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I have mentioned our large European Union funded Do CHANGE project in previous blogs. Do CHANGE is an acronym for Do Cardiac Health Advanced New Generation Ecosystem. The project aims to improve the health of patients with cardiovascular disease (heart attack patients, those with implanted defribrillators or ICD’s ,and those with heart failure). It will provide patients and their medical teams with a whole new ecosystem to support the changes they need to make to optimize their wellbeing. At the centre of the project will be new Do Something Different programmes, delivered by SMS text/email to a phone or via a patient's tablet 'care' portal . Over several weeks in their home situation, patients will do tailored small new behaviours to break old habits and expand their behavioural flexibility – the key to a healthier life. We are hopeful that – as well as helping with the heart disease risks - the CHD Do Something Different programmes will keep patient anxiety and depression in check, as we usually see in Do Something Different programmes, whatever the target of behavior change. The work is going well and I will update readers periodically.
I have argued strongly that if you want to change behavior, then it is important to focus on behaviours - not on thinking, willpower, information or education (which is not needed for many people who know what they should do). Making small bite-sized changes can provide new experiences and insights that lever the person from their negative past ways. I am pleased to see, therefore, two new research papers, that show how important behavioural risk factors are in morbidity and mortality, and that SMS text-based delivery can assist patients with heart disease.
The first piece of research – done by a very large team lead by Public Health England - was published in the top medical journal The Lancet on 15th September. The team looked at health in England from 1990-2103 from the Global Burden of Disease (GBD) project which measured mortality risk and years lived with chronic health disability. This is a worldwide exercise to integrate the best possible knowledge about the causes of ill-health disability and mortality. The study has been widely reported in the media but those reports concentrated on the finding that diet was now more important than smoking in ill health prediction. This is important, but the study showed something much more important in my view.
The researchers used a new method to measure health burden due to a range of different risk factors, including behavioural risk factors and metabolic risk factors. Behavioural factors include diet, physical activity and smoking, Metabolic risks – which other medical research shows are affected by behavioural factors, included high cholesterol, blood sugar levels, high blood pressure and high body mass index. All of our Do Something Different programmes are focused on behavioural factors and a number of them specifically target the habits seen as so important in this study.
The results that may surprise readers is the large role behavioural risks played in health and disease. The authors measured disability adjusted life years (DALYs) – a measure of life expectancy taking account of chromic disabilities due to disease. Overall, behavioural risks accounted for 28% of the DALYs, with metabolic risks contributing 19.2% and environmental and occupational risks only 4.7%. About half of the DALYs for metabolic risks also overlapped with the behavioural risks confirming interdependence. The aspect of the research that caught the media attention was that – of the behavoural risks – diet was now more important than smoking, with low fruit and vegetable consumption, low intake of whole grains, nuts and seeds, high processed meat consumption and high sugar drinks all being responsible. Each of these areas have been tackled with Do Something Different programmes for such issues as Self-Management of Long Term Conditions, Quit Smoking, No Diet Diet etc. so the research confirms my belief that changing behaviours one step at a time could have a key role in improving health and well-being.
The second piece of research is very different and was done by a team led by Clara Chow in Sydney and published in the Journal of the American Medical Association (JAMA. 2015;314(12):1255-1263. doi:10.1001/jama.2015.10945). It was a randomized clinical trail of providing text messages to patients with coronary heart disease to reduce their ill-health risks, in particular focused on cholesterol levels. Patients either received 4 SMS text messages a week for up to 6 months or ‘treatment as usual’ They had 352 people in the intervention group and 358 in the usual care group. The text messages were simple pieces of information such as “for many it can take several attempts to quit [smoking], so keep trying” , “try avoiding adding salt to your foods by using other spices or herbs” or “walking is cheap. It can be done almost anywhere. .All you need is comfortable shoes and clothing”. Despite the simple informational or exhorting nature of the messages – and that they were not tailored psychologically or behaviourally to the individual as we do in Do Something Different – the effects of receiving the text on health-related measures were excellent. I show some of the key results in the table below (all highly statistically different for the 2 groups).
TEXT Group CONTROL group
Cholesterol (LDL-C mg/DL 79 84
Systolic blood pressure 128 136
% smoking 26 61
Waist circumference (cm) 100.6 105
Total Physical Activity (MET min/wk) 936 643
Achieving at least 3 goal behaviours (%) 63 34
The fact that such simple text reminders can help patients with cardiovascular disease is a confirmation for text-delivery methods and that health behavior and wellbeing can be improved dramatically using SMS text and online tools. The fact that this approach is also scalable makes it a most effective way to bring about health changes. It is likely that providing much more than simple informational texts would be even more beneficial which is why we use Do’s that give the person tailored small behavioural steps to provide them with relevant new experiences and break old habits, or that shape Do’s around the personality of the individual to expand their behavioural repertoire. We will know more about this when the full evaluation study of Do CHANGE is completed, but that will not be for a while yet.
Partially supported by EU Horizon 2020 grant 643735.
