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Cardiovascular risk self-management in older people: Development and
evaluation of an eHealth platform
Beishuizen, C.R.L.
Publication date
2018
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Citation for published version (APA):
Beishuizen, C. R. L. (2018). Cardiovascular risk self-management in older people:
Development and evaluation of an eHealth platform.
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J Med Internet Res. 2016 Mar 11;18(3):e55
Cathrien R. L. Beishuizen, Blossom C. M. Stephan, Willem A. van
Gool, Carol Brayne, Ron J. G. Peters, Sandrine Andrieu, Miia Kivipelto, Hilkka Soininen, Wim B. Busschers, Eric P. Moll van Charante and Edo Richard
web-based interventions targeting
cardiovascular risk factors in
middle-aged and older people: a systematic
review and meta-analysis
Chapter 2
J Med Internet Res. 2016 Mar 11;18(3):e55
Cathrien R. L. Beishuizen, Blossom C. M. Stephan, Willem A. van
Gool, Carol Brayne, Ron J. G. Peters, Sandrine Andrieu, Miia Kivipelto, Hilkka Soininen, Wim B. Busschers, Eric P. Moll van Charante and Edo Richard
web-based interventions targeting
cardiovascular risk factors in
middle-aged and older people: a systematic
review and meta-analysis
Chapter 2
28
ABSTRACT
Background Web-based interventions can improve single cardiovascular risk factors
in adult populations. In view of global ageing and the associated increasing burden of cardiovascular disease, older people form an important target population as well.
Objectives In this systematic review and meta-analysis, we evaluate whether
web-based interventions for cardiovascular risk factor management reduce the risk of cardiovascular disease in older people.
Methods Embase, Medline, Cochrane and Cinahl were systematically searched from
1995 to November 2014. Search terms included cardiovascular risk factors and diseases (specified), web-based interventions (and synonyms) and randomised controlled trial. Two authors independently performed study selection, data-extraction and risk of bias assessment. In a meta-analysis, outcomes regarding treatment effects on cardiovascular risk factors (blood pressure, HbA1C, LDL-cholesterol, smoking status, weight and physical inactivity) and incident cardiovascular disease were pooled with random effects models.
Results 57 studies (n=19,862) fulfilled eligibility criteria and 47 studies contributed to
meta-analysis. A significant reduction in systolic blood pressure (-2.66 mmHg; 95%CI, -3.81 to -1.52), diastolic blood pressure (-1.26 mmHg; 95%CI, -1.92 to -0.60), HbA1c level (-0.13 %; 95%CI, -0.22 to -0.05), LDL-cholesterol level (-2.18 mg/dL; 95%CI, -3,96 to -0.41), weight (-1.34 kg; 95%CI -1.91 to -0.77) and an increase of physical activity (standardised mean difference 0.25; 95%CI, 0.10 to 0.39) in the web-based intervention group was found. The observed effects were more pronounced in studies with short (<12 months) follow-up and studies that combined the internet-application with human support (blended care). No difference in incident cardiovascular disease was found between groups (6 studies).
Conclusions Web-based interventions have the potential to improve the cardiovascular
risk profile of older people, but the effects are modest and decline with time. Currently, there is insufficient evidence for an effect on incident cardiovascular disease. A focus on long-term effects, clinical endpoints and strategies to increase sustainability of treatment effects is recommended for future studies.
28
ABSTRACT
Background Web-based interventions can improve single cardiovascular risk factors
in adult populations. In view of global ageing and the associated increasing burden of cardiovascular disease, older people form an important target population as well.
Objectives In this systematic review and meta-analysis, we evaluate whether
web-based interventions for cardiovascular risk factor management reduce the risk of cardiovascular disease in older people.
Methods Embase, Medline, Cochrane and Cinahl were systematically searched from
1995 to November 2014. Search terms included cardiovascular risk factors and diseases (specified), web-based interventions (and synonyms) and randomised controlled trial. Two authors independently performed study selection, data-extraction and risk of bias assessment. In a meta-analysis, outcomes regarding treatment effects on cardiovascular risk factors (blood pressure, HbA1C, LDL-cholesterol, smoking status, weight and physical inactivity) and incident cardiovascular disease were pooled with random effects models.
Results 57 studies (n=19,862) fulfilled eligibility criteria and 47 studies contributed to
meta-analysis. A significant reduction in systolic blood pressure (-2.66 mmHg; 95%CI, -3.81 to -1.52), diastolic blood pressure (-1.26 mmHg; 95%CI, -1.92 to -0.60), HbA1c level (-0.13 %; 95%CI, -0.22 to -0.05), LDL-cholesterol level (-2.18 mg/dL; 95%CI, -3,96 to -0.41), weight (-1.34 kg; 95%CI -1.91 to -0.77) and an increase of physical activity (standardised mean difference 0.25; 95%CI, 0.10 to 0.39) in the web-based intervention group was found. The observed effects were more pronounced in studies with short (<12 months) follow-up and studies that combined the internet-application with human support (blended care). No difference in incident cardiovascular disease was found between groups (6 studies).
Conclusions Web-based interventions have the potential to improve the cardiovascular
risk profile of older people, but the effects are modest and decline with time. Currently, there is insufficient evidence for an effect on incident cardiovascular disease. A focus on long-term effects, clinical endpoints and strategies to increase sustainability of treatment effects is recommended for future studies.
29
2
INTRODuCTION
The field of eHealth is expanding the potential of contemporary medicine.1 Global
ageing and its associated burden of cardiovascular disease may expand the scope
for innovative internet interventions.2 3 Current cardiovascular risk management
programs in primary care will become too expensive and, although they are highly
effective in research settings,4-6 their effectiveness is markedly lower in daily life.7
This evidence-practice gap has several causes.8 Adherence to life-long lifestyle
and medication regimens is a serious challenge, illustrated by long-term adherence
rates in chronic diseases that average as low as 50%.9 10 Web-based interventions are
cheap, have a wide reach, and they enable self-management.11 This renders web-based
interventions potentially powerful and scalable tools to enhance sustained adherence
in cardiovascular risk management.12
Older people form an important target population because cardiovascular risk reduction
appears effective until old age13-16. In 2012, 42% of European people aged between 55
and 74 years used the internet and this number is increasing17. Meta-analyses showed
that web-based interventions targeting single cardiovascular risk factors can induce
improvements in adult populations18-21. However, optimal cardiovascular prevention
and risk management practice, as affirmed by the European Society of Cardiology and
the American Heart Association23, requires targeting the complete cardiovascular risk
profile. This is particularly applicable for older people, who often have multiple risk factors or already suffered a cardiovascular event. A comprehensive approach would increase the value of web-based interventions for daily practice. Currently, little is known about the effectiveness of web-based interventions in older people.
In this systematic review and meta-analysis, we aim to answer the question whether web-based interventions for cardiovascular risk factor management reduce cardiovascular risk and disease in older people.
METHODS
Search strategy and selection of eligible studies
We performed a systematic literature search for randomised controlled trials (RCT) on web-based interventions in older people targeting one or more cardiovascular risk factors and/or disease. Methods were predefined in a research protocol using the PRISMA checklist and the Systematic Reviews Guidelines of the Center of Reviews and Dissemination (Supplementary Appendix 1). We defined web-based interventions as web-based participant-centered treatment or prevention programmes
delivered via the internet and interacting with the participant in a tailored fashion.24 25
29
2
INTRODuCTION
The field of eHealth is expanding the potential of contemporary medicine.1 Global
ageing and its associated burden of cardiovascular disease may expand the scope
for innovative internet interventions.2 3 Current cardiovascular risk management
programs in primary care will become too expensive and, although they are highly
effective in research settings,4-6 their effectiveness is markedly lower in daily life.7
This evidence-practice gap has several causes.8 Adherence to life-long lifestyle
and medication regimens is a serious challenge, illustrated by long-term adherence
rates in chronic diseases that average as low as 50%.9 10 Web-based interventions are
cheap, have a wide reach, and they enable self-management.11 This renders web-based
interventions potentially powerful and scalable tools to enhance sustained adherence
in cardiovascular risk management.12
Older people form an important target population because cardiovascular risk reduction
appears effective until old age13-16. In 2012, 42% of European people aged between 55
and 74 years used the internet and this number is increasing17. Meta-analyses showed
that web-based interventions targeting single cardiovascular risk factors can induce
improvements in adult populations18-21. However, optimal cardiovascular prevention
and risk management practice, as affirmed by the European Society of Cardiology and
the American Heart Association23, requires targeting the complete cardiovascular risk
profile. This is particularly applicable for older people, who often have multiple risk factors or already suffered a cardiovascular event. A comprehensive approach would increase the value of web-based interventions for daily practice. Currently, little is known about the effectiveness of web-based interventions in older people.
In this systematic review and meta-analysis, we aim to answer the question whether web-based interventions for cardiovascular risk factor management reduce cardiovascular risk and disease in older people.
METHODS
Search strategy and selection of eligible studies
We performed a systematic literature search for randomised controlled trials (RCT) on web-based interventions in older people targeting one or more cardiovascular risk factors and/or disease. Methods were predefined in a research protocol using the PRISMA checklist and the Systematic Reviews Guidelines of the Center of Reviews and Dissemination (Supplementary Appendix 1). We defined web-based interventions as web-based participant-centered treatment or prevention programmes
delivered via the internet and interacting with the participant in a tailored fashion.24 25
30
Internet had to be the main medium through which the intervention was delivered, but other media (phone, face-to-face) could be included too. We excluded the following eHealth interventions: telemonitoring, telemedicine, and mobile phone-mediated interventions. The target of the intervention had to be one or more cardiovascular risk factors and/or cardiovascular disease. Thus, we included interventions for both primary
and secondary prevention of cardiovascular disease.22 The target population had to
have a mean age of 50 years or older and could have a mixed level of cardiovascular risk (one or more cardiovascular risk factors or established cardiovascular disease). Main outcomes of interest were incident cardiovascular disease (myocardial infarction, angina pectoris, heart failure, stroke or transient ischemic attack, and peripheral arterial disease), cardiovascular mortality and overall mortality, and changes in
cardiovascular risk factors including blood pressure (BP), glycated haemoglobin A1c
(HbA1c), low-density lipoprotein (LDL) cholesterol, smoking status, weight, level of
physical exercise, or a composite cardiovascular risk score.
We performed a comprehensive literature search in the EMBASE, Medline, CINAHL, and Cochrane databases from 1995 onward (because the internet was not widely available before then). Key search terms were cardiovascular risk factors and diseases (separate diseases and risk factors specified), terms related to aspects of cardiovascular risk management (e.g., diet, exercise, BP control), web-based interventions (including all definitions and synonyms), and RCT/review/meta-analysis. The search was last updated on November 3, 2014 by CRB. The comprehensive search strategy is provided in Supplementary Appendix 2. Studies were included if (1) they were on web-based interventions targeting cardiovascular risk factors and/or disease, (2) study design was a RCT, (3) at least 50 patients were included, (4) mean age was at least 50 years, (5) the duration of the intervention was four or more weeks and follow-up was three or more months, (6) at least one of the outcomes of our interest was reported, and (7) language was English. Study selection was performed by two independent researchers (CRB and BS) by means of screening of titles and abstracts, and thereafter reading full texts on the basis of the inclusion criteria. If two publications described the same trial, the paper that reported the primary outcomes of the trial was included. Disagreements were resolved by discussion or by a third investigator (ER). We assessed reviews and meta-analyses encountered with our search strategy to check for additional relevant articles.
Data extraction
Two reviewers (BS and CRB) extracted data using a predefined data extraction form (Supplementary Appendix 3) for half of the included articles and checked each other’s results. Extracted information included study characteristics, patient baseline
30
Internet had to be the main medium through which the intervention was delivered, but other media (phone, face-to-face) could be included too. We excluded the following eHealth interventions: telemonitoring, telemedicine, and mobile phone-mediated interventions. The target of the intervention had to be one or more cardiovascular risk factors and/or cardiovascular disease. Thus, we included interventions for both primary
and secondary prevention of cardiovascular disease.22 The target population had to
have a mean age of 50 years or older and could have a mixed level of cardiovascular risk (one or more cardiovascular risk factors or established cardiovascular disease). Main outcomes of interest were incident cardiovascular disease (myocardial infarction, angina pectoris, heart failure, stroke or transient ischemic attack, and peripheral arterial disease), cardiovascular mortality and overall mortality, and changes in
cardiovascular risk factors including blood pressure (BP), glycated haemoglobin A1c
(HbA1c), low-density lipoprotein (LDL) cholesterol, smoking status, weight, level of
physical exercise, or a composite cardiovascular risk score.
We performed a comprehensive literature search in the EMBASE, Medline, CINAHL, and Cochrane databases from 1995 onward (because the internet was not widely available before then). Key search terms were cardiovascular risk factors and diseases (separate diseases and risk factors specified), terms related to aspects of cardiovascular risk management (e.g., diet, exercise, BP control), web-based interventions (including all definitions and synonyms), and RCT/review/meta-analysis. The search was last updated on November 3, 2014 by CRB. The comprehensive search strategy is provided in Supplementary Appendix 2. Studies were included if (1) they were on web-based interventions targeting cardiovascular risk factors and/or disease, (2) study design was a RCT, (3) at least 50 patients were included, (4) mean age was at least 50 years, (5) the duration of the intervention was four or more weeks and follow-up was three or more months, (6) at least one of the outcomes of our interest was reported, and (7) language was English. Study selection was performed by two independent researchers (CRB and BS) by means of screening of titles and abstracts, and thereafter reading full texts on the basis of the inclusion criteria. If two publications described the same trial, the paper that reported the primary outcomes of the trial was included. Disagreements were resolved by discussion or by a third investigator (ER). We assessed reviews and meta-analyses encountered with our search strategy to check for additional relevant articles.
Data extraction
Two reviewers (BS and CRB) extracted data using a predefined data extraction form (Supplementary Appendix 3) for half of the included articles and checked each other’s results. Extracted information included study characteristics, patient baseline
31
2
characteristics, characteristics of the intervention and control conditions, and availabledata on clinical and intermediate outcomes. For BP, glucose control, weight, lipids, and physical activity level, we extracted all baseline and follow-up levels, change scores or mean differences. Corresponding authors were contacted if needed. We used an adapted Cochrane Risk of Bias Tool to evaluate randomisation procedures, representativeness of study populations, blinding of outcome assessors (blinding of participants was usually not possible due to study design), completeness of outcome data, and completeness of reporting.
Meta-analysis
For categorical variables, we calculated odds ratios (ORs) with 95% confidence intervals (95% CIs). We estimated pooled ORs with Mantel-Haenszel random-effects models. For continuous outcomes, mean differences (MDs) or standardised mean differences (Hedges’ g effect sizes) with 95% CI were calculated. We estimated pooled effects with
DerSimonian and Laird random-effects models. All HbA1c values were converted to
percentages. All LDL cholesterol values were converted to mg/dL. All weight values were converted to kg. For level of physical activity, which was assessed with various instruments, we calculated standardised mean differences (SMDs) and 95%CI. If MDs or SMDs were reported, we included them directly in the pooled analyses. If not, we calculated change scores (difference between baseline and follow-up within group) or values assessed at follow-up. If values were measured at multiple time points, we used the values recorded at the last follow-up contact.
For studies with multiple arms, we included only one intervention arm in the meta-analysis in order not to create “unit-of-meta-analysis” error by double counting the control group. Where possible, we selected the internet-only intervention arm. No data were imputed.
We estimated pooled effects for all single cardiovascular risk factors. To address the overall question of efficacy of web-based interventions for cardiovascular risk factor management, we evaluated the effect on cardiovascular composite scores, clinical outcomes (cardiovascular morbidity and mortality), and pooled the standardised primary outcomes of all studies. We used the primary outcomes as defined by the authors of the studies.
Funnel plots were inspected to assess for potential publication bias. Statistical
heterogeneity was assessed using Q and I2 tests. We explored reasons for heterogeneity
by jackknife analysis and subgroup analyses. We assessed the following factors in subgroup analyses: study duration (predefined, short term [<12 months] versus long term [≥12 months]), type of cardiovascular prevention (primary versus secondary)
31
2
characteristics, characteristics of the intervention and control conditions, and availabledata on clinical and intermediate outcomes. For BP, glucose control, weight, lipids, and physical activity level, we extracted all baseline and follow-up levels, change scores or mean differences. Corresponding authors were contacted if needed. We used an adapted Cochrane Risk of Bias Tool to evaluate randomisation procedures, representativeness of study populations, blinding of outcome assessors (blinding of participants was usually not possible due to study design), completeness of outcome data, and completeness of reporting.
Meta-analysis
For categorical variables, we calculated odds ratios (ORs) with 95% confidence intervals (95% CIs). We estimated pooled ORs with Mantel-Haenszel random-effects models. For continuous outcomes, mean differences (MDs) or standardised mean differences (Hedges’ g effect sizes) with 95% CI were calculated. We estimated pooled effects with
DerSimonian and Laird random-effects models. All HbA1c values were converted to
percentages. All LDL cholesterol values were converted to mg/dL. All weight values were converted to kg. For level of physical activity, which was assessed with various instruments, we calculated standardised mean differences (SMDs) and 95%CI. If MDs or SMDs were reported, we included them directly in the pooled analyses. If not, we calculated change scores (difference between baseline and follow-up within group) or values assessed at follow-up. If values were measured at multiple time points, we used the values recorded at the last follow-up contact.
For studies with multiple arms, we included only one intervention arm in the meta-analysis in order not to create “unit-of-meta-analysis” error by double counting the control group. Where possible, we selected the internet-only intervention arm. No data were imputed.
We estimated pooled effects for all single cardiovascular risk factors. To address the overall question of efficacy of web-based interventions for cardiovascular risk factor management, we evaluated the effect on cardiovascular composite scores, clinical outcomes (cardiovascular morbidity and mortality), and pooled the standardised primary outcomes of all studies. We used the primary outcomes as defined by the authors of the studies.
Funnel plots were inspected to assess for potential publication bias. Statistical
heterogeneity was assessed using Q and I2 tests. We explored reasons for heterogeneity
by jackknife analysis and subgroup analyses. We assessed the following factors in subgroup analyses: study duration (predefined, short term [<12 months] versus long term [≥12 months]), type of cardiovascular prevention (primary versus secondary)
32
[22], and type of intervention (internet only or “blended” [internet application combined with human support]). Subgroup analyses were performed on the studies used for the analysis on primary outcomes only. The latter subgroup analysis (on type of intervention) consisted of two separate analyses, one to evaluate the internet-only interventions versus the control conditions and one to evaluate the blended interventions versus control conditions. In case a study tested both types of interventions with a multiple-arm design, the appropriate arm was included for each analysis. In addition, we performed a mixed effects meta-regression using the unrestricted maximum likelihood method to explore the association between study duration and effect size (standardised primary outcome). Last, we performed sensitivity analyses for the different domains of the risk-of-bias assessment by repeating the analysis on standardised primary outcomes in subgroups of studies with low risk of bias versus studies with an unclear or high risk of bias. For this analysis, we wanted to include all studies that contributed to one of the meta-analyses. Therefore, we complemented the sample of studies with defined primary outcomes that were cardiovascular risk factors of interest with studies that had not defined their primary outcome. If there was no defined primary outcome, we used the cardiovascular risk factor that was targeted most directly in the intervention studied. We used Review Manager 5.2 to draw the risk-of-bias assessment figure and to calculate standard deviations (SDs) or 95% CIs in cases where only standard errors (SEs) were available in the original data. We used Microsoft Office Excel version 10, SPSS version 20, and Comprehensive Meta Analysis version 2.2.064 for the statistical analyses.
RESuLTS
Study selection
The search yielded 5,251 papers after removal of duplicates. We did not identify additional studies by searching reference lists. After screening of titles and abstracts, 462 papers remained. Review of these full texts resulted in 57 RCTs (corresponding with 84 papers) that fulfilled the selection criteria and were included in the systematic review. We contacted 16 authors to request additional data: nine authors responded and three authors complied with our request. Out of this final selection, 47 studies could be included in the meta-analysis (see Figure 1 for PRISMA flowchart).
Study characteristics
The 57 RCTs included 19,862 individuals (Tables 1-5). Study sample size ranged from 61 to 2,140 participants. Median study duration was 9 months (interquartile range (IQR) 6, range 3-60 months). The mean dropout rate was 15% (range 0%-62%). The mean age of the study populations ranged from 50 to 71 years. In only seven studies
32
[22], and type of intervention (internet only or “blended” [internet application combined with human support]). Subgroup analyses were performed on the studies used for the analysis on primary outcomes only. The latter subgroup analysis (on type of intervention) consisted of two separate analyses, one to evaluate the internet-only interventions versus the control conditions and one to evaluate the blended interventions versus control conditions. In case a study tested both types of interventions with a multiple-arm design, the appropriate arm was included for each analysis. In addition, we performed a mixed effects meta-regression using the unrestricted maximum likelihood method to explore the association between study duration and effect size (standardised primary outcome). Last, we performed sensitivity analyses for the different domains of the risk-of-bias assessment by repeating the analysis on standardised primary outcomes in subgroups of studies with low risk of bias versus studies with an unclear or high risk of bias. For this analysis, we wanted to include all studies that contributed to one of the meta-analyses. Therefore, we complemented the sample of studies with defined primary outcomes that were cardiovascular risk factors of interest with studies that had not defined their primary outcome. If there was no defined primary outcome, we used the cardiovascular risk factor that was targeted most directly in the intervention studied. We used Review Manager 5.2 to draw the risk-of-bias assessment figure and to calculate standard deviations (SDs) or 95% CIs in cases where only standard errors (SEs) were available in the original data. We used Microsoft Office Excel version 10, SPSS version 20, and Comprehensive Meta Analysis version 2.2.064 for the statistical analyses.
RESuLTS
Study selection
The search yielded 5,251 papers after removal of duplicates. We did not identify additional studies by searching reference lists. After screening of titles and abstracts, 462 papers remained. Review of these full texts resulted in 57 RCTs (corresponding with 84 papers) that fulfilled the selection criteria and were included in the systematic review. We contacted 16 authors to request additional data: nine authors responded and three authors complied with our request. Out of this final selection, 47 studies could be included in the meta-analysis (see Figure 1 for PRISMA flowchart).
Study characteristics
The 57 RCTs included 19,862 individuals (Tables 1-5). Study sample size ranged from 61 to 2,140 participants. Median study duration was 9 months (interquartile range (IQR) 6, range 3-60 months). The mean dropout rate was 15% (range 0%-62%). The mean age of the study populations ranged from 50 to 71 years. In only seven studies
33
2
were all participants older than 50 years of age. All participants had an increased risk of cardiovascular disease: 46 studies conducted primary prevention (control of cardiovascular risk factors or diabetes) and 11 studies conducted secondary prevention. In 41 studies, the intervention targeted a single cardiovascular risk factor; in 16 studies, multiple risk factors were addressed. We found no studies on interventions for smoking cessation meeting our inclusion criteria. In most studies, the primary outcome was change in a specific cardiovascular risk factor targeted by the intervention. Sixteen
studies reported on clinical outcomes including new cardiovascular events26-31 and
mortality rates29-41 as a part of adverse event monitoring. All interventions included
lifestyle education and were participant-centered. Forty-four studies stimulated self-management by means of goal setting and self-monitoring. Half of interventions were stand-alone internet-platforms and the other half were “blended” (i.e., the platforms were supported by a nurse or another health care professional). Intervention usage was reported by 22 studies. The median percentage of participants logging in to the intervention platform was 72% (range 33%-100%).
Figuur 1 PRISMA flowchart illustrating literature search
33
2
were all participants older than 50 years of age. All participants had an increased risk of cardiovascular disease: 46 studies conducted primary prevention (control of cardiovascular risk factors or diabetes) and 11 studies conducted secondary prevention. In 41 studies, the intervention targeted a single cardiovascular risk factor; in 16 studies, multiple risk factors were addressed. We found no studies on interventions for smoking cessation meeting our inclusion criteria. In most studies, the primary outcome was change in a specific cardiovascular risk factor targeted by the intervention. Sixteen
studies reported on clinical outcomes including new cardiovascular events26-31 and
mortality rates29-41 as a part of adverse event monitoring. All interventions included
lifestyle education and were participant-centered. Forty-four studies stimulated self-management by means of goal setting and self-monitoring. Half of interventions were stand-alone internet-platforms and the other half were “blended” (i.e., the platforms were supported by a nurse or another health care professional). Intervention usage was reported by 22 studies. The median percentage of participants logging in to the intervention platform was 72% (range 33%-100%).
Figuur 1 PRISMA flowchart illustrating literature search
34 Ta bl e 1 C ha ra ct er ist ic s o f t he s tu di es i ncl ud ed f or t he s ys te m at ic r ev ie w : i nt er ve nt io ns t ar get in g d ia bet es a Study Set ting and study length Participants A ge (y ears), mean (SD) Sex (% female) Interv ention Contr ol
Primary; secondary out
-comes B on d 2 010 42 2-ar m R C T; U SA ; 6 m 62 p eo pl e w ith D M v ia un iv er sit y/ vet era n c lin ic 67. 2 ( 6. 0) 45 W eb sit e: e du ca tion , s el f-mon ito ri ng (g lu co se, e xe rc ise, w ei gh t, B P, m ed ic a-tio n) , f or um; nu rs e s up po rt ( em ai l, c ha t) St an da rd d iab et es c ar e H bA1c , B P, w ei gh t, t ot al c ho -le st er ol , H D L c hol es te rol ID EAT EL 20 00 -20 10 34 2-ar m R C T; U SA ; 6 0 m 16 65 M ed ic are re cip ie nt s w ith D M 70 .9 ( 6. 7) 63 O nl in e h om e t el em ed ic in e u ni t: nu rs e su pp or t ( vi de o c ha t), W eb p or ta l f or se lf-m on itor in g ( gl uc os e, B P), e duc at io n St an da rd d iab et es c ar e H bA1c , s ys to lic B P, d ia st ol ic BP , t ot al c ho le st er ol , L D L ch ol es te rol D -n et 2 001 43 4-ar m R C T; U SA ; 1 0 m 32 0 p eo pl e w ith D M 2, I n-te rn et , f ro m 1 6 G Ps 59 (9. 2) 53 W eb sit e: ( 1) S el f-m an ag em en t ( gl uc os e) , co ac h s up po rt ; ( 2) e du ca tio n, f or um; ( 3) 1 an d 2 c om bi ne d b (4 ) I nf or m at io n o n m ed ic al an d l ife st yl e a sp ec ts o f d ia be te s N ot d efi ne d; b eh av io ra l, b io -lo gi ca l, a nd p sy ch os oc ia l o ut -com es My p at h 20 10 44 3-ar m R C T; U SA ; 1 2 m 46 3 M ed ic are re cip ie nt s w ith D M 2, B M I ≥ 25 k g/ m 2 o r ≥ 1 C V r isk f ac to r, In te rn et 58 .4 (9. 2) 50 (1 ) W eb sit e f or c om pu te r-as sis te d se lf-m an ag em en t(CA SM ): g oa l se tt in g, mon ito ri ng (H bA1c , B P, c ho le st er ol ), for um , e duc at io n; b, c (2 ) C A SM + s oc ia l su pp or t ( coa ch , g ro up se ss io ns ) b, c (3 ) C om pu te r-ba se d h ea lth ri sk a pp ra isa l, n o k ey f ea tu re s of C A SM B eh av io r c ha ng es i n d ie t, ph ys ic al a ct iv ity , m ed ic at io n ad he re nc e My c ar e te am 2 00 5 45 2-ar m R C T; U SA ; 1 2 m 10 4 p eo pl e w ith D M , H bA1c ≥ 9. 0% v ia v et er an cl in ic 63 .5 (7. 0) 0. 5 W eb sit e: se lf-m an ag em en t ( gl uco se, B P) , ed uc at io n, r em in de rs ( ph on e) ; c ar e m an -ag er su pp or t D M s el f-m an ag em en t t ra in -in g, u su al c ar e H bA1c a nd B P a t 3 , 6 , 9 , a nd 12 m M ob ile D M 20 11 32 4-ar m c lu st er R C T; U SA ; 12 m 26 p hy sic ia n p ra ct ic es w ith 16 3 p eo pl e w ith D M a nd H bA1c ≥ 7. 5% 52 .8 (8 .1) 50 (2 ) S el f-m an ag em en t v ia w eb sit e + m o-bi le p ho ne , p at ie nt i nf or m s d oc to r; b (3 ) 2 + d oc to r a cc es s t o d at a; ( 4) 3 + a dv ic e fr om d oc tor c (1 ) C ar e a s u su al C ha ng e i n H bA1c ov er 1 ye ar A vd al 2 011 46 2-ar m R C T; Tu rk ey ; 6 m 12 2 p eo pl e w ith D M 2, I n-te rn et f ro m c lin ic 51 (7. 3) 51 W eb sit e: r ev ie w r isk p ro fil e, m es sa gi ng to r es ea rc he r, d ai ly g lu co se m on ito ri ng Ed uc at io n a nd u su al c ar e H bA1c , a tt en da nc e r at es a t o ut -pa tie nt c lin ic C ho 2 00 6 47 2-ar m R C T; So ut h Ko re a; 30 m 80 p eo pl e w ith D M , I nt er -ne t f ro m c lin ic 53 (9 ) 39 W eb sit e: m on ito ri ng ( gl uc os e, m ed ic a-tio n, B P, w ei gh t, l ife st yl e) , nu rs e f ee d-ba ck , m ed ic at io n a lte ra tio ns C on ve nt io na l n ot e-ke ep in g re co rd sys te m H bA1c a nd H bA1c flu ct ua tio n ind ex Lo ri g 2 010 48 3-ar m R C T; U SA ; 6 m 76 1 p eo pl e w ith D M 2, In te rn et 54 .3 (9. 9) 73 Se lf-m an ag em en t w eb sit e w ith p ee r su pp or t: l es so ns , a cti on p la ns , b ul le ti n bo ar d, m ess ag in g C ar e a s u su al H bA1C le ve l a t 6 a nd 1 8 mon th s G ran t 2 00 8 49 2-ar m c lu st er R C T; U SA ; 12 m 24 4 p eo pl e w ith D M , H bA1c > 7. 0% f ro m 1 1 pr im ar y c lini cs 56 .1 (11 .6 ) 49 O nl in e p er so na l h ea lth r ec or d: e du ca -tio n, d ia be te s c ar e p la n, a ge nd a, m es -sa gi ng , p re sc rip tio n re fil ls A cc es s t o g en er al w eb sit e Pa -tien t G ate w ay C ha ng es i n H bA1c , B P, a nd LD L c hol es te rol 34 Ta bl e 1 C ha ra ct er ist ic s o f t he s tu di es i ncl ud ed f or t he s ys te m at ic r ev ie w : i nt er ve nt io ns t ar get in g d ia bet es a Study Set ting and study length Participants A ge (y ears), mean (SD) Sex (% female) Interv ention Contr ol
Primary; secondary out
-comes B on d 2 010 42 2-ar m R C T; U SA ; 6 m 62 p eo pl e w ith D M v ia un iv er sit y/ vet era n c lin ic 67. 2 ( 6. 0) 45 W eb sit e: e du ca tion , s el f-mon ito ri ng (g lu co se, e xe rc ise, w ei gh t, B P, m ed ic a-tio n) , f or um; nu rs e s up po rt ( em ai l, c ha t) St an da rd d iab et es c ar e H bA1c , B P, w ei gh t, t ot al c ho -le st er ol , H D L c hol es te rol ID EAT EL 20 00 -20 10 34 2-ar m R C T; U SA ; 6 0 m 16 65 M ed ic are re cip ie nt s w ith D M 70 .9 ( 6. 7) 63 O nl in e h om e t el em ed ic in e u ni t: nu rs e su pp or t ( vi de o c ha t), W eb p or ta l f or se lf-m on itor in g ( gl uc os e, B P), e duc at io n St an da rd d iab et es c ar e H bA1c , s ys to lic B P, d ia st ol ic BP , t ot al c ho le st er ol , L D L ch ol es te rol D -n et 2 001 43 4-ar m R C T; U SA ; 1 0 m 32 0 p eo pl e w ith D M 2, I n-te rn et , f ro m 1 6 G Ps 59 (9. 2) 53 W eb sit e: ( 1) S el f-m an ag em en t ( gl uc os e) , co ac h s up po rt ; ( 2) e du ca tio n, f or um; ( 3) 1 an d 2 c om bi ne d b (4 ) I nf or m at io n o n m ed ic al an d l ife st yl e a sp ec ts o f d ia be te s N ot d efi ne d; b eh av io ra l, b io -lo gi ca l, a nd p sy ch os oc ia l o ut -com es My p at h 20 10 44 3-ar m R C T; U SA ; 1 2 m 46 3 M ed ic are re cip ie nt s w ith D M 2, B M I ≥ 25 k g/ m 2 o r ≥ 1 C V r isk f ac to r, In te rn et 58 .4 (9. 2) 50 (1 ) W eb sit e f or c om pu te r-as sis te d se lf-m an ag em en t(CA SM ): g oa l se tt in g, mon ito ri ng (H bA1c , B P, c ho le st er ol ), for um , e duc at io n; b, c (2 ) C A SM + s oc ia l su pp or t ( coa ch , g ro up se ss io ns ) b, c (3 ) C om pu te r-ba se d h ea lth ri sk a pp ra isa l, n o k ey f ea tu re s of C A SM B eh av io r c ha ng es i n d ie t, ph ys ic al a ct iv ity , m ed ic at io n ad he re nc e My c ar e te am 2 00 5 45 2-ar m R C T; U SA ; 1 2 m 10 4 p eo pl e w ith D M , H bA1c ≥ 9. 0% v ia v et er an cl in ic 63 .5 (7. 0) 0. 5 W eb sit e: se lf-m an ag em en t ( gl uco se, B P) , ed uc at io n, r em in de rs ( ph on e) ; c ar e m an -ag er su pp or t D M s el f-m an ag em en t t ra in -in g, u su al c ar e H bA1c a nd B P a t 3 , 6 , 9 , a nd 12 m M ob ile D M 20 11 32 4-ar m c lu st er R C T; U SA ; 12 m 26 p hy sic ia n p ra ct ic es w ith 16 3 p eo pl e w ith D M a nd H bA1c ≥ 7. 5% 52 .8 (8 .1) 50 (2 ) S el f-m an ag em en t v ia w eb sit e + m o-bi le p ho ne , p at ie nt i nf or m s d oc to r; b (3 ) 2 + d oc to r a cc es s t o d at a; ( 4) 3 + a dv ic e fr om d oc tor c (1 ) C ar e a s u su al C ha ng e i n H bA1c ov er 1 ye ar A vd al 2 011 46 2-ar m R C T; Tu rk ey ; 6 m 12 2 p eo pl e w ith D M 2, I n-te rn et f ro m c lin ic 51 (7. 3) 51 W eb sit e: r ev ie w r isk p ro fil e, m es sa gi ng to r es ea rc he r, d ai ly g lu co se m on ito ri ng Ed uc at io n a nd u su al c ar e H bA1c , a tt en da nc e r at es a t o ut -pa tie nt c lin ic C ho 2 00 6 47 2-ar m R C T; So ut h Ko re a; 30 m 80 p eo pl e w ith D M , I nt er -ne t f ro m c lin ic 53 (9 ) 39 W eb sit e: m on ito ri ng ( gl uc os e, m ed ic a-tio n, B P, w ei gh t, l ife st yl e) , nu rs e f ee d-ba ck , m ed ic at io n a lte ra tio ns C on ve nt io na l n ot e-ke ep in g re co rd sys te m H bA1c a nd H bA1c flu ct ua tio n ind ex Lo ri g 2 010 48 3-ar m R C T; U SA ; 6 m 76 1 p eo pl e w ith D M 2, In te rn et 54 .3 (9. 9) 73 Se lf-m an ag em en t w eb sit e w ith p ee r su pp or t: l es so ns , a cti on p la ns , b ul le ti n bo ar d, m ess ag in g C ar e a s u su al H bA1C le ve l a t 6 a nd 1 8 mon th s G ran t 2 00 8 49 2-ar m c lu st er R C T; U SA ; 12 m 24 4 p eo pl e w ith D M , H bA1c > 7. 0% f ro m 1 1 pr im ar y c lini cs 56 .1 (11 .6 ) 49 O nl in e p er so na l h ea lth r ec or d: e du ca -tio n, d ia be te s c ar e p la n, a ge nd a, m es -sa gi ng , p re sc rip tio n re fil ls A cc es s t o g en er al w eb sit e Pa -tien t G ate w ay C ha ng es i n H bA1c , B P, a nd LD L c hol es te rol
35
2
M cM ah on 201 2 50 3-ar m R C T; U SA ; 1 2 m 15 1 p eo pl e w ith D M , H bA1c >8 .5 % fr om v et er an he al th se rv ic es 60 .2 (1 0. 8) 5 (1 ) S el f-m on ito ri ng v ia p ho ne ( BP , g lu c-os e) ; ( 2) w eb sit e: s el f-m on ito ri ng ( BP , gl uc os e) , e du ca tio n, s up po rt b y c ar e m an -ag er s b, c (3 ) W eb sit e w ith l in ks t o o th er D M w eb sit es ; u su al c ar e C ha ng e i n H bA1c a nd B P o ve r ti me R al ston 20 09 51 2-ar m R C T; U SA ; 1 2 m 83 p eo pl e w ith D M 2, H bA1c ≥7 .0 % a nd I nt er ne t fr om c lin ic : 6 5% w ith 2 C V r isk f ac to rs 57. 3 ( — ) 52 El ec tr on ic m ed ic al re co rd : s el f-mon ito r-in g ( gl uc os e, e xe rc ise , d ie t, m ed ic at io n) , su pp or t b y c ar e m an ag er , u su al c ar e v isi ts Us ua l c ar e v isi ts C ha ng e i n H bA1c Kw on 2 00 4 52 2-ar m R C T; So ut h Ko re a; 3 m 11 0 p eo pl e w ith D M 2, I n-te rn et f ro m c lin ic : 2 7% h y-pe rten sio n 54 .1 (9.1 ) 33 W eb sit e: s el f-m on ito ri ng ( gl uc os e) , r e-m in der s, p ro fe sso r/ nu rs e/ di et ic ia n-su p-por t M on th ly v isi t t o d ia be te s s pe -ci al ist H bA1c EM -PO W ER-D 201 3 39 2-ar m R C T; U SA ; 1 2 m 41 5 p eo pl e w ith D M a nd H bA1c ≥ 7. 5% f ro m c lin ic 53 .7 (1 0. 2) 40 O nl in e h ea lth r ec or d: r isk e st im at io n, se lf-m on ito ri ng (g lu co se, d ie t, e xe rc ise, BP ), nu rs e s up po rt , o w n d oc to r i nf or m ed Us ua l c ar e H bA1c a t 1 2 m R ED EE M 201 3 53 3-ar m R C T; U SA ; 1 2 m 39 2 p eo pl e w ith D M 2, I n-te rn et f ro m c om m un ity cen te rs 56 .1 (9. 6) 54 (1 ) C A SM w eb sit e: g oa l s et ti ng ; se lf-mon ito ri ng (H bA1c , B P, c ho le st er ol ); 8 p ho ne c al ls; b (2 ) C om pu te r-as sis te d se lf-m an ag em en t + p ro bl em s ol vi ng tr ea tm en t ( C A SP ): C A SM + 8 s es sio ns pr obl em solv in g C om pu te r h ea lth r isk a p-pr ais al , e du ca tio n, sa m e p ho ne ca lls a s i nt er ve nt io n D ia be te s d ist re ss ; H bA1c , p hy s-ic al a ct iv ity , m ed ic at io n c om -pl ia nc e a A bb re vi at ion s: B P: b loo d p re ssur e; C A SM : c om put er -a ssi ste d se lf-m an ag em en t; C A SP : c om put er -a ssi ste d se lf-m an ag em en t + p ro bl em s olv in g t re at m en t; C V: c ar di ov asc ul ar ; D M : d ia be tes m ell itu s; D M 2: t yp e 2 d ia be tes m ell itu s; G P: g en er al p ra cti tio ne r; H bA 1c ; g ly ca ted h em og lob in A 1c ; H D L: h igh -d en sit y lip op ro tein ; LD L: l ow -d en sit y l ip op ro tein . b F or s tu die s w ith m or e t ha n 2 a rm s, t hi s a rm w as u se d f or a ll a na ly se s . c F or s tu die s w ith m or e t ha n 2 a rm s, t hi s a rm w as u se d f or t he s ub gr oup a na ly sis o n b len de d in ter ve nt ion s. Ta bl e 1 C on tin ue d. 352
M cM ah on 201 2 50 3-ar m R C T; U SA ; 1 2 m 15 1 p eo pl e w ith D M , H bA1c >8 .5 % fr om v et er an he al th se rv ic es 60 .2 (1 0. 8) 5 (1 ) S el f-m on ito ri ng v ia p ho ne ( BP , g lu c-os e) ; ( 2) w eb sit e: s el f-m on ito ri ng ( BP , gl uc os e) , e du ca tio n, s up po rt b y c ar e m an -ag er s b, c (3 ) W eb sit e w ith l in ks t o o th er D M w eb sit es ; u su al c ar e C ha ng e i n H bA1c a nd B P o ve r ti me R al ston 20 09 51 2-ar m R C T; U SA ; 1 2 m 83 p eo pl e w ith D M 2, H bA1c ≥7 .0 % a nd I nt er ne t fr om c lin ic : 6 5% w ith 2 C V r isk f ac to rs 57. 3 ( — ) 52 El ec tr on ic m ed ic al re co rd : s el f-mon ito r-in g ( gl uc os e, e xe rc ise , d ie t, m ed ic at io n) , su pp or t b y c ar e m an ag er , u su al c ar e v isi ts Us ua l c ar e v isi ts C ha ng e i n H bA1c Kw on 2 00 4 52 2-ar m R C T; So ut h Ko re a; 3 m 11 0 p eo pl e w ith D M 2, I n-te rn et f ro m c lin ic : 2 7% h y-pe rten sio n 54 .1 (9.1 ) 33 W eb sit e: s el f-m on ito ri ng ( gl uc os e) , r e-m in der s, p ro fe sso r/ nu rs e/ di et ic ia n-su p-por t M on th ly v isi t t o d ia be te s s pe -ci al ist H bA1c EM -PO W ER-D 201 3 39 2-ar m R C T; U SA ; 1 2 m 41 5 p eo pl e w ith D M a nd H bA1c ≥ 7. 5% f ro m c lin ic 53 .7 (1 0. 2) 40 O nl in e h ea lth r ec or d: r isk e st im at io n, se lf-m on ito ri ng (g lu co se, d ie t, e xe rc ise, BP ), nu rs e s up po rt , o w n d oc to r i nf or m ed Us ua l c ar e H bA1c a t 1 2 m R ED EE M 201 3 53 3-ar m R C T; U SA ; 1 2 m 39 2 p eo pl e w ith D M 2, I n-te rn et f ro m c om m un ity cen te rs 56 .1 (9. 6) 54 (1 ) C A SM w eb sit e: g oa l s et ti ng ; se lf-mon ito ri ng (H bA1c , B P, c ho le st er ol ); 8 p ho ne c al ls; b (2 ) C om pu te r-as sis te d se lf-m an ag em en t + p ro bl em s ol vi ng tr ea tm en t ( C A SP ): C A SM + 8 s es sio ns pr obl em solv in g C om pu te r h ea lth r isk a p-pr ais al , e du ca tio n, sa m e p ho ne ca lls a s i nt er ve nt io n D ia be te s d ist re ss ; H bA1c , p hy s-ic al a ct iv ity , m ed ic at io n c om -pl ia nc e a A bb re vi at ion s: B P: b loo d p re ssur e; C A SM : c om put er -a ssi ste d se lf-m an ag em en t; C A SP : c om put er -a ssi ste d se lf-m an ag em en t + p ro bl em s olv in g t re at m en t; C V: c ar di ov asc ul ar ; D M : d ia be tes m ell itu s; D M 2: t yp e 2 d ia be tes m ell itu s; G P: g en er al p ra cti tio ne r; H bA 1c ; g ly ca ted h em og lob in A 1c ; H D L: h igh -d en sit y lip op ro tein ; LD L: l ow -d en sit y l ip op ro tein . b F or s tu die s w ith m or e t ha n 2 a rm s, t hi s a rm w as u se d f or a ll a na ly se s . c F or s tu die s w ith m or e t ha n 2 a rm s, t hi s a rm w as u se d f or t he s ub gr oup a na ly sis o n b len de d in ter ve nt ion s. Ta bl e 1 C on tin ue d.36 Ta bl e 2 C ha ra ct er ist ic s o f t he s tu di es i ncl ud ed f or t he s ys te m at ic r ev ie w : i nt er ve nt io ns t ar get in g b lo od p re ss ur e a Study Set
ting and study
length Participants Ag e (y ears), mean (SD) Sex (% f emale) Interv ention Contr ol
Primary; secondary outcomes
e-BP 2 00 8 29 3-ar m R C T; U SA ; 12 m 77 8 p eo pl e w ith I n-te rn et , h yp er ten -sio n, f ro m G Ps : 6 1. 1% ob es e 59.1 (8 .5 ) 52 (1 ) W eb sit e: B P s el f-m on -ito ri ng; b (2 ) 1 + p ha rm ac ist sup po rt c G en er al w eb sit e: p er -so nal m ed ic al re co rd C ha ng e i n d ia st ol ic , sy st ol ic a nd m ea n B P N ol an 2 01 2 54 2-ar m R C T; C an ad a; 4 m 38 7 p eo pl e w ith h y-pe rt en sio n v ia w eb -sit e: 4 1% o be se 56 .5 (7. 4) 59 BP a ct io n p la n w eb sit e: a s-se ss ing m ot iv at io na l r ea di -ne ss , a dv ic e, f ee db ac k, e du -ca tio n E-ne w sle tt er s C ha ng e i n d ia st ol ic a nd sy st ol ic B P, a nd p ul se pre ss ure B ov e 2 013 55 2-ar m R C T; U SA ; 6 m 24 1 p eo pl e w ith e l-ev at ed B P f ro m 2 cl in ic s 59 .6 (1 3.6 ) 65 W eb site + te lep ho ne sy ste m : ed uc at ion , s el f-mon ito ri ng (B P, w ei gh t, e xe rc ise ), o n-lin e nu rs e s up po rt , d oc to r inf or m ed Pr ov isi on o f d at a f ro m in iti al a ss es sm en t, u su al ca re Pr op or tio n o f p ar ti -ci pa nt s w ith c ont ro lle d BP a t 6 m M ad se n 2 00 8 56 2-ar m R C T; D en -m ar k; 6 m 23 6 p eo pl e w ith hy pe rten sio n f ro m 10 G Ps 55 .9 (11 .7 ) 50 W eb sit e: se lf-mon ito ri ng (B P) , f ee db ac k f ro m o w n d oc -to r b y e m ai l Us ua l c ar e Ch an ge in a m bu lat or y sy st ol ic B P -at 6 m M ag id 2 01 3 57 2-ar m R C T; U SA ; 6 m 34 8 p eo pl e w ith h y-pe rt en sio n f ro m 1 0 cl in ic s 60 (11 ) 40 W ri tt en e duc at io na l m at er -ia l, w eb sit e: se lf-mon ito r-in g ( BP ), p ha rm ac ist s up po rt , do ct or inf or m ed , r em in de rs W ri tt en e du ca tio n m a-te ri al , u su al c ar e Pr op or tio n o f p ar ti -ci pa nt s w ith c ont ro lle d BP a t 6 m M cK in st ry 201 3 38 2-ar m R C T; S co t-la nd ; 6 m 40 1 p eo pl e w ith h y-pe rten sio n f ro m 20 G Ps 60 .7 (11 .2 ) 40 Te le m on ito ri ng u ni t + w eb -sit e: se lf-mon ito ri ng (B P) , fe ed ba ck f ro m o w n d oc to r Us ua l c ar e M ea n a m bu la to ry B P at 6 m T hi bo ut ot 201 3 58 2-ar m c lu st er R C T; U SA ; 1 2 m 50 0 p at ie nt s w ith el ev at ed B P f ro m 54 G Ps 60 .5 (11 .9 ) 58 W eb sit e: se lf-mon ito ri ng (B P, m ed ic at io n) , f ee db ac k, re m in der s D iff er ent p re ve nt io n w eb sit e ( eg , b re as t sc re en in g) BP c on tr ol a t 1 2 m a A bb re vi at ion s: B P: b loo d p re ssur e; G P: g en er al p ra cti tio ne r. b F or s tu die s wi th m or e t ha n 2 a rm s, t hi s a rm w as u se d f or a ll a na ly se s . c F or s tu die s wi th m or e th an 2 a rm s, t hi s a rm w as u se d f or t he s ub gr oup a na ly sis o n b len de d in ter ve nt ion s 36 Ta bl e 2 C ha ra ct er ist ic s o f t he s tu di es i ncl ud ed f or t he s ys te m at ic r ev ie w : i nt er ve nt io ns t ar get in g b lo od p re ss ur e a Study Set
ting and study
length Participants Ag e (y ears), mean (SD) Sex (% f emale) Interv ention Contr ol
Primary; secondary outcomes
e-BP 2 00 8 29 3-ar m R C T; U SA ; 12 m 77 8 p eo pl e w ith I n-te rn et , h yp er ten -sio n, f ro m G Ps : 6 1. 1% ob es e 59.1 (8 .5 ) 52 (1 ) W eb sit e: B P s el f-m on -ito ri ng; b (2 ) 1 + p ha rm ac ist sup po rt c G en er al w eb sit e: p er -so nal m ed ic al re co rd C ha ng e i n d ia st ol ic , sy st ol ic a nd m ea n B P N ol an 2 01 2 54 2-ar m R C T; C an ad a; 4 m 38 7 p eo pl e w ith h y-pe rt en sio n v ia w eb -sit e: 4 1% o be se 56 .5 (7. 4) 59 BP a ct io n p la n w eb sit e: a s-se ss ing m ot iv at io na l r ea di -ne ss , a dv ic e, f ee db ac k, e du -ca tio n E-ne w sle tt er s C ha ng e i n d ia st ol ic a nd sy st ol ic B P, a nd p ul se pre ss ure B ov e 2 013 55 2-ar m R C T; U SA ; 6 m 24 1 p eo pl e w ith e l-ev at ed B P f ro m 2 cl in ic s 59 .6 (1 3.6 ) 65 W eb site + te lep ho ne sy ste m : ed uc at ion , s el f-mon ito ri ng (B P, w ei gh t, e xe rc ise ), o n-lin e nu rs e s up po rt , d oc to r inf or m ed Pr ov isi on o f d at a f ro m in iti al a ss es sm en t, u su al ca re Pr op or tio n o f p ar ti -ci pa nt s w ith c ont ro lle d BP a t 6 m M ad se n 2 00 8 56 2-ar m R C T; D en -m ar k; 6 m 23 6 p eo pl e w ith hy pe rten sio n f ro m 10 G Ps 55 .9 (11 .7 ) 50 W eb sit e: se lf-mon ito ri ng (B P) , f ee db ac k f ro m o w n d oc -to r b y e m ai l Us ua l c ar e Ch an ge in a m bu lat or y sy st ol ic B P -at 6 m M ag id 2 01 3 57 2-ar m R C T; U SA ; 6 m 34 8 p eo pl e w ith h y-pe rt en sio n f ro m 1 0 cl in ic s 60 (11 ) 40 W ri tt en e duc at io na l m at er -ia l, w eb sit e: se lf-mon ito r-in g ( BP ), p ha rm ac ist s up po rt , do ct or inf or m ed , r em in de rs W ri tt en e du ca tio n m a-te ri al , u su al c ar e Pr op or tio n o f p ar ti -ci pa nt s w ith c ont ro lle d BP a t 6 m M cK in st ry 201 3 38 2-ar m R C T; S co t-la nd ; 6 m 40 1 p eo pl e w ith h y-pe rten sio n f ro m 20 G Ps 60 .7 (11 .2 ) 40 Te le m on ito ri ng u ni t + w eb -sit e: se lf-mon ito ri ng (B P) , fe ed ba ck f ro m o w n d oc to r Us ua l c ar e M ea n a m bu la to ry B P at 6 m T hi bo ut ot 201 3 58 2-ar m c lu st er R C T; U SA ; 1 2 m 50 0 p at ie nt s w ith el ev at ed B P f ro m 54 G Ps 60 .5 (11 .9 ) 58 W eb sit e: se lf-mon ito ri ng (B P, m ed ic at io n) , f ee db ac k, re m in der s D iff er ent p re ve nt io n w eb sit e ( eg , b re as t sc re en in g) BP c on tr ol a t 1 2 m a A bb re vi at ion s: B P: b loo d p re ssur e; G P: g en er al p ra cti tio ne r. b F or s tu die s wi th m or e t ha n 2 a rm s, t hi s a rm w as u se d f or a ll a na ly se s . c F or s tu die s wi th m or e th an 2 a rm s, t hi s a rm w as u se d f or t he s ub gr oup a na ly sis o n b len de d in ter ve nt ion s
37
2
Ta bl e 3 C ha ra ct er ist ic s o f t he s tu di es i ncl ud ed f or t he s ys te m at ic r ev ie w : i nt er ve nt io ns t ar get in g w ei gh t l os s a nd w ei gh t l os s m ai nt en an ce a Study Set ting and study length Participants Ag e (y ears), mean (SD) Sex (% female) Interv ention Contr olPrimary; secondary outcomes
w eight loss App el 2 011 35 3-ar m R C T; U SA ; 2 4 m 41 5 p eo pl e w ith o be sit y, ≥1 C V r isk f ac to r, I nt er ne t fr om 6 p ri m ar y c lin ic s 54 (1 0. 2) 64 (1 ) W eb sit e + m ob ile c oa ch s up po rt : e du ca -tio n, se lf-m on ito ri ng (w ei gh t, d ie t, e xe rc ise ), re m in de rs , d oc to r i nf or m ed ; b, c (2 ) 1 + i n-pe r-so n s up po rt 1 ( or 2 ) m ee ti ng s w ith co ac h; b ro ch ur e w ith w eb sit es f or w ei gh t l os s C ha ng e i n w ei gh t f ro m ba se lin e t o 2 4 m B en ne tt 201 2 28 2-ar m R C T; U SA ; 2 4 m 36 5 o be se p eo pl e w ith h y-pe rt en sio n f ro m 3 c lin ic s 54 .6 (1 0. 9) 69 W eb sit e/i nt er ac tiv e vo ic e r es po ns e s ys te m : se lf-m on ito ri ng w ei gh t, se tt in g, coa ch su pp or t (p ho ne ), g rou p s es sio ns , e du ca tio n Sel f-hel p b oo kle t C ha ng e i n w ei gh t a t 24 m B en ne tt 20 10 59 2-ar m R C T; U SA ; 3 m 10 1 o be se p eo pl e w ith h y-pe rten sio n, In te rn et fr om cl in ic 54 .4 (8 .1 ) 48 W eb sit e: g oa l s et ti ng, se lf-mon ito ri ng, b eh a-vi or al s ki lls e du ca tio n, f or um , c oa ch s up po rt (o nl in e, p ho ne, fa ce -t o-fa ce ) Fo ld er o n h ea lth y w ei gh t, u su al c ar e C ha ng e i n w ei gh t a t 1 2 we ek s K ra s-ch ne w sk y 20 11 60 2-ar m R C T; U SA ; 3 m 10 0 o ve rw ei gh t p eo pl e, I n-ter ne t v ia fl yer s/ In ter ne t 50 .3 (1 0. 9) 70 W eb sit e: t ar ge t b od y w ei gh t, m on ito ri ng , b e-ha vi or al t ip s, v id eo s, w ei gh t l os s p la n, t ai lo re d fe ed ba ck , r em in der s W ai t l ist , p eo pl e g ot ac ce ss t o w eb sit e a ft er 12 w ee ks We ig ht lo ss We bb er b 20 08 61 2-ar m R C T; U SA ; 4 m 66 w om en , B M I 2 5-40 , I n-te rn et fro m a dve rt ise m ent s 50 .0 (9. 9) 10 0 W eb sit e: w ei gh t l os s t ip s, l es so ns , m es sa ge boa rd , se lf-m on ito ri ng (w ei gh t, d ie t), c ha t se ss io ns A ll f ea tu re s o f i nt er -ve nt io n e xc ep t f or o n-lin e c ha t s es sio ns N ot d efi ne d; w ei gh t, BM I, d ie t, e xe rc ise E-LI T E 201 3 36 3-ar m R C T; U SA ; 1 5 m 24 1 p eo pl e w ith a B M I ≥ 25 , m et ab ol ic s yn dr om e f ro m 1 c lin ic 52 .9 (1 0.6 ) 47 (1 ) W eb sit e + 1 2 l ife st yl e c la ss es ; c (2 ) w ebsi te : se lf-m on ito ri ng (w ei gh t, e xe rc ise ), m es sa gi ng , D V D w ith l ife st yl e c la ss es b Us ua l c ar e C ha ng e i n B M I f ro m ba se lin e t o 1 5 m POW ER 20 14 62 4-ar m R C T; U K ; 12 m 17 9 p eo pl e w ith B M I ≥ 30 kg /m 2 o r ≥28 kg/ m 2 + C V ri sk f ac to rs f ro m 5 G Ps 51 .2 (1 3. 1) 66 (1 ) W eb sit e: 1 2 s el f-m an ag em en t s es sio ns m on -ito ri ng ( w ei gh t), nu rs e s up po rt ( em ai l); b, c (2 ) 1 + 3 nu rs e c on ta ct s; ( 3) 1 + 7 nu rs e c on ta ct s Us ua l c ar e W ei gh t a t 1 2 m w eight loss maintenance St op R eg ai n 20 08 41 3-ar m R C T; U SA ; 1 8 m 31 4 p eo pl e w ith 1 0% w ei gh t l os s i n 2 y ea rs , v ia ad ve rt ise m ent s 51 (1 0) 81 (1 ) W eb sit e: se lf-mon ito ri ng, e m ai l c ou ns el in g, ex pe rt s c hat ; b (2 ) fa ce -t o-fa ce : se lf-m on ito ri ng vi a p ho ne , w ee kl y g ro up s es sio ns (3 ) N ew sle tt er s W ei gh t g ai n a t 1 8 m W LM 2 00 8 40 2-ph as e 3-ar m R C T; U SA ; 3 0 m 10 32 p eo pl e w ith ≥ 4 k g pr ev io us w ei gh t l os s, h y-pe rten sio n, In te rn et v ia un iv er sit y/ m ed ic are 55 .6 (8 .7 ) 63 (1 ) W eb sit e: g oa l s et ti ng , a ct io n p la ns , se lf-m on itor in g ( w ei gh t, P A , d ie t), e duc at io n, bu lle ti n b oa rd , r em in de rs , s up po rt (e m ai l/ ph on e) ; b (2 ) p er so na l c on ta ct ( ph on e + fa ce -to -fa ce ) Pri nt ed li fe st yl e gu id el in es , 1 v isi t w ith coa ch C ha ng e i n w ei gh t a A bb re vi at ion s: B M I: b od y m as s in de x; C V: c ar di ov asc ul ar ; G P: g en er al p ra cti tio ne r; P A : p hy sic al a cti vi ty . b F or s tu die s w ith m or e t ha n 2 a rm s, t hi s a rm w as use d f or a ll a na ly se s. c F or s tu die s wi th m or e t ha n 2 a rm s, t hi s a rm w as u se d f or t he s ub gr oup a na ly sis o n b len de d in ter ve nt ion s. d C on tro l a rm c on sis ts o f s am e in ter ac tiv e I nt er ne t-pl atf or m as int er ve nt ion ar m . 37
2
Ta bl e 3 C ha ra ct er ist ic s o f t he s tu di es i ncl ud ed f or t he s ys te m at ic r ev ie w : i nt er ve nt io ns t ar get in g w ei gh t l os s a nd w ei gh t l os s m ai nt en an ce a Study Set ting and study length Participants Ag e (y ears), mean (SD) Sex (% female) Interv ention Contr olPrimary; secondary outcomes
w eight loss App el 2 011 35 3-ar m R C T; U SA ; 2 4 m 41 5 p eo pl e w ith o be sit y, ≥1 C V r isk f ac to r, I nt er ne t fr om 6 p ri m ar y c lin ic s 54 (1 0. 2) 64 (1 ) W eb sit e + m ob ile c oa ch s up po rt : e du ca -tio n, se lf-m on ito ri ng (w ei gh t, d ie t, e xe rc ise ), re m in de rs , d oc to r i nf or m ed ; b, c (2 ) 1 + i n-pe r-so n s up po rt 1 ( or 2 ) m ee ti ng s w ith co ac h; b ro ch ur e w ith w eb sit es f or w ei gh t l os s C ha ng e i n w ei gh t f ro m ba se lin e t o 2 4 m B en ne tt 201 2 28 2-ar m R C T; U SA ; 2 4 m 36 5 o be se p eo pl e w ith h y-pe rt en sio n f ro m 3 c lin ic s 54 .6 (1 0. 9) 69 W eb sit e/i nt er ac tiv e vo ic e r es po ns e s ys te m : se lf-m on ito ri ng w ei gh t, se tt in g, coa ch su pp or t (p ho ne ), g rou p s es sio ns , e du ca tio n Sel f-hel p b oo kle t C ha ng e i n w ei gh t a t 24 m B en ne tt 20 10 59 2-ar m R C T; U SA ; 3 m 10 1 o be se p eo pl e w ith h y-pe rten sio n, In te rn et fr om cl in ic 54 .4 (8 .1 ) 48 W eb sit e: g oa l s et ti ng, se lf-mon ito ri ng, b eh a-vi or al s ki lls e du ca tio n, f or um , c oa ch s up po rt (o nl in e, p ho ne, fa ce -t o-fa ce ) Fo ld er o n h ea lth y w ei gh t, u su al c ar e C ha ng e i n w ei gh t a t 1 2 we ek s K ra s-ch ne w sk y 20 11 60 2-ar m R C T; U SA ; 3 m 10 0 o ve rw ei gh t p eo pl e, I n-ter ne t v ia fl yer s/ In ter ne t 50 .3 (1 0. 9) 70 W eb sit e: t ar ge t b od y w ei gh t, m on ito ri ng , b e-ha vi or al t ip s, v id eo s, w ei gh t l os s p la n, t ai lo re d fe ed ba ck , r em in der s W ai t l ist , p eo pl e g ot ac ce ss t o w eb sit e a ft er 12 w ee ks We ig ht lo ss We bb er b 20 08 61 2-ar m R C T; U SA ; 4 m 66 w om en , B M I 2 5-40 , I n-te rn et fro m a dve rt ise m ent s 50 .0 (9. 9) 10 0 W eb sit e: w ei gh t l os s t ip s, l es so ns , m es sa ge boa rd , se lf-m on ito ri ng (w ei gh t, d ie t), c ha t se ss io ns A ll f ea tu re s o f i nt er -ve nt io n e xc ep t f or o n-lin e c ha t s es sio ns N ot d efi ne d; w ei gh t, BM I, d ie t, e xe rc ise E-LI T E 201 3 36 3-ar m R C T; U SA ; 1 5 m 24 1 p eo pl e w ith a B M I ≥ 25 , m et ab ol ic s yn dr om e f ro m 1 c lin ic 52 .9 (1 0.6 ) 47 (1 ) W eb sit e + 1 2 l ife st yl e c la ss es ; c (2 ) w ebsi te : se lf-m on ito ri ng (w ei gh t, e xe rc ise ), m es sa gi ng , D V D w ith l ife st yl e c la ss es b Us ua l c ar e C ha ng e i n B M I f ro m ba se lin e t o 1 5 m POW ER 20 14 62 4-ar m R C T; U K ; 12 m 17 9 p eo pl e w ith B M I ≥ 30 kg /m 2 o r ≥28 kg/ m 2 + C V ri sk f ac to rs f ro m 5 G Ps 51 .2 (1 3. 1) 66 (1 ) W eb sit e: 1 2 s el f-m an ag em en t s es sio ns m on -ito ri ng ( w ei gh t), nu rs e s up po rt ( em ai l); b, c (2 ) 1 + 3 nu rs e c on ta ct s; ( 3) 1 + 7 nu rs e c on ta ct s Us ua l c ar e W ei gh t a t 1 2 m w eight loss maintenance St op R eg ai n 20 08 41 3-ar m R C T; U SA ; 1 8 m 31 4 p eo pl e w ith 1 0% w ei gh t l os s i n 2 y ea rs , v ia ad ve rt ise m ent s 51 (1 0) 81 (1 ) W eb sit e: se lf-mon ito ri ng, e m ai l c ou ns el in g, ex pe rt s c hat ; b (2 ) fa ce -t o-fa ce : se lf-m on ito ri ng vi a p ho ne , w ee kl y g ro up s es sio ns (3 ) N ew sle tt er s W ei gh t g ai n a t 1 8 m W LM 2 00 8 40 2-ph as e 3-ar m R C T; U SA ; 3 0 m 10 32 p eo pl e w ith ≥ 4 k g pr ev io us w ei gh t l os s, h y-pe rten sio n, In te rn et v ia un iv er sit y/ m ed ic are 55 .6 (8 .7 ) 63 (1 ) W eb sit e: g oa l s et ti ng , a ct io n p la ns , se lf-m on itor in g ( w ei gh t, P A , d ie t), e duc at io n, bu lle ti n b oa rd , r em in de rs , s up po rt (e m ai l/ ph on e) ; b (2 ) p er so na l c on ta ct ( ph on e + fa ce -to -fa ce ) Pri nt ed li fe st yl e gu id el in es , 1 v isi t w ith coa ch C ha ng e i n w ei gh t a A bb re vi at ion s: B M I: b od y m as s in de x; C V: c ar di ov asc ul ar ; G P: g en er al p ra cti tio ne r; P A : p hy sic al a cti vi ty . b F or s tu die s w ith m or e t ha n 2 a rm s, t hi s a rm w as use d f or a ll a na ly se s. c F or s tu die s wi th m or e t ha n 2 a rm s, t hi s a rm w as u se d f or t he s ub gr oup a na ly sis o n b len de d in ter ve nt ion s. d C on tro l a rm c on sis ts o f s am e in ter ac tiv e I nt er ne t-pl atf or m as int er ve nt ion ar m .
38 Ta bl e 4 C ha ra ct er ist ic s o f t he s tu di es i ncl ud ed f or t he s ys te m at ic r ev ie w : i nt er ve nt io ns t ar get in g p hy sic al a ct iv ity a nd c ho le st er ol a Study Set ting and study length Participants Ag e (y ears), mean (SD) Sex (% female) Interv ention Contr ol
Primary; secondary outcomes
Ph ysical acti vity Richa rd so n b 20 10 63 2-ar m R C T; U SA ; 4 m 32 4 p at ie nt s f ro m c lin ic : 1 2% C H D , 2 0% D M 2, 6 2% B M I > 30 52 .0 (11 .4 ) 65 W eb sit e a s c on tr ol + o nl in e c om -m uni ty fo ru m W eb sit e: p ed om et er , ta ilo red fe ed ba ck C ha ng e i n a ve ra ge d ai ly s te p co un t, pa tie nt a tt ri tio n R ei d 2 011 30 2-ar m R C T; C an ad a; 1 2 m 22 3 p at ie nt s w ith a r ec en t C H D ev en t, I nt er ne t v ia 2 c ar di ac cen te rs 56 .4 (9. 0) 16 W eb sit e: t ut or ia ls, e xe rc ise p la ns , se lf-mon ito ri ng, sp ec ia lis t s up po rt Us ua l c ar e, e du ca tio n boo kl et M ea n s te ps p er d ay Fer ney 20 09 64 2-ar m R C T; A us tr al ia ; 6 m 10 6 i na ct iv e r es id en ts : 5 8% ove rw ei ght 52 .0 (4 .6 ) 72 W eb sit e: b eh av io ra l s tra te gi es , g oa l se tt in g, se lf-mon ito ri ng, a dv ic e, b ul -le ti n b oa rd , n ew s W eb sit e w ith m in im al in te ra cti vi ty N ot d efi ne d; p hy sic al a ct iv -ity , w eb sit e u se A ct iv e a ft er 55 2 01 3 65 2-ar m R C T; U SA ; 3 m 40 5 s ed en ta ry p eo pl e w ith I n-te rn et v ia sen io r c en te rs /w eb -sit es 60 .3 (4 .9 ) 69 W eb sit e: e du ca tio n, g oa l s et ti ng , e x-erc ise p la nn in g, 1 1 o nl in e e xe rc ise l es -son s, s el f-mon ito ri ng, re m in de rs N o a cc es s t o t he i nt er -ve nt io n N ot d efi ne d; p hy sic al a ct iv -ity , B M I H EA RT 20 14 37 2-ar m R C T; N ew Zea l-an d; 6 m 17 1 p eo pl e w ith s ta bl e C H D , I n-te rn et f ro m 2 h os pi ta ls 60 .2 (9 .2 ) 19 Ex erc ise p re sc ri pt io n, b eh av io ra l st ra te gi es , W eb sit e: v id eo s, s el f-m on -itor in g ( ex er ci se ), e duc at io n, re -m in der s Us ua l c ar e C ha ng e i n p ea k o xy ge n u p-ta ke f ro m b as el in e t o 6 m Ph ili ps D ir -ec t L ife 201 3 66 2-ar m R C T; Ne the rl an ds ; 3 m 23 5 i na ct iv e p eo pl e w ith I nt er -ne t t hr ou gh l oc al m ed ia 64 .8 (2 .9 ) 41 W eb sit e: g oa l s et ti ng, se lf-mon ito ri ng (e xe rc ise ), e -coa ch fe ed ba ck W ai tl ist c ont ro l C ha ng e i n p hy sic al a ct iv ity Su boc 20 14 67 3-ar m R C T; U SA ; 3 m 11 4 s ed en ta ry p eo pl e t hr ou gh m ed ia a nd I nt er ne t 63 .0 (7 .0 ) 34 (1 ) P ed om et er ; ( 2) w eb sit e + p ed o-m et er : e xe rc ise s tr at eg ie s, g oa l s et -ti ng , s el f-m on ito ri ng ( ex erc ise ) f ee d-ba ck , f or um c N o i nt er ve nt io n End ot hel ia l f unc tio n; v as -cu la r s ti ffn es s, s te p c ou nt , ex er ci se Pe el s 2 01 3 68 5-ar m c lu st er R C T; N et h-erl an ds ; 1 2 m 21 40 p eo pl e f ro m 6 m un ic ip al re gi on s, ± 50 % o ve rw ei gh t 63 .2 (8 .4 ) 51 (1 ) P ri nt ed f ee db ac k r ep or t; ( 2) 1 + lo ca l e xe rc ise t ip s; ( 3) W eb -b as ed fe ed ba ck r ep or t; ( 4) 3 + l oc al e xe r-ci se t ip s c W ai tl ist c ont ro l Ph ys ic al a ct iv ity 38 Ta bl e 4 C ha ra ct er ist ic s o f t he s tu di es i ncl ud ed f or t he s ys te m at ic r ev ie w : i nt er ve nt io ns t ar get in g p hy sic al a ct iv ity a nd c ho le st er ol a Study Set ting and study length Participants Ag e (y ears), mean (SD) Sex (% female) Interv ention Contr ol
Primary; secondary outcomes
Ph ysical acti vity Richa rd so n b 20 10 63 2-ar m R C T; U SA ; 4 m 32 4 p at ie nt s f ro m c lin ic : 1 2% C H D , 2 0% D M 2, 6 2% B M I > 30 52 .0 (11 .4 ) 65 W eb sit e a s c on tr ol + o nl in e c om -m uni ty fo ru m W eb sit e: p ed om et er , ta ilo red fe ed ba ck C ha ng e i n a ve ra ge d ai ly s te p co un t, pa tie nt a tt ri tio n R ei d 2 011 30 2-ar m R C T; C an ad a; 1 2 m 22 3 p at ie nt s w ith a r ec en t C H D ev en t, I nt er ne t v ia 2 c ar di ac cen te rs 56 .4 (9. 0) 16 W eb sit e: t ut or ia ls, e xe rc ise p la ns , se lf-mon ito ri ng, sp ec ia lis t s up po rt Us ua l c ar e, e du ca tio n boo kl et M ea n s te ps p er d ay Fer ney 20 09 64 2-ar m R C T; A us tr al ia ; 6 m 10 6 i na ct iv e r es id en ts : 5 8% ove rw ei ght 52 .0 (4 .6 ) 72 W eb sit e: b eh av io ra l s tra te gi es , g oa l se tt in g, se lf-mon ito ri ng, a dv ic e, b ul -le ti n b oa rd , n ew s W eb sit e w ith m in im al in te ra cti vi ty N ot d efi ne d; p hy sic al a ct iv -ity , w eb sit e u se A ct iv e a ft er 55 2 01 3 65 2-ar m R C T; U SA ; 3 m 40 5 s ed en ta ry p eo pl e w ith I n-te rn et v ia sen io r c en te rs /w eb -sit es 60 .3 (4 .9 ) 69 W eb sit e: e du ca tio n, g oa l s et ti ng , e x-erc ise p la nn in g, 1 1 o nl in e e xe rc ise l es -son s, s el f-mon ito ri ng, re m in de rs N o a cc es s t o t he i nt er -ve nt io n N ot d efi ne d; p hy sic al a ct iv -ity , B M I H EA RT 20 14 37 2-ar m R C T; N ew Zea l-an d; 6 m 17 1 p eo pl e w ith s ta bl e C H D , I n-te rn et f ro m 2 h os pi ta ls 60 .2 (9 .2 ) 19 Ex erc ise p re sc ri pt io n, b eh av io ra l st ra te gi es , W eb sit e: v id eo s, s el f-m on -itor in g ( ex er ci se ), e duc at io n, re -m in der s Us ua l c ar e C ha ng e i n p ea k o xy ge n u p-ta ke f ro m b as el in e t o 6 m Ph ili ps D ir -ec t L ife 201 3 66 2-ar m R C T; Ne the rl an ds ; 3 m 23 5 i na ct iv e p eo pl e w ith I nt er -ne t t hr ou gh l oc al m ed ia 64 .8 (2 .9 ) 41 W eb sit e: g oa l s et ti ng, se lf-mon ito ri ng (e xe rc ise ), e -coa ch fe ed ba ck W ai tl ist c ont ro l C ha ng e i n p hy sic al a ct iv ity Su boc 20 14 67 3-ar m R C T; U SA ; 3 m 11 4 s ed en ta ry p eo pl e t hr ou gh m ed ia a nd I nt er ne t 63 .0 (7 .0 ) 34 (1 ) P ed om et er ; ( 2) w eb sit e + p ed o-m et er : e xe rc ise s tr at eg ie s, g oa l s et -ti ng , s el f-m on ito ri ng ( ex erc ise ) f ee d-ba ck , f or um c N o i nt er ve nt io n End ot hel ia l f unc tio n; v as -cu la r s ti ffn es s, s te p c ou nt , ex er ci se Pe el s 2 01 3 68 5-ar m c lu st er R C T; N et h-erl an ds ; 1 2 m 21 40 p eo pl e f ro m 6 m un ic ip al re gi on s, ± 50 % o ve rw ei gh t 63 .2 (8 .4 ) 51 (1 ) P ri nt ed f ee db ac k r ep or t; ( 2) 1 + lo ca l e xe rc ise t ip s; ( 3) W eb -b as ed fe ed ba ck r ep or t; ( 4) 3 + l oc al e xe r-ci se t ip s c W ai tl ist c ont ro l Ph ys ic al a ct iv ity
