Digitally Supported Lifestyle Intervention to Prevent Type 2 Diabetes Through Healthy Habits: Secondary Analysis of Long-Term User Engagement Trajectories in a Randomized Controlled Trial.

BACKGROUND: Digital health interventions may offer a scalable way to prevent type 2 diabetes (T2D) with minimal burden on health care systems by providing early support for healthy behaviors among adults at increased risk for T2D. However, ensuring continued engagement with digital solutions is a challenge impacting the expected effectiveness. OBJECTIVE: We aimed to investigate the longitudinal usage patterns of a digital healthy habit formation intervention, BitHabit, and the associations with changes in T2D risk factors. METHODS: This is a secondary analysis of the StopDia (Stop Diabetes) study, an unblinded parallel 1-year randomized controlled trial evaluating the effectiveness of the BitHabit app alone or together with face-to-face group coaching in comparison with routine care in Finland in 2017-2019 among community-dwelling adults (aged 18 to 74 years) at an increased risk of T2D. We used longitudinal data on usage from 1926 participants randomized to the digital intervention arms. Latent class growth models were applied to identify user engagement trajectories with the app during the study. Predictors for trajectory membership were examined with multinomial logistic regression models. Analysis of covariance was used to investigate the association between trajectories and 12-month changes in T2D risk factors. RESULTS: More than half (1022/1926, 53.1%) of the participants continued to use the app throughout the 12-month intervention. The following 4 user engagement trajectories were identified: terminated usage (904/1926, 46.9%), weekly usage (731/1926, 38.0%), twice weekly usage (208/1926, 10.8%), and daily usage (83/1926, 4.3%). Active app use during the first month, higher net promoter score after the first 1 to 2 months of use, older age, and better quality of diet at baseline increased the odds of belonging to the continued usage trajectories. Compared with other trajectories, daily usage was associated with a higher increase in diet quality and a more pronounced decrease in BMI and waist circumference at 12 months. CONCLUSIONS: Distinct long-term usage trajectories of the BitHabit app were identified, and individual predictors for belonging to different trajectory groups were found. These findings highlight the need for being able to identify individuals likely to disengage from interventions early on, and could be used to inform the development of future adaptive interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT03156478; https://clinicaltrials.gov/ct2/show/NCT03156478. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-019-6574-y.

Longitudinal associations between intuitive eating and weight-related behaviors in a population-based sample of young adults.

Intuitive eating has been associated with markers of better health in cross-sectional studies, but less is known about long-term associations between intuitive eating and subsequent eating and weight-related behaviors. This study assessed how intuitive eating in early adulthood is related to weight status, dieting, healthy and unhealthy weight control behaviors, and binge eating with loss of control five years later. Young adults (N = 1660) were asked about intuitive eating as part of the 2008-2009 third wave of the Project EAT (Eating and Activity in Teens and Young Adults) longitudinal cohort study. Weight status, dieting, healthy and unhealthy weight control behaviors, and binge eating with loss of control were assessed during both the third (EAT-III: mean age 25.3 ± 1.5) and fourth (EAT-IV mean age 31.1 ± 1.5) waves. In analyses adjusted for sociodemographic characteristics, both male and female intuitive eaters had a lower prevalence of high weight status and lower engagement in dieting, unhealthy weight control behaviors, and binge eating at the 5-year follow-up, compared to non-intuitive eaters. Among women, after additional adjustment for EAT-III values for the respective outcome measures, intuitive eating was unrelated to any of the behaviors studied at 5-year follow-up. Among men, intuitive eating predicted a lower likelihood of engaging in unhealthy weight control behaviors (intuitive eaters: 30.0% vs. non-intuitive: 41.9%, p = 0.002) and binge eating (intuitive eaters: 0.9% vs. non-intuitive: 1.5%, p = 0.046) independent of participating in these behaviors at EAT-III. In a population-based sample of young adults, intuitive eating was associated with better markers of eating and weight-related behaviors five years later, suggesting intuitive eating may have potential long-term benefits.

Comprehensive Two-Dimensional Gas Chromatography-Mass Spectrometry Analysis of Exhaled Breath Compounds after Whole Grain Diets.

Exhaled breath is a potential noninvasive matrix to give new information about metabolic effects of diets. In this pilot study, non-targeted analysis of exhaled breath volatile organic compounds (VOCs) was made by comprehensive two-dimensional gas chromatography-mass spectrometry (GCxGC-MS) to explore compounds relating to whole grain (WG) diets. Nine healthy subjects participated in the dietary intervention with parallel crossover design, consisting of two high-fiber diets containing whole grain rye bread (WGR) or whole grain wheat bread (WGW) and 1-week control diets with refined wheat bread (WW) before both diet periods. Large interindividual differences were detected in the VOC composition. About 260 VOCs were detected from exhaled breath samples, in which 40 of the compounds were present in more than half of the samples. Various derivatives of benzoic acid and phenolic compounds, as well as some furanones existed in exhaled breath samples only after the WG diets, making them interesting compounds to study further.

The Effects of Acceptance and Commitment Therapy (ACT) Intervention on Inflammation and Stress Biomarkers: a Randomized Controlled Trial.

BACKGROUND: Psychological processes can be manifested in physiological health. We investigated whether acceptance and commitment therapy (ACT), targeted on psychological flexibility (PF), influences inflammation and stress biomarkers among working-age adults with psychological distress and overweight/obesity. METHOD: Participants were randomized into three parallel groups: (1) ACT-based face-to-face (n = 65; six group sessions led by a psychologist), (2) ACT-based mobile (n = 73; one group session and mobile app), and (3) control (n = 66; only the measurements). Systemic inflammation and stress markers were analyzed at baseline, at 10 weeks after the baseline (post-intervention), and at 36 weeks after the baseline (follow-up). General PF and weight-related PF were measured with questionnaires (Acceptance and Action Questionnaire, Acceptance and Action Questionnaire for Weight-Related Difficulties). RESULTS: A group × time interaction (p = .012) was detected in the high-sensitivity C-reactive protein (hsCRP) level but not in other inflammation and stress biomarkers. hsCRP decreased significantly in the face-to-face group from week 0 to week 36, and at week 36, hsCRP was lower among the participants in the face-to-face group than in the mobile group (p = .035, post hoc test). Age and sex were stronger predictors of biomarker levels at follow-up than the post-intervention PF. CONCLUSION: The results suggest that ACT delivered in group sessions may exert beneficial effects on low-grade systemic inflammation. More research is needed on how to best apply psychological interventions for the health of both mind and body among people with overweight/obesity and psychological distress. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01738256, Registered 17 August, 2012.

The effects of acceptance and commitment therapy on eating behavior and diet delivered through face-to-face contact and a mobile app: a randomized controlled trial.

BACKGROUND: Internal motivation and good psychological capabilities are important factors in successful eating-related behavior change. Thus, we investigated whether general acceptance and commitment therapy (ACT) affects reported eating behavior and diet quality and whether baseline perceived stress moderates the intervention effects. METHODS: Secondary analysis of unblinded randomized controlled trial in three Finnish cities. Working-aged adults with psychological distress and overweight or obesity in three parallel groups: (1) ACT-based Face-to-face (n = 70; six group sessions led by a psychologist), (2) ACT-based Mobile (n = 78; one group session and mobile app), and (3) Control (n = 71; only the measurements). At baseline, the participants' (n = 219, 85% females) mean body mass index was 31.3 kg/m2 (SD = 2.9), and mean age was 49.5 years (SD = 7.4). The measurements conducted before the 8-week intervention period (baseline), 10 weeks after the baseline (post-intervention), and 36 weeks after the baseline (follow-up) included clinical measurements, questionnaires of eating behavior (IES-1, TFEQ-R18, HTAS, ecSI 2.0, REBS), diet quality (IDQ), alcohol consumption (AUDIT-C), perceived stress (PSS), and 48-h dietary recall. Hierarchical linear modeling (Wald test) was used to analyze the differences in changes between groups. RESULTS: Group x time interactions showed that the subcomponent of intuitive eating (IES-1), i.e., Eating for physical rather than emotional reasons, increased in both ACT-based groups (p = .019); the subcomponent of TFEQ-R18, i.e., Uncontrolled eating, decreased in the Face-to-face group (p = .020); the subcomponent of health and taste attitudes (HTAS), i.e., Using food as a reward, decreased in the Mobile group (p = .048); and both subcomponent of eating competence (ecSI 2.0), i.e., Food acceptance (p = .048), and two subcomponents of regulation of eating behavior (REBS), i.e., Integrated and Identified regulation (p = .003, p = .023, respectively), increased in the Face-to-face group. Baseline perceived stress did not moderate effects on these particular features of eating behavior from baseline to follow-up. No statistically significant effects were found for dietary measures. CONCLUSIONS: ACT-based interventions, delivered in group sessions or by mobile app, showed beneficial effects on reported eating behavior. Beneficial effects on eating behavior were, however, not accompanied by parallel changes in diet, which suggests that ACT-based interventions should include nutritional counseling if changes in diet are targeted. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT01738256 ), registered 17 August, 2012.

Psychological flexibility mediates change in intuitive eating regulation in acceptance and commitment therapy interventions.

OBJECTIVE: Despite the promising results related to intuitive eating, few studies have attempted to explain the processes encouraging this adaptive eating behaviour. The focus of the present study was on exploring mechanisms of change in intuitive eating and weight in acceptance and commitment therapy (ACT) interventions. Mediation provides important information regarding the treatment processes and theoretical models related to specific treatment approaches. The study investigates whether psychological flexibility, mindfulness skills and sense of coherence mediated the interventions' effect on intuitive eating and weight. DESIGN: Secondary analysis of a randomized control trial. Mediation analysis compared two ACT interventions - face-to-face (in a group) and mobile (individually) - with a control group using a latent difference score model. Settings Data were collected in three Finnish towns. SUBJECTS: The participants were overweight or obese (n 219), reporting symptoms of perceived stress. RESULTS: The effect of the interventions on participants' (i) BMI, (ii) intuitive eating and its subscales, (iii) eating for physical rather than emotional reasons and (iv) reliance on internal hunger and satiety cues was mediated by changes in weight-related psychological flexibility in both ACT groups. CONCLUSIONS: These findings suggest that ACT interventions aiming for lifestyle changes mediate the intervention effects through the enhanced ability to continue with valued activities even when confronted with negative emotions and thoughts related to weight.

High perceived stress is associated with unfavorable eating behavior in overweight and obese Finns of working age.

Stress-related eating may be a potential factor in the obesity epidemic. Rather little is known about how stress associates with eating behavior and food intake in overweight individuals in a free-living situation. Thus, the present study aims to investigate this question in psychologically distressed overweight and obese working-aged Finns. The study is a cross-sectional baseline analysis of a randomized controlled trial. Of the 339 study participants, those with all the needed data available (n = 297, 84% females) were included. The mean age was 48.9 y (SD = 7.6) and mean body mass index 31.3 kg/m(2) (SD = 3.0). Perceived stress and eating behavior were assessed by self-reported questionnaires Perceived Stress Scale (PSS), Intuitive Eating Scale, the Three-Factor Eating Questionnaire, Health and Taste Attitude Scales and ecSatter Inventory. Diet and alcohol consumption were assessed by 48-h dietary recall, Index of Diet Quality, and AUDIT-C. Individuals reporting most perceived stress (i.e. in the highest PSS tertile) had less intuitive eating, more uncontrolled eating, and more emotional eating compared to those reporting less perceived stress (p < 0.05). Moreover, individuals in the highest PSS tertile reported less cognitive restraint and less eating competence than those in the lowest tertile (p < 0.05). Intake of whole grain products was the lowest among those in the highest PSS tertile (p < 0.05). Otherwise the quality of diet and alcohol consumption did not differ among the PSS tertiles. In conclusion, high perceived stress was associated with the features of eating behavior that could in turn contribute to difficulties in weight management. Stress-related way of eating could thus form a potential risk factor for obesity. More research is needed to develop efficient methods for clinicians to assist in handling stress-related eating in the treatment of obese people.

Real-world effectiveness of digital and group-based lifestyle interventions as compared with usual care to reduce type 2 diabetes risk - A stop diabetes pragmatic randomised trial.

Background: No real-world randomised controlled trials (RCTs) have explored the effectiveness of lifestyle interventions based on multiple behaviour change theories and using combined digital and group-based face-to-face delivery to improve risk factors for type 2 diabetes (T2D). Methods: We conducted a one-year, multi-centre, unblinded, pragmatic RCT in primary healthcare using the habit formation, self-determination, and self-regulation theories among 2907 adults aged 18-74 years at increased T2D risk randomised into a digital lifestyle intervention group (DIGI, n = 967), a combined digital and group-based lifestyle intervention group (DIGI+GROUP, n = 971), and a control group receiving usual care (CONTROL, n = 969). We collected data on primary outcomes (diet quality by Healthy Diet Index [HDI], physical activity, body weight, fasting plasma glucose, 2-hour plasma glucose) and secondary outcomes (sedentary time, waist circumference, fasting plasma insulin) using digital questionnaires, clinical examinations, fasting blood tests, and 2-hour oral glucose tolerance tests. Main statistical analyses were performed using linear mixed-effects models adjusted for age, sex, and province. This RCT was registered with ClinicalTrials.gov, NCT03156478. Findings: The 2907 participants assigned were recruited between March 1st, 2017, and February 28th, 2018. Diet quality improved more (3·2 vs. 1·4 HDI points, p<0·001 for difference between groups, p'<0·001 for group*time interaction) and waist circumference tended to decrease more (-1·8 vs. -1·3 cm, p = 0·028, p' = 0·068) in DIGI+GROUP than in CONTROL. Fasting insulin tended to increase in CONTROL but not in DIGI (1·0 vs. 0·0 mU/L, p = 0·033, p' = 0·054) or in DIGI+GROUP (1·0 vs. 0·5 mU/L, p = 0·042, p' = 0·054). Good adherence to DIGI and DIGI+GROUP (≥median of 501 habits/year in DIGI, ≥5 of all 6 sessions in GROUP) was associated with improved diet quality and good adherence to DIGI with increased physical activity and decreased sedentary time. Interpretation: A lifestyle intervention based on multiple behaviour change theories and combined digital and group-based face-to-face delivery improves diet quality and tends to decrease abdominal adiposity and prevent an increase in insulin resistance. Good adherence improves the results of the interventions. Funding: Strategic Research Council at Academy of Finland, Academy of Finland, Novo Nordisk Foundation, and Finnish Diabetes Research foundation.

Sensory Appeal and Routines Beat Health Messages and Visibility Enhancements: Mixed-Methods Analysis of a Choice-Architecture Intervention in a Workplace Cafeteria.

Easier recognition and enhanced visibility of healthy options supposedly increase healthy choices, but real-world evidence remains scarce. Addressing this knowledge gap, we promoted nutritionally favourable foods in a workplace cafeteria with three choice-architectural strategies-priming posters, point-of-choice nutrition labels, and improved product placement-and assessed their effects on visual attention, food choices, and food consumption. Additionally, we developed a method for analysing real-world eye-tracking data. The study followed a pretest-posttest design whereby control and intervention condition lasted five days each. We monitored visual attention (i.e., total number and duration of fixations) and food choices with eye tracking, interviewed customers about perceived influences on food choices, and measured cafeteria-level food consumption (g). Individual-level data represents 22 control and 19 intervention participants recruited at the cafeteria entrance. Cafeteria-level data represents food consumption during the trial (556/589 meals sold). Results indicated that the posters and labels captured participants' visual attention (~13% of fixations on defined areas of interest before food choices), but the intervention had insignificant effects on visual attention to foods, on food choices, and on food consumption. Interviews revealed 17 perceived influences on food choices, the most common being sensory appeal, healthiness, and familiarity. To conclude, the intervention appeared capable of attracting visual attention, yet ineffective in increasing healthier eating. The developed method enabled a rigorous analysis of visual attention and food choices in a natural choice setting. We discuss ways to boost the impact of the intervention on behaviour, considering target groups' motives. The work contributes with a unique, mixed-methods approach and a real-world setting that enabled a multi-dimensional effects evaluation with high external validity.

Intuitive Eating is Associated With Higher Fruit and Vegetable Intake Among Adults.

OBJECTIVE: Assess how intuitive eating relates to dietary intake. METHODS: Survey data were collected in Project Eating and Activity in Teens and Young Adults, the fourth wave of a longitudinal cohort study (weighted n = 1,830, 49% women; mean age = 31 years). Intuitive eating was assessed using a 7-item scale adapted from the Intuitive Eating Scale and Intuitive Eating Scale-2. Dietary intake was measured via a semiquantitative food frequency questionnaire. Mean servings were stratified by gender and intuitive eating quartiles and adjusted for sociodemographic characteristics and caloric intake. RESULTS: Women and men in the top intuitive eating quartile consumed 0.6-0.3 servings more fruit and 0.4-0.6 servings more vegetables daily, respectively, compared with the bottom quartile, whereas men in the top quartile also consumed 0.6 servings fewer whole grains (all P < 0.05) than the bottom quartile. CONCLUSIONS AND IMPLICATIONS: Intuitive eating shows promise as a healthier alternative to practices such as dieting.

Enhanced Eating Competence Is Associated with Improved Diet Quality and Cardiometabolic Profile in Finnish Adults with Increased Risk of Type 2 Diabetes.

Eating competence (EC) is characterized by positive attitudes towards food and eating, having regular meals, eating a variety of foods, and internally regulated eating. We investigated the associations of changes in EC with changes in lifestyle, anthropometrics and biomarkers of glucose and lipid metabolism in 2291 adults at increased risk of type 2 diabetes as part of the StopDia study conducted in primary healthcare. EC and diet quality were assessed with validated digital questionnaires. During the intervention, the participants received either (1) the digital lifestyle intervention, (2) the combined digital and face-to-face group-based lifestyle intervention, or (3) standard care. EC increased among the participants independent of the intervention type. Increase in EC was associated with an increase in diet quality, high-density lipoprotein (HDL) cholesterol, and with a decrease in body mass index and waist circumference, regardless of baseline EC. Of the subdomains of EC, the contextual skills, food acceptance and eating attitudes were associated with various of these changes. Our results thus suggest that EC could be a potential target in lifestyle interventions aiming to improve the cardiometabolic health of people at type 2 diabetes risk.

Sleep-time physiological recovery is associated with eating habits in distressed working-age Finns with overweight: secondary analysis of a randomised controlled trial.

BACKGROUND: Association of physiological recovery with nutrition has scarcely been studied. We investigated whether physiological recovery during sleep relates to eating habits, i.e., eating behaviour and diet quality. METHODS: Cross-sectional baseline analysis of psychologically distressed adults with overweight (N = 252) participating in a lifestyle intervention study in three Finnish cities. Recovery measures were based on sleep-time heart rate variability (HRV) measured for 3 consecutive nights. Measures derived from HRV were 1) RMSSD (Root Mean Square of the Successive Differences) indicating the parasympathetic activation of the autonomic nervous system and 2) Stress Balance (SB) indicating the temporal ratio of recovery to stress. Eating behaviour was measured with questionnaires (Intuitive Eating Scale, Three-Factor Eating Questionnaire, Health and Taste Attitude Scales, ecSatter Inventory™). Diet quality was quantified using questionnaires (Index of Diet Quality, Alcohol Use Disorders Identification Test Consumption) and 48-h dietary recall. RESULTS: Participants with best RMSSD reported less intuitive eating (p = 0.019) and less eating for physical rather than emotional reasons (p = 0.010) compared to those with poorest RMSSD; participants with good SB reported less unconditional permission to eat (p = 0.008), higher fibre intake (p = 0.028), higher diet quality (p = 0.001), and lower alcohol consumption (p < 0.001) compared to those with poor SB, although effect sizes were small. In subgroup analyses among participants who reported working regular daytime hours (n = 216), only the associations of SB with diet quality and alcohol consumption remained significant. CONCLUSIONS: Better nocturnal recovery showed associations with better diet quality, lower alcohol consumption and possibly lower intuitive eating. In future lifestyle interventions and clinical practice, it is important to acknowledge sleep-time recovery as one possible factor linked with eating habits. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01738256 , Registered 17 August 2012.

Plasma lipid profile associates with the improvement of psychological well-being in individuals with perceived stress symptoms.

Psychological stress is a suggested risk factor of metabolic disorders, but molecular mediators are not well understood. We investigated the association between the metabolic profiles of fasting plasma and the improvement of psychological well-being using non-targeted liquid chromatography-mass spectrometry (LC-MS) platform. The metabolic profiles of volunteers participating in the face-to-face intervention group (n = 60) in a randomised lifestyle intervention were compared to ones of controls (n = 64) between baseline and 36-week follow-up. Despite modest differences in metabolic profile between groups, we found associations between phosphatidylcholines (PCs) and several parameters indicating stress, adiposity, relaxation, and recovery. The relief of heart-rate-variability-based stress had positive, while improved indices of recovery and relaxation in the intervention group had an inverse association with the reduction of e.g. lysophosphatidylcholines (LPC). Interleukin-1 receptor antagonist and adiposity correlated positively with the suppressed PCs and negatively with the elevated plasmalogens PC(P-18:0/22:6) and PC(P-18:0/20:4). Also, we found changes in an unknown class of lipids over time regardless of the intervention groups, which also correlated with physiological and psychological markers of stress. The associations between lipid changes with some markers of psychological wellbeing and body composition may suggest the involvement of these lipids in the shared mechanisms between psychological and metabolic health.

Leisure-time physical activity and intra-abdominal fat in young adulthood: A monozygotic co-twin control study.

OBJECTIVE: To investigate differences in abdominal fat compartments between young adult monozygotic twin pairs discordant for leisure-time physical activity. METHODS: Ten young adult male monozygotic twin pairs (age range 32-36 years) discordant for leisure-time physical activity during the past 3 years were systematically selected from a population-based Finnish twin cohort. Magnetic resonance image at the level of the L2-L3 intervertebral disc was used to predict intra-abdominal and subcutaneous abdominal fat masses. Dietary intake was assessed with a 4-day food diary. RESULTS: Inactive twins had 31% more intra-abdominal fat than their active co-twins (mean difference 0.52 kg, 95% CI 0.12 to 0.91, P = 0.016), whereas the difference in subcutaneous abdominal fat was only 13% (P = 0.21) and 3% in body mass index (P = 0.28). Intraperitoneal fat mass was 41% higher among inactive twins compared to their active co-twins (mean difference 0.41 kg, 95% CI 0.11 to 0.70, P = 0.012). Dietary intake did not differ between co-twins. CONCLUSIONS: A lower level of physical activity is related to greater accumulation of intra-abdominal fat among healthy adult males in their mid-30s. The findings highlight the importance of leisure-time physical activity independent of genes and diet in the prevention of intra-abdominal fat accumulation from early adulthood onward.

Subjective stress, objective heart rate variability-based stress, and recovery on workdays among overweight and psychologically distressed individuals: a cross-sectional study.

BACKGROUND: The present study aimed to investigate how subjective self-reported stress is associated with objective heart rate variability (HRV)-based stress and recovery on workdays. Another aim was to investigate how physical activity (PA), body composition, and age are associated with subjective stress, objective stress, and recovery. METHODS: Working-age participants (n = 221; 185 women, 36 men) in this cross-sectional study were overweight (body mass index, 25.3-40.1 kg/m(2)) and psychologically distressed (≥3/12 points on the General Health Questionnaire). Objective stress and recovery were based on HRV recordings over 1-3 workdays. Subjective stress was assessed by the Perceived Stress Scale. PA level was determined by questionnaire, and body fat percentage was assessed by bioelectrical impedance analysis. RESULTS: Subjective stress was directly associated with objective stress (P = 0.047) and inversely with objective recovery (P = 0.046). These associations persisted after adjustments for sex, age, PA, and body fat percentage. Higher PA was associated with lower subjective stress (P = 0.037). Older age was associated with higher objective stress (P < 0.001). After further adjustment for alcohol consumption and regular medication, older age was associated with lower subjective stress (P = 0.043). CONCLUSIONS: The present results suggest that subjective self-reported stress is associated with objective physiological stress, but they are also apparently affected by different factors. However, some of the found associations among these overweight and psychologically distressed participants with low inter-individual variation in PA are rather weak and the clinical value of the present findings should be studied further among participants with greater heterogeneity of stress, PA and body composition. However, these findings suggest that objective stress assessment provides an additional aspect to stress evaluation. Furthermore, the results provide valuable information for developing stress assessment methods.