e-mail intervention program helps improve diet and lifestyle

May 19 2009

An e-mail intervention program is an effective way to significantly improve diet and physical activity by helping people move more, sit less, and make healthier food choices, according to a Kaiser Permanente Division of Research study in the American Journal of Preventive Medicine.

The study was a randomized controlled trial of the ALIVE (A Lifestyle Intervention Via E-mail) program conducted among 787 Kaiser Permanente Northern California employees at their worksites. Through the ALIVE program, developed by NutritionQuest, (www.nutritionquest.com) weekly e-mails were sent to the 351 employees randomized to the intervention group; the 436 employees in the control group received only immediate e-mail feedback at the start of the intervention indicating whether or not their reported physical activity and diet met national guidelines. The messages to the participants in the intervention group suggested small, practical, individually tailored goals, such as eating fruit for a snack three times a week, walking for 10 minutes a day at lunch time, or walking to the store instead of driving.

At the end of the 16-week trial, the participants in the intervention group were more physically active, eating more fruits and vegetables, and reducing their intake of saturated fats and trans fats, compared to the control group. The biggest changes occurred among those in the intervention group, who did not meet behavioral recommendations at the start of the trial. For example, employees who were not regularly active before receiving the intervention increased their participation in moderate intensity physical activities by almost an hour a week and decreased the amount of time they spent in sedentary activities, like watching TV and videos, by about two hours a week. These changes had a lasting effect four months after the intervention ended, the study found.

"The takeaway message here for people who want to improve their diet and physical activity, and for employers who want a healthier workforce, is that e-mail intervention programs are a very cost-effective way to get healthy," said study lead investigator Barbara Sternfeld, Ph.D., senior research scientist with the Kaiser Permanente Division of Research and the study's lead investigator. "A tailored e-mail program includes all the things that behavioral scientists have said for years about changing behavior: small goals tailored for the individual, reinforcement, and tracking but delivered in a mass, cost-effective way."

Funded by the U.S. Centers for Disease Control and Prevention, this study offers additional support for the effectiveness of the Internet and e-mail to reach large segments of the population to inspire healthier lifestyle choices. It is one of the first studies to send messages directly into individuals' e-mail inboxes, rather than requiring individuals to actively access messages via the World Wide Web.

Given that the majority of Americans eat poorly and fail to exercise enough, effective e-mail programs could be a useful way to improve health, researchers say. According to the CDC, 55 percent don't perform the recommended 30 minutes of moderate physical activity most days of the week. Additionally, the daily diet for about three-quarters of the population consists of more than 30 percent fat, a percentage that's generally considered too high.

Participants received weekly e-mails in their work or home accounts for four months that were tailored to their individual needs and life situation (for example, whether they had small children at home or busy schedules that posed barriers to exercise and diet improvement.) The e-mails linked to a personal home page with tips for achieving the small-step goals the respondent had selected, educational materials and tracking and simulation tools. Reminder messages were sent between each intervention message.

The study cohort was composed of employees who worked in the regional offices of Kaiser Permanente Northern California. The employees worked in administrative, financial, regulatory, technical and professional services and were not involved with direct patient care. They tend to use computers for much of their work. Participation had no bearing on job performance, employment status, or health benefits. The participants' information was kept confidential and did not appear on medical records or employee files.

Before the program began, participants were evaluated on their eating and exercise habits by answering a short, online questionnaire, to which they received immediate feedback. They filled out the online questionnaire twice more, at the end of the program and four months later.

Another paper published in January in the Journal of Medical Internet Research found that the ALIVE e-mail program reduced presenteeism among the trial participants and reduced bodily pain. Presenteeism is lost productivity that occurs when employees come to work but perform below par due to any kind of illness. The study did not look at whether employees used the e-mail program during their lunch hour or during their regular work hour.

"Using e-mail to get people active is a great use of existing technology that is cheap and readily available," said Bob Sallis, MD, a Kaiser Permanente family physician who is the regional exercise champion for Kaiser Permanente's Southern California region and immediate past president of the American College of Sports Medicine. "Anything we can do to increase activity level is going to improve health because we know that exercise is medicine. It's medicine you can take to live a longer and healthier life."

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