The App That is Tackling Type 2 Diabetes in Finland One Healthy Habit at a Time
For anyone creating health tracking mobile apps today (including us!), the StopDia type 2 diabetes prevention project and its BitHabit app are fantastic sources of inspiration.
StopDia is a research and public engagement project that is tackling prevention of type 2 diabetes in Finland, through simple and daily lifestyle health interventions. The University of Eastern Finland, Finland’s National Institute for Health and Welfare, the VTT Technical Research Institute of Finland and regional healthcare organizations in Finland have teamed up to conduct one of the largest population risk screenings ever completed for type 2 diabetes, and to evaluate a technology-mediated intervention for at-risk individuals.
LifeOmic chatted with several StopDia researchers this week to learn more about the project and its web app for healthy habit formation. At LifeOmic, we are currently developing a robust health tracking and precision health mobile app — LIFE Extend — that will apply lessons from the best health intervention and research tools out there, within a cloud platform framework that can drive insights for researchers, healthcare providers and patients alike.
StopDia began with a large-scale recruitment effort in which the citizens of Finland were encouraged to fill out an online diabetes risk assessment, now known around the world as FINDRISC. Over 200,000 individuals in Finland have completed the assessment, which incorporates risk factors such as age, family history, daily physical activity, vegetable and fruit intake, blood sugar control and blood pressure.
Based on their responses to the FINDRISC questionnaire, individuals across three participating counties who score at a moderate or high risk for type 2 diabetes are recruited to participate in the StopDia research project. Active research participants receive a range of clinical tests related to diabetes risk (blood pressure measurements, fasted insulin response tests, etc.) before being randomly assigned to an experimental or control study arm for 12 months. Individuals in the experimental study arms are directed to use a health tracking web app, called BitHabit, that theoretically will move them toward healthier daily behaviors to prevent type 2 diabetes.
“We have now more than 3,000 people with high risk of developing type 2 diabetes participating in the study,” said Riia Järvenpää, a communications development manager at the National Institute for Health and Welfare in Finland. At StopDia, Riia is working to improve research participant recruitment via novel methods. “The intervention will last for two years, so we will have the final results next year. So far the findings seem promising; people are adhering well to the app.”
The project is still in research phase, but StopDia researchers are now analyzing preliminary data on user engagement with the app and health outcomes.
StopDia’s Tiny Approach to Healthy Habits for Diabetes Prevention
“When we started to discuss and design the concept for this app, the BitHabit, we used other health coaching apps as our starting point. But we felt that we didn’t want to replicate apps with coaching approaches to health, because we know from research that the long-term adherence to these types of apps is very low,” said Dr. Pilvikki Absetz, a researcher at the University of Eastern Finland and sole owner of Collaborative Care Systems Finland, an organization that specializes in research, consultancy and training in health promotion and disease prevention. Pilvikki has over 15 years of experience designing, disseminating and implementing behavioral interventions with a strong element of community engagement in different “real world” settings.
“Very few participants, relatively, can stick with health coaching apps long term,” Pilvikki said. “There are also a lot of commercial health tracking apps out there, for tracking behaviors such as exercise, diet, etc. Users have high expectations for these apps as consumer-facing products, and we didn’t want to or feel that we could compete with these apps.”
In Goldilocks fashion, the researchers and designers behind BitHabit landed somewhere in between. They went for a web app that combines features of health coaching apps with a habit creation approach to health behavior tracking. They chose to create a web app in particular so that any recruited research participants are able to easily participate in the StopDia research project, regardless of the type of mobile device they use at home.
“Our target population isn’t tech geeks, Pilvikki said. “It was apparent to us that our target research participants wouldn’t have the tools and resources to search app stores and download/install a complicated app.”
Each StopDia research participant receives a personalized link that associates their app data with their participant ID. Impressively, StopDia researchers report that over 99% of research participants who have agreed to participate in the project have been able to open the app, and only 7% of the app users haven’t chosen any “bithabits” to practice and track for health.
Could Preventing Type 2 Diabetes Be as Easy as Online Shopping?
“Everybody has health behaviors that they engage in every once in a while,” said Pilvikki, a behavioral scientist and a leading expert in real-world implementation of type 2 diabetes prevention and lifestyle change programs. Pilvikki has a doctorate degree in health psychology and has put many of the principles of this field to work in BitHabit. “But how do we support creation of habits out of these isolated instances of healthy behavior? We set out to foster healthy behavior habit creation with BitHabit.”
Pilvikki and colleagues took their inspiration from online shopping. Everyone knows how to shop for products online. It’s intuitive and rewarding. What if engaging in healthy habits on a daily basis, like flossing, walking 150 minutes per day or going to sleep at your ideal bedtime, were as easy as online shopping?
“We envisioned a library or store of defined, context-specific behaviors, which we call ‘bithabits,’ that have an evidence-based link with prevention of type 2 diabetes,” Pilvikki said. “Imagine the online store, and then imagine the different departments you can browse through. In each department, you have products — in our app, these products are bithabits that participants can browse, select and track over time.”
The BitHabit app prompts users to select healthy behaviors that they feel will work best for them. It’s as easy as putting healthy products into your online “shopping cart.” The goal is for users of the app to report daily on their performance of the bithabits they’ve selected.
“It’s quite simple,” Pilvikki said. The app and its bithabit approach to health behaviors is inspired by the work of Wendy Wood, a social psychologist who studies habit theories, and B.J. Fogg, a researcher who leads the Persuasive Technology Lab at Stanford University and has created a model for human behavior that relies on motivations to act, ability to act and triggers.
“In this model (FBM), behavior is a product of three factors: motivation, ability, and triggers, each of which has subcomponents. The FBM asserts that for a person to perform a target behavior, he or she must (1) be sufficiently motivated, (2) have the ability to perform the behavior, and (3) be triggered to perform the behavior. These three factors must occur at the same moment, else the behavior will not happen.” — B.J. Fogg, A Behavior Model for Persuasive Design
“The easiest way to change behavior is to create paths out of dots, such that single, isolated behaviors (the dots) start to span longer periods of time. In other words, they become habit-like,” Pilvikki said. “The idea is to give people a sense of self-efficacy and perceived control over health promoting behaviors.”
Preventing Type 2 Diabetes with Daily “BitHabit” Healthy Behaviors
One of the “bithabits” that StopDia research participants can select in the project’s web app, for example, is to balance on one foot while brushing their teeth. At one minute per foot, users who practice and track this bithabit will end up practicing their balancing skills (strengthening their ankles and legs in the process) a total of four minutes per day, 28 minutes per week, 23 hours per year.
“We know that moderate levels of physical activity, low sugar intake, and a healthy diet low in saturated fats and high in fiber can help prevent or reduce individuals’ risk of type 2 diabetes,” Pilvikki said. Healthy behaviors incorporated into the BitHabit web app include various physical activity behaviors, fruit and vegetable intake, sugar / sugary beverage avoidance, stress management behaviors such as meditation, and getting adequate amounts and quality of sleep, among others. The idea is for users to select one or a few bithabits to focus on at a time, in order to make a long-term improvement to their health by creating a new healthy habit for life.
Daily engagement with healthy behaviors is also the approach that LifeOmic’s LIFE Extend app will take toward helping people extend their healthspan and track health outcomes. LIFE Extend will help users track fruit and vegetable intake, physical activity, intermittent fasting, sleep duration and quality, and stress reduction activities.
The StopDia project is still in a research phase. It has involved a 12-month health intervention for BitHabit users, with several hundred users having just recently completed their participation in the study. Over 2,000 participants have been randomized to the BitHabit web app study arm. While the outcome data are still too preliminary to report on, the app activity data has already been impressive.
“We have a very high adherence rate — over 60% of users engaged the app weekly over the course of four months, and that percentage was still as high as 40% at one year,” Pilvikki said.
Pilvikki attributes the success of the BitHabit app in terms of engaging users over time to its simplicity. It only asks users to do three things: browse, choose an attractive bithabit, and track that behavior for several months. On top of its simplicity, the app shows users their accumulation of daily health behaviors in such a way that users are motivated to continue making an effort to meet their goals and to not break their “streak” of success. Other apps that do this well include Duolingo, which prompts users to continue their “X-days-in-a-row” practice accomplishment.
“If you look at how people use apps like Facebook or Instagram, they often use them when they have a few minutes of spare time, on the go,” Pilvikki said. “If you have an activity or health coaching item that requires users to sit for a long time, read a lot or answer many complicated questions, you might have an issue. All of these things require a lot of deliberation and effort on the part of the user.”
This is why, in LifeOmic’s LIFE Extend app, we will be taking an on-the-go approach to health tracking, engaging with LIFE friends, and data collection via short “pulse” surveys.
Pilvikki also points out that while researchers and health app creators may have health interventions and improvements as their primary goal, users may not share this priority, especially after overcoming the initial hump of installing or downloading an app for health reasons. Instead, they may continue to engage with a health app over time primarily for entertainment, community building and social connectivity, for example.
One way to promote the entertainment aspect of healthy behavior tracking is to gamify habit formation. Pilvikki says that BitHabit and other health apps do this by showing users a calendar view of their achievements over time, with notifications about “steak” achievements — “Congrats! You just practiced mindfulness 10 days in a row!” People love to rack up achievements and badges, and don’t like to “lose,” especially during a winning streak.
Engagement in most health apps, however, is finite. Given the simplicity of the BitHabit app, which doesn’t incorporate substantial social components, StopDia researchers never expected that their app would be something that users would continue to engage with longer term. Even habit formation theory posits that after 10–12 weeks, a simple health behavior may become a habit and no longer requires active concentration and tracking to be a stable component of an individual’s lifestyle.
The BitHabit web app is also limited by its lack of a social component, Pilvikki says, which can incentivize long-term engagement. Health app friends can pull you back to an app experience or activity over time; if it’s just you, there’s not as much accountability. There may be limited incentive to continue to select and track health behaviors over time within an app that incorporates no social accountability or interactive, real-time healthcare, especially once these behaviors have become habit for individuals.
Changing Diabetes One Research Participant at a Time
The goal of the StopDia project, in addition to engaging users in health behaviors via the BitHabit web app, is to collect data to determine the effectiveness of an app-based health intervention program on type 2 diabetes risk. StopDia researchers also collect data via health questionnaires and clinical measurements for T2D risk factors. Clinical measurements are collected for each participant at the onset and at the conclusion of a 12-month BitHabit intervention.
At three months of BitHabit app use, participants are asked to fill out a questionnaire related to their enjoyment and acceptance of the app and its approach to health interventions for type 2 diabetes. BitHabit app users have already reported over 1.5 million bithabits, a huge wealth of information for researchers who may want to investigate how bithabit tracking corresponds to improvements in type 2 diabetes risk factors, which healthy behaviors individuals typically find easier or more difficult to adopt, which bithabits are typically chosen together, and which healthy behavior changes are effective for which people based on individual characteristics.
Taking Action on Pre-diabetes
Health tracking apps like BitHabit and LifeOmic’s LIFE Fasting Tracker and upcoming LIFE Extend app are all about helping users take daily preventative action for diabetes and diseases of aging. BitHabit researchers and science communicators Riia Järvenpää and Pilvikki Absetz recommend that individuals at high risk for type 2 diabetes and related complications take action by completing a risk assessment and taking steps to incorporate daily physical activity into their lives.
“Based on our risk assessment, even 30 minutes of physical activity each day lessens an individual’s risk of developing type 2 diabetes substantially,” Riia said.
But even 30 minutes of physical activity, although it sounds simple, can be a daunting task for particular individuals to tackle.
“Think of simpler things that you can do to add more physical activity to your daily life — the more of these simple things you add on a daily basis, even five minutes here and five minutes there, the better off you are,” Pilvikki said.
“I would start by looking at what you already do, and simply try to do more of that,” Pilvikki said. “If you like apples, eat apples every day. If a particular activity, like a morning walk, is easy for you, do it more often; not every once in a while, but every day. And if you always do these healthy behaviors in the same context, at the same time of day, etc., you don’t have to think as much about them — they will become habit. We have one research participant who says that when he puts a meal into the microwave oven to heat it up, he does a plank while he is waiting! He does this every day now, every time he puts something into the microwave. Go to the app stores, look at the health tracking and coaching apps, and just try out several of them and see what fits you the best.”
