Mobile App for Weight Management Designed by and for Veterans with Serious Mental Illness
HSR&D’s monthly publication Veterans’ Perspectives highlights research conducted by HSR&D and/or QUERI investigators, showcasing the importance of research for Veterans – and the importance of Veterans for research.
In the January 2020 Issue:
MOVE! Weight Management ProgramSupported by VA's National Center for Health Promotion and Disease Prevention (NCP) the MOVE! weight management program includes the most up-to-date approaches for weight management. CoachToFit delivers MOVE! via a smartphone app with support from peer wellness coaches. It is tailored to meet the needs of individuals with serious mental illness.
Obesity is an epidemic. Sixty percent of individuals with serious mental illness (SMI), including those with schizophrenia, bipolar disorder, and major depression are obese. Obesity has devastating impacts on individuals with SMI, including high rates of diabetes, cardiovascular disease, and reduced life expectancy by 15-20 years.
The VA weight management program MOVE! is evidence-based and effective for weight loss in the general Veteran population. However, fewer than 5% of Veterans with SMI attend MOVE!, primarily due to the complexity of the educational materials, travel issues, and a dislike of group interventions. Effective weight management programs have been designed to meet the needs of people with SMI, but due to their time-intensive nature and the need for trained providers who are often in short supply, effective adapted weight management programs are not routinely offered in VA.
To address the obesity epidemic experienced by Veterans with SMI, a Los Angeles-based team of HSR&D researchers, led by Dr. Amy Cohen, worked alongside obese Veterans with SMI to develop a program for weight management specifically designed for this group. Key challenges to address were the need for skilled providers, patient travel to a VA site, and this vulnerable population’s reticence for group participation. The partnership was powerful, and the VA HSR&D-funded effort led to a new tool called CoachToFit that produced excellent initial outcomes.
Development and Initial Testing
CoachToFit is a weight management program that includes a smartphone app coupled with VA peer specialists who deliver weekly coaching by phone. The app delivers 30 educational modules covering nutrition and activity, knowledge checks of the learning, weekly goal setting and tracking, and reminders. The app also retrieves data from a Bluetooth scale and an activity tracker watch, which are part of the CoachToFit program. The app is enhanced by weekly coaching calls from VA peer specialists who are Veterans with lived experience with SMI. Peer specialists use motivational interviewing techniques to enhance impact. CoachToFit is available on both Android and Apple platforms. A web-based peer specialist coaching dashboard allows for visualization of app data in real time, allowing for personalized coaching.
The CoachToFit App delivers the MOVE! Program via Smartphone
It was critical that CoachToFit be adapted for Veterans with SMI, meeting design elements necessary to accommodate this population’s symptoms and cognitive deficits. To achieve this goal, researchers partnered with obese Veterans with SMI in every step of CoachToFit development.
Development started with colored mock-ups of each app page, which were presented to a focus group of Veterans who provided input on the amount of information per page, color scheme, logo, and the name of the app, CoachToFit. App wireframes were then constructed and presented to a second, separate focus group of Veterans, where further refinements were made. Once a working app was available, in-lab usability testing was conducted individually with Veterans, who completed a list of tasks with the app (e.g., start new learning, find the graph of your weight, enter progress on your weekly goal) which were observed by developers and content experts. These observations led to final programming changes. Meanwhile, a Veteran who had experience as a peer coach and who had lived experience with a family member with SMI, provided input on the development of a peer dashboard through an iterative process. Finally, experiential usability testing was conducted with 37 obese Veterans with SMI who carried the app and received weekly peer coaching via telephone for 8 weeks. Both the app and peer coaching sessions were met with positive reviews by Veteran participants.
“It challenged me to set new goals after the old goal was achieved”
– Veteran CoachToFit user
“It challenged me to set new goals after the old goal was achieved. [The contents] were interesting, concise, and brief and I couldn’t ask for anything more than that.” – Veteran CoachToFit user
“It just made me more aware of what I’m choosing to eat and makes me think about the healthy choices in my life.” – Veteran CoachToFit user
“Someone else was following it, someone who could say, ‘Well, look, let's look at what you did last week,’ and ask me about the goals, ‘Did you achieve them or not?’ That was really, I thought, very reinforcing. “– Veteran CoachToFit user
“Because what [the CoachToFit peer coach] was able to do was tell about how she had the same battles… and she had lost the weight… I’m already a self-motivated person, but she kept me motivated.” – Veteran CoachToFit user
Impacts of CoachToFit
“It just made me more aware of what I’m choosing to eat and makes me think about the healthy choices in my life.”
– Veteran CoachToFit user
Those who participated in the experiential trial of CoachToFit lost a clinically and statistically significant amount of weight. Specifically, as a group, they lost about 4.5% of their body mass over 8 weeks, which was, on average, 9 pounds per participant. Even the peer coach reported weight loss! There were also positive reports of acceptability of both the app and the coaching.
Importantly, CoachToFit literally puts an evidence-based weight management treatment in Veterans’ hands and reduces burden from the healthcare system. There is no doubt that much of the success of CoachToFit is attributable to the involvement of Veterans throughout development; no previous app development has involved individuals with SMI to this extent.
The CoachToFit Team (Top Row) Wren Reynolds, Rose Rocchio, Ed Sakabu, Keith Rozett, (Bottom Row) Jackie Lewis, Cathy Trance, Lauren Cullen, Rebecca Oberman, Amy Cohen.
Amy N. Cohen, PhD, is a licensed clinical psychologist, Director of the Implementation Science Unit at the VA Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC), and a Core Investigator at the VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP).
A randomized controlled trial of CoachToFit has been funded by VA HSR&D and is slated to begin in early 2020. If found to be efficacious, the peer dashboard will be integrated with the medical record, the CoachToFit app will be offered to obese Veterans with SMI through the app stores, and coaching banks will be set up regionally.