highly
more objective and precise measurements of behavior changes heterogeneous characteristics of the selected studies,
in future research. a quantitative meta-analysis was not possible. Despite
Although more than half of the 24 studies demonstrated these limitations, this study provides a broad overview of
some positive effects of mHealth interventions on obesity or mHealth applications for the treatment and management
diabetes control, our findings related to the effectiveness of of obesity and diabetes and sheds some light on future
mHealth should be interpreted with caution. This is also be- research.
cause of the limitations of the published related studies in In conclusion, a growing body of research has investi-
study design and implementation. First, sample sizes of gated some mHealth interventions for the management
most available studies were small. Only 5 of 24 studies had and treatment of obesity and diabetes across countries,
>60 subjects in the intervention and control groups (25– with most conducted in the United States. Although the
27, 33, 44). Second, the intervention period in more preliminary evidence collected from existing research is
than half of the studies was <3 mo. Such short-term inter- mixed, mHealth interventions are likely a promising
ventions showed more positive effects than long-term inter- means to promote behavior changes among patients
ventions (>6 mo). Some studies revealed that long-term with chronic diseases by providing them with health in-
effects of mHealth technologies were difficult to maintain formation and timely suggestions for improving health
in obesity and diabetes interventions for a number of rea- behaviors, providing them with feedback and social sup-
sons. For example, if an intervention is long enough to cover port, helping them collect health data, and showing
holiday seasons, changes in diet and PA patterns during the data to patients and their care providers. In the future,
holidays may affect the intervention (26, 35, 54), the burden more research with rigorous and innovative study de-
of long-time adherence to self-monitoring may also poten- signs and intervention strategies should be conducted. In
tially affect long-term effects (26, 35, 54), and personal addition, studies with large sample sizes and long-term