Health Information Technology: Comprehensive Telehealth Interventions to Improve Diet Among Patients with Chronic Diseases

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to nutrition.

Kelly JT, Reidlinger DP, Hoffmann TC, Campbell KL. Telehealth methods to deliver dietary interventions in adults with chronic disease: a systematic review and meta-analysis. American Journal of Clinical Nutrition 2016;104(6):1693-702.

The systematic review and meta-analysis included 25 randomized controlled trials (search period through 2015).

The CPSTF finding is based on results from the published review and expert input from team members and the CPSTF.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 25 studies.

• Dietary Change Outcomes
  • Diet quality improved significantly (3 studies).
  • Sodium intake decreased significantly (5 studies).
  • Fruit and vegetable intake increased by one serving per day (4 studies) and three servings per week (2 studies).
  • Patients reported significant improvements in diet quality and sodium intake at 12 and 24 months (4 studies).
  • Interventions to increase the consumption of fruit and vegetables were more effective when delivered weekly rather than monthly (1 study).
• Clinical Outcomes
  • While telehealth interventions led to improvements in blood pressure, weight loss, and waist circumference, conclusions were limited by the small number of studies and inconsistent results.
  • Studies reported mixed effects on patient illness (2 studies).

A systematic review of economic evidence has not been conducted.

Based on results of the systematic review, findings are applicable to the following:

• Community and ambulatory care settings
• Patients with diet-related chronic conditions (e.g., diabetes and cardiovascular disease)
• Healthcare providers, including nurses, social workers, health educators, and physicians
• Media, including telephone, email, video, internet, or mobile applications

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• Are interventions effective in changing dietary behaviors using additional communication channels (e.g., web-paged programs, videoconferencing)?
• Do these interventions improve clinical outcomes and reduce morbidity and mortality?
• How does intervention effectiveness vary when implemented for the following groups?
  • Patients who vary by race, ethnicity, or socioeconomic status
  • Patients with chronic conditions other than those included in this review

• Participants in the evaluated interventions reported a range of chronic health conditions, including cardiovascular disease (15 studies), diabetes (5 studies), end-stage renal disease (2 studies), and obesity (1 study).
• Over half of the studies reported a study duration of less than six months (15 studies).
• The median number of participants reported in studies was 131.
• The telephone was the most common telehealth delivery method (13 studies).

Effectiveness Review

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Analytic Framework [PDF – 85 kB]

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Kelly JT, Reidlinger DP, Hoffmann TC, Campbell KL. Telehealth methods to deliver dietary interventions in adults with chronic disease: a systematic review and meta-analysis. American Journal of Clinical Nutrition 2016;104(6):1693-702.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Albert NM, Buchsbaum R, Li J. Randomized study of the effect of video education on heart failure healthcare utilization, symptoms, and self-care behaviors. Patient Educ Couns 2007;69:129 39.

Arora S, Burner E, Lam J, De Santos R, Meeks A, Menchine M. Trial to examine text-message based mhealth in ed patients with diabetes (TExT-MED). Acad Emerg Med 2013;20:S180.

Chiu CW, Wong FKY. Effects of 8 weeks sustained follow-up after a nurse consultation on hypertension: a randomized trial. Int J Nurs Stud 2010;47:1374 82.

Chow CK, Redfern J, Hillis GS, Thakkar J, Santo K, Hackett ML, Jan S, Graves N, de Keizer L, Barry T, et al. Effect of lifestyle-focused text messaging on risk factor modi?cation in patients with coronary heart disease: a randomized clinical trial. JAMA 2015;314: 1255 63.

Cicolini G, Simonetti V, Comparcini D, Celiberti I, Di Nicola M, Capasso LM, Flacco ME, Bucci M, Mezzetti A, Manzoli L. Ef?cacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: a randomized controlled trial. Int J Nurs Stud 2014;51:833 43.

Pfaeffli Dale L, Whittaker R, Jiang Y, Stewart R, Rolleston A, Maddison R. Text message and Internet support for coronary heart disease self-management: results from the Text4Heart randomized controlled trial. J Med Internet Res 2015;17:e237.

Eakin E, Reeves M, Lawler S, Graves N, Oldenburg B, Del Mar C, Wilke K, Winkler E, Barnett A. Telephone counseling for physical activity and diet in primary care patients. Am J Prev Med 2009;36: 142 9.

Eakin EG, Winkler EA, Dunstan DW, Healy GN, Owen N, Marshall AM, Graves N, Reeves MM. Living well with diabetes: 24-month outcomes from a randomized trial of telephone-delivered weight loss and physical activity intervention to improve glycemic control. Diabetes Care 2014;37:2177 85.

Ferrante D, Varini S, Macchia A, Soifer S, Badra R, Nul D, Grancelli H, Doval H. Long-term results after a telephone intervention in chronic heart failure: DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure) follow-up. J Am Coll Cardiol 2010;56:372 8.

Friedberg JP, Rodriguez MA, Watsula ME, Lin I, Wylie-Rosett J, Allegrante JP, Lipsitz SR, Natarajan S. Effectiveness of a tailored behavioral intervention to improve hypertension control: primary outcomes of a randomized controlled trial. Hypertension 2015;65:440 6.

Glasgow RE, Toobert DJ. Brief, computer-assisted diabetes dietary self-management counseling: effects on behavior, physiologic outcomes, and quality of life. Med Care 2000;38:1062 73.

Green BB, Anderson ML, Cook AJ, Catz S, Fishman PA, McClure JB, Reid RJ. e-Care for heart wellness: a feasibility trial to decrease blood pressure and cardiovascular risk. Am J Prev Med 2014;46:368 77.

Hawkes A, Patrao T, Atherton J, Ware R, Taylor C, O’Neil A, Foreman R, Oldenburg B. Effect of a telephone-delivered coronary heart disease secondary prevention program (ProActive Heart) on quality of life and health behaviours: primary outcomes of a randomized controlled trial. Int J Behav Med 2013;20:413 24.

Izquierdo R, Lagua CT, Meyer S, Ploutz-Snyder RJ, Palmas W, Eimicke JP, Kong J, Teresi JA, Shea S, Weinstock RS. Telemedicine intervention effects on waist circumference and body mass index in the IDEATel Project. Diabetes Technol Ther 2010;12:213 20.

Lear SA, Singer J, Banner-Lukaris D, Horvat D, Park JE, Bates J, Ignaszewski A. Improving access to cardiac rehabilitation using the internet: a randomized trial. Stud Health Technol Inform 2015;209: 58 66.

McConnon A, Kirk SF, Cockroft JE, Harvey EL, Greenwood DC, Thomas JD, Ransley JK, Bojke L. The Internet for weight control in an obese sample: results of a randomized controlled trial. BMC Health Serv Res 2007;7:206.

Migneault JP, Dedier JJ, Wright JA, Heeren T, Campbell MK, Morisky DE, Rudd P, Friedman RH. A culturally adapted telecommunication system to improve physical activity, diet quality, and medication adherence among hypertensive African-Americans: a randomized controlled trial. Ann Behav Med 2012;43:62 73.

Miller ER, Cooper LA, Carson KA, Wang N-Y, Appel LJ, Gayles D, Charleston J, White K, You N, Weng Y. A dietary intervention in urban African Americans: results of the “Five Plus Nuts and Beans” randomized trial. Am J Prev Med 2016;50:87 95.

Mok VK, Sit JW, Tsang AS, Chair SY, Cheng TL, Chiang CS. A controlled trial of a nurse follow-up dietary intervention on maintaining a heart-healthy dietary pattern among patients after myocardial infarction. J Cardiovasc Nurs 2013;28:256 66.

Philipson H, Hagelind SSE, Swedberg KS, Ekman IE, Schaufelberger MS. Salt and water restriction is effective in patients with chronic heart failure. Eur J Heart Fail 2011;10(Suppl):S202 3.

Sone H, Tanaka S, Iimuro S, Tanaka S, Oida K, Yamasaki Y, Oikawa S, Ishibashi S, Katayama S, Yamashita H, et al. Long-term lifestyle intervention lowers the incidence of stroke in Japanese patients with type 2 diabetes: a nationwide multicentre randomised controlled trial (the Japan Diabetes Complications Study). Diabetologia 2010;53:419 28.

Welch JL, Astroth KS, Perkins SM, Johnson CS, Connelly K, Siek KA, Jones J, Scott LL. Using a mobile application to self-monitor diet and ?uid intake among adults receiving hemodialysis. Res Nurs Health 2013;36:284 98.

Woollard J, Beilin L, Lord T, Puddey I, MacAdam D, Rouse I. A controlled trial of nurse counselling on lifestyle change for hypertensives treated in general practice: preliminary results. Clin Exp Pharmacol Physiol 1995;22:466 8.

Woollard J, Burke V, Beilin LJ, Verheijden M, Bulsara MK. Effects of a general practice-based intervention on diet, body mass index and blood lipids in patients at cardiovascular risk. J Cardiovasc Risk 2003; 10:31 40.

Wong FK, Chow SK, Chan TM. Evaluation of a nurse-led disease management programme for chronic kidney disease: a randomized controlled trial. Int J Nurs Stud 2010;47:268 78.

Implementation Resources

• CDC’s Division for Heart Disease and Stroke Prevention developed an implementation resource to help communities and health systems implement telehealth interventions to improve chronic diseases.

Refer to the existing systematic review for information about the search strategy:

Kelly JT, Reidlinger DP, Hoffmann TC, Campbell KL. Telehealth methods to deliver dietary interventions in adults with chronic disease: a systematic review and meta-analysis. American Journal of Clinical Nutrition 2016;104(6):1693-702.

Kelly JT, Reidlinger DP, Hoffmann TC, Campbell KL . Telehealth methods to deliver dietary interventions in adults with chronic disease: a systematic review and meta-analysis. American Journal of Clinical Nutrition 2016; 104(6):1693-1702.

Kelly JT, Reidlinger DP, Hoffmann TC, Campbell KL. Telehealth methods to deliver multifactorial dietary interventions in adults with chronic disease: a systematic review protocol. Systematic Reviews 2015; 4:185.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Implementers should understand state policies regarding application of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to electronic communications involving patients.
• Comprehensive telehealth interventions may reduce the number of in-person visits and subsequently decrease opportunities for patients to receive other preventive services, such as blood pressure monitoring and periodic cancer screening.
• This CPSTF recommendation should not be considered an endorsement of any specific technology.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of adults who use IT to track health care data or communicate with providers — HC/HIT-07
• Increase fruit consumption by people aged 2 years and over — NWS-06
• Increase vegetable consumption by people aged 2 years and older — NWS-07
• Reduce consumption of sodium by people aged 2 years and over — NWS-12