Needs and Objectives: Lifestyle-related chronic diseases take 450,000 lives and cost $2.25 trillion annually in the U.S. Primary care providers (PCPs), despite seeing such patients multiple times a year, are ill-equipped to meaningfully improve the lifestyle of those at risk for chronic disease. Behavioral change literature suggests patients need frequent, personalized, and timely support to adopt and maintain healthy behaviors. Therefore, we created MyLife, a comprehensive digital lifestyle health program designed for patients and PCPs. Our program uses wearable fitness trackers, automated text messaging, and trained health coaches to help primary care patients improve their lifestyles and lose weight. The objectives of the program are to: 1) enable patients to adopt healthier lifestyle behaviors, 2) improve patient engagement and motivation, and 3) help providers prevent lifestyle-related chronic diseases. Here we describe the continuous improvement efforts of the program and the change in program performance over time.

Setting and Participants: Patients are referred from UCLA Department of Medicine primary care practices by their PCP. They must be ages 18-64 with BMI ≥ 27, average  ≤ 150 minutes per week of moderate to vigorous physical activity (MVPA), a desire to lose weight, and a text-capable phone. Patients are excluded if they are too unhealthy to participate per their PCP, have an uncontrolled chronic disease, already actively use a wearable device, or participate in a weight loss program.

Description of Program/Intervention: Patients attend an in-person (remote during covid pandemic) intake appointment to receive and learn to use their wearable device. They are educated on our program’s goal of 150 minutes MPVA per week and healthy eating goals. Then they set personalized physical activity, nutrition, and weight loss goals. They also give their main motivations for participating and discuss potential barriers and ways to overcome such barriers. Patients then begin a 16-week intervention. They are supported by their health coach throughout, with scheduled follow-up calls every 2 weeks and additional contact ad-lib. They receive 4 automated text messages per week, including a message on Mondays to report their weight and set their active minutes goal for the upcoming week and Thursdays to report their progress toward their active minutes goal.

Over time we made multiple iterative changes to the intervention. For phase 2, we increased the frequency of photo food diaries from monthly to every 2 weeks to increase our nutrition data collection and feedback. A frameshift change happened for Phase 3. For this phase, we changed our intake, follow-ups, and outtakes so that all survey and data collection questions were automatically delivered and then completed online by the patient, prior to meeting with the health coach. This allowed our coaches to better prepare for shorter calls in advance that focused more on relationship building, reviewing barriers, problem-solving, and goal setting. We improved our data visualization to allow coaches to continually monitor progress. We also standardized our nutrition module and our text messaging schedule, with a nutrition tip message every Tuesday and a motivational message every Saturday. For Phase 4, we implemented a new platform (Way to Health) that allowed us to create a patient portal and integrate our messaging and surveys onto one, more powerful, platform. Coaches now receive automated updates on patient progress and survey completion.

Given the large change between phases 2 and 3, we sought to assess whether there was a meaningful difference in patient outcomes between phases 1 and 2, and phases 3 and 4 (the latter is currently on-going)

Evaluation (Measures of success) 

At baseline, we collect demographic information, biometrics, and baseline level of physical activity. Weight is collected both on our clinic scale and their home scale. Patients then self-report their weight every week via text message. Comparing phase 1-2 vs. 3-4, patients displayed similar sex, age, race/ethnicity, education level, baseline BMI, weight, and MVPA (p ≥ 0.10). Since phase 4 is still ongoing, we compared weight change per week between groups. Phase 3-4 had significantly increased weight loss per week, median -0.97 lbs per week (IQR 0.53) vs. median -0.43 lbs per week (IQR -0.43), p=0.04.

Discussion / reflection / lessons learned

• Standardization of effective practices can lead to better overall results

• Giving health coaches more data on their patients and decreasing their administrative burden may improve their effectiveness

• In phase 4, we hope that automated messages to coaches on patient performance and survey completion will make our intervention even more effective. We are currently evaluating this iteration of the program vs. wearable device alone in a randomized controlled trial.

• We hope continuous improvements like these will continue to enable our patients to improve their lifestyles, lose weight, and prevent chronic disease.