WHAT IS MHEALTH?
MHealth is the concept of mobile health care. It’s a collection of consumer technologies that enable consumers to capture their own health data, often without our assistance or ability to interpret it. And presumably, this data can be used to enhance the health of the user.
WHAT CAN OF MHEALTH TECH IS THERE?
Often, when we think about mHealth, we’re thinking about wearables, and there are many different types. Some include activity trackers, some with a very specific purpose, and some with multipurpose activities. Trackers can be used to detect steps and can be used to track sleep. They can also be used for heart rate monitoring. They're also separate types of trackers that are used with GPS that can be used for activity. There are personal cardiac rhythm monitors, and there are even smart fabrics such as smart underwear.
Activity trackers are accelerometers, maybe as watch-based or can be worn on the wrist. Some are clipped onto your clothing. Others are smartphone-based. And some can also be worn as chest straps.
Most of these will also have smartphone companion applications. If you don't want to have an extra device, some of these also work based on your smartphone. Google has the Google Fit app that has a tracker included that uses the smartphone’s accelerometer. Apple also has a step tracker in their device that operates through Apple health.
When it comes to GPS trackers, these have a lot of the same features as an activity tracker, including the ability to track heart rate as well as to detect motion. But they also will include GPS capabilities, which allow you to leave your phone at home. Many of you have probably used some of these different trackers. So one of the biggest questions, though, when it comes to looking at these devices and potentially even recommending them to our patients is we want to know:
DO MHEALTH TRACKERS ACTUALLY WORK?
It’s good to break that down into two different types of assessments. One is accuracy, and the other is efficacy. To look into this a little bit further, let’s take a look at some systematic reviews of several different types of activity trackers.
A FAILED STUDY
The first one we're going to talk about is a review from 2015 that looked at 22 different studies that assessed both the Fitbit and Jawbone devices that were attached to the wrist or waist. They specifically looked at testing step estimates during walking and jogging, how far was traveled, how much energy was expended, as well as sleep, and compared them against appropriate goal standards for each activity.
So with the results, there was a pretty substantial error for both wrist and waist in terms of how many steps were counted, about 3 percent from the waist and about 10 percent for the wrist. And in general, they were more accurate at normal speeds. For distance traveled, there was an error rate of about 10 percent, with a range of about 5 to 40 percent.
For energy expenditure, these activity trackers were off by up to about 25 percent, with a range of 13 to 45 percent, and this was when we're at the waist after activity labeling. For sleep, these trackers often overestimated the total sleep time by anywhere from 10 to 40 minutes and overestimated sleep efficiency by about 15 percent.
A SLIGHTLY IMPROVED STUDY
Three years later, there is another systematic review that looked at just Fitbit devices. But it also looked at both controlled, experimental settings and how these performed in real-life situations. Within that one standard deviation, there is about a 3 percent error in step count in about 46 percent of the different studies and a much wider range of variation for energy expenditure for these step trackers.
It turns out that speed is important with how well these trackers were detecting errors. In general, it was found that there was less error in the step count at a normal hour jog pace, and as the pace decreased, the error increased. The average error was still trending towards undercounting no matter what pace.
In summary, tracker placement does matter. The torso seems to be more accurate than activity trackers that we seem to like to wear on a wrist. And movement speed matters also; a slower gait makes it more prone to error.
Now, let's take a look at energy expenditure. There appears to be very wide variability in calculated energy expenditure with activity independent of track replacement during activity. Let's take a look at how that varies with speed. Again, there's quite a wide dispersion. And so, in summary, when it comes to energy expenditure in controlled settings, there is a tendency to overestimate energy expenditure during activity and also a tendency to underestimate energy expenditure during rest.
In real life, just looking at daily energy expenditure, it actually turned out that there was a tendency to underestimate by about 77 percent how much energy expended through these trackers over the course of about 15 days.
DOES DISTANCE TRAVELED MATTER?
Now let's look at distance traveled. So again, looking at different walking speeds, at slower speeds, there seems to be a tendency to overestimate how far was traveled by even up to about 25 percent for trackers worn at the wrist. At faster speeds, it seemed to underestimate how far it was traveled by up to about 15 percent at the wrist. And at normal speeds, there was a tendency to overestimate at the waist and underestimate at the wrist.
So, again, quite a bit of variability. And over a long run, if, say someone walked ten miles a day, that could be off by plus or minus a mile. Now, some of these trackers will also advertise that they work well for detecting sleep efficiency. But most were found to overestimate total sleep time by more than 10 percent.
WHAT FITNESS TRACKER IS THE BEST FOR HEART MONITORING?
Let's look at just the type of wearables that only will look at heart rate monitoring. And so there's a study that came from JAMA Cardiology in 2017 that looked at these different devices: the Fitbit charge, an Apple Watch, Mio Alpha, and a Basis Peak that captured heart rate at both rest and at different speeds while walking on a treadmill.
Each participant tried two different devices, and they compared these against gold standards being a lead and then a polar H7 chest strap. Overall, there was about 95 percent agreement within about 25 to 40 beats per minute, but that's a pretty wide range of heart rate variability. And so my take away from looking at this study is if heart rate tracking is important to you for your exercise, at least based on this technology, don't rely on a wrist-worn device.
DO FITNESS TRACKERS CHANGE BEHAVIOR?
When it comes to efficacy, a lot of times we're talking to our patients about these devices as a way to try to help with facilitating behavioral change. So there was a study that was done in 2016 called the Idea Trial. That was a randomized controlled trial of 171 young adults with a BMI, age 25 to 40. So overweight or obese, and they were split into two groups. In the first six months, everyone was given the same low-calorie diet until decreased activity and given group counseling.
However, they were split into one group that was given telephone counseling prompted by text messaging on special website access, and another was given the same, plus access to a wearable device.
The primary outcome that was looked at was overall weight at 24 months and was found that the standard group, i.e. the group that did not have the device, ended up losing about 2.4 kilograms more. And this difference was significant and with really no difference in baseline body composition, fitness levels, activity, or other diet diets between the two groups.
DO FITNESS TRACKERS HELP YOU LOSE WEIGHT?
Twelve studies looked to try to facilitate weight loss. Most interventions were between 12 to 24 weeks and some did have some inactive comparison groups. Overall, when pulled together, there did appear to be some improvement with respect to promoting physical activity overall, but the differences seem to be pretty minimal when it came to weight-loss interventions.
Some notable observations and findings from this review are that more than half who owned the wearable stopped using it. And most of that use stops within the first one to two months.
In these studies, some appear to show some benefit for the short-term use for both middle age or older adults, but there did not appear to be a clear benefit for younger adults at all. Bottom line, when it comes to wearable activity trackers, there might be some small benefit towards increasing activity and promoting weight loss. But the novelty seems to wear off after a while, and over 50 percent of the patients will stop using them after a couple of months.
But what about the lack of activity detection? So it turns out these accelerators could also have other uses, and one of them could be to assess when some of our older patients may have fallen.
When we think of my health, in addition to the different wearable devices, there's been an explosion of different apps and monitoring devices that may be useful for a lot of our patients.
One of the helpful things that we can talk to our patients about is how useful these are at managing specific conditions. And so, in 2017, there was a systematic review that looked at how well some of these different apps and devices can be used for monitoring certain conditions. This one looked at with diabetes and obesity management.
Specific interventions include text messaging, using a portable monitoring device or specific apps, and working on a few different types of interventions, including educational interventions, dietary interventions, or physical activity interventions such as telling a patient to make sure to move a percentage of time per day.
When looking at diabetes, patients enrolled in one of these types of programs did experience an improvement in about one percent in their hemoglobin agency, which is pretty substantial, about as much as adding a medication in a lot of our patients. And when it came to weight, there were some good short-term effects, but not as much when it came to long-term effects.
And it turned out that the patients who did do this did have a weekly positive odds ratio for improved medication adherence. And so there might be something different about these patients in terms of activation, but when it comes to medication here, there doesn't appear to be very strong data about improved adherence for those recommendations.
WHICH HEALTH APPS TO RECOMMEND TO PATIENTS
I do want to caveat this: there is not a lot of evidence behind these apps because they haven't been very well studied. Weight discussions are a common reason why different apps will be recommended. There are also some apps out there that will allow patients to track micro-macro macronutrients. And so two common examples that are fairly popular are Lose It! and MyFitnessPal.
One of the secrets for a lot of these apps is the very broad food database, which lets people enter in a common food item, sometimes even scan it and take away a lot of the work that was part of the food diaries that came before.
There's an app called Noom, which you may have heard of as well, that not only helps you with logging your meals, but also provides someone with personalized coaching that a lot of patients have found to be very helpful in reaching their weight loss goals.
Insomnia is also a common problem that we see in our clinical practice and cognitive behavioral therapy. Unfortunately, getting a lot of our patients into an in-person class can be difficult.
There’s an app created by Veterans Affairs called CBT-i Coach that your patients can use for free. If you're having trouble getting your patients into a CBT session, this is something that you can recommend to them, that they could then complete themselves for free using their mobile device.
STAY QUIT COACH
Veterans Affairs has also come up with several other apps. Another one of these is the Stay Quit Coach for helping with smoking cessation. Stress management and mindfulness are important parts of managing many conditions, including stress, anxiety, and chronic pain.
MINDFULNESS COACH & CALM
Mindfulness Coach is again through Veterans Affairs. Calm is another popular app for mindfulness and reflection. There are many goals that this app can help you with, including improving focus, decreasing anxiety, and reducing stress with targeted programming towards each of those.
Quirk CBT is an open-source app, so you can get access to the full app without any cost to yourself. However, they do have a paid version that is only a few dollars per month that will implement a lot of the same CBT-type techniques that you would see otherwise in a clinical setting.
Another app for cognitive restructuring is called CBT Companion, and this offers a lot of the same features that work does as well. It's a slightly different format and again, available for your patients. But they do not have that readily available access to in-person CBT.
STOP, BREATHE & THINK
There's an app called Stop, Breathe & Think that focuses on teaching people how to meditate. That can be helpful for guided meditation mindfulness.
Headspace is another app that also fits within this category. This one has been promoted pretty heavily, and it’s also available for health care providers for free. If you haven't had a chance to try this out, you may have the opportunity to do so.
The bottom line: when it comes to apps, there have been some small victories, including the ability to potentially decrease hemoglobin, A1C by one percent, some signs that it may help with increasing activity, and give some small but short-lived effects on weight. It also turns out that patients who track themselves with either diet activity or sleep may be more prone to keeping track of their medications. And there are a lot of different useful apps out there for promoting patient self-management. And by the time you read this, there may be some more.
You may have heard of some of the different personal cardiac rhythm monitors. Let's take a look at some of those and some of the evidence behind them.
Some of the current ones are the AliveCor heart check, Zeo Patch, and the MEGO wristband. So there have been a few studies looking at a few of these different devices. One, including the mHealth Screening to Prevent Strokes or the mSTOPs study, is a randomized control study from 2018 that looked at prospective detection of atrial fibrillation with the Zeo Patch in high-risk patients defined as a chance to best score with a median of three. At one year, this device detected about 4.1 percent more cases of atrial fibrillation.
There is another study that looked at using the iPhone and cleverly called the iHeart Study that took a look at 23 patients who had smartphone usage monitors against controls. We're looking for specifically restoration recurrence of atrial fibrillation after their rhythm had been restored and about 61 percent had detected recurrence compared to 30 percent of controls using this technology with the hazard ratio of 2.5 percent.
And some did report improved quality of life by having this device available because they felt less anxious about their rhythm recurring since they could check it whenever they felt uncomfortable.
And so the bottom line for these different devices, when it comes to heart rhythm, they seem to work for both detections of atrial fibrillation and diagnosis of palpitations. And they might help with some of the associate anxiety about being out of sinus rhythm. And some studies appear to have shown cost-effectiveness, but those have been done outside of the U.S.
CONCLUSION – THE FUTURE OF MHEALTH
I do encourage you to take a look and try some of these out that I mentioned today and also look in the different app stores for other ones that may potentially be beneficial for your patients.
A lot of them that I’ve discussed do have some free trials and just be familiar with these because if you haven't seen your patients come to a clinic and ask you about these apps, they probably will in the future.