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

Abstract

Background: Prevalent 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.

Objective: The Make Better Choices 2 trial tested whether a multicomponent intervention integrating mHealth, modest incentives, and remote coaching could sustainably improve diet and activity.

Methods: Between 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.

Results: Both 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.

Conclusions: Multicomponent mHealth diet and activity intervention involving connected coaching and modest initial performance incentives holds potential to reduce chronic disease risk.

Trial registration: ClinicalTrials.gov NCT01249989; https://clinicaltrials.gov/ct2/show/NCT01249989 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT01249989).

Keywords: behavioral medicine; health behavior; mobile health; randomized controlled trial; risk factors.

Figure 1

Make Better Choices 2 app user interfaces for (a) receiving behavioral feedback in simultaneous and sequential treatments; (b) reporting sedentary leisure screen time in simultaneous and sequential treatments; (c) receiving feedback in contact control treatment.

Figure 2

Make Better Choices 2 Trial study timeline.

Figure 3

CONSORT Flow Diagram of the Make Better Choices 2 Trial: 212 adults were eligible for inclusion, randomly assigned to an intervention condition, and included in analyses.

Figure 4

A: Mean Composite Diet-Activity Improvement Scores over time for combined simultaneous and sequential treatment groups vs control. Combined treatment groups produced greater healthy change at each postbaseline assessment point. B: Mean Composite Diet-Activity Improvement Scores over time for each of the three conditions. Error bars represent 1 SE. Gray background indicates the treatment initiation phase (weeks 0-12); white background, follow-up maintenance phase.

Figure 5

Effects of the 3 intervention conditions on changes over time in each behavior expressed in natural units. Gray background indicates treatment initiation phase (weeks 0-12); white background, follow-up maintenance phase.