title: Design and rationale of the tobacco, exercise and diet messages (TEXT ME) trial of a text message-based intervention for ongoing prevention of cardiovascular disease in people with coronary disease: a randomised controlled trial protocol Development of a set of mobile phone text messages designed for prevention of recurrent cardiovascular events A cardiovascular disease policy model that predicts life expectancy taking into account socioeconomic deprivation Psychological Morbidity after Myocardial Infarction in an Area of Deprivation in the UK: Evaluation of a Self-Help Package Prevalence of a healthy lifestyle among individuals with cardiovascular disease in high-, middle- and low-income countries: The Prospective Urban Rural Epidemiology (PURE) study. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies Factors Influencing Engagement, Perceived Usefulness and Behavioral Mechanisms Associated with a Text Message Support Program Effect of Lifestyle-Focused Text Messaging on Risk Factor Modification in Patients With Coronary Heart Disease: A Randomized Clinical Trial. Association of Diet, Exercise, and Smoking Modification With Risk of Early Cardiovascular Events After Acute Coronary Syndromes
abstract: Background Although supporting lifestyle change is an effective way of preventing further events in people with cardiovascular disease , providing access to such interventions is a major challenge . This study aims to investigate whether simple reminders about behaviour change sent via mobile phone text message decrease cardiovascular risk . Methods and analysis R and omised controlled trial with 6 months of follow-up to evaluate the feasibility , acceptability and effect on cardiovascular risk of repeated lifestyle reminders sent via mobile phone text messages compared to usual care .  A total of 720 patients with coronary artery disease will be r and omised to either st and ard care or the TEXT ME intervention . The intervention group will receive multiple weekly text messages that provide information , motivation , support to quit smoking ( if relevant ) and recommendations for healthy diets and exercise . The primary end point is a change in plasma low-density lipoprotein cholesterol at 6 months . Secondary end points include a change in systolic blood pressure , smoking status , quality of life , medication adherence , waist circumference , physical activity levels , nutritional status and mood at 6 months . Process outcomes related to acceptability and feasibility of TEXT ME will also be collected . Ethics and dissemination Primary ethics approval was received from Western Sydney Local Health Network Human Research Ethics Committee — Westmead . Results will be disseminated via the usual scientific forums including peer- review ed publications and presentations at international conferences . Clinical trials registration number ACTRN12611000161921 Background : Supporting lifestyle change is an effective way of preventing recurrent events in people with cardiovascular disease ( CVD ) . However , there is a need to develop innovative strategies that increase access to programmes for individuals at high risk of CVD . This study aim ed to develop a bank of text messages design ed to provide advice , motivation , and support for decreasing cardiovascular risk . Design : Iterative development process with mixed methods Methods : An initial bank of 120 text messages was drafted based on behaviour change techniques , guidelines , and input from clinicians and public health experts . A question naire was then administered to participants ( n = 53 ) for evaluation of message content , usefulness , and language . To test the process of delivery , a pilot study was conducted using a specifically design ed computer programme that delivered messages to multiple mobile phones according to a pre-specified schedule . Data were collected regarding message timing , delivery , and usefulness . Results : In the qualitative question naire , 92 % of participants found the messages easy to underst and and 86 % found the messages contained useful information . Positive feedback was also obtained from the pilot study . Based on these results , together with suggestions provided , several messages were reworded and an additional 44 were written . The need for semi-personalization was also identified and a r and om set of 103 individualized messages was created . Conclusions : A final bank of 137 mobile telephone text messages design ed to support behaviour change and decrease cardiovascular risk have been developed through a multistep iterative process . This provides a scientific approach for future developers of health-related text messages Objectives A policy model is a model that can evaluate the effectiveness and cost-effectiveness of interventions and inform policy decisions . In this study , we introduce a cardiovascular disease ( CVD ) policy model which can be used to model remaining life expectancy including a measure of socioeconomic deprivation as an independent risk factor for CVD . Design A state transition model was developed using the Scottish Heart Health Extended Cohort ( SHHEC ) linked to Scottish morbidity and death records . Individuals start in a CVD-free state and can transit to three CVD event states plus a non-CVD death state . Individuals who have a non-fatal first event are then followed up until death . Taking a competing risk approach , the cause-specific hazards of a first event are modelled using parametric survival analysis . Survival following a first non-fatal event is also modelled parametrically . We assessed discrimination , validation and calibration of our model . Results Our model achieved a good level of discrimination in each component ( c-statistics for men (women)—non-fatal coronary heart disease ( CHD ) : 0.70 ( 0.74 ) , non-fatal cerebrovascular disease ( CBVD ) : 0.73 ( 0.76 ) , fatal CVD : 0.77 ( 0.80 ) , fatal non-CVD : 0.74 ( 0.72 ) , survival after non-fatal CHD : 0.68 ( 0.67 ) and survival after non-fatal CBVD : 0.65 ( 0.66 ) ) . In general , our model predictions were comparable with observed event rates for a Scottish r and omised statin trial population which has an overlapping follow-up period with SHHEC . After applying a calibration factor , our predictions of life expectancy closely match those published in recent national life tables . Conclusions Our model can be used to estimate the impact of primary prevention interventions on life expectancy and can assess the impact of interventions on inequalities Background : Psychological morbidity after an acute myocardial infa rct ion ( AMI ) is known to be common , but can be addressed by appropriate rehabilitation . The area in which this research was conducted experiences high rates of deprivation and of coronary heart disease and limited access to hospital-based rehabilitation . Responding to concern about psychological needs of AMI patients , a self-help package was introduced and evaluated alongside st and ard hospital-based cardiac rehabilitation . Aims : To evaluate the impact of a home-based self-help package ( the Heart Manual ) , alongside existing cardiac rehabilitation provision , on psychological morbidity and health status after AMI . A secondary aim was to assess the suitability of the Heart Manual for older patients aged over 80 years . Methods : A controlled observational study , comparing two cohorts of patients discharged from hospital after AMI . The intervention group was given the self-help package in addition to st and ard care . The control group received st and ard care alone . Outcome measures used were the Hospital Anxiety and Depression Scale and the EuroQol . Results : The intervention group showed significant improvement in anxiety and depression scores after 3 months and nonsignificant improvement in general health status .  Patients who attended hospital-based rehabilitation classes , and those aged over 80 years , also benefited from the intervention . Conclusion : A home-based self-help rehabilitation package is an effective tool alongside hospital-based rehabilitation classes and can be given to all age groups IMPORTANCE Little is known about adoption of healthy lifestyle behaviors among individuals with a coronary heart disease ( CHD ) or stroke event in communities across a range of countries worldwide . OBJECTIVE To examine the prevalence of avoidance or cessation of smoking , eating a healthy diet  , and undertaking regular physical activities  by individuals with a CHD or stroke event . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve Urban Rural Epidemiology ( PURE ) was a large , prospect i ve cohort study that used an epidemiological survey of 153,996 adults , aged 35 to 70 years , from 628 urban and rural communities in 3 high-income countries ( HIC ) , 7 upper-middle-income countries ( UMIC ) , 3 lower-middle-income countries ( LMIC ) , and 4 low-income countries ( LIC ) , who were enrolled between January 2003 and December 2009 . MAIN OUTCOME MEASURES Smoking status ( current , former , never ) , level of exercise ( low , < 600 metabolic equivalent task [MET]-min/wk ; moderate , 600 - 3000 MET-min/wk ; high , > 3000 MET-min/wk ) , and diet ( classified by the Food Frequency Question naire and defined using the Alternative Healthy Eating Index ) . RESULTS Among 7519 individuals with self-reported CHD ( past event : median , 5.0 [ interquartile range { IQR } , 2.0 - 10.0 ] years ago ) or stroke ( past event : median , 4.0 [ IQR , 2.0 - 8.0 ] years ago ) , 18.5 % ( 95 % CI , 17.6%-19.4 % ) continued to smoke ; only 35.1 % ( 95 % CI , 29.6%-41.0 % ) undertook high levels of work- or leisure-related physical activity , and 39.0 % ( 95 % CI , 30.0%-48.7 % ) had healthy diets ; 14.3 % ( 95 % CI , 11.7%-17.3 % ) did not undertake any of the 3 healthy lifestyle behaviors and 4.3 % ( 95 % CI , 3.1%-5.8 % ) had all 3 . Overall , 52.5 % ( 95 % CI , 50.7%-54.3 % ) quit smoking ( by income country classification : 74.9 % [ 95 % CI , 71.1%-78.6 % ] in HIC ; 56.5 % [ 95 % CI , 53.4%-58.6 % ] in UMIC ; 42.6 % [ 95 % CI , 39.6%-45.6 % ] in LMIC ; and 38.1 % [ 95 % CI , 33.1%-43.2 % ] in LIC ) . Levels of physical activity increased with increasing country income but this trend was not statistically significant . The lowest prevalence of eating healthy diets was in LIC ( 25.8 % ; 95 % CI , 13.0%-44.8 % ) compared with LMIC ( 43.2 % ; 95 % CI , 30.0%-57.4 % ) , UMIC ( 45.1 % , 95 % CI , 30.9%-60.1 % ) , and HIC ( 43.4 % , 95 % CI , 21.0%-68.7 % ) . CONCLUSION AND RELEVANCE Among a sample of patients with a CHD or stroke event from countries with varying income levels , the prevalence  of healthy lifestyle behaviors  was low , with even lower levels in poorer countries Summary Background The main associations of body-mass index ( BMI ) with overall and cause-specific mortality can best be assessed by long-term prospect i ve follow-up of large numbers of people . The Prospect i ve Studies Collaboration aim ed to investigate these associations by sharing data from many studies . Methods Collaborative analyses were undertaken of  baseline BMI versus mortality  in 57 prospect i ve studies with 894 576 participants , mostly in western Europe and North America ( 61 % [ n=541 452 ] male , mean recruitment age 46 [ SD 11 ] years , median recruitment year 1979 [ IQR 1975–85 ] , mean BMI 25 [ SD 4 ] kg/m2 ) . The analyses were adjusted for age , sex , smoking status , and study . To limit reverse causality , the first 5 years of follow-up were excluded , leaving 66 552 deaths of known cause during a mean of 8 ( SD 6 ) further years of follow-up ( mean age at death 67 [ SD 10 ] years ) : 30 416 vascular ; 2070 diabetic , renal or hepatic ; 22 592 neoplastic ; 3770 respiratory ; 7704 other . Findings In both sexes , mortality was lowest at about 22·5–25 kg/m2 . Above this range , positive associations were recorded for several specific causes and inverse associations for none , the absolute excess risks for higher BMI and smoking were roughly additive , and each 5 kg/m2 higher BMI was on average associated with about 30 % higher overall mortality ( hazard ratio per 5 kg/m2 [ HR ] 1·29 [ 95 % CI 1·27–1·32 ] ) : 40 % for vascular mortality ( HR 1·41 [ 1·37–1·45 ] ) ; 60–120 % for diabetic , renal , and hepatic mortality ( HRs 2·16 [ 1·89–2·46 ] , 1·59 [ 1·27–1·99 ] , and 1·82 [ 1·59–2·09 ] , respectively ) ; 10 % for neoplastic mortality ( HR 1·10 [ 1·06–1·15 ] ) ; and 20 % for respiratory and for all other mortality ( HRs 1·20 [ 1·07–1·34 ] and 1·20 [ 1·16–1·25 ] , respectively ) . Below the range 22·5–25 kg/m2 , BMI was associated inversely with overall mortality , mainly because of strong inverse associations with respiratory disease and lung cancer . These inverse associations were much stronger for smokers than for non-smokers , despite cigarette consumption per smoker varying little with BMI . Interpretation Although other anthropometric measures ( eg , waist circumference , waist-to-hip ratio ) could well add extra information to BMI , and BMI to them , BMI is in itself a strong predictor of overall mortality both above and below the apparent optimum of about 22·5–25 kg/m2 . The progressive excess mortality above this range is due mainly to vascular disease and is probably largely causal . At 30–35 kg/m2 , median survival is reduced by 2–4 years ; at 40–45 kg/m2 , it is reduced by 8–10 years ( which is comparable with the effects of smoking ) . The definite excess mortality below 22·5 kg/m2 is due mainly to smoking-related diseases , and is not fully explained . Funding UK Medical Research Council , British Heart Foundation , Cancer Research UK , EU BIOMED programme , US National Institute on Aging , and Clinical Trial Service Unit ( Oxford , UK ) Introduction Many studies have now demonstrated the efficacy of text messaging in positively changing behaviours . We aim ed to identify features and factors that explain the effectiveness of a successful text messaging program in terms of user engagement , perceived usefulness , behavior change and program delivery preferences . Methods Mixed methods qualitative design combining four data sources ; ( i ) analytic data extracted directly from the software system , ( ii ) participant survey , ( iii ) focus groups to identify barriers and enablers to implementation and mechanisms of effect and ( iv ) recruitment screening logs and text message responses to examine engagement . This evaluation was conducted within the TEXT ME trial — a parallel design , single-blind r and omized controlled trial ( RCT ) of 710 patients with coronary heart disease ( CHD ) . Qualitative data were interpreted using inductive thematic analysis . Results 307/352 ( 87 % response rate ) of recruited patients with CHD completed the program evaluation survey at six months and 25 participated in a focus group . Factors increasing engagement included ( i ) ability to save and share messages , ( ii ) having the support of providers and family , ( iii ) a feeling of support through participation in the program , ( iv ) the program being initiated close to the time of a cardiovascular event , ( v ) personalization of the messages , ( vi ) opportunity for initial face-to-face contact with a provider and ( vii ) that program and content was perceived to be from a credible source . Clear themes relating to program delivery were that diet and physical activity messages were most valued , four messages per week was ideal and most participants felt program duration should be provided for at least for six months or longer . Conclusions This study provides context and insight into the factors influencing consumer engagement with a text message program aim ed at improving health-related behavior . The study suggests program components that may enhance potential success but will require integration at the development stage to optimize up-scaling . Trial Registration Australia and New Zeal and Clinical Trials Registry , ACTRN12611000161921 IMPORTANCE Cardiovascular disease prevention , including lifestyle modification , is important but underutilized . Mobile health strategies could address this gap but lack evidence of therapeutic benefit . OBJECTIVE To examine the effect of a lifestyle-focused semipersonalized support program delivered by mobile phone text message on cardiovascular risk factors . DESIGN AND SETTING The Tobacco , Exercise and Diet Messages ( TEXT ME ) trial was a parallel-group , single-blind , r and omized clinical trial that recruited 710 patients ( mean age , 58 [ SD , 9.2 ] years ; 82 % men ; 53 % current smokers ) with proven coronary heart disease ( prior myocardial infa rct ion or proven angiographically ) between September 2011 and November 2013 from a large tertiary hospital in Sydney , Australia . INTERVENTIONS Patients in the intervention group ( n = 352 ) received 4 text messages per week for 6 months in addition to usual care . Text messages provided advice , motivational reminders , and support to change lifestyle behaviors . Patients in the control group ( n=358 ) received usual care . Messages for each participant were selected from a bank of messages according to baseline characteristics ( eg , smoking ) and delivered via an automated computerized message management system . The program was not interactive . MAIN OUTCOMES AND MEASURES The primary end point was low-density lipoprotein cholesterol ( LDL-C ) level at 6 months . Secondary end points included systolic blood pressure , body mass index ( BMI ) , physical activity , and smoking status . RESULTS At 6 months , levels of LDL-C were significantly lower in intervention participants , with concurrent reductions in systolic blood pressure and BMI , significant increases in physical activity , and a significant reduction in smoking . The majority reported the text messages to be useful ( 91 % ) , easy to underst and ( 97 % ) , and appropriate in frequency ( 86 % ) . [ table : see text ] . CONCLUSIONS AND RELEVANCE Among patients with coronary heart disease , the use of a lifestyle-focused text messaging service compared with usual care result ed in a modest improvement in LDL-C level and greater improvement in other cardiovascular disease risk factors . The duration of these effects and hence whether they result in improved clinical outcomes remain to be determined . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12611000161921 Background — Although preventive drug therapy is a priority after acute coronary syndrome , less is known about adherence to behavioral recommendations . The aim of this study was to examine the influence of adherence to behavioral recommendations in the short term on risk of cardiovascular events . Methods and Results — The study population included 18 809 patients from 41 countries enrolled in the Organization to Assess Strategies in Acute Ischemic Syndromes ( OASIS ) 5 r and omized clinical trial . At the 30-day follow-up , patients reported adherence to diet , physical activity , and smoking cessation . Cardiovascular events ( myocardial infa rct ion , stroke , cardiovascular death ) and all-cause mortality were documented to 6 months . About one third of smokers persisted in smoking . Adherence to neither diet nor exercise recommendations was reported by 28.5 % , adherence to either diet or exercise by 41.6 % , and adherence to both by 29.9 % . In contrast , 96.1 % of subjects reported antiplatelet use , 78.9 % reported statin use , and 72.4 % reported angiotensin-converting enzyme/angiotensin receptor blocker use . Quitting smoking was associated with a decreased risk of myocardial infa rct ion compared with persistent smoking ( odds ratio , 0.57 ; 95 % confidence interval , 0.36 to 0.89 ) . Diet and exercise adherence was associated with a decreased risk of myocardial infa rct ion compared with nonadherence ( odds ratio , 0.52 ; 95 % confidence interval , 0.4 to 0.69 ) . Patients who reported persistent smoking and nonadherence to diet and exercise had a 3.8-fold ( 95 % confidence interval , 2.5 to 5.9 ) increased risk of myocardial infa rct ion/stroke/death compared with never smokers who modified diet and exercise . Conclusions — Adherence to behavioral advice ( diet , exercise , and smoking cessation ) after acute coronary syndrome was associated with a substantially lower risk of recurrent cardiovascular events . These findings suggest that behavioral modification should be given priority similar to other preventive medications immediately after acute coronary syndrome . Clinical Trial Registration Information— URL : http:// clinical trials.gov/ct2/show/NCT00139815 . Unique identifier : NCT00139815
target: The intervention can therefore be considered cost-saving and health-improving .
  Neither parameter nor structural uncertainty had a significant impact on the conclusion that TEXT ME is cost-effective .
  Conclusions The provision of TEXT ME is predicted to lead to better health outcomes and an overall saving in costs for the health system .
background: Objective To estimate the cost-effectiveness of Tobacco , Exercise and Diet Messages ( TEXT ME ) , a text message-based intervention that provides advice , motivation , information and support to improve health-related behaviours .