The Promise and Realities of Mobile Technologies for Cardiovascular Prevention

The recent proliferation of wireless and mobile health (mHealth) technologies provides a valuable mechanism to collect and transmit information in the real-world via cellular phones and wearable sensors. This technology, when coupled with fixed sensors embedded in the environment, presents an unprecedented opportunity to produce continuous streams of data on an individual’s biology, psychology (attitudes, cognitions, and emotions), behavior, and daily environment. The ubiquity of these tools, diversity of information they provide, and the data generated, have the potential to enhance the evidence base for a wide range of prevention, intervention, and basic science efforts.

Given this potential it is not surprising that mHealth tools have been developed and examined across a range of cardiovascular disease prevention areas. Cardiovascular disease prevention is an important area for public health research because, while there have been great strides in treatment options over the past 50 years, improvements in mortality rates are becoming static, and new cases of cardiovascular disease continually emerge. Enhanced strategies to decrease the incidence of cardiovascular disease and attenuate the progression of existing disease are of paramount importance.

Thus, the article by Burke and colleagues¹ is an important and timely examination of the evidence base for the use of mobile technologies to address the key factors that are crucial to preventing heart disease: weight loss, physical activity, dyslipidemia management, smoking and control of blood pressure and blood glucose. The hype in the area of mHealth technologies has been high, but the science in this area has been lean. Burke and colleagues’ article delves into the current work to summarize the literature, points to future directions, and highlights best practice for consumers and practitioners.

Burke and colleagues examined a range of trials utilizing mobile technologies, most of which were cell-phone or web based. Studies targeted text messaging (SMS), interactive voice response, smart phones and apps, as well as various web-based systems that are generally accessed through the phone (e.g., podcasts). Attention was also given to the area of physical activity tracking. Burke and associates found support for the use of mobile health tools across all the cardiovascular disease prevention targets, although the interventions and the size of the effect varied. Some areas, such as weight loss, showed positive effects, but they were smaller than reported in traditional interventions (i.e., in person); while other areas (e.g., smoking) were comparable to previous research. For example, there was consistent support for the use of mHealth technology for weight reduction, especially areas identified by Khaylis and colleagues² as the key components for conventional weight loss interventions: deployment of a personalized structured program with feedback and communication, self-monitoring, and social support. When more elements of best practice were embedded in mobile intervention, the outcomes were improved. Thus, the findings suggest that much of the evidence accumulated in in-person interventions could have value within the world of mobile health.

In addition to these findings, any exploration of mobile health must address the explosion of commercial technology and apps for activity tracking, weight loss, and smoking cessation. In 2012, the number of mobile health applications downloaded at least once reached 247 million, and fitness tracking and weight loss are both prominent app areas. Burke and colleagues¹ have found that, similar to earlier work on weight reduction and smoking cessation apps, very few of the consumer technologies are building the evidence base,^3,4 and few have been empirically evaluated (e.g., commercial activity trackers). Although there is great interest by consumers and some practitioners implementing mobile technology for health, the evidence base needs to be strengthened.

Overall, this paper can be taken as an indication that mHealth in the area of cardiovascular disease prevention is beginning to achieve its promise. The paper highlights the potential for achieving health outcomes and research beyond the limits of conventional approaches. Alternatively, this can be seen as a call to action. This review covered 6 key areas with a relative small number of available randomized control trials. As previous work suggests, there are many ongoing trials now listed in Clinicaltrials.gov,⁵ but Burke and associates’ work makes it clear that mHealth research requires a systematic approach that transcends the specific technology being deployed and that transcends conventional research partners. Burke and associates’ work illustrates that work towards a more robust body of evidence is essential and will entail participation of manufacturers, consumers, researchers, and clinical communities.¹

Furthermore, as Burke and colleagues note,¹ this review highlights the lack of diversity in cardiovascular prevention mHealth research. The very ubiquity of mobile technologies amongst diverse populations, including low income and minority ethno-cultural groups, points to the vast potential of mHealth in these populations. National surveys show that although African-Americans trail Whites by 12% when considering broadband access to the internet, Blacks and Whites show parallel rates of mobile platform ownership.⁶ Furthermore, national samples indicate that 92% of Black adults are cell phone owners and 56% own a smart phone. Latinos, African-Americans, adults between the ages of 18 and 49, and college graduates are the groups most likely to use mobile platforms to access health-related information.⁷ Ownership of cell phones in Latinos has also increased now to roughly 86%, and Latinos are more likely than Whites to use a mobile device for the internet.⁸ Minority groups are now not only more likely to own a mobile phone, and specifically smart phones, but they are also more likely than Whites to use their device to access health-specific information. Part of the reason that mobile health has the potential to be such a transformative force in cardiovascular disease prevention is that it can support health literacy with its multiple modalities, dynamically present information in a way that is tailored to and useful for the user, and generate information that is based on rich, contextualized input, and assessment processes. Thus, if used correctly, mobile health can ensure that important social, behavioral, and environmental data are used to provide a comprehensive health picture. Health outcomes may be improved and cardiovascular disease can be reduced across the entire nation by building a robust body of evidence that includes diverse groups. These efforts will need to be inclusive of all demographics including high risk, underserved populations, where there is tremendous potential to improve outcomes and population health with mobile interventions. The next comprehensive review of technologies to enhance cardiovascular health should be one in which ubiquitous technology is used to seamlessly improve the heart health of the nation.