SAN ANTONIO, Texas—So much of our information from—and interaction with—the world is now mediated by computers, cell phones and tablets that health experts have been practically running themselves ragged trying to find ways to use these conduits to help people make healthier choices.
Great success stories have come out of parts of the developing world, where cell phones have been used to improve maternal and infant care and help people adhere to medication guidelines. But in the U.S., attempts using mobile and online technology to tackle basic health problems, such as obesity, have largely been underwhelming, especially among the tech-savvy younger set.
Researchers at the Obesity Society’s Annual Scientific Meeting in San Antonio, Texas., presented some of their own work on these efforts on September 23 and discussed why so many of these programs have so far failed to take hold.
With teenagers, and, increasingly, younger children, in near-constant text message contact with their friends, many researchers have figured this mode of communication might be an effective way to reach those who are overweight and obese in age groups with health-related texts. And as Susan Woolford of the University of Michigan pointed out, as she showed a video of a dance flash mob, we know that cell phone messages “can get them to come out and dance, but can you get them to change their weight-related behavior?”
She and her colleagues decided to find out. They enrolled 20 obese adolescents and sent them health-related text messages over three months. Although the kids generally accepted the program, it was unclear just how much the messages (such as reminders to drink enough water or suggestions for healthy meals) were put into practice. One of the major complaints in follow-up interviews was that the messages were flat. The kids said they “sounded like an English person from the 1950s,” Woolford noted.
Enter Zamzee. At the U.C.L.A. School of Medicine, Steve Cole and his team have moved in an entirely different direction. They are working on an interactive health platform aimed to increase physical activity in adolescents: Kids begin by carrying around a Zamzee, a small device that contains accelerometers to detect movement and a USB plug to upload the data into a computer. But that is only the key to unlock the whole Zamzee program. When the Zamzee is plugged in, it launches an online portal that kids can use to view their track their progress.
The program was tested in a six-month randomized controlled trial for 448 subjects, ages 11 to 14. All of them had the Zamzee stick, although the control half only got general, upbeat feedback about their activity levels from the online service. The experimental half were allowed into the full Zamzee interactive experience, which is designed to look like a social-gaming platform, with different modules that show individual activity levels, goals, rewards, and opportunities to interact with other users.
After the trial period, kids in the control group were getting about 74 minutes of moderate to vigorous physical activity a week. Those with full use of the program, however, were getting about 118 minutes a week, which is about a 59 percent increase, an effect that held steady throughout the six months. More impressively, kids in the experimental group who were overweight or obese at the start of the study were getting just as much physical activity as the normal weight kids. And at the end of the six months, the increased activity had positive effects on lipid and metabolic biomarkers in the experimental group.
Why was this program so much more successful than so many others for this age group? “We worked very hard to eradicate education from this,” Cole said of the program—a radical statement in itself. He also added that they tried to banish references to health and even exercise because, as they found, those topics are not desirable to teens—especially those who are already overweight or obese and have negative associations with them. Cole’s take is to use “positive psychology”—setting obtainable yet healthy individual goals—in an effort to eventually translate these behavior changes from a program-mediated shift to one of intrinsic motivation—all without telling the kids to go do an extra set of jumping jacks.
Adults, on the other hand, seem more willing to accept unmasked health information delivered to them via a digital platform. Michael Lin of Johns Hopkins University is currently working on a randomized controlled trial to test a tailored text-messaging system to help residents in an underserved population in Baltimore achieve healthier weights.
Half of the 120 participants received brief counseling sessions and handouts on diet and nutrition, along with a pedometer. The other half received the same materials but were also enrolled in the tailored text-messaging program, during which subjects received three to six texts a day. The messages were timed to the individuals’ goals, challenges and schedules (such as a reminder sent right before a person’s usual lunchtime to avoid their favorite unhealthful food and instead choose more vegetables). One message a day contained a question (such as one about a participant’s weight or exercise that day). The system had preprepared messages that could use information from the subject’s text to formulate a personalized response. Although participants were told at the beginning that these responses were from a computer, many reported later in the study that they felt like they were communicating with someone about their progress, which helped with motivation.
Lin’s final research results are not yet in, but the participation and adherence so far seem promising. Unlike the group of adolescents in Woolford’s study, these folks had a mean age in their 50s, and many of them had never used text messaging before enrolling. But after a five-minute tutorial, they were off and running. Or if not running, at least getting more physical activity than they were before, thanks to on-the-go technology.