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Background Many patients exhibit multiple chronic disease risk behaviors. Research provides little information about advice that can maximize simultaneous health behavior changes. Methods To test which combination of diet and activity advice maximizes healthy change, we randomized 204 adults with elevated saturated fat and low fruit/vegetable intakes, high sedentary leisure time and low physical activity to one of four treatments: increase fruit/vegetable and physical activity; decrease fat and sedentary leisure; decrease fat and increase physical activity; increase fruit/vegetable and decrease sedentary leisure. Treatments provided three weeks of remote coaching supported by mobile decision support technology and financial incentives. During treatment, incentives were contingent on using the mobile device to self-monitor and attain behavioral targets; during follow-up they were contingent only on recording. The outcome was standardized, composite improvement on the four diet and activity behaviors at end of treatment and five month follow-up. Results Of those randomized, 200 (98%) completed follow-up. The increase fruit/vegetable and decrease sedentary leisure treatment improved more than the other 3 treatments (p<.001). Specifically, fruit/vegetables increased from 1.2 servings/day to 5.5; sedentary leisure decreased from 219.2 minutes/day to 89.3; saturated fat decreased from 12.0% of calories consumed to 9.5%. Differences between treatment groups were maintained through follow-up. Traditional dieting (decrease fat and increase physical activity) improved less than the other 3 treatments (p<.001). Conclusions Remote coaching supported by mobile technology and financial incentives holds promise to improve diet and activity. Targeting fruits/vegetables and sedentary leisure together maximizes overall adoption and maintenance of multiple healthy behavior changes.

Obesity is a public health crisis that has reached epidemic proportions. Although intensive behavioral interventions can produce clinically significant weight loss, their cost to implement, coupled with resource limitations, pose significant barriers to scalability. To overcome these challenges, researchers have made attempts to shift intervention content to the Internet and other mobile devices. This article systematically reviews the recent literature examining technology-supported interventions for weight loss and maintenance among overweight and obese adults. Thirteen studies were identified that satisfied our inclusion criteria (12 weight loss trials, 1 weight maintenance trial). Our findings suggest that technology interventions may be efficacious at producing weight loss. However, several studies are limited by methodologic shortcomings. There are insufficient data to evaluate their efficacy for weight maintenance. Further research is needed that employs state-of-the-art methodology, with careful attention being paid to adherence and fidelity to intervention protocols.

Aims To update our prior meta-analysis that showed past major depression (MD+) to be unrelated to smoking cessation outcome [Hitsman et al. J Consult Clin Psychol 2003; 71:657–63]. Methods Eligible trials included 14 from our original review and 28 identified through an updated systematic review (2000–2009). We coded for assessment of past MD, exclusion for recent MD episode (MDE; ≤6 months versus no exclusion), duration/modality of cognitive behavioral treatment (CBT; face-to-face versus self-help), and other factors. To minimize influence of experimental treatments that may selectively benefit MD+ smokers, we analyzed placebo/lowest intensity control arms only. Study-specific odds ratios (ORs) for the effect of past MD on short-term (≤3 months) and long-term (≥6 months) abstinence were estimated and combined using random effects. Two-way interaction models of past MD with study methodology and treatment factors were used to evaluate hypothesized moderators of the past MD-abstinence association. Results MD+ smokers had 17% lower odds of short-term abstinence (n=35, OR=0.83, 95% CI=0.72–0.95, p=0.009) and 19% lower odds of long-term abstinence (n=38, OR=0.81, 95% CI=0.67–0.97, p=0.023) than MD− smokers after excluding the sole study of varenicline because of its antidepressant properties. The association between past MD and abstinence was affected by methodological (recent MDE exclusion, type of MD assessment) and treatment (CBT modality) factors. Conclusions Past major depression has a modest adverse effect on abstinence during and after smoking cessation treatment. An increased focus on the identification of effective treatments or treatment adaptations that eliminate this disparity in smoking cessation for MD+ smokers is needed.

BackgroundObesity remains a major public health challenge, demanding cost-effective and scalable weight management programs. Delivering key treatment components via mobile technology offers a potential way to reduce expensive in-person contact, thereby lowering the cost and burden of intensive weight loss programs. The ENGAGED study is a theory-guided, randomized controlled trial designed to examine the feasibility and efficacy of an abbreviated smartphone-supported weight loss program.Methods/designNinety-six obese adults (BMI 30–39.9 kg/m2) will be randomized to one of three treatment conditions: (1) standard behavioral weight loss (STND), (2) technology-supported behavioral weight loss (TECH); or (3) self-guided behavioral weight loss (SELF). All groups will aim to achieve a 7% weight loss goal by reducing calorie and fat intake and progressively increasing moderate intensity physical activity to 175 minutes/week. STND and TECH will attend 8 group sessions and receive regular coaching calls during the first 6 months of the intervention; SELF will receive the Group Lifestyle Balance Program DVD’s and will not receive coaching calls. During months 1–6, TECH will use a specially designed smartphone application to monitor dietary intake, body weight, and objectively measured physical activity (obtained from a Blue-tooth enabled accelerometer). STND and SELF will self-monitor on paper diaries. Linear mixed modeling will be used to examine group differences on weight loss at months 3, 6, and 12. Self-monitoring adherence and diet and activity goal attainment will be tested as mediators.DiscussionENGAGED is an innovative weight loss intervention that integrates theory with emerging mobile technologies. We hypothesize that TECH, as compared to STND and SELF, will result in greater weight loss by virtue of improved behavioral adherence and goal achievement.Trial registrationNCT01051713

BackgroundSuboptimal diet and physical inactivity are prevalent, co-occurring chronic disease risk factors, yet little is known about how to maximize multiple risk behavior change. Make Better Choices, a randomized controlled trial, tests competing hypotheses about the optimal way to promote healthy change in four bundled risk behaviors: high saturated fat intake, low fruit and vegetable intake, low physical activity, and high sedentary leisure screen time. The study aim is to determine which combination of two behavior change goals - one dietary, one activity - yields greatest overall healthy lifestyle change.Methods/DesignAdults (n = 200) with poor quality diet and sedentary lifestyle will be recruited and screened for study eligibility. Participants will be trained to record their diet and activities onto a personal data assistant, and use it to complete two weeks of baseline. Those who continue to show all four risk behaviors after baseline recording will be randomized to one of four behavior change prescriptions: 1) increase fruits and vegetables and increase physical activity, 2) decrease saturated fat and increase physical activity, 3) increase fruits and vegetable and decrease saturated fat, or 4) decrease saturated fat and decrease sedentary activity. They will use decision support feedback on the personal digital assistant and receive counseling from a coach to alter their diet and activity during a 3-week prescription period when payment is contingent upon meeting behavior change goals. They will continue recording on an intermittent schedule during a 4.5-month maintenance period when payment is not contingent upon goal attainment. The primary outcome is overall healthy lifestyle change, aggregated across all four risk behaviors.DiscussionThe Make Better Choices trial tests a disseminable lifestyle intervention supported by handheld technology. Findings will fill a gap in knowledge about optimal goal prescription to facilitate simultaneous diet and activity change. Results will shed light on which goal prescription maximizes healthful lifestyle change.Trial RegistrationClinical Trials Gov. Identifier NCT00113672

Abstract Background and Objectives We compared the effectiveness of standard Fit & Strong! (F&S!; targets physical activity [PA]) to Fit & Strong! Plus (F&S! Plus; targets PA and dietary weight loss) on weight, diet quality, and PA outcomes. Research Design and Methods We randomly assigned 413 overweight older adults with OA to the F&S! or F&S! Plus programs and assessed outcomes at 2 and 6 months. Results The F&S! Plus group lost −2.0 ± 0.2 kg (mean ± SE, 2% of starting weight) at 2 months that was maintained at 6 months. Two- and 6-month BMI and waist circumference improved significantly in the F&S! Plus group (p &lt; .001). Diet quality at 2 months showed greater improvement in the F&S! Plus group: 4.6 ± 0.7 versus 2.0 ± 0.7, p = .006, with no significant difference between groups at 6 months. The F&S! Plus group differentially improved on PA engagement at 2 months and at 2 and 6 months in joint pain (6-month mean ± SE: −1.5 ± 0.3 vs −0.6 ± 0.3, p = .02), function (−4.7 ± 0.9 vs −1.5 ± 0.9, p = .01), and 6-min walk test (29.5 ± 5.1 m vs 14.1 ± 5.2 m, p = .04). Discussion and Implications Adding a dietary weight loss component to F&S! achieved weight and waist circumference benefits that were maintained at 6 months. Importantly, the weight loss was accompanied by clinically meaningful improvements in OA symptoms and mobility. Future work should investigate minimum thresholds for weight reduction that improve long-term function in this population.

Objective The Make Better Choices 1 trial demonstrated that participants with unhealthy diet and activity behaviors who were randomized to increase fruits/vegetables and decrease sedentary leisure achieved greater diet and activity improvement than those randomized to change other pairs of eating and activity behaviors. Participants randomized to decrease saturated fat and increase physical activity achieved the least diet-activity improvement. This study examined which psychological mechanisms mediated the effects of the study treatments on healthy behavior change. Methods Participants (n=204) were randomized to one of four treatments: increase fruits/vegetables and physical activity; decrease saturated fat and sedentary leisure; decrease saturated fat and increase physical activity; increase fruits/vegetables and decrease sedentary leisure. Treatments provided three weeks of remote coaching supported by mobile decision support technology and financial incentives. Mediational analyses were performed to examine whether changes in positive and negative affect, and self-efficacy, stages of readiness to change, liking, craving and attentional bias for fruit/vegetable intake, saturated fat intake, physical activity and sedentary leisure, explained the impact of the treatments on diet-activity improvement. Results Greater diet-activity improvement in those randomized to increase fruits/vegetables and decrease sedentary leisure was mediated by increased self-efficacy (indirect effect estimate=0.04; 95% bias corrected CI: 0.003, 0.11). All treatments improved craving, stage of change and positive affect. Conclusion Accomplishing healthy lifestyle changes for 3 weeks improves positive affect, increases cravings for healthy foods and activities and enhances readiness to make healthy behavior changes. Maximal diet and activity improvement occurs when interventions enhance self-efficacy to make multiple healthy behavior changes.