Use of smartphone app to prepare patients for bariatric surgery

Although we have recently seen a stabilization of the overall prevalence of obesity in the United States, the number of individuals with a body mass index (BMI) of 40 or greater (class III obesity) continues to grow.

Manpreet S. Mundi, M.D., of the Division of Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic's campus in Rochester, Minnesota, says: "Fortunately, we now have multiple options to offer patients seeking assistance with weight loss. Within the last few years we have seen two new drugs approved for long-term treatment of obesity — lorcaserin (Belviq) and the combination preparation of phentermine and topiramate extended-release (Qsymia) — and the emergence of endoscopic interventions to manage weight.

"Recent randomized, controlled trials have further solidified bariatric surgery as the most effective means of achieving adequate and sustained weight loss, with a concomitant improvement in related comorbidities, particularly type 2 diabetes mellitus.

"Regardless of the intervention used, however, successful weight management depends on an adequate understanding of nutrition and physical activity fundamentals, coupled with mechanisms to assist patients in developing and maintaining a high level of engagement in lifestyle modification.

"Unfortunately, the comprehensive nature of weight management often necessitates tremendous resource utilization. Given the high level of scrutiny to control health care costs, it can be difficult to reconcile obtaining the required resources with those available."

Real-time engagement and intervention

Paul A. Lorentz, R.N., of the Division of Endocrinology, Diabetes, Metabolism, and Nutrition, explains: "Fortunately, mobile technology, with its rapid and widespread adoption by the general population, offers a unique platform to provide valuable resources in a cost-considerate manner.

"Recent research suggests that traditional weight-loss programs can be enhanced by mobile technology such as text messages, social media and virtual coaching. Much of this research suggests that patients are generally accepting of and often prefer mobile platforms for intervention delivery."

Dr. Mundi continues: "However, we feel that this is simply the tip of the iceberg. In addition to cost-effectively educating patients, mobile technology can also engage and intervene with patient populations in real time, while in their natural environment.

"Using the concepts of ecological momentary assessment (EMA) and ecological momentary intervention (EMI), terms first coined by Stone and Shiffman in 1994, a powerful, synergistic behavior modification platform can be created. In fact, one of the main benefits is that the interventions can be facile and simple, but significant enough to increase self-awareness and mindfulness, such as asking patients to photo capture diet choices through a smartphone app.

"Similarly, because mobile technology supports real-time data gathering, the significant recall bias prevalent in traditional, self-report formats is drastically reduced, allowing for a more objective clinical assessment."

Lorentz explains: "Building upon these principles, our group has developed smartphone apps to assist patients preparing for bariatric surgery and those who have undergone bariatric surgery. The apps educate our patients through the use of video-based education modules that are paired with short assessments, ensuring mastery or identifying deficiencies in a particular topic."

Through the use of algorithmic EMA/EMI text messaging, the apps allow for robust, real-time data collection, while simultaneously providing an intervention. Dr. Mundi highlights: "We recently completed a trial, assessing the acceptability and feasibility of using this mobile technology in our clinical practice. Overall, the subjects expressed very high satisfaction, with most feeling that the app fit into their routine easily, while containing an appropriate amount of messaging. Patients also reported that the app was quite helpful in their preparation for bariatric surgery.

"Our feasibility trial also provided us with some intriguing data. To ensure that the EMA messaging was 'real time,' unanswered messages were programmed to expire within 60 minutes. Interestingly, we learned that the EMA response rate, arguably a correlate of patient engagement, was highest right after patients completed their initial appointment. The response rate started and continued to decrease for eight to 10 weeks after the patient's initial appointment.

"Interestingly, the EMA response rate started to increase as patients were preparing to return for their follow-up appointments. This certainly points out a clinical need to identify methods, mobile and otherwise, that can increase and sustain patient engagement throughout the pre-surgical period. Although this study was simply a feasibility trial, we did note that patients using the apps tended to lose slightly more weight prior to surgery."

Dr. Mundi concludes: "Clearly, mobile technology has a role to play in the delivery of efficient and effective health care. It's also likely that what we've found to be beneficial in our bariatric surgery practice will be diffusible to many areas of specialty practice with similar needs, such as patient education, engagement, connection and cost containment.

"What remains to be answered is how the role of mobile technology will evolve, and how to best utilize the same, augmenting traditional care models with its known attributes (low-cost, dynamic, real-time interaction, and so on) while not compromising the quality of patient care and related outcomes."