Traditional approaches haven’t stemmed the growth of lifestyle-related diseases, but digital therapeutics show a promising path forward.

The persistent rise of lifestyle-related diseases remains a troubling global health trend. Today, conditions like diabetes and cardiovascular disease account for roughly 70 percent of deaths and health care costs worldwide. The good news is these conditions are preventable, often with moderate changes in diet and physical activity. The proliferation of smartphones also makes it possible for billions of people to find reliable health resources instantly.

The challenge is traditional health information is not very engaging. Behavioral research suggests the “emotional” part of the brain governs most lifestyle choices, like what to eat. As such, appeals to the “rational” part of the brain, like black-and-white nutrition labels, often fall short. What’s more, nearly half of adults struggle with health literacy. While information is more available, it may not be accessible or actionable for everyone.

Dr. Tryggvi Thorgeirsson and Dr. Saemundur Oddsson are working to change that. As co-founders of the digital therapeutics company SidekickHealth, the Icelandic physicians are combining clinical expertise with behavioral economics and mobile technology to improve people’s health.

“As medical doctors, we had treated thousands of patients who had or were at risk of lifestyle diseases,” said Thorgeirsson. “Our clinical advice would be a familiar refrain: eat well, get active, be mindful of stress, and take medication as prescribed. But the better option would have been to help shape the lifestyle choices that led people to our clinic or hospital in the first place.”

“We hypothesized that a mobile health engagement platform could support people with lifestyle change at scale,” said Oddsson. “Smartphones are almost ubiquitous, so the channel for intervention was clear. The key was to make it engaging for as many people as possible – not just the folks who were already interested in managing their health.”

Working with universities in Europe and the U.S., and bringing together a team of experienced game developers, Thorgeirsson and Oddsson created the SidekickHealth platform. With a text-light design and game-like experience, SidekickHealth enables users of different ages, backgrounds and levels of health literacy to take a more active role in their health.

Over the past two years, employers and health care providers have used SidekickHealth to engage their employees and patients at work, at home and everywhere in between. Users complete individual health missions and team challenges focused on nutrition, physical activity and stress. As they accumulate points for their progress, they earn motivating altruistic rewards, such as clean water donations to help children in need.

Hlynur Hauksson, an airline employee based in Reykjavik, Iceland, joined a SidekickHealth challenge as part of a three-week workplace wellness initiative. “It was fun, I was always earning points for veggies, water, workouts and even housework,” said Hauksson. “I started doing mindfulness exercises with my four-year-old, which gave us great quality time together. Plus, I lost five kilos.” After the wellness challenge, Hauksson continued using SidekickHealth as part a four-month lifestyle change program with a local health provider. He kept up his healthy habits throughout the summer, culminating in the completion of his first 21km run in the Reykjavík marathon.

The use of smartphones and gaming has shown promise in helping people overcome potential barriers to change. In a diabetes prevention program with participants who were over age 65 and had never used an app, SidekickHealth users averaged seven exercises per day, with 84 percent continuing in their program after four months. A similar program with a predominantly Spanish-speaking population averaged six exercises per day, with 83 percent retention.

“We collaborated with SidekickHealth because it makes our program scalable, allowing us to provide more diabetes prevention programs to those in need,” said Marlayna Bollinger, Founder and Executive Director of the Skinny Gene Project, a non-profit organization with a Diabetes Prevention Program recognized by the U.S. Centers for Disease Control and Prevention. “We can modify the program to make it culturally relevant and ensure information is not just received; it’s understood. In groups that are at high risk for diabetes, like Hispanics and Native Americans, SidekickHealth has been especially effective in helping people lower their risk for diabetes.”

By taking a new perspective on health engagement and empowering people with technology, a key indicator of global health may start moving in the right direction.

This post originally appeared on the Vertical Blog.

Organizations that want to reduce healthcare costs must first identify those drivers that are preventable and then determine the optimal path to avoid them. For lifestyle-related diseases like Type 2 diabetes, health promotion and lifestyle change programs present a real opportunity to lower healthcare costs while improving people’s health outcomes and care experience—all goals of the Institute for Healthcare Improvement’s Triple Aim.

In Iceland’s capital, Reykjavik, a combination of behavioral economics, big data and mobile technology is a promising way forward to identify individuals at increased risk of lifestyle-related diseases and reverse their condition.

What is behavioral economics? It combines lessons from psychology and economics to consider how people behaveas opposed to how they would behave if they were perfectly rational, with unlimited willpower, and solely acting out of self-interest. It considers how people are influenced by their emotions, identity, environment and the framing of information.

Behavioral economics can be applied to the prevention and management of diabetes, a disease that now costs an estimated $825 billion each year globally. A significant part of the economic burden stems from the number of people affected. About 422 million people have the disease, which equates to about 8.5% of the world’s population. In Iceland, where the population tends to be more physically active than the norm, the rate is 6.1%. However, it is experiencing an upward trend.

Because Type 2 diabetes develops slowly over months and years, the good news is the disease can often be delayed, prevented or even reversed. More than 1 in 3 adults are prediabetic—at higher risk for type 2 diabetes and cardiovascular disease—but a structured lifestyle change program focused on diet and physical activity can be an effective formula for achieving and maintaining a healthy weight and normal blood sugar level.

Large clinical trials, including the Centers for Disease Control and Prevention’s National Diabetes Prevention Program, have shown this type of program can cut the risk of progression from prediabetes to type 2 diabetes.

As a physician who has worked with thousands of patients with lifestyle diseases, I recognize that messages of behavior change—eating right, exercising more and managing stress—do not so easily translate to everyday life. People have priorities that demand their time and attention, from managing a career to raising a family, that often relegate lifestyle choices to an afterthought.

In addition, adult health literacy is a challenge, and many people may have a low motivation for lifestyle change until a medical episode brings new perspective to the effects of unhealthy habits. As the industry looks to combat the impact of diabetes and help people engage in their healthcare, two dynamics have emerged to encourage prevention efforts.

First, we are developing a better understanding for how individuals make their lifestyle choices, particularly when a behavioral economics model is applied. Lessons from behavioral economics can support public health because they help us guide people toward better choices. To date, the more traditional, “rational” appeals—such as black-and-white nutrition labels on the back of a food packages—have fallen short in steering people toward healthier habits. Since the more “emotional” part of our brain is responsible for most of our lifestyle choices, targeting decision-making with emotional appeals—such as games, instant gratification and rewards—can more effectively activate the triggers that motivate people.

That dovetails well with the fact that mobile devices are approaching ubiquity, providing a direct channel for preventive care. Not only are smartphones widely distributed, but people carry them at all times, spending several hours per day using apps that often deliver powerful emotional triggers in the brain. Mobile devices can increase provider-patient interaction for lifestyle interventions, as well as offer opportunities for primary prevention.

Combining behavioral economics with technology has applications for both providers and employers. By incorporating a digital layer to traditional lifestyle programs, clinicians and coaches can complement in-person sessions with tools that help people manage their health anywhere and open channels for support along their journey. Employers can integrate similar methods into workplace initiatives to promote employee wellness and reduce the risk lifestyle-related disease among the workforce.

One example of how this approach has been successfully deployed is in Reykjavik. Earlier this year, more than 2,000 municipal employees across the country’s capital participated in the first step of a new workplace wellness program. Using a health engagement platform on their smartphones, employees took part in health challenges in three focus areas.

The first was nutrition, enabling participants to set goals for consuming healthy meals, practicing mindful eating and avoiding sugary foods. The second was exercise, allowing participants to count steps, log workouts and record activities like household chores. The last was stress reduction, such as relaxation, mindfulness and meditation exercises.

Over the course of three weeks, employees who took part in the initiative completed more than 500,000 health-improving activities, including stair-walking the equivalent of 100 trips up Mount Everest.

In addition to the health advantages, the “Reykjavik Health Games” encouraged competition and teamwork across the organization as participants worked to earn the most points for their group or department. Further motivating participants, the points they were earning accumulated towards a charity water donation, which the City of Reykjavik provided to an organization focused on helping children in need. 

Participants were also offered a simple, seven-question prediabetes screening through their phone as part of the initiative. Of the employees who completed the questionnaire, more than 200 were determined to be at increased risk for diabetes and were referred to a 16-week, structured lifestyle change program administered through a digital platform in association with a local healthcare provider.

This approach can support efforts by insurers, providers and employers to reduce health costs. The Agency for Healthcare Research and Quality found diabetes with complications ranked at the top for hospitalizations covered by Medicare and Medicaid and those who were uninsured. Reducing the number of diabetes patients requiring inpatient admissions can help lower this expenditure.

Second, diabetes prevention programs that can effectively motivate their participants to lose weight and adhere to their program can improve the health of their populations and achieve quality metrics for reimbursement.

While cutting healthcare costs is a daunting challenge on its face, lifestyle-related diseases present a clear opportunity for progress. Helping people recognize their potential risk for diabetes, empowering them to make lifestyle change and engaging the triggers that motivate their behaviors and are the keys to keeping them healthy and out of the hospital.

This article originally appeared at FierceHealthcare.

Doctors have all had the lifestyle change talk, probably thousands of times.

We’re treating a patient with a lifestyle disease – obesity, hypertension, prediabetes. We assess the patient, evaluate treatment options and recommend a plan of care. Typically, this guidance amounts to better diet, more physical activity and less stress.

It’s a completely rational course of action. It’s the right approach to living healthier. But it just doesn’t take hold.

We distinctly recall instances of the lifestyle change talk with patients. Once, a middle-aged man recovering from a heart attack came in for an appointment. He seemed to understand the gravity of the situation, received evidence-based guidance delivered in a traditional way, and then was seen outside the clinic lighting a cigarette. On another occasion, a 60-year old woman was admitted to the hospital with high blood pressure. Because the traditional lifestyle change talk wasn’t working for her, the best treatment plan was to prescribe her an antihypertension drug… when she was already taking two.

We were trying to put out fires we would have liked to prevent, and we knew there had to be a better way. After years of research with leading universities and institutions and many real-world examples, we think we’ve found it.

The Dual Rise of Diseases and Devices

Chronic lifestyle-related diseases account for about 70 percent of deaths and up to 80 percent of health care costs worldwide. In 2014, diabetes affected 422 million people, and the trend continues on an upward trajectory. About one in three adults in the U.S. and the UK has prediabetes, increasing risk of heart attack, stroke, and type 2 diabetes. These diseases pose an escalating threat to global health and wellbeing.

At the same time, mobile devices have seen explosive growth and use. Not only are they widely distributed, but people carry them constantly, spending several hours per day using smartphone apps. As such, mobile devices can potentially increase provider-patient interaction during lifestyle interventions, as well as offer an avenue for primary prevention.

At a time where we need to flip the trend of lifestyle diseases, we have a ubiquitous, adaptive vehicle to tailor behavioral interventions to patients. But we still need to make those interventions more effective.

A new approach: Finding the triggers for lifestyle choices

The field of behavioral economics combines lessons from psychology and economics to investigate how individuals actually behave, as opposed to how they would behave if they were perfectly rational, with unlimited willpower, and solely acting out of self-interest. It considers how people are influenced by their emotions, identity, environment and the framing of the information.

Many lessons from behavioral economics apply to public health because they help us understand why people make choices, and in turn, how to guide them towards better ones. In three years of research, we teamed with experts from Harvard, MIT, and more than two dozen professionals on both sides of the Atlantic to determine how these applications could be put into practice.

Effective Engagement to Change Behaviors

We hypothesized that a mobile health-engagement platform could significantly enhance a structured lifestyle change program. We integrated principles of behavioral economics, gaming technology, artificial intelligence, evidence-based guidelines and personal coaching. We combined our clinical expertise with a team of experienced game developers and launched SidekickHealth to prevent and manage lifestyle disease.
Seven concepts from behavioral economics serve as pillars for the platform.

1. “Fast thinking” controls most lifestyle choices    

Behavioral research suggests two separate cognitive systems control our choices. Psychologist Daniel Kahneman describes them as fast thinking – which is intuitive, impulsive and emotionally charged – and slow thinking – which is rational, deliberate and reflective.

By targeting fast thinking, advertisers have been winning our hearts, minds and stomachs for years. The cartoon characters synonymous with breakfast cereals are examples of the food industry’s adept appeal. Public health organizations, on the other hand, typically target slow thinking. Just turn the cereal box over for a black and white label densely packed with nutrition information. There’s a lot of squinting at tiny print required for a rational, healthy choice.

To use fast thinking for good, we designed a gamified platform with colorful graphics, characters, competitions and instant gratification through rewards. The result is a highly engaging experience that enables patients of different health literacy levels, languages and ages to get and stay involved in the management of their health.

2. People use mental shortcuts, which can cause unhealthy behaviors

Studies indicate that lifestyle decisions, like how much to eat, are frequently biased toward an initial “anchor” value. For example, the quantities consumed at a meal are subconsciously cued by the size of plates and glasses. Referred to as “mindless eating,” this anchoring can increase how much people serve and consume.

With our platform, we deliver appetite awareness training to encourage users to eat in response to internal hunger cues – a method that has shownpromise for the treatment of obesity.

3. Stress and cognitive demands may increase the use of fast thinking and adversely affect lifestyle choices

Human cognitive capacity has limits, and slow-thinking processes require significant effort and cognitive demand. To compensate, our brains often outsource lifestyle choices to our more impulsive, fast-thinking brain. The effects on our decision-making can be compounded when multitasking or stress are further straining cognitive resources.

To counter the effects of stress on lifestyle choices, we incorporate relaxation, meditation and mindfulness exercises into our platform as part of an evidence-based curriculum.

4. People tend to discount future costs and benefits, placing a higher value on the present

“Future discounting” works against health behaviors, which usually involve efforts in the present for benefits in an undetermined future (e.g., floss now to avoid a dentist visit later).

SidekickHealth provides opportunities for instant gratification, such as highlighting short-term benefits, promoting self-monitoring (e.g., dietary tracking, step counting, activity logging) and providing immediate feedback to users. We also employ commitment contracts to allow users to pre-commit to lifestyle changes, such as forfeiting soda or sweets, and to have a supporter, such as a coach or friend, for added accountability.

5. Framing health behavior as an enjoyable task, as opposed to an obligation, may positively influence behavior 

The way healthy behaviors are presented to people can fundamentally alter their understanding of the experience. For example, Wansink and colleagues showed that study participants who exercised out of duty rewarded themselves with twice as much candy post-exercise than participants who received a message framing the exercise as an enjoyable nature walk.

In our gamified platform, we integrate messages that emphasize personal achievement, social interaction and fun to promote healthy behaviors. This approach can be especially effective with groups, such as a diabetes prevention program or a workplace wellness initiative.

6. Open channels may encourage some behaviors, while closed channels may inhibit others

“Channel factors” are the many small details that can have surprisingly large effects on people’s behavior. Examples that can lower the threshold for healthy choices include pre-slicing apples at a cafeteria (shown to increase apple sales), and making water more accessible by placing it at eye-level (shown to increase water sales).

We decided to open up channels for health improvement through a veritable “buffet” of options for improving diet, physical activity and stress reduction. Conversely, we avoid blocking channels by adhering to low health literacy guidelines and a visual design.

7. Behavioral economics models assume people are motivated by more than self-interest 

Altruism is an important motivator for health-related behaviors like blood and organ donations, as well as many group- and peer-based interventions. Incentives benefitting our friends can also be several times more effective than standard individual incentives.

For completing health missions on our platform, users accumulate points. Over time, points earn them altruistic rewards in the form of clean water that is sent by charities to help children in need. Users’ earned points and rewards can also benefit their friends in the program.

Making it personal: The role of data

While behavioral economics powers our platform, we use big data and artificial intelligence to drive personalization. Each time a user chooses one of 120 different activities, SidekickHealth’s artificial neural networks learn from these behaviors to make intelligent future suggestions based on user profile and surroundings. Machine learning enables us to predict and present users with the choices that are most likely to activate them – boosting engagement and program retention much like Netflix’s curated suggestions increase viewer engagement.

Data is also important for the invaluable role clinicians and coaches supporting the patient’s path to better health. Through the platform’s care team portal, administrators can efficiently track participants’ activity, remotely send supportive messages and tailor instruction for in-person sessions.

Beyond promise: Results in weight loss, program adherence 

Over the past year, the data-driven, gamified platform has been deployed to improve outcomes for in-person, community-based programs across the U.S., including those serving vulnerable populations at increased risk. Users were up to three times more likely to reach their five percent weight loss goals after 16 weeks, and they were up to 30 percent more likely to remain in the DPP for the full program. Similar results from a clinical trial were presented at the American Diabetes Association’s 77th Scientific Sessions in San Diego this June.

The use of images, games and smartphones overcomes the barriers to change otherwise attributed to social disparities and cultural differences. In a Los Angeles-based Medicare-age DPP where many people had never used an app, participants averaged seven exercises per day, with 84 percent retention at month four. A San Diego-based DPP with a Spanish-speaking cohort averaged six exercises per day, with 83 percent retention.

We have also seen success at scale with large employee wellness initiatives. For example, more than 2,000 municipal employees in Iceland’s capital participated in a three-week engagement program, completing 500,000 health-improving activities. Of the 700 who used SidekickHealth to complete a prediabetes screening, more than 200 were determined to be at risk and were referred to a lifestyle change program.

Conclusion

By understanding why people choose certain behaviors, we can help them choose healthier ones. By combining clinical and gaming expertise to make lifestyle change more engaging, we can help prevent and manage chronic disease. And by using technology, we can bring about the type of change that is needed at scale.

So now, in addition to having the talk with patients, we can empower them to walk the walk.

This article originally appeared in Healthcare Analytics News.