Urinary levels of 30 metal/metalloids in the Brazilian southeast population: Findings from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

The assessment of risks associated with environmental exposure to metals/metalloids requires well-established reference values for each population since it varies considerably according to distinct local/regional characteristics. However, very few studies establish baseline values for these elements (essential and toxic) in large population groups, especially in Latin American countries. This study was aimed at establishing urinary reference levels of 30 metals/metalloids: aluminum (Al), antimony (Sb), arsenic (As), barium (Ba), beryllium (Be), cadmium (Cd), cerium (Ce), cesium (Cs), chromium (Cr), cobalt (Co), copper (Cu), lanthanum (La), lead (Pb), lithium (Li), strontium (Sr), manganese (Mn), mercury (Hg), molybdenum (Mo), nickel (Ni), platinum (Pt), rubidium (Rb), selenium (Se), silver (Ag), tin (Sn), tellurium (Te), thallium (Tl), thorium (Th), tungsten (W), uranium (U) and zinc (Zn) in a Brazilian southeast adult population. This pilot study is a cross-sectional analysis conducted with the first wave of the ELSA-Brasil cohort (baseline examination). A total of 996 adults (45.5% men, N = 453, mean age: 50.5, and 54.5% women, N = 543, mean age: 50.6) were included in the study. Sample analyses were performed by Inductively Coupled Plasma Mass Spectrometry (ICP-MS). Percentiles (2.5, 10, 25, 50, 75, 95 (CI95%), and 97.5) of each element (µg/g of creatinine) in the study are presented according to sex. Moreover, differences in the mean metal/metalloid urinary levels according to age, education, smoking, and alcohol intake are also presented. Finally, median found values were compared to established values of large human biomonitoring surveys previously conducted in North America and France. This is the first comprehensive and systematic human biomonitoring study that established population reference ranges for 30 (essential and/or toxic elements) in a Brazilian population group.

Social support modifies the negative effects of acculturation on obesity and central obesity in Mexican men.

Background: This study examined the moderating role of social support in the acculturation-obesity/central obesity relationship in Mexican American (MA) men and women. Methods: Data from NHANES 1999-2008 were used. Acculturation derived from language use, country of birth and length of residence in the U.S. Social support assessed emotional and financial support. BMI (≥30) and waist circumference (≥88 cm for women; ≥102 cm for men) measured obesity and central obesity, respectively. Weighted multivariate logistic regression models were used to describe associations. Results: Compared to less acculturation, more acculturation was associated with higher odds of obesity (ORs 2.48; 95% CI 1.06-5.83) and central obesity (2.90; 1.39-6.08) among MA men with low/no social support, but not among MA men reporting high social support. The modifying effects was not observed among women. Conclusion: Higher amounts of social support appeared to attenuate the risk of obesity/central obesity associated with acculturation. Interventions enhancing social support maybe effective among acculturated MAs, particularly among men.

Effect of Health Information Technologies on Cardiovascular Risk Factors among Patients with Diabetes.

PURPOSE OF REVIEW: To identify a common effect of health information technologies (HIT) on the management of cardiovascular disease (CVD) risk factors among people with type 2 diabetes (T2D) across randomized control trials (RCT). RECENT FINDINGS: CVD is the most frequent cause of morbidity and mortality among patients with diabetes. HIT are effective in reducing HbA1c; however, their effect on cardiovascular risk factor management for patients with T2D has not been evaluated. We identified 21 eligible studies (23 estimates) with measurement of SBP, 20 (22 estimates) of DBP, 14 (17 estimates) of HDL, 14 (17 estimates) of LDL, 15 (18 estimates) of triglycerides, and 10 (12 estimates) of weight across databases. We found significant reductions in SBP, DBP, LDL, and TG, and a significant improvement in HDL associated with HIT. As adjuvants to standard diabetic treatment, HIT can be effective tools for improving CVD risk factors among patients with T2D, especially in those whose CVD risk factors are not at goal.

Sugar-Sweetened Beverage, Obesity, and Type 2 Diabetes in Children and Adolescents: Policies, Taxation, and Programs.

PURPOSE OF REVIEW: Obesity has grown at an alarming rate in children and adolescents. Concurrently, consumption on sugar-sweetened beverages (SSBs) also rose significantly. This review provides an overview of obesity and type 2 diabetes mellitus (T2DM) related to SSBs and current policies restricting SSBs in schools, school-based interventions, and taxation on reducing SSB intake and obesity. We also discuss challenges of and future steps for these initiatives. RECENT FINDINGS: Clinical and epidemiological studies suggest a strong association between SSB intake and obesity and T2DM. School food policies have been initiated at federal, state, and local levels. School-based interventions have shown positive effects on SSB intake and obesity reduction. Taxation on SSBs is promising in combating obesity and in generating revenue. Challenges towards compliance and implementation of the policies and programs exist. The relationship between SSB and obesity and T2DM is a complex problem which requires comprehensive solutions. Continued efforts in restricting SSBs in schools are needed. Intervention programs should be tailored to age, gender, language, and culture and involve participation from families and local communities. Taxation can reduce SSB consumption by direct economic incentive, earmarking revenues to support healthy foods, and sending negative message. However, a higher tax rate may be necessary to have a measurable effect on weight.

Effect of Health Information Technologies on Glycemic Control Among Patients with Type 2 Diabetes.

PURPOSE OF REVIEW: This study was to present meta-analysis findings across selected clinical trials for the effect of health information technologies (HITs) on glycemic control among patients with type 2 diabetes. RECENT FINDINGS: HITs may be promising in diabetes management. However, findings on effect size of glycated hemoglobin level (HbA1c) yielded from HITs varied across previous studies. This is likely due to heterogeneity in sample size, adherence to standard quantitative method, and/or searching criteria (e.g., type of HITs, type of diabetes, specification of patient population, randomized vs. nonrandomized trials). We systematically searched Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and the Cochrane Library for peer-reviewed randomized control trials that studied the effect of HITs on HbA1c reduction. We also used Google Scholar and a hand search to identify additional studies. Thirty-four studies (40 estimates) met the criteria and were included in the analysis. Overall, introduction of HITs to standard diabetes treatment resulted in a statistically and clinically reduced HbA1c. The bias adjusted HbA1c reduction due to the combined HIT interventions was - 0.56 [Hedges' g = - 0.56 (- 0.70, - 0.43)]. The reduction was significant across each of the four types of HIT intervention under review, with mobile phone-based approaches generating the largest effects [Hedges' g was - 0.67 (- 0.90, - 0.45)]. HITs can be an effective tool for glycemic control among patients with type 2 diabetes. Future studies should examine long-term effects of HITs and explore factors that influence their effectiveness.

Breast cancer related perceptions and practices of health professionals working in Brazil's network of primary care units.

In 2004 the Brazilian National Cancer Institute (INCA) established breast cancer screening guidelines for women in Brazil: annual clinical breast exam for women age 40-49 and biennial mammogram for women age 50-69. Healthcare provider's adherence to these guidelines is currently unknown. The objective of this study is to describe the perceptions and practices related to breast cancer screening among physicians, nurses, and health unit coordinators working in the network of primary healthcare units (HCUs) in Brazil. In 2011, 1600 primary HCUs were randomly sampled from all regions in Brazil. At each HCU the coordinator and one health professional were asked to participate in a telephone survey to gathered information on their knowledge, attitudes, and practices related to breast cancer screening. Participation rates for coordinators, physicians, and nurses were 78%, 34%, and 65% respectively. Health unit coordinators identified numerous barriers that prevent patients from receiving appropriate screening, many (44%) were unaware of INCA cancer screening guidelines. Despite a high perceived impact of INCA guidelines, a majority of physicians and nurses did not follow them. Most physicians and nurses recommended mammograms on an annual basis (~75%) and 50.9% of nurses and 25.1% of physicians initiated routine breast cancer screening in women under age 40. Physicians and nurses in Brazil screen at younger ages and more frequently than recommended by INCA guidelines. Given that primary HCUs are the source of health care for many women, interventions that educate healthcare providers on the appropriate ages and intervals for breast cancer screening may prove useful.

Ovarian Cancer Survival in Missouri, 1996-2014.

We evaluated relative survival (RS) for ovarian cancer (OC) overall, by demographic and by clinicopathological characteristics in Missouri. Survival data from the Missouri Cancer Registry were obtained for cases diagnosed 1996-2014. An improved OC survival, especially in late stage, was observed in the study period. Our findings showed demographic, especially race-associated, and geographical variations of OC survival. OC survival also differed by first course treatment received and histology. These differences indicate disparities in OC care.

Effectiveness of a scaled up physical activity intervention in Brazil: A natural experiment.

Physical inactivity causes 5.3 million deaths annually worldwide. We evaluated the impact on population leisure-time physical activity (LTPA) of scaling up an intervention in Brazil, Academia das Cidades program (AC-P). AC-P is a health promotion program classified as physical activity classes in community settings which started in the state of Pernambuco state in 2008. We surveyed households from 80 cities of Pernambuco state in 2011, 2012 and 2013, using monitoring data to classify city-level exposure to AC-P. We targeted 2370 individuals in 2011; 3824 individuals in 2012; and 3835 individuals in 2013. We measured participation in AC-P and whether respondents had seen an AC-P activity or heard about AC-P. We measured LTPA using the International Physical Activity Questionnaire. We estimated the odds of reaching recommended LTPA by levels of exposure to the three AC-P measures. For women, the odds of reaching recommended LTPA were 1.10 for those living in cities with AC-P activity for less than three years, and 1.46 for those living in cities with AC-P activity for more than three years compared to those living in cities that had not adopted AC-P. The odds of reaching recommended LTPA increased with AC-P participation and knowledge about AC-P. AC-P exposure is associated with increased population LTPA. Extending AC-P to all cities could potentially impact non-communicable diseases in Brazil.

Health promoting practices and personal lifestyle behaviors of Brazilian health professionals.

BACKGROUND: This study was conducted to examine the lifestyle behaviors and health promoting practices of physicians, nurses, and community health workers in Brazil. METHODS: A random sample of primary health care units in Brazil was selected, and a pretested questionnaire was administered via phone interviews, in 2011, to 182 physicians, 347 nurses, and 269 community health workers, totaling 798 health professionals. The total initial sample included 1600 eligible health professionals. Variables measured included physical activity, alcohol intake, hours of sleep, diet, and perceived self-efficacy to provide preventive counseling on related lifestyle behaviors. RESULTS: More than 25 % of physicians, nurses, and community health workers reported eating 0-2 portions of fruits and vegetables per day. In terms of cervical and breast cancer, nurses reported to be 'very prepared' to advise patients on these topics more frequently than physicians. The prevalence of smoking ranged from 4.9 % among nurses to 7.4 % among community health workers. The proportion of physical inactivity ranged from 40.3 % among nurses to 52.1 % among community health workers. CONCLUSION: A reasonably high proportion of physicians, nurses, and community health workers report not engaging in healthy lifestyle behaviors that impact chronic diseases, thus, they may be less likely to encourage such behaviors in their patients.

A Strategy for Addressing Population Health Management.

CONTEXT: Population health management in the era of the Affordable Care Act focuses on identifying needs of health care service areas for targeted strategies. The United States has a "health disadvantage" compared with peer countries, particularly regarding obesity and women's life expectancy, while having high rates of mammography screening. Emphasizing lifestyle factors is a strategy to reduce one's risk of obesity and heart disease, as well as some breast cancers. OBJECTIVE: We explored perceptions of the risk of female population-based breast cancer mortality compared with heart disease mortality; perceived likelihood of developing breast cancer; and recognition of the association between modifiable lifestyle factors and breast cancer risk. DESIGN: Cross-sectional online survey. SETTING: Service area of one mid-Missouri health care system. PARTICIPANTS: Female US residents ages 35 to 49 years who did not have a personal history of any cancer. RESULTS: Minority women and women with a college education or less had greater odds of reporting that breast cancer, rather than heart disease, would cause more deaths in women this year. Women who had ever had a mammogram had greater odds of reporting a moderate/high compared with low likelihood of developing breast cancer. Women with less than a college education had greater odds of not knowing of any lifestyle behaviors or reporting only clinical behaviors related to reducing one's risk of breast cancer. CONCLUSIONS: The present study illuminates areas of lagging information dissemination that may be used for targeted strategies for population health management in the era of the Affordable Care Act, that of bridging healthy lifestyle strategies for heart health with messages for breast health.

Providers' knowledge, attitudes, and practices related to colorectal cancer control in Brazil.

In Brazil, colorectal cancer (CRC) is the fourth most common cause of cancer-related death among men, and the third most common among women. We aimed to examine CRC screening-related knowledge, attitudes, and practices among physicians and nurses working in Brazil's network of health units, and to describe the capacity of these units for CRC screening. In 2011, 1600 health units were randomly selected from all 26 states and the Federal District. One coordinator and one health care provider were selected for the interview. Response rates were 78% for coordinators, 34% for physicians, and 65% for nurses. The Brazilian National Cancer Institute (INCA) recommendations for CRC screening were not often used in the health units, but screening outreach and use of CRC exams were more common in units that were using them. Physicians and nurses differed in most characteristics, and in their knowledge, attitudes, and practices of CRC screening. Forty-seven percent of physicians reported not conducting CRC screening compared to 65% of nurses. Fecal occult blood test was most often used by physicians and nurses, but fewer physicians than nurses perceived this exam as very effective in reducing CRC mortality. Physicians' gender, years since graduation, and geographical region of practice in Brazil were associated to CRC screening practice. The findings may reflect the low influence of INCA CRC screening recommendations, physicians receiving their medical education when CRC burden in Brazil was of low concern, and the lack of CRC screening capacity in some regions of Brazil.

A priority health index identifies the top six priority risk and related factors for non-communicable diseases in Brazilian cities.

BACKGROUND: In Brazil, 72% of all deaths in 2007 were attributable to non-communicable diseases (NCD). We used a risk and related factor based index to prioritize NCD prevention programs in the combined 26 capital cities and the federal district (i.e., Brasilia) of Brazil. METHODS: We used 2006-2011 data (adults) from census and Brazil's surveillance of 12 NCD risk factors and 74 disease group mortality. The risk and related factors were: smoking, physical inactivity, overweight-obesity, low fruits and vegetables intake, binge drinking, insufficient Pap smear screening (women aged 25 to 59 years), insufficient mammography screening (women aged 50 to 69 years), insufficient blood pressure screening, insufficient blood glucose screening, diagnosis of hypercholesterolemia, diagnosis of hypertension and diagnosis of diabetes. We generated six indicators: intervention reduction of the risk factor prevalence, intervention cost per person, prevalence of risk factor, deaths attributable to risk factor, risk factor prevalence trend and ratio of risk factor prevalence between people with and without a high school education. We transformed risk and related factor indicators into priority scores to compute a priority health index (PHI). We implemented sensitivity analysis of PHI by computing it with slightly altered formulas and altering values of indicators under the assumption of bias in their estimation. We ranked risk factors based on PHI values. RESULTS: We found one intermediate (i.e., overweight-obesity) and six top risk and related factors priorities for NCD prevention in Brazil's large urban areas: diagnosed hypertension, physical inactivity, blood pressure screening, diagnosed hypercholesterolemia, smoking and binge drinking. CONCLUSION: Brazil has already prioritized the six top priorities (i.e., hypertension, physical inactivity, blood pressure screening, hypercholesterolemia, smoking and binge drinking) and one intermediate priority (i.e., overweight-obesity) for NCD prevention identified in this report. Because effective interventions to reduce disease burden associated with each of the six priority risk factors are available, strategies based on these interventions need to be sustained in order to reduce NCD burden in Brazil. PHI can be used to track NCD prevention and health promotion actions at the local and national level in Brazil and in countries with similar public health surveillance systems.

Association of knowledge, preventive counseling and personal health behaviors on physical activity and consumption of fruits or vegetables in community health workers.

BACKGROUND: There is evidence that if a health professional is active and has a healthy diet, he/she is more likely to advise patients about the benefits of physical activity and healthy eating The aims of this study were to: (1) describe the personal physical activity, consumption of fruits and vegetables behaviors and nutritional status of community health workers; (2) evaluate the association between knowledge, delivery of preventive counseling and personal behaviors among community health workers. METHODS: This was a cross-sectional study conducted in a nationally sample of health professionals working in primary health care settings in Brazil in 2011. This survey was part of the second phase of the Guide for Useful Interventions for Activity in Brazil and Latin America project, and data were collected through telephone interviews of 269 community health workers from the Unified Health Care system of Brazil. We applied questionnaires about personal reported behaviors, knowledge and preventive counseling in physical activity and consumption of fruits and vegetables. We calculated the prevalence and associations between the variables with logistic regression. RESULTS: The proportion of community health workers that practiced 150 minutes per week of physical activity in leisure time or transportation was high (64.9%). Half of community health workers were overweight and only 26.2% reported consuming five portions/day of fruits or vegetables. Most community health workers reported counseling about physical activity for more than six months (59.7%), and most were not knowledgeable of the fruits and vegetables and physical activity recommendations. Meeting the fruits and vegetables recommendations was associated with correct knowledge (OR = 4.5; CI95% 1.03;19.7), with reporting 150 minutes or more of physical activity per week (OR = 2.0; CI95% 1.03;3.7) and with reporting physical activity in leisure time (OR = 2.0; CI95% 1.05;3.6). Regular physical activity counseling was associated with reporting 10-149 minutes per week (OR = 3.8; CI95% 1.1;13.3) and with more than 150 minutes of physical activity per week (OR = 4.9; CI95% 1.5;16.5). CONCLUSION: Actions to promote physical activity and healthy eating and to improve knowledge among community health workers within the health care system of Brazil could have a potential positive influence on delivery of preventive counseling to patients on this topic.

Effects of Massachusetts health reform on the use of clinical preventive services.

BACKGROUND: Expansion of health insurance coverage, and hence clinical preventive services (CPS), provides an opportunity for improvements in the health of adults. The degree to which expansion of health insurance coverage affects the use of CPS is unknown. OBJECTIVE: To assess whether Massachusetts health reform was associated with changes in healthcare access and use of CPS. DESIGN: We used a difference-in-differences framework to examine change in healthcare access and use of CPS among working-aged adults pre-reform (2002-2005) and post-reform (2007-2010) in Massachusetts compared with change in other New England states (ONES). SETTING: Population-based, cross-sectional Behavioral Risk Factor Surveillance System surveys. PARTICIPANTS: A total of 208,831 survey participants aged 18 to 64 years. INTERVENTION: Massachusetts health reform enacted in 2006. MEASUREMENTS: Four healthcare access measures outcomes and five CPS. KEY RESULTS: The proportions of adults who had health insurance coverage, a healthcare provider, no cost barrier to healthcare, an annual routine checkup, and a colorectal cancer screening increased significantly more in Massachusetts than those in the ONES. In Massachusetts, the prevalence of cervical cancer screening in pre-reform and post-reform periods was about the same; however, the ONES had a decrease of -1.6 percentage points (95 % confidence interval [CI] -2.5, -0.7; p <0.001). As a result, the prevalence of cervical cancer screening in Massachusetts was increased relative to the ONES (1.7, 95 % CI 0.2, 3.2; p = 0.02). Cholesterol screening, influenza immunization, and breast cancer screening did not improve more in Massachusetts than in the ONES. LIMITATIONS: Data are self-reported. CONCLUSIONS: Health reform may increase healthcare access and improve use of CPS. However, the effects of health reform on CPS use may vary by type of service and by state.

Comparison of Three Deep Learning Models in Accurate Classification of 770 Dermoscopy Skin Lesion Images.

Accurately determining and classifying different types of skin cancers is critical for early diagnosis. In this work, we propose a novel use of deep learning for classification of benign and malignant skin lesions using dermoscopy images. We obtained 770 de-identified dermoscopy images from the University of Missouri (MU) Healthcare. We created three unique image datasets that contained the original images and images obtained after applying a hair removal algorithm. We trained three popular deep learning models, namely, ResNet50, DenseNet121, and Inception-V3. We evaluated the accuracy and the area under the curve (AUC) receiver operating characteristic (ROC) for each model and dataset. DenseNet121 achieved the best accuracy (80.52%) and AUC ROC score (0.81) on the third dataset. For this dataset, the sensitivity and specificity were 0.80 and 0.81, respectively. We also present the SHAP (SHapley Additive exPlanations) values for the predictions made by different models to understand their interpretability.

Physical activity counseling in primary health care in Brazil: a national study on prevalence and associated factors.

BACKGROUND: The aim of this study was to determine the prevalence and correlates of physical activity counseling among physicians and nurses working in primary health care in Brazil. METHODS: A phone survey was carried out in 2011 with professionals working in primary health care in Brazil. The target sample consisted of 1,600 randomly selected primary care units covering all regions of the country. We successfully interviewed 529 professionals within the sampled units; 182 physicians and 347 nurses. The overall response rate was 49.6%. Multivariable logistic regression was used to estimate correlates of counseling in the whole sample and separately for physicians and nurses. RESULTS: The prevalence of regular physical activity counseling for at least six months was 68.9% (95% CI 64.9; 72.8) and was significantly higher among physicians compared to nurses (p < 0.05). Most professionals (93.2%) interviewed were unfamiliar with current physical activity recommendations for health. In the adjusted analysis, physical activity counseling was more frequent among those who report assessing patient's physical activity (OR = 2.16; 95% CI 1.41; 3.29), those reporting that lack of time was not a barrier for counseling (OR = 0.62 95% CI 0.42-0.93), those who felt prepared to provide physical activity counseling (OR = 2.34; 95% CI 1.50-3.66), and those working at primary care units offering physical activity programs for patients (OR = 2.06; 95% CI 1.33-3.20). In the stratified analysis, only assessing patient's physical activity was a significant correlate among physicians whereas assessing patient's physical activity, feeling prepared to provide counseling and working in units with physical activity interventions were significant correlates among nurses. CONCLUSIONS: Physicians and nurses deemed physical activity counseling of great importance in primary health care in Brazil. However, in order to increase the quality of counseling and the number of professionals engaging in this activity, these health teams require greater knowledge about physical activity (global recommendations for health) as well as training on the application of instruments for assessing physical activity. Moreover, sufficient time must be allowed during consultations for the counseling process, and physical activity promotion programs should be implemented within the primary health care units.

Association between leisure-time physical activity and self-reported hypertension among Brazilian adults, 2008.

INTRODUCTION: Physical inactivity is a risk factor for hypertension. The objective of this study was to examine the association between self-reported leisure-time physical activity and hypertension among Brazilian adults categorized by sex and body weight. METHODS: The study used data from adult respondents in 26 capital cities and the Federal District to VIGITEL (N = 54,353), Brazil's 2008 national surveillance system for risk and protective factors for chronic diseases. We conducted a multivariate logistic regression analysis to investigate the association between self-reported leisure-time physical activity and hypertension and examined whether sex or body weight modified this relationship. RESULTS: The prevalence of self-reported hypertension was high among women, older people, and people with fewer years of education. Overall, leisure-time physical activity decreased with increasing age, increased with increasing education level, and was higher among men than women. The association for leisure-time physical activity and hypertension was modified by sex but not body weight. Leisure-time physical activity reduced the odds of hypertension in men. CONCLUSION: On the basis of self-reporting, leisure-time physical activity may be protective against hypertension in Brazilian men. Inclusion of other physical activity domains in the analyses may be necessary to fully understand the complex relationship between physical activity and hypertension by sex. In addition, public health priorities in Brazil for improving physical activity can target the entire population and not just those who are overweight or obese.

The United States public health services failure to control the coronavirus epidemic.

The unprecedented COVID-19 epidemic in the United States (US) and worldwide, caused by a new type of coronavirus (SARS-CoV-2), occurred mostly because of higher-than-expected transmission speed and degree of virulence compared with previous respiratory virus outbreaks, especially earlier Coronaviruses with person-to-person transmission (e.g., MERS, SARS). The epidemic's size and duration, however, are mostly a function of failure of public health systems to prevent/control the epidemic. In the US, this failure was due to historical disinvestment in public health services, key players equivocating on decisions, and political interference in public health actions. In this communication, we present a summary of these failures, discuss root causes, and make recommendations for improvement with focus on public health decisions.

The Role of Healthy Diet and Lifestyle in Centenarians.

Life expectancy at birth (hereafter, life expectancy) and longevity are established indicators of population health [...].

Analysis of Healthy Coping Feedback Messages from Diabetes Mobile Apps: Validation Against an Evidence-Based Framework.

BACKGROUND: In this study, we focused on Healthy Coping, a key principle of ADCES7 Self-Care Behaviors® (ADCES7®) that enables people with diabetes to achieve health goals for self-care. We aimed to validate Healthy Coping-related feedback messages from diabetes mobile apps against the framework based on behavioral change theories. METHODS: We searched apps using the search terms: "diabetes," "blood sugar," "glucose," and "mood" from iTunes and Google Play stores. We entered a range of values on 3 Healthy Coping domains: (1) diabetes-related measures including blood glucose, blood pressure, HbA1c, weight, (2) physical exercise/activity, and (3) mood to generate feedback messages. We used a framework by adopting validated behavioral change theory-based models to evaluate the feedback messages against 3 dimensions of timing, intention, and content (feedback purpose and feedback response). The feedback purposes in this study were categorized into 7 purposes; warning, suggestion, self-monitoring, acknowledging, reinforcement, goal setting, and behavior contract. RESULTS: We identified 1,749 apps from which 156 diabetes mobile apps were eligible and generated 473 feedback messages. The majority of generated feedback messages were related to blood sugar measurement. Only feedback messages on blood sugar under diabetes-related measures and mood domains encompassed all 7 feedback purposes under the content dimension. CONCLUSIONS: Many feedback messages neither supported Healthy Coping domains nor followed the behavioral theory-based framework. It is important that feedback messages be structured around the dimensions of the behavioral theory-based framework to promote behavior change. Furthermore, our framework had the generalizability that can be used in other clinical areas.