Prediabetes, which has reached epidemic levels in the U.S., is also prevalent among Veterans, many of whom have already been diagnosed with diabetes. Although people with prediabetes have a 30% risk of developing primarily type 2 diabetes, they can reduce that risk by 60%-70% through modifiable behavioral lifestyle changes, specifically, through improved dietary habits and increased physical activity (PA). Interventions intended for achieving these goals are needed that do not incur large costs in the form of professional staff that are required to manage and maintain the program, and which could reach individuals in rural areas or who cannot commute easily to clinics. My HealtheVet (MHV), a web-based personal health record (PHR) introduced by the Veterans Health Administration (VHA) intended for empowering patients to play a more active role in their healthcare, has a powerful interactive feature, Track Health (TH), designed to help its users adopt healthy dietary and physically active lifestyles and potentially understand how changes in these lifestyles may translate into positive health measures. Evidence indicates, however, that most Veterans are either not aware of or do not use many of the functionalities, such as TH, that MHV has to offer. In this pilot study, we investigated the potential benefits of using this PHR's TH function for adopting positive lifestyle changes in a sample of overweight and obese Veterans with prediabetes.
The primary goal of this study was to determine if a training intervention directed at helping Veterans understand how to use and understand MHV's TH function, coupled with use of MHV's Secure Messaging (SM) feature to enable communication with study coordinators, can translate into actual adherence to PA and an improved diet. We were also interested in determining if this intervention would increase these individuals' self-efficacy, patient activation, and intent to adhere to PA and improved diet. Another objective was to determine if participants' would adhere to use of MHV based on meeting criteria specified to them regarding making weight, PA, and diet entries in MHV's TH functions, and whether they would be satisfied with the longitudinal intervention trial.
Thirty-eight Veterans (29 males and 9 females, mean age 57.7, 24% Hispanic, 55% Black) recruited from primary care clinics of the Miami Veterans Administration Medical Center (VAMC) completed this pilot study. Inclusion criteria included: a diagnosis of prediabetes (HbA1c 5.7-6.4%, fasting plasma glucose 100-125 mg/dL or oral glucose tolerance test 140-199 mg/dL); older than 20 years of age; English speaking; had access to the Internet; had a body mass index (BMI) of 25-42 kg/m; were not physically active three days per week for 20 minutes each time for the previous six months; were able to engage in a regular program of mild-to-moderate intensity PA but were not currently following a weight loss diet or participating in an intervention trial; and were not cognitively impaired or depressed. Assessments took place during each of four visits to a laboratory within the VAMC. The first visit included screening on study inclusion and exclusion criteria and training on use of MHV's TH function (nine people were excluded based on not meeting the study eligibility criteria). Participants also completed diet and PA self-efficacy and intention to adhere questionnaires, were given an accelerometer to wear over the next 7 days, and were asked to make food intake, PA, and weight entries a specified number of times into MHV over the next week. They were informed that if they failed to meet accelerator use and information entry criteria for the first week, they would not qualify for the study, but would receive $175 if they completed the entire study. During the participants' second (baseline) visit (week 1 of the study), accelerometer and MHV log data were obtained (five people did not meet the accelerometer use and four people did not meet the MHV information entry criteria). Participants had their weight, abdominal circumference, pulse, and systolic and diastolic blood pressure measured, and a dietary analysis computer program (Nutritional Data System for Research; NDSR) designed for the collection and analysis of 24-hour dietary recalls (from which a kcal dietary intake measure was computed) administered, followed by the administration of questionnaires for measuring health literacy, objective numeracy, graph literacy, patient activation (PAM), and the System Usability Scale (SUS), a 10-item questionnaire that provides a general assessment of the usability of a product (in this case, MHV) that could be compared to national norms. They were also provided with dietary guidelines and exercise regimens that they should incorporate into their lifestyle. During the third (week 12) visit, the PA and diet self-efficacy and intention to adhere questionnaires, as well as the NDSR, were administered a second time; measures of weight, abdominal circumference, pulse, and systolic and diastolic blood pressure were also collected. Participants were again given an accelerometer to wear over the following week. During participants' fourth (week 13) visit, the accelerometer data and MHV log data (over their 13-week period of participation in the study) were downloaded, the PAM was administered a second time, and a questionnaire which gauged satisfaction with various aspects of the study was administered.
The primary outcome measures were the differences over the 3-month period (week 13 - week 1) in weight (kg), abdominal circumference (inches), energy expenditure (measured in kcal/day using an accelerometer), dietary intake (kcal, 24-hour recall using the NDSR), and systolic and diastolic blood pressure. Three-month differences in diet and PA self-efficacy and intention to adhere measures were also computed.
The primary study intervention involved the provision to study participants of targeted instruction and practice on use of MHV's TH function's Journals and its Vitals + Readings. Seven interactive multimedia instructional modules were developed by the study team specifically for this pilot study. These modules demonstrated how to enter PA and diet information into the Journals feature of MHV's TH function; how to add weight data into the Vitals + Readings feature of the TH function and view these and other measures in tabular and graphical formats over different time frames; the concept of possible cause-effect links between behavioral lifestyle and physiological outcome (e.g., weight) data; and how to use MHV's Secure Messaging (SM) function to communicate with study team members. Participants were asked to enter food intake information at least four times per week; PA information at least three times per week; and weight recordings at least once a week over the three-month study period. An identical weight scale was provided to all participants.
Statistically significant differences between post-intervention (3-month) and baseline measures were found in the direction of lower weight and reduced abdominal circumference, increased PA, and lower systolic and diastolic blood pressure. The percentage of participants that met the 3-month PA (> 100 kcal increase/day over 7 days), dietary intake (reduction in kcal/day > 100 kcal), weight (> than 6 lbs. weight loss), abdominal circumference (reduction > 1 inch), and BMI (reduction > 1) criteria established for the study were, respectively, 44.7%, 44.7%, 26.3%, 52.6%, and 36.8%. Significant positive correlations were found between objective numeracy and abdominal circumference, graph literacy and abdominal circumference, and graph literacy and weight loss. Ratings based on the System Usability Scale indicated a mean score that places its usability above products such as MS Word and the Wii, and just below the iPhone. Participants' reactions regarding their satisfaction with the study were generally positive. For example, 89.2% either agreed or strongly agreed that the training on the TH function of MHV was easy to understand, and 97.3% either agreed or strongly agreed that they were satisfied with participating in this study.
We believe that the customized multimedia instructional program, which not only introduced participants to the TH function of MHV but also provided insights into how to best use it and understand possible cause-effect relationships related to its use, played a critical role among the participants who demonstrated engagement with MHV and positive outcomes in lifestyle behaviors. Between 24% and 45% of the participants met positive lifestyle change (e.g., reduction in weight) criteria, which when generalized to the larger population of Veterans, could have potentially important implications for disease prevention and self-health management. The intervention also provided insights into changes to MHV (e.g., in the form of training modules embedded within this PHR), which could further enhance the potential usefulness of this PHR as a self-health management tool, including the provision of aids that could help users lower in health numeracy and graph literacy skills to be able to better understand and act on the data that populates PHRs such as MHV. Indications of this need derive from findings demonstrating significant correlations between graph literacy and weight loss; we have found graph literacy to a particularly powerful predictor of successful health-management task performance using MHV in a prior study involving the usability of MHV among Veterans. In particular, given the dependence of electronic tools such as PHRs on quantitative displays of tabular and graphical health-related information, it is essential that future designs of MHV provide for ways in which users lower in health numeracy and graph literacy skills can derive the benefits that such PHRs can potentially provide. Such research can then serve as a model for the general population with respect to guiding designs of future PHRs.
- Sharit J, Idrees T, Andrade AD, Anam R, Karanam C, Valencia W, Florez H, Ruiz JG. Use of an online personal health record's Track Health function to promote positive lifestyle behaviors in Veterans with prediabetes. Journal of Health Psychology. 2018 Apr 1; 23(5):681-690.