Evidence-Based Strategies in Weight-Loss Mobile Apps

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Background

Physicians have limited time for weight-loss counseling, and there is a lack of resources to which they can refer patients for assistance with weight loss. Weight-loss mobile applications (apps) have the potential to be a helpful tool, but the extent to which they include the behavioral strategies included in evidence-based interventions is unknown.

Purpose

The primary aims of the study were to determine the degree to which commercial weight-loss mobile apps include the behavioral strategies included in evidence-based weight-loss interventions, and to identify features that enhance behavioral strategies via technology.

Methods

Thirty weight-loss mobile apps, available on iPhone and/or Android platforms, were coded for whether they included any of 20 behavioral strategies derived from an evidence-based weight-loss program (i.e., Diabetes Prevention Program). Data on available apps were collected in January 2012; data were analyzed in June 2012.

Results

The apps included on average 18.83% (SD=13.24; range=0%–65%) of the 20 strategies. Seven of the strategies were not found in any app. The most common technology-enhanced features were barcode scanners (56.7%) and a social network (46.7%).

Conclusions

Weight-loss mobile apps typically included only a minority of the behavioral strategies found in evidence-based weight-loss interventions. Behavioral strategies that help improve motivation, reduce stress, and assist with problem solving were missing across apps. Inclusion of additional strategies could make apps more helpful to users who have motivational challenges.

Introduction

Primary care physicians (PCPs) have limited time for weight-loss counseling and would benefit from tools that help patients lose weight. Mobile technology has the potential to develop and deliver such tools, especially given the high prevalence of mobile phone use in the U.S. (285 million subscribers).1 Weight-loss mobile applications (apps) have been proliferating in the market in recent years.2 Given the sheer number of apps and the lack of standards, PCPs have little guidance as to which apps, if any, to recommend to patients. Thus, mobile apps that have features that are included in evidence-based behavioral weight-loss interventions need to be identified.

Behavioral weight-loss strategies are reflected in evidence-based lifestyle interventions, most notably the Diabetes Prevention Program (DPP), which have been shown to be effective for weight-loss and reduction of risk for cardiovascular disease and diabetes.3, 4 Evidence-based lifestyle interventions are intensive, involving multiple in-person visits, generally for a period of 6 months to 1 year or more. If effective behavioral strategies could be delivered via mobile technology, a more cost-effective model of care may be possible. In addition to reducing costs, mobile apps may have the capacity to leverage technology in order to reduce some of the burden of behavioral strategies (e.g., nutrition information could be retrieved from packaged foods by barcode scanners) and to enhance behavioral strategies (e.g., by providing in-the-moment context-sensitive intervention).

The extent to which current weight-loss mobile apps are based on the behavioral science of weight loss is unclear. The only existing review of weight-loss mobile apps was conducted in 2009 and found that the range of behavioral strategies addressed by apps was quite narrow.5 Only 43% of 204 mobile apps reviewed included dietary self-monitoring, a hallmark strategy of evidence-based behavioral weight-loss interventions. A limitation of that review is that the range of strategies evaluated was based on information that was found to be consistent among four government-sponsored websites, not on an evidence-based weight-loss intervention. Also, it included dietary strategies that are not essential to weight loss (e.g., fruit and vegetable intake, water intake) and omitted key strategies common to evidence-based weight-loss protocols (e.g., problem solving and stress management).6, 7, 8

The number of apps on the market has continued to proliferate since 2009 as the mobile health (mHealth) movement has gained increasing interest in the healthcare arena.9 The aims of the present review were to extend past work by (1) identifying the commercial weight-loss mobile phone apps that include the highest proportion of behavioral strategies represented in evidence-based lifestyle interventions; (2) identify which behavioral strategies have yet to be adapted into a mobile phone app format; (3) identify technology-enhanced features of apps that reduce user burden (e.g., barcode scanners) or provide in-the-moment intervention (e.g., automatic reminders to record food intake); and (4) compare free to paid apps in terms of evidence-based strategies and technology-enhanced features. Findings will inform healthcare providers about the extent to which weight-loss mobile apps approximate evidence-based practices, and mobile technology developers about strategies that have yet to be adapted into the mobile format.

Section snippets

Inclusion Criteria

The list of all apps available for download, for both iPhone and Android systems, was accessed in January 2012. Apps in the top 100 paid and top 100 free “health and fitness” categories of iTunes and the Android Market were searched. Inclusion in the top 100 is determined by the number of times the app has been downloaded. iTunes lists a total of 400 free and paid apps in “health and fitness,” and the Android Market lists 480.

The description for each app provided by each website marketplace was

Proportion of Apps That Included Each Behavioral Strategy

The vast majority of apps included goal setting for weight loss (93.3%) and diet (90%; Table 2). Goal setting was typically accomplished by having users select a target goal weight and then providing a calorie-intake goal according to the goal weight. Only 20% of mobile apps gave users a specific physical activity goal in terms of days or minutes per week. The next most common strategy included in the apps was calorie balance; 86.7% of the apps allowed users to view their net calories (i.e.,

Discussion

The most common behavioral strategies in 30 popular weight-loss mobile apps were weight-loss goal setting, dietary goal setting, and calorie balance. The majority of apps included these functions (along with self-monitoring, an inclusion criterion of this review), but few provided other behavioral strategies. Most striking was that seven behavioral strategies were completely missing from the weight-loss mobile apps coded (i.e., stress reduction, relapse prevention, social cues, negative

Acknowledgments

No financial disclosures were reported by the authors of this paper.

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