Multicomponent mHealth Intervention for Large, Sustained Change in Multiple Diet and Activity Risk Behaviors: The Make Better Choices 2 Randomized Controlled Trial

Abstract

BackgroundPrevalent co-occurring poor diet and physical inactivity convey chronic disease risk to the population. Large magnitude behavior change can improve behaviors to recommended levels, but multiple behavior change interventions produce small, poorly maintained effects.ObjectiveThe Make Better Choices 2 trial tested whether a multicomponent intervention integrating mHealth, modest incentives, and remote coaching could sustainably improve diet and activity.MethodsBetween 2012 and 2014, the 9-month randomized controlled trial enrolled 212 Chicago area adults with low fruit and vegetable and high saturated fat intakes, low moderate to vigorous physical activity (MVPA) and high sedentary leisure screen time. Participants were recruited by advertisements to an open-access website, screened, and randomly assigned to either of two active interventions targeting MVPA simultaneously with, or sequentially after other diet and activity targets (N=84 per intervention) or a stress and sleep contact control intervention (N=44). They used a smartphone app and accelerometer to track targeted behaviors and received personalized remote coaching from trained paraprofessionals. Perfect behavioral adherence was rewarded with an incentive of US $5 per week for 12 weeks. Diet and activity behaviors were measured at baseline, 3, 6, and 9 months; primary outcome was 9-month diet and activity composite improvement.ResultsBoth simultaneous and sequential interventions produced large, sustained improvements exceeding control (P<.001), and brought all diet and activity behaviors to guideline levels. At 9 months, the interventions increased fruits and vegetables by 6.5 servings per day (95% CI 6.1-6.8), increased MVPA by 24.7 minutes per day (95% CI 20.0-29.5), decreased sedentary leisure by 170.5 minutes per day (95% CI –183.5 to –157.5), and decreased saturated fat intake by 3.6% (95% CI –4.1 to –3.1). Retention through 9-month follow-up was 82.1%. Self-monitoring decreased from 96.3% of days at baseline to 72.3% at 3 months, 63.5% at 6 months, and 54.6% at 9 months (P<.001). Neither attrition nor decline in self-monitoring differed across intervention groups.ConclusionsMulticomponent mHealth diet and activity intervention involving connected coaching and modest initial performance incentives holds potential to reduce chronic disease risk.Trial RegistrationClinicalTrials.gov NCT01249989; https://clinicaltrials.gov/ct2/show/NCT01249989 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT01249989).

Impact of a diet and activity health promotion intervention on regional patterns of DNA methylation

“…In the parent study, both the sequential and simultaneous groups showed comparably large, sustained diet and activity improvements, as described previously [40]. Therefore, we compared the control group to pooled samples from the sequential and simultaneous groups.…”

“…The primary study outcome was sustained improvement from baseline through 9-month follow-up, and the secondary outcomes were improvement in individual diet and activity behaviors. In the original study, sequential and simultaneous interventions produced similar and sustained diet and activity improvement compared to control (p < 0.001), and the effects were comparable between intervention groups [40].…”

“…MBC2 was a 9-month randomized controlled trial (RCT) conducted between 2012 and 2014 among adults (n = 68) aged 18-65 with non-optimal levels of all of 4 lifestyle behaviors: fruits/vegetables, saturated fats, sedentary leisure screen time, and moderate-vigorous physical activity (MVPA) [40,56]. Specifically, this included the following thresholds for diet: < 5 servings of fruits and vegetables per day and ≥ 8% daily calories from saturated fat; physical activity: < 150 min per week MVPA; and sedentary behavior: > 120 min per week of leisure screen time from sources such as television or video games [40]. The MBC2 participants were randomly assigned to one of three 12-week treatments using a smartphone application and remote coaching to (1) increase MVPA while improving fruits/vegetables and sedentary leisure (simultaneous), (2) improve fruits/ vegetables and sedentary leisure first, followed by MVPA (sequential), or (3) improve stress and sleep (control).…”

The Impact of Timing of Exercise Initiation on Weight Loss: An 18‐Month Randomized Clinical Trial

“…For example, Vandelanotte et al reported that sequential delivery was slightly more effective in producing sustained increases in PA and decreases in fat intake after 2 years. The Make Better Choices 2 Trial , a multicomponent mobile health intervention targeting increases in fruit and vegetable intake and MVPA, produced a composite improvement in diet and PA when interventions were delivered sequentially. However, weight loss was not an outcome in either study.…”

“…An alternative approach, which has not been widely considered, is to deliver diet and exercise interventions sequentially. Delaying the start of an exercise intervention after diet‐induced weight loss could result in enhanced exercise adherence and improved weight loss long term because (1) perceived enjoyment of exercise may be higher at a lower body weight , (2) risk of exercise‐related injuries may be reduced after weight loss , and (3) focusing on one behavioral change at a time may lead to greater long‐term adherence to both diet and exercise behaviors . However, there has been limited evidence regarding the effect of simultaneous versus sequential interventions to improve diet and PA behaviors on weight loss.…”