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Mobile Apps for RDNs in Patient Care, What’s the Evidence Say?

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MFLN Intro

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Today’s Presenters

Justine Karduck, MS, RDN, LDN, CDEkarduck@Illinois.edu

•Director the Didactic Program in Dietetics at the University of Illinois.

•Previously worked as a Clinical Dietitian & Diabetes Educator.

•PhD Student in Human Nutrition in the Department of Food Science and Human Nutrition at the University of Illinois.

•Research focus on the efficacy of smartphone apps in dietetics practice for diabetes management. 3

Today’s Presenters

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Kristen DiFilippo, MS, RDN, LDNkdifilip@illinois.edu

•PhD Student in the Division of Nutritional Sciences at the University of Illinois

•Previously worked as a wellness Dietitian

•Research interest in apps for nutrition education

Today’s Webinar:

Mobile Apps for RDNs in Patient Care: What does the evidence say?

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Webinar Learning Objectives:

After this presentation, participants should be able to: 1. Identify the most popular health-related mobile apps being used in dietetics practice.

2. Objectively evaluate apps for selection in nutrition interventions.

3. Explain current developments and future directions in apps research relevant for the dietetics practitioner.

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Mobile Health (mHealth) Defined

“a component of eHealth, a medical and public health practice supported by mobile devices, such as mobile phones, patient-

monitoring devices, personal digital assistants & other wireless devices.”

7(Ryu 2012)

US Smartphone Users

8(Smith 2015)

Nutrition Education Using Apps

“Nutrition education is defined as any combination of educational strategies, accompanied by

environmental supports, designed to facilitate voluntary adoption of food choices and other food- and nutrition-related behaviors conducive to health

and well-being.”

What is your go to app to support nutrition education?

(What apps are you recommending to clients?)

9(Contento, 2010)

My Go to App

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Apps & Nutrition EducationSystematic Review of Literature

Will nutrition apps result in – increased knowledge or– improved nutrition behavior?

•Specifics:– Adults– Without disease– Intervention included nutrition app

(DiFilippo, Huang, Andrade, & Chapman-Novakofski, 2015) 11

Apps & Nutrition EducationSystematic Review of Literature

• Very few published studies exploring behavior and knowledge outcomes – 3 high quality studies identified from 17,032

reviewed titles– All focused on weight loss

12(DiFilippo, Huang, Andrade, & Chapman-Novakofski, 2015)

Knowledge Measures

• Only one study reviewed measured knowledge

• No change in knowledge found

13(DiFilippo, Huang, Andrade, & Chapman-Novakofski, 2015)

Behavior Change Measures

• No app = less willing to continue diet1

• App = higher participant retention2

• App = increased use of intervention tools2

• App = more user control3• App = recorded twice as many days3

Take home: People are more likely to remain engaged with your

recommendations with the support of an app.1Brindal et al., 20132Carter et al., 20113Turner-McGrievy &Tate, 2011 14

Weight Change Measures

• But does this mean they lose weight?• Yes:

• Weight loss with app was similar or greater than the same diet education without app1,2,3

• Weight change at 6 months2

• With app: -4.6 kg (10 pounds)• With paper diary: -2.9 kg (6 pounds)• With website: -1.3 kg (3 pounds)

• Same results found in another review4

151Brindal et al., 20132Carter et al., 20113Turner-McGrievy &Tate, 2011Mateo et al., 2015

Most Common Behavior Change Techniques in Apps

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FeedbackGoal setting Self-monitoring

(Bardus et al., 2016)

Apps for Weight Management

• App quality assessment– Moderate overall– Higher in functionality & aesthetics– Lowest in information quality

17(Bardus et al., 2016)

mHealth & You Poll

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App Evaluation

• Hundreds of apps available• Aspects to consider when evaluating apps

– Quality of content– Technology – Usability

19(Bardus et al. 2016; DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

App Evaluation

• App Quality Evaluation Tool (AQEL)– Quantitative tool for Dietitians to use for

nutrition app evaluation– Allows for comparison of apps based on

various aspects of app content, design, and function

20 (DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

App Evaluation

• Categories:– Purpose– Knowledge Building– Skill Building– Behavior Change– Appropriateness for Target Age Group– Appropriateness for Target Audience– Educational Quality– Functionality– Personal App Use

21 (DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

App Evaluation

22 (DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

App Evaluation

23 (DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

Question Break

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Why use Health Apps inPatient Care Settings?

• Improved scalability & feasibility of health services– Decreased health care costs & burden

• Frequent engagement– Consistency– Convenience– Feedback w/ pts

***Superior effectiveness on health outcomes & related behaviors?

25(Sutton & Redman 2016)

Limitations to Using Apps in Patient Care Settings

• Evidence-based app quality poor– Rate of app dissemination outpaces research

• Lack of personalization, health care expert involvement, behavior theory, & scientific evaluation in apps

• Time consuming data entry & analysis of apps-continuing patient engagement

• Data safety & privacy• High level of health & technology literacy of patients

and providers needed– Training & Charting for HCPs?

26 (Brzan et at al. 2016)

Patient Perceptions of Health Apps

• 58% downloaded a health app • 42% downloaded more than 5 health apps¹

– Apps positively influence eating & exercise behaviors²• Health App Users = obese, younger, with higher income & ed levels,

Latino/Hispanic or African American• Nutrition & Fitness apps are most popular w/ daily use

– Trust in accuracy & data safety high – Perceived improved health

• Preferred App Features– provider communications, reminders, tracking, progress charts,

view medical records, personalized recs• Barriers to App Use

– cost, data entry burden, attrition

27(¹Krebs & Duncan 2015) (²Wang et al. 2016)

Dietitian Perceptions of Health Apps

(Sauceda, Frederico, Pellechia, Starin 2016)

• Surveyed RDs at FNCE 2015 (n = 72)– 83% recommend apps – PA, nutrition, food journals

• Favorite Apps = My Fitness Pal™ & Fitbit™– Few collect & analyze data

from pt. apps

(Karduck & Chapman-Novakofski 2016)

• Surveyed US clinicians (n = 719)– 93% use smartphone apps– 62% use apps to assess pt’s

diet & PA levels• Most Recommended Apps =

My Fitness Pal™, Calorie King™, Fitbit™ & Weight Watchers™

• Desired Apps Features = diet, PA, & wt tracking, progress charts, barcode scanning, SMBG, & recipe sharing

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mHealth & You Poll

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Review of Apps for DM Management

30(Brzan et al. 2016)

• Systematic review of apps in popular app stores– Which free diabetes apps provide basic features for successful self-

management?– What are the characteristics of these apps?

• Initial search (n = 956), only 9 met all inclusion criteria– Diabetes: M, Diabetes Tracker, Glucose Buddy: Diabetes Log, Diabetes

Journal, Diabetes Connect, Diabetes App Lite, Diabetes in check, Carburetor: Diabetes Logbook Manager, dbees.com

• Apps should support (Chomutare et al. 2011):– Insulin & meds management– Diet, PA, Wt & BP Ed– Social media & alerts– Communication with health care team

• Most only provide some of the basic features

– Designed for type of DM

Challenges & Opportunities of Apps for DM Management

Features:• Self-management metrics

with progress charts in one app:

• Education– Diet tips, GI, Recipes,

Research Findings

• Personalized feedback • Enhanced reminder

system• Daily goal setting

Barriers:• Information gap• Technical Illiteracy• Already satisfied with

current self management tools

• Not yet recommended by their health care team

• Accountability• Required time & effort

31(Peng, Yuan, & Holtz 2016)

App Outcomes & Efficacy in DM Self-Management

• Pubmed searched through January 2016 (n = 485)

• Limited data available on effectiveness of apps for DM self-management– Some clinical improvements, but only 3 studies with statistically

significant improvements in HbA1c• Preliminary data encouraging

– Few apps support the AADE7 self-management behaviors

• Self-monitoring with provision of feedback common • DM education lacking in apps• Apps as FDA medically regulated devices

32(Hood et al. 2016)

33(Ristau, Yang, & White, 2013)

Conclusions

• mHealth & health apps are in their infancy• Apps show promise for:

– Supporting nutrition education– Promoting behavior change– Improving health outcomes

• Careful evaluation and selection of apps is warranted before use

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References1. Bardus, M., van Beurden, S., Smith, J., & Abraham, C. (2016). A review and content analysis of engagement, functionality, aesthetics, information quality, and change

techniques in the most popular commercial apps for weight management. Int J Behav Nutr Phys Act, 13(1). http://dx.doi.org/10.1186/s12966-016-0359-9.2. Boudreaux, E., Waring, M., Hayes, R., Sadasivam, R., Mullen, S., & Pagoto, S. (2014). Evaluating and selecting mobile health apps: strategies for healthcare providers and

healthcare organizations. Translational Behavioral Medicine, 4(4), 363-371. http://dx.doi.org/10.1007/s13142-014-0293-9.3. Brindal, E., Hendrie, G., Freyne, J., Coombe, M., Berkovsky, S., & Noakes, M. (2013). Design and pilot results of a mobile phone weight-loss application for women starting

a meal replacement programme. Journal of Telemedicine and Telecare, 19, 166–174.4. Brzan, P., Rotman, E., Pajnkihar, M., & Klanjsek, P. (2016). Mobile Applications for Control and Self Management of Diabetes: A Systematic Review. J Med Syst, 40(9).

http://dx.doi.org/10.1007/s10916-016-0564-8.5. Carter, M. C., Burley, V. J., Nykjaer, C., & Cade, J. E. (2013). Adherence to a Smartphone Application for Weight Loss Compared to Website and Paper Diary: Pilot

Randomized Controlled Trial. Journal of Medical Internet Research, 15(4), e32. http://doi.org/10.2196/jmir.22836. Contento, I. R. (2010). Nutrition Education: Linking Research, Theory, and Practice. 2010.7. DiFilippo, K. N., Andrade, J. E., Huang, W.-H., & Chapman-Novakofski, K. M. (2015). Development of a tool to evaluate the quality of nutrition apps. Journal of the Academy

of Nutrition and Dietetics, 115(9), A15.8. DiFilippo, K. N., Andrade, J. E., Huang, W.-H., & Chapman-Novakofski, K. M. (2016). Reliability testing of a mobile app quality assessment tool. Journal of Nutrition

Education and Behavior, 48(7S), P87.9. DiFilippo, K. N., Huang, W.-H., Andrade, J. E., & Chapman-Novakofski, K. M. (2015). The use of mobile apps to improve nutrition outcomes: A systematic literature review.

Journal of Telemedicine and Telecare, 21(5), 243–253. http://doi.org/10.1177/1357633X1557220310. Flores Mateo, G., Granado-Font, E., Ferré-Grau, C., & Montaña-Carreras, X. (2015). Mobile Phone Apps to Promote Weight Loss and Increase Physical Activity: A

Systematic Review and Meta-Analysis. J Med Internet Res, 17(11), e253. http://dx.doi.org/10.2196/jmir.483611. Hood, M., Wilson, R., Corsica, J., Bradley, L., Chirinos, D., & Vivo, A. (2016). What do we know about mobile applications for diabetes self-management? A review of

reviews. J Behav Med. http://dx.doi.org/10.1007/s10865-016-9765-3.12. Jospe, M., Fairbairn, K., Green, P., & Perry, T. (2015). Diet App Use by Sports Dietitians: A Survey in Five Countries. JMIR Mhealth Uhealth, 3(1), e7.

http://dx.doi.org/10.2196/mhealth.334513. Karduck, J., & Chapman-Novakofski K. (2016) Results of the Clinician Apps Survey, How Do RDNs Use Health-related Smartphone Apps in Patient Care Settings? Journal

of the Academy of Nutrition and Dietetics , Volume 116, Issue 9 , A93. http://dx.doi.org/10.1016/j.jand.2016.06.338.14. Krebs, P. & Duncan, D. (2015). Health App Use Among US Mobile Phone Owners: A National Survey. JMIR Mhealth Uhealth, 3(4), e101.

http://dx.doi.org/10.2196/mhealth.4924.15. Lieffers, J., Vance, V., & Hanning, R. (2014). Use of Mobile Device Applications In Canadian Dietetic Practice. Canadian Journal Of Dietetic Practice And Research, 75(1),

41-47. http://dx.doi.org/10.3148/75.1.2014.41.16. Peng, W., Yuan, S., & Holtz, B. (2016). Exploring the Challenges and Opportunities of Health Mobile Apps for Individuals with Type 2 Diabetes Living in Rural Communities.

Telemedicine And E-Health. http://dx.doi.org/10.1089/tmj.2015.0180.17. Office of Health Policy, & Office of the Assistant Secretary for Planning and Evaluation (ASPE). (2016). Report to Congress: E-health and Telemedicine. Retrieved from

https://aspe.hhs.gov/sites/default/files/pdf/206751/TelemedicineE-HealthReport.pdf18. Redman, L. & Sutton, E. (2016). Smartphone applications to aid weight loss and management: current perspectives. Diabetes, Metabolic Syndrome And Obesity: Targets

And Therapy, Volume 9, 213-216. http://dx.doi.org/10.2147/dmso.s89839.19. Ristau, R., Yang, J., & White, J. (2013). Evaluation and Evolution of Diabetes Mobile Applications: Key Factors for Health Care Professionals Seeking to Guide Patients.

Diabetes Spectrum, 26(4), 211-215. http://dx.doi.org/10.2337/diaspect.26.4.21120. Ryu, S. (2012). Book Review: mHealth: New Horizons for Health through Mobile Technologies: Based on the Findings of the Second Global Survey on eHealth (Global

Observatory for eHealth Series, Volume 3). Healthc Inform Res, 18(3), 231. http://dx.doi.org/10.4258/hir.2012.18.3.231.21. Sauceda, A., Frederico, C., Pellechia, K., & Starin, D. (2016). Results of the Academy of Nutrition and Dietetics' Consumer Health Informatics Work Group ’s 2015 Member

App Technology Survey.Journal Of The Academy Of Nutrition And Dietetics, 116(8), 1336-1338. http://dx.doi.org/10.1016/j.jand.2016.04.00922. Turner-McGrievy, G., & Tate, D. (2011). Tweets, Apps, and Pods: Results of the 6-month Mobile Pounds Off Digitally (Mobile POD) Randomized Weight-Loss Intervention

Among Adults. Journal of Medical Internet Research, 13(4), e120. http://doi.org/10.2196/jmir.184123. Wang, Q., Egelandsdal, B., Amdam, G., Almli, V., & Oostindjer, M. (2016). Diet and Physical Activity Apps: Perceived Effectiveness by App Users. JMIR Mhealth Uhealth,

4(2), e33. http://dx.doi.org/10.2196/mhealth.5114.24. Wharton, C., Johnston, C., Cunningham, B., & Sterner, D. (2014). Dietary Self-Monitoring, But Not Dietary Quality, Improves With Use of Smartphone App Technology in an

8-Week Weight Loss Trial. Journal Of Nutrition Education And Behavior, 46(5), 440-444. http://dx.doi.org/10.1016/j.jneb.2014.04.291.

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Nutrition and Wellness Upcoming Event

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