Upfront: Personal technology for health: curiosity or clinically useful?

Personal technologies for health include mobile phone apps, pedometers and activity and fitness trackers (e.g. watches). Many of these technologies are focused on healthy lifestyle and fitness, but there are also apps which are designed to help patients manage specific medical conditions, e.g. diabetes and asthma.

Health apps aimed at patients have generally been designed to fulfil one or more of the following functions:¹

• Increase accessibility to health information
• Track health information, e.g. diet and physical activity
• Link to social media, e.g. sharing and comparing running times
• Provide entertainment for health purposes, e.g. carbohydrate counting games for people with diabetes
• Perform calculations and analyses, e.g. calculating insulin doses or analysing an image of a skin lesion

The common thread of these technologies is that they provide users with health information and advice, monitoring of health goals and behaviour reinforcement. The questions that arise for clinicians are whether the information these technologies provide is reliable and whether using them improves patient outcomes or if they could actually cause harm.

How effective are weight loss and fitness apps and devices?

Among the hundreds of health conditions that are the focus of a health app, apps that target weight loss, improving dietary intake and increasing physical activity levels are some of the most popular. There have been few studies into the efficacy of apps designed for these purposes. Those that have been done have often included components such as text-message support and follow-up from a dietitian or counsellor. Systematic reviews of these studies suggest some people lose weight and improve lifestyle behaviours with the use of an app, but evidence is mixed.^{7, 8} It is uncertain whether patients using an app alone would achieve the same results as seen in clinical trials.^{7, 8}

A randomised controlled trial in Auckland into the effect of apps for improving fitness in young, inactive people found no overall improvement in participants’ fitness after using an app.⁹ Some participants did not like the apps and hardly used them (reasons given included lack of time, lack of interest and finding the app tedious to operate), whereas others found them beneficial and reported that they would keep using them after the study and thought they would help them achieve fitness goals.⁹

Most weight loss and fitness apps incorporate a limited range of strategies for producing behavioural change, e.g. how to read nutrition labels, relapse prevention, developing a regular pattern of eating, time management and stress reduction.^{10, 11} Therefore, patients may not learn the same skills and derive the same benefit as they would if they were able to see a dietitian or health professional trained in assisting patients with weight loss.

Pedometers (step counters) are one of the earliest forms of wearable health technology and have been the most thoroughly assessed. A meta-analysis of pedometer use for weight loss, that included nine clinical trials with a total of 307 overweight individuals, found that on average, use of a pedometer for 16 weeks resulted in a mean weight loss of 1.27 kg (95% CI: 0.70 – 1.85 kg).¹² The longer people used a pedometer, the greater the degree of their weight loss; the longest study of pedometer use lasted for one year and resulted in an average increase of 1,800 steps per day and 3.7 kg weight loss.¹²

Although this amount of weight loss may seem small, in the United States Diabetes Prevention Program overweight participants had a 55% reduction in the risk of developing type 2 diabetes over three years with a weight loss of 5 kg (equivalent to 5.3% of their initial body weight).¹³

Fitness trackers and activity monitors typically include a pedometer with additional functions such as heart rate or sleep monitoring, and are usually worn on the wrist. There may also be a supporting website where users can view their information and receive motivational, dietary or exercise advice and share information on social networks. There is currently little evidence that activity trackers are more effective in achieving weight loss or increasing activity than a simple pedometer. For example, one study of overweight postmenopausal women (average age 60 years) found that a pedometer provided the same benefits (increased activity levels) as a more expensive activity tracker.¹⁴ Current research suggests that sleep tracking functions on activity monitors are not able to identify waking accurately and consequently overestimate the time spent asleep.¹⁵

Questions to discuss with patients considering using apps

1. Who are the developers? Has the app been developed by an independent company, e.g. a respected patient organisation or medical authority, or a company with an “ulterior motive”, e.g. a pharmaceutical company who manufacturers a medicine related to the topic of the app.
2. Where did they get their information? Check if the app lists where the information provided comes from, whether the source is appropriate, e.g. a clinical practice guideline, and whether it is regularly updated.
3. Is the app content and advice suitable for New Zealand? Information related to investigation and treatment of the health condition covered by the app may not be appropriate, or align well with New Zealand guidelines, if apps are designed for an overseas market.
4. Is there a disclaimer? e.g. “for entertainment purposes only”.
5. Does the app record patient data? e. g. food intake, an exercise log, location data or health information. Is the patient comfortable with the level of privacy and security of their information? Is this information used to target advertisements to the user?
6. Does the app take physiological measurements? Ensure the patient knows that these measurements may not be accurate and should not be relied upon.
7. How is the patient proposing to use the app? Advise patients not to make any treatment decisions or alter the dosing or frequency of their medicines on the basis of apps.
8. Is it all a bit too much? Consider whether the app may be causing harm, such as obsessive fixation on body weight or food intake, or “disease mongering” behaviour.