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Smartphone Applications for Patients' Health and Fitness

  • John P. Higgins
    Correspondence
    Requests for reprints should be addressed to John P. Higgins, MD, MBA, MPhil, The The University of Texas Health Science Center at Houston, LBJ General Hospital, 5656 Kelley St, UT Annex-Room 104, Houston, TX 77026-1967.
    Affiliations
    Memorial Hermann Sports Medicine Institute, The University of Texas Health Science Center at Houston, Houston
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      Abstract

      Healthcare providers are often looking for ways to objectively monitor and improve their patients' health and fitness, especially in between patient visits. Some insurance companies are using applications data as incentives to improve health and lower premiums. As more and more people start to use smartphones, they may provide a tool to help improve a patient's health and fitness. Specifically, fitness applications or “apps” on smartphones are programs that use data collected from a smartphone's inbuilt tools, such as the Global Positioning System, accelerometer, microphone, speaker, and camera, to measure health and fitness parameters. The apps then analyze these data and summarize them, as well as devise individualized plans based on users' goals, provide frequent feedback, personalized coaching, and additional motivation by allowing milestones to be shared on social media. This article introduces evidence that apps can better help patients reach their health and fitness goals. It then discusses what features to look for in an app, followed by an overview of popular health and fitness apps. Last, patient scenarios with app recommendations, limitations of apps, and future research are discussed.

      Keywords

      Clinical Significance
      • Health and fitness applications or “apps” can help monitor and manage exercise, diet, weight, and sleep.
      • Apps, by providing rapid reliable feedback, may encourage people to achieve health and wellness goals, such as 10,000 steps a day, and gently remind them when they do not meet minimum goals.
      • Sharing app information on social media can result in friendly competition and camaraderie among strangers that may facilitate behavior change and improve well-being.
      SEE RELATED COMMENTARY p. 5
      Fitness, the state of being physically fit and healthy through proper exercise, diet, and sleep habits, is a priority in many countries.
      • Phillips A.C.
      • Der G.
      • Carroll D.
      Self-reported health, self-reported fitness, and all-cause mortality: prospective cohort study.
      Physical inactivity is a major cause of lack of fitness; according to the World Health Organization, approximately 31% of adults are insufficiently active, and approximately 3.2 million deaths each year are due to insufficient physical activity.

      World Health Organization. Physical inactivity: a global public health problem. Available at: http://www.who.int/dietphysicalactivity/factsheet_inactivity/en/. Accessed August 8, 2014.

      Given that healthcare providers see their patients for only a brief moment of time, it is a challenge to motivate them to pursue health and fitness in between visits. Internet-based systems have been used to motivate patients to pursue fitness and seem to improve compliance.
      • Spittaels H.
      • De Bourdeaudhuij I.
      • Vandelanotte C.
      Evaluation of a website-delivered computer-tailored intervention for increasing physical activity in the general population.
      A review of internet-based physical activity interventions noted that 61% of studies reported significant increases in physical activity.
      • Joseph R.P.
      • Durant N.H.
      • Benitez T.J.
      • et al.
      Internet-based physical activity interventions.
      With the rapid increase of smartphone use in recent years, a new way of monitoring and motivating patients to engage in health and fitness is taking shape.
      Smartphone users are able to download applications or “apps” to their devices. Apps are self-contained programs for smartphones designed to fulfill a particular purpose.

      Oxford University Press. Definition of app in English. Available at: http://www.oxforddictionaries.com/definition/english/app. Accessed August 8, 2014.

      Of the more than 1 million apps available, there are 23,490 and 17,756 “health and fitness” apps available on Apple iTunes (iOS) (Apple Inc, Cupertino, Calif) and Google Play (Android OS) (Google, Inc, Mountain View, Calif), respectively.

      Apple. iTunes Preview. App Store “Health & Fitness”. Available at: https://itunes.apple.com/us/genre/ios-health-fitness/id6013?mt=8&ls=1&v0=www-iphone-5s-appstore-health-fitness. Accessed August 8, 2014.

      Google. Google Play. Android apps: health and fitness. Available at: https://play.google.com/store/apps/category/HEALTH_AND_FITNESS?hl=en. Accessed August 8, 2014.

      • Middelweerd A.
      • Mollee J.S.
      • van der Wal C.
      • et al.
      Apps to promote physical activity among adults: a review and content analysis.
      This number continues to grow, with the use of health and fitness apps on Apple's iPhone and iPad having increased by 62% in 2014 compared with 33% for apps in general.

      Dredge S. Health and fitness apps booming ahead of Apple's iOS 8 launch. Available at: http://www.theguardian.com/technology/2014/jun/19/health-fitness-apps-apple-ios-8. Accessed August 8, 2014.

      Given that 58% of US adults own smartphones and 47% of those with a household income less than $30,000 have a smartphone, health and fitness apps may have great potential to reach those very populations with limited access to healthcare information and interventions.

      Pew Research Center. Mobile technology fact sheet. Available at: http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/. Accessed August 8, 2014.

      • Pratt M.
      • Sarmiento O.L.
      • Montes F.
      • et al.
      The implications of megatrends in information and communication technology and transportation for changes in global physical activity.
      Most of the popular mobile health and fitness apps focus on fitness and self-monitoring.
      • Sama P.R.
      • Eapen Z.J.
      • Weinfurt K.P.
      • et al.
      An evaluation of mobile health application tools.
      Fitness apps may represent another tool to assist healthcare providers in measuring health and fitness parameters, setting goals for patients, and helping patients achieve their goals.

      Pew Research Center. Mobile technology fact sheet. Available at: http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/. Accessed August 8, 2014.

      Materials and Methods

      Background

      A search of the English-language scientific literature was performed primarily by searching MEDLINE, PubMed, Google Scholar, and Search for the time period 1976 to April 2015. Keywords used in the search included “smartphone,” “goals,” “apps,” “trainer,” “motivation,” “support,” “aerobic training,” “resistance training,” “healthy lifestyle,” “fitness,” “coach,” “obesity,” “weight,” “overweight,” “exercise,” “physical activity,” and “management.” The bibliographies of articles from these searches were also explored for relevant articles, and links on websites containing published articles were searched for pertinent information. A list of applications was collected on August 8, 2014, using the Power Search function of iTunes version 11.1.5.5 and the Google Play Store Version 4.9.13.

      Identification, Eligibility, and Selection of Apps

      An approach was chosen to identify preferred apps by using information from both the main smartphone app stores (iTunes and Google Play) and the independent reviews. First, the Apple App and Google Play stores under the “Health & Fitness” categories were reviewed on August 8, 2014. From the iTunes store, 30 apps were selected composed of the top 10 from each of the categories “Top Paid Apps, Top Free Apps, and Top Grossing.” From the Google Play store, 30 apps were selected composed of the top 10 from each of the categories “Top Paid, Top Free, and Top All Prices.” Second, for the independent reviews, the following sources were chosen from top ranking results after a Google search on August 8, 2014, using the key words “Best Fitness Apps Review 2014”: (1) “The 65 Best Health & Fitness Apps of 2014: 65 apps

      Team TG. The 65 best health & fitness apps of 2014. Available at: http://greatist.com/fitness/best-health-fitness-apps. Accessed August 8, 2014.

      ; (2) PC Magazine's “The 100 Best iPhone Apps of 2014—Health and Fitness”: 7 apps

      Duffy J. The 100 best iPhone apps of 2014. Available at: http://www.pcmag.com/article2/0%2c2817%2c2393847%2c00.asp. Accessed August 8, 2014.

      ; and “The 100 Best Android Apps of 2014—Health and Fitness”: 7 apps

      Eddy M. The 100 best android apps of 2014. Available at: http://www.pcmag.com/article2/0,2817,2393101,00.asp. Accessed August 8, 2014.

      ; (3) Active.com “15 Best iPhone Fitness Apps for 2014”: 15 apps

      Rosenzweig F. 15 Best iPhone fitness apps for 2014. Available at: http://www.active.com/fitness/articles/15-best-iphone-fitness-apps-for-2014. Accessed August 8, 2014.

      ; (4) Men's Fitness “The Top 10 Fitness Apps for 2014”: 10 apps

      Barroso M, Walkiewicz S. The top 10 fitness apps for 2014. Available at: http://www.mensfitness.com/life/gearandtech/the-top-10-fitness-apps-for-2014. Accessed August 8, 2014.

      ; and (5) Business Insider “RANKED: The 13 Best Health And Fitness Apps”: 13 apps.

      Borison R. RANKED: the 13 best health and fitness apps. Available at: http://www.businessinsider.com/13-best-health-and-fitness-apps-2014-7?op=1. Accessed August 8, 2014.

      Key criteria used by the top/best app lists included highly rated by users, unique, user-friendly, reliable, ability to grow and innovate, cost of app, and number of users logging into app via Facebook. Compiling the apps from all of the listed independent sources resulted in a total of 131 apps being identified.
      Apps were only eligible if they (1) were available for both iOS and Android OS systems; (2) could be used by most adults (children, adolescents, gender, or pregnancy-specific apps were ineligible); and (3) involved a specific measure and intervention designed to improve some aspect of health and fitness (passive information only apps were ineligible). By using Excel PivotTable (Microsoft Corp, Redmond, Wash), apps that appeared in 2 or more independent lists were chosen, resulting in 19 apps. This search strategy is certainly subject to market response and may not reflect or provide evidence of efficacy or quality. However, because this is such a new field, there are few medical journal articles in the app area.

      Smartphone Applications as Behavior Changers

      Smartphone technology, including the Global Positioning System, accelerometer, microphone, speaker, and camera, has average-to-excellent accuracy to measure a range of physical activities and can generally differentiate static activities, stair use, cycling, walking, and running.
      • Bort-Roig J.
      • Gilson N.D.
      • Puig-Ribera A.
      • et al.
      Measuring and influencing physical activity with smartphone technology: a systematic review.
      This technology has made it possible for smartphone apps to monitor biological parameters, diabetes, cardiac rehabilitation, falls in the elderly, and physical activity.
      • Recio-Rodriguez J.I.
      • Martin-Cantera C.
      • Gonzalez-Viejo N.
      • et al.
      Effectiveness of a smartphone application for improving healthy lifestyles, a randomized clinical trial (EVIDENT II): study protocol.
      Smartphone apps have the capacity to facilitate behavior change.
      • Fanning J.
      • Mullen S.P.
      • McAuley E.
      Increasing physical activity with mobile devices: a meta-analysis.
      • Glynn L.G.
      • Hayes P.S.
      • Casey M.
      • et al.
      Effectiveness of a smartphone application to promote physical activity in primary care: the SMART MOVE randomised controlled trial.
      • Carter M.C.
      • Burley V.J.
      • Nykjaer C.
      • et al.
      Adherence to a smartphone application for weight loss compared to website and paper diary: pilot randomized controlled trial.
      • Boulos M.N.
      • Yang S.P.
      Exergames for health and fitness: the roles of GPS and geosocial apps.
      They have been adopted and used successfully by young adults to improve eating habits and physical activity.
      • Wohlers E.M.
      • Sirard J.R.
      • Barden C.M.
      • et al.
      Smart phones are useful for food intake and physical activity surveys.
      • Ashrafian H.
      • Toma T.
      • Harling L.
      • et al.
      Social networking strategies that aim to reduce obesity have achieved significant although modest results.
      Studies are ongoing to look at apps for older adults.
      • Recio-Rodriguez J.I.
      • Martin-Cantera C.
      • Gonzalez-Viejo N.
      • et al.
      Effectiveness of a smartphone application for improving healthy lifestyles, a randomized clinical trial (EVIDENT II): study protocol.
      Apps whose interventions include features such as goal-setting, rapid intention formation, performance measurement, self-monitoring, individually tailored feedback, goal reviewing, and progression have been associated with greater effectiveness.
      • Middelweerd A.
      • Mollee J.S.
      • van der Wal C.
      • et al.
      Apps to promote physical activity among adults: a review and content analysis.
      • Abraham C.
      • Michie S.
      A taxonomy of behavior change techniques used in interventions.
      • Conn V.S.
      • Hafdahl A.R.
      • Mehr D.R.
      Interventions to increase physical activity among healthy adults: meta-analysis of outcomes.
      • Foster C.
      • Richards J.
      • Thorogood M.
      • et al.
      Remote and web 2.0 interventions for promoting physical activity.
      • Direito A.
      • Dale L.P.
      • Shields E.
      • et al.
      Do physical activity and dietary smartphone applications incorporate evidence-based behaviour change techniques?.
      Activity monitoring apps typically include goal-setting, self-monitoring, and feedback content that closely matches recommendations from social cognitive theory.
      • Lyons E.J.
      • Lewis Z.H.
      • Mayrsohn B.G.
      • et al.
      Behavior change techniques implemented in electronic lifestyle activity monitors: a systematic content analysis.
      One review of 57 popular physical activity apps noted that on average they included 5 behavior change interventions (range, 2-8), and this did not differ between free and paid apps.
      • Middelweerd A.
      • Mollee J.S.
      • van der Wal C.
      • et al.
      Apps to promote physical activity among adults: a review and content analysis.
      Others have found more behavior change interventions present in paid apps.
      • Direito A.
      • Dale L.P.
      • Shields E.
      • et al.
      Do physical activity and dietary smartphone applications incorporate evidence-based behaviour change techniques?.
      Given that apps are a relatively new tool, there is limited medical research that has been conducted to date. However, several studies on smartphone app use to change health and fitness have been performed, and these are reviewed in the current article.
      A meta-analysis involving 1350 subjects using mobile device interventions, including text messaging, smartphone apps, and self-reports, found the technology was an effective means for influencing physical activity behavior.
      • Fanning J.
      • Mullen S.P.
      • McAuley E.
      Increasing physical activity with mobile devices: a meta-analysis.
      One study that was part of this meta-analysis noted that in initially underactive adults aged 50 years or more, those who received daily feedback, goal setting, and mobile device support significantly increased their moderate-vigorous physical activity by 178 minutes per week, compared with 80 minutes per week for the control group.
      • King A.C.
      • Ahn D.K.
      • Oliveira B.M.
      • et al.
      Promoting physical activity through hand-held computer technology.
      An 8-week, open-label, randomized controlled trial in Ireland recruited 90 patients aged 16 years or more who were smartphone users and evaluated the effectiveness of app use on physical activity.
      • Glynn L.G.
      • Hayes P.S.
      • Casey M.
      • et al.
      Effectiveness of a smartphone application to promote physical activity in primary care: the SMART MOVE randomised controlled trial.
      All participants were provided with similar physical activity goals and information on the benefits of exercise. The intervention group was provided with a smartphone app and detailed instructions on how to use it to achieve these goals. The primary outcome was change in physical activity, as measured by daily step count between baseline and follow-up. The difference in mean improvement in daily step count from week 1 to week 8 was 1029 (95% confidence interval, 214-1843) steps per day, favoring the intervention.
      In a study comparing a self-monitoring weight management intervention delivered by a smartphone app with a website and paper diary in 128 overweight volunteers, the app group adherence was significantly higher (mean, 92 days) compared with the website (mean, 35 days) or diary group (mean, 29 days) (P < .001).
      • Carter M.C.
      • Burley V.J.
      • Nykjaer C.
      • et al.
      Adherence to a smartphone application for weight loss compared to website and paper diary: pilot randomized controlled trial.
      Mean weight change at 6 months was −4.6 kg, −2.9 kg, and −1.3 kg in the app, website, and diary groups, respectively. Another weight loss trial compared the mobile app for dietary self-monitoring and weight loss, “Lose It!,” (Lose It!, Boston, MA) with traditional diet counseling and entry methods in 47 overweight subjects.
      • Wharton C.M.
      • Johnston C.S.
      • Cunningham B.K.
      • et al.
      Dietary self-monitoring, but not dietary quality, improves with use of smartphone app technology in an 8-week weight loss trial.
      They noted that both the app group and the traditional group lost the same amount of weight over the 8-week trial.
      Another study looked at the feasibility of an app called “Persuasive Social Network for Physical Activity,” modeled on evidence-based health behavior change theories and strategies, as well as delivery of effective and innovative interventions.
      • Al Ayubi S.U.
      • Parmanto B.
      • Branch R.
      • et al.
      A persuasive and social mHealth application for physical activity: a usability and feasibility study.
      The study enrolled 13 subjects, aged 24 to 45 years, with body mass index from 18.5 to 42.9 kg/m2, with the goal of increasing step count per day. Half of them were experienced with smartphones, and all were familiar with a social network system. After training, the app was able to be used by all. After 1 week, they unlocked the social networking feature allowing the users to share and compare with others in the trial. The addition of positive social support from social networks was shown to significantly increase the step count: Without the social support at baseline after 1 week, mean steps were 4202 per day compared with including the social feature, mean steps were 6352 per day.

      Basics of Health and Fitness Applications

      Health and Fitness apps cover a wide range, including improving fitness activities, weight goals, nutrition and diet, sleep, relaxation, general healthcare information, pregnancy, and alternative medicine. Most fitness apps have a free trial/lite version that allows one to use basic features of the app and test whether it is relevant. The Pro version charges a 1-time fee or alternatively a subscription fee. Once the user has downloaded the app, basic data are required, such as gender, date of birth, weight, and height. The apps use combinations of the device's accelerometer, Global Positioning System, camera, diary, microphone, and speaker to gather data on the user during his/her activity. Some apps also synchronize wirelessly with other wearable devices, such as wristband sensor, heart rate sensor, belt sensor, shoe sensor, or more recently, smart clothing with wearable sensing technologies.
      • Zheng Y.L.
      • Ding X.R.
      • Poon C.C.
      • et al.
      Unobtrusive sensing and wearable devices for health informatics.
      Some apps include an adventure storyline that the user gets immersed into, which distracts them while they get a moderate aerobic workout. Many apps have virtual coaches that can talk and inspire the user, and make them feel like someone is training them in a more personal way. Examples include providing the user with real-time data (on-screen/verbal split times), positive feedback (on-screen/verbal “Awesome! Way to go!,” or encouragement (on-screen/verbal “Keep Going! One more set!” “Hi. I'm Shalane Flanagan. I may have the record for the fastest American 5k, but that was an impressive run!”). The more popular apps have excellent illustrations and animations of the correct way to exercise, such as gym workouts on specific resistance weight machines or free weights, as well as running, jogging, bicycling, rowing, step aerobics, and X-training postures. Apps generally tabulate your data, such as energy output totals for your workouts, energy in for diet apps (taking pictures of food, scanning barcodes, estimates by user), total workout data (miles, speed, reps), body weight data, and sleep-quality data.
      Lack of encouragement, support, or companionship from family and friends has been identified by the US Centers for Disease Control and Prevention as the major barrier to physical activity.

      Centers for Disease Control and Prevention. Division of Nutrition, Physical Activity, and Obesity. Overcoming barriers to physical activity. Available at: http://www.cdc.gov/physicalactivity/everyone/getactive/barriers.html. Accessed August 8, 2014.

      Apps that encourage social networking and sharing workout achievements, such as Fitocracy (1 million users; Fitocracy, New York, NY) and RunKeeper (23 million users; RunKeeper, Boston, MA), may help overcome these barriers.
      • Nakhasi A.
      • Shen A.X.
      • Passarella R.J.
      • et al.
      Online social networks that connect users to physical activity partners: a review and descriptive analysis.
      Currently, most health and fitness apps allow users to share their accomplishments with friends on social media (Facebook, Twitter, Pinterest, Instagram). The addition of positive social support from social networks can promote feedback and friendly competition, and amplify the smartphone applications' persuasive power.
      • Al Ayubi S.U.
      • Parmanto B.
      • Branch R.
      • et al.
      A persuasive and social mHealth application for physical activity: a usability and feasibility study.
      Most apps send summary statistics for the user to review and incorporate into his/her health and fitness data management program and may include weekly summaries and suggestions on new workouts and goals for the coming weeks.

      Things to Look for in Good Health and Fitness Applications

      Important features of a good health and fitness app are as follows: has a user-friendly interface; offers a free trial version; is easy to initiate and reliable during activity; allows for goal setting; provides real-time personalized feedback; is customized to the user's skill and fitness level; has expert consultation available; incorporates evidence-based behavior change techniques; syncs with other health and fitness apps, devices (eg, Fitbit activity monitoring device; Fitbit Inc, San Francisco, Calif), and computers to allow easy review and sharing of statistics; supports social networking; and provides periodic summaries.
      • Middelweerd A.
      • Mollee J.S.
      • van der Wal C.
      • et al.
      Apps to promote physical activity among adults: a review and content analysis.

      Khan A. What to look for in a fitness app. Available at: http://health.usnews.com/health-news/health-wellness/articles/2014/07/18/what-to-look-for-in-a-fitness-app. Accessed August 8, 2014.

      Recommended Health and Fitness Applications

      Apps recommended in this article are based on both sales data (top selling) from the main smartphone app stores (iTunes and Google Play) and independent reviews that rank apps on the basis of criteria, including highly rated by users, unique, user-friendly, reliable, ability to grow and innovate, cost of app, and downloads. These recommended apps are summarized in categories represented by each letter in the word F-I-T-N-E-S-S and shown in Table 1 with their uses and prices, and key features are summarized in Table 2.
      Table 1Recommended Applications
      CategoryApp NameUseCost US$
      FantasyZombies, Run! (Six to Start, London, UK)Increase aerobic exercise (running, jogging) by providing an adventure mission to complete. Interval training, walking, jogging, and favorite songs also can be incorporated.$3.99
      Intense CardioStrava Running and Cycling (Strava, San Francisco, CA)Tracks running and cycling. Users can compare their performance on social media with friends, professionals, and network locally to find popular places to run or ride.Free lite,
      Lite version contains basic features of the app.
      $5.99 Pro
      Pro version contains complete features of the app.
      Nike+ Running (Nike Inc, Beaverton, OR)Tracks indoor (treadmill) or outdoor running and coaches user to complete races (5 km to marathon). Provides in-run audio feedback of mile split metrics including time, miles, calories, elevation, average pace, and number of runs.Free
      RunKeeperTracks all aerobic exercises and weight loss. Synchronizes with 70 other apps, including Fitbit (Fitbit Inc, San Francisco, Calif), Fitocracy, and MyFitnessPal (MyFitnessPal Inc, San Francisco, CA), and synchronizes with devices (eg, Fitbit activity monitoring device).Free lite, $9.99 Pro
      Runtastic (Runtastic, San Francisco, CA)Tracks running and other aerobic exercises (biking, walking), including interval training, target pace, and challenge running. It shows the users route on a map, provides 1-mile split times, distance, duration, speed, elevation change, and calories burned.Free lite, $4.99 Pro
      Tracking and AnalyticsMap My Fitness (MapMyFitness Inc, Austin, TX)Workout trainer with 600 exercises; tracks running, cycling, and calories (input and output). Synchronizes with heart rate, speed, cadence, and power sensors from CycleOps, Wahoo, Polar, Garmin, Fitbit, Nike+, and others.Free lite, $2.99 Pro
      FitbitTracks exercises, food intake, net calories, weight, and sleep. Provides weekly summaries to users featuring steps, miles, calories burned, calories consumed, and weight.Free
      Map My Run (MapMyFitness Inc, Austin, TX)Tracks multiple aerobic and resistance exercises, including running, cycling, cardio, jogging, walking, and gym workouts. For outdoor activities, it provides pace, elevation, calories burned, and split-times.Free lite, $2.99 Pro
      FitocracyTracks workouts and motivates through extensive social network sharing. Expert guidance with virtual coaches is available, and team fitness routines can be chosen.Free
      Net weight lossLose It!Creates customized weight loss plan based on users' goals (weight, body fat, hydration, sleep, exercise, nutrients, hip/waist measurements). It accurately tracks food calories and calories burned with exercise.Free lite, $39.99 Pro
      MyFitnessPalTracks food calorie intake by barcode scanner, and exercises can be entered to monitor net calories. It also tracks major nutrients (fat, protein, carbohydrates), sugar, fiber, and cholesterol.Free
      Noom Weight Loss Coach (Noom Inc, New York, NY)Tracks energy in (food calories) and out (exercise), and provides evidence-based weight-loss strategies. Intelligent coaching keeps the user motivated with instant feedback, wellness articles, and healthy recipes daily appropriate for their goals.Free lite, $9.99 Pro
      Eating/dietFitocracy Macros (Fitocracy, New York, NY)Separately tracks macronutrients in the diet (protein, fat, carbohydrates) to help user achieve dieting goals. Counts fiber, water, and alcohol, and can synchronize with Fitocracy, so it is also able to report energy expenditure.Free
      Fooducate (Fooducate LTD, Hod Hasharon, IL)Ranks overall nutrition value of food item from grade A (great) to D (avoid) and suggests alternative for unhealthy food choices. Customized to the user's age, gender, weight, height, activity level, desired weigh loss rate, diet goals, health conditions, and special diets (eg, gluten free, vegan, and allergens).Free lite, $1.99 Pro
      SleepSleep Cycle alarm clock (Northcube AB, Göteborg, Sweden)Tracks sleep quality and quantity, including sounds (snoring) and motion (restlessness); also optimizes wake-up interval. Users also can see how different daily activities (exercise, caffeine consumption, alcohol) affect their sleep.$0.99
      SpecializedCouch to 5K (Active Network LLC, San Diego, CA)Takes a nonexerciser and prepares them to run a 5-km (3.1 mile) race in 3 mo. Includes a training plan, 4 different motivating virtual coaches, real human audio cues, together with their favorite playlists.$1.99
      Runtastic Six Pack Abs (Runtastic, San Francisco, CA)Provides 20 core-strengthening exercises with the goal of 6-pack abdominals in 10 wk. Clearly shows the move and its components, explains it verbally, and the muscles being targeted in the workout are highlighted on screen.Free lite, $4.99 Pro
      Charity Miles (Charity Miles LLC, New York, NY)Motivates more miles (walking, running, or cycling) as each mile results in money donation to charity of users' choice. They earn $0.10/mile for cycling and $0.25/mile for walking and running.Free
      WebMD (WebMD, New York, NY)A basic medical encyclopedia of helpful tips for a patient regarding their medical condition and healthy lifestyle. Healthcare providers need to be aware that although the WebMD app self-diagnosis can provide a correct clinical diagnosis, it also provides a large number of differential diagnoses, some of which may be inappropriate.Free
      Lite version contains basic features of the app.
      Pro version contains complete features of the app.
      Table 2Health and Fitness Applications
      App NameAudio CuesBarcode ScanningVirtual CoachingDiet MonitoringExercise MonitoringFacebook/TwitterGoal SettingMusic PlaylistNarrative StoryProgressionSleep MonitoringSync with Other AppsSync with Other DevicesTailored Feedback
      Zombies, Run!
      Strava Running and Cycling
      Nike+ Running
      RunKeeper
      Runtastic
      Map My Fitness
      Fitbit
      Map My Run
      Fitocracy
      Lose It!
      MyFitnessPal
      Noom Weight Loss Coach
      Fitocracy Macros
      Fooducate
      Sleep Cycle alarm clock
      Couch to 5K
      Runtastic Six Pack Abs
      Charity Miles
      WebMD

      Patient Scenarios and Health and Fitness Applications Recommendations

      Several patient scenarios and recommended apps are shown in Table 3.
      Table 3Patient Scenarios and Suggested Applications
      Patient ScenarioSuggested App
      Healthy patient wanting to start basic aerobic exerciseFitbit, Couch to 5K, Zombies, Run!, Map My Fitness, Map My Run
      Healthy patient already exercising regularly looking to improve fitness or to enter a raceStrava Running and Cycling, Nike+ Running, RunKeeper, Runtastic
      Healthy patient wanting to focus on protein in his/her diet and build more lean muscle for resistance exercisesFitocracy Macros, Fitocracy
      Healthy patient wanting to flatten his/her abdomen and improve back supportRuntastic Six Pack Abs
      Patient with hypertension wanting to start some exercise to reduce his/her cardiovascular riskFitbit, Map My Run
      Overweight patient with osteoarthritis wanting to lose weight and start exercisingLose It!, Noom Weight Loss Coach, MyFitnessPal
      Gluten intolerant or vegan patient, or patient with food allergy wanting to lose weightFooducate
      Patient wanting to exercise and at the same time making a difference to the worldCharity Miles
      Overweight patient wanting to lose weight and consume healthier foodsLose It!, MyFitnessPal, Noom Weight Loss Coach, Fooducate
      Patient wanting to learn more about his/her medical condition(s) and set some basic exercise goalsWebMD
      Patient with suspected sleep disorderSleep Cycle alarm clock

      Limitations of Using Health and Fitness Applications

      Some of the limitations of using health and fitness apps are shown in Table 4.
      • Middelweerd A.
      • Mollee J.S.
      • van der Wal C.
      • et al.
      Apps to promote physical activity among adults: a review and content analysis.

      Pew Research Center. Mobile technology fact sheet. Available at: http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/. Accessed August 8, 2014.

      • Richards J.
      • Thorogood M.
      • Hillsdon M.
      • et al.
      Face-to-face versus remote and web 2.0 interventions for promoting physical activity.
      • Visser B.J.
      • Buijink A.W.
      Need to peer-review medical applications for smart phones.
      • Lubans D.R.
      • Smith J.J.
      • Skinner G.
      • et al.
      Development and implementation of a smartphone application to promote physical activity and reduce screen-time in adolescent boys.
      • Lepp A.
      • Barkley J.E.
      • Sanders G.J.
      • et al.
      The relationship between cell phone use, physical and sedentary activity, and cardiorespiratory fitness in a sample of U.S. college students.
      • Backinger C.L.
      • Augustson E.M.
      Where there's an app, there's a way?.
      • Conroy D.E.
      • Yang C.H.
      • Maher J.P.
      Behavior change techniques in top-ranked mobile apps for physical activity.
      • Vandelanotte C.
      • Kirwan M.
      • Rebar A.
      • et al.
      Examining the use of evidence-based and social media supported tools in freely accessible physical activity intervention websites.
      • Rabin C.
      • Bock B.
      Desired features of smartphone applications promoting physical activity.
      • Grindrod K.A.
      • Li M.
      • Gates A.
      Evaluating user perceptions of mobile medication management applications with older adults: a usability study.
      Table 4Limitations of Smartphone Applications
      App Limitation
      • Need to own a smartphone and have sufficient Wi-Fi data plan.
      • Most apps not yet peer reviewed by appropriately trained professionals.
      • May not work for users with certain disabilities (visual or hearing impaired) or those with insufficient intellectual capabilities.
      • Smartphone needs to be present during activity (bulky, inconvenient, sweat/water, and extremes of weather may result in smartphone failure).
      • Technical problems and app malfunctions.
      • Most physical activity apps are not developed on the basis of evidence-based strategies or on established behavior change theories.
      • Other behavior change techniques have not yet been integrated into apps (YouTube videos, Tweets).
      • Smartphone sensors may not be as accurate as other stand-alone sensor devices.
      • Some apps do not sync with other health and fitness apps and devices.
      • Lack of advice on hydration and when not to exercise (illness/fever, environmental extremes).
      • Apps require users to actively engage with it to benefit.
      • Adults currently at retirement age or older may be less likely to adopt such technology because they are less familiar with smartphone technology.

      How to Best Integrate Applications into Practice

      Peter Drucker once said: “What gets measured gets managed.”
      • Willcocks L.
      • Lester S.
      Beyond the IT productivity paradox.
      In this respect, the health care provider can first use apps to get an idea of various aspects of the patient's health and wellness, such as activity, dietary intake, medication compliance, and sleep patterns. Apps in addition to wearable devices and clothing can be a great way for these data to be gathered so that the patient and provider know what is actually taking place. Then, having these data, the provider can implement behavior changes and track the resulting changes using the apps. Finally, the app may provide an early warning system for when health and wellness are going off course. In the future, as communication and technology improve, there will likely be a more personalized/precision medicine approach whereby the patient can get advice from his/her provider via the app and query the provider on questions regarding specific health and wellness issues that arise.

      Future Directions in Health and Fitness Applications

      The following are recommended:
      • Most research to date on changing behavior has found that interventions are more likely to be effective if they are based on behavior change theory models and specifically include features such as goal-setting, rapid intention formation, performance, self-monitoring, individually tailored feedback, goal-reviewing, and progression.
        • Middelweerd A.
        • Mollee J.S.
        • van der Wal C.
        • et al.
        Apps to promote physical activity among adults: a review and content analysis.
        • Abraham C.
        • Michie S.
        A taxonomy of behavior change techniques used in interventions.
        • Conn V.S.
        • Hafdahl A.R.
        • Mehr D.R.
        Interventions to increase physical activity among healthy adults: meta-analysis of outcomes.
        • Foster C.
        • Richards J.
        • Thorogood M.
        • et al.
        Remote and web 2.0 interventions for promoting physical activity.
        Health and fitness apps should contain some or all of these features and need to be tested with rigorous evidence-based research trials whose results are peer reviewed by independent experts to determine whether the app is safe and effective. In addition, apps should carry a standardized grade based on the listed features so potential users can quickly assess the suitability.
      • Long-term and large sample size randomized control trials in the outpatient setting are required to assess the safety and efficacy of health and fitness apps, and should include heterogeneous participants in terms of age, gender, socioeconomic status, personality type, smartphone, and social networking experience.
      • Apps currently lack an emphasis on evidence-based and medical professional involvement.
        • Mobasheri M.H.
        • Johnston M.
        • King D.
        • et al.
        Smartphone breast applications–what's the evidence?.
        For them to be effective and more user-friendly, these features should be incorporated.
      • Apps need to keep up with ongoing developments of smartphone and wireless sensor technology to provide more accurate data. Sensors are being developed that can be woven or integrated into clothing, accessories, and the living environment, such that health and fitness information can be acquired seamlessly and pervasively in daily living.
        • Zheng Y.L.
        • Ding X.R.
        • Poon C.C.
        • et al.
        Unobtrusive sensing and wearable devices for health informatics.
        Such sensors may provide more objective and accurate data on health and fitness to the smartphones, and apps may be better able to prescribe activities that will improve the user's health and fitness.
      • The ability of apps to run within apps so that multiple features and data sharing can occur will likely be a feature of newer-generation smartphones that will provide a more complete overall health and fitness summary for the user.
      • The development of health informatics and apps that deal with the acquisition, transmission, processing, storage, retrieval, and use of health information is needed. This may promote better transparency between the health and fitness app users and their medical provider.
        • Zheng Y.L.
        • Ding X.R.
        • Poon C.C.
        • et al.
        Unobtrusive sensing and wearable devices for health informatics.
      • New medical mobile device (mHealth) applications are being developed that will revolutionize how the healthcare industry interacts with patients and create virtual health records that can be accessed worldwide.
        • Becker S.
        • Miron-Shatz T.
        • Schumacher N.
        • et al.
        mHealth 2.0: experiences, possibilities, and perspectives.
      • Development of security and privacy for app users and healthcare providers: Most apps lack privacy policies, and those that do are not transparent.
        • Sunyaev A.
        • Dehling T.
        • Taylor P.L.
        • et al.
        Availability and quality of mobile health app privacy policies.
      • Development of apps incorporating more game design or fun tricks to engage users more, while getting them to achieve goals, may improve user app compliance.

        Farr C, Nayak M. New health apps, games reward patients who take their meds. Available at: http://in.reuters.com/article/2014/08/15/mobilephone-health-idINKBN0GF02L20140815. Accessed August 8, 2014.

      • Development of a single powerful “super app” that covers all major aspects of health and fitness, thus eliminating the need for sync between various specialized apps.

      Conclusions

      Healthcare providers are always seeking ways to monitor and improve their patients' health and fitness, and smartphone applications may fill this niche. Health and fitness apps can help people with exercise, diet, weight management, stress relief, and sleep monitoring. In addition, the healthcare providers can learn about their patients' health and fitness activities via data summaries provided by the apps. Apps that incorporate evidence-based behavior change techniques are more likely to be effective. These apps also may serve as a handy tool to evaluate and motivate smartphone owners who have limited access to healthcare. More research is needed to objectively examine app effectiveness in changing patients' behaviors and improving their well-being. Health and fitness applications contain a wealth of behavior change techniques typically used in clinical behavioral interventions and may represent a medium by which these interventions could be translated for widespread use. This app technology has the potential for a wide range of uses, including clinical, preventive, public health, and rehabilitation settings.

      References

        • Phillips A.C.
        • Der G.
        • Carroll D.
        Self-reported health, self-reported fitness, and all-cause mortality: prospective cohort study.
        Br J Health Psychol. 2010; 15: 337-346
      1. World Health Organization. Physical inactivity: a global public health problem. Available at: http://www.who.int/dietphysicalactivity/factsheet_inactivity/en/. Accessed August 8, 2014.

        • Spittaels H.
        • De Bourdeaudhuij I.
        • Vandelanotte C.
        Evaluation of a website-delivered computer-tailored intervention for increasing physical activity in the general population.
        Prev Med. 2007; 44: 209-217
        • Joseph R.P.
        • Durant N.H.
        • Benitez T.J.
        • et al.
        Internet-based physical activity interventions.
        Am J Lifestyle Med. 2014; 8: 42-68
      2. Oxford University Press. Definition of app in English. Available at: http://www.oxforddictionaries.com/definition/english/app. Accessed August 8, 2014.

      3. Apple. iTunes Preview. App Store “Health & Fitness”. Available at: https://itunes.apple.com/us/genre/ios-health-fitness/id6013?mt=8&ls=1&v0=www-iphone-5s-appstore-health-fitness. Accessed August 8, 2014.

      4. Google. Google Play. Android apps: health and fitness. Available at: https://play.google.com/store/apps/category/HEALTH_AND_FITNESS?hl=en. Accessed August 8, 2014.

        • Middelweerd A.
        • Mollee J.S.
        • van der Wal C.
        • et al.
        Apps to promote physical activity among adults: a review and content analysis.
        Int J Behav Nutr Phys Act. 2014; 11: 97
      5. Dredge S. Health and fitness apps booming ahead of Apple's iOS 8 launch. Available at: http://www.theguardian.com/technology/2014/jun/19/health-fitness-apps-apple-ios-8. Accessed August 8, 2014.

      6. Pew Research Center. Mobile technology fact sheet. Available at: http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/. Accessed August 8, 2014.

        • Pratt M.
        • Sarmiento O.L.
        • Montes F.
        • et al.
        The implications of megatrends in information and communication technology and transportation for changes in global physical activity.
        Lancet. 2012; 380: 282-293
        • Sama P.R.
        • Eapen Z.J.
        • Weinfurt K.P.
        • et al.
        An evaluation of mobile health application tools.
        JMIR Mhealth Uhealth. 2014; 2: e19
      7. Team TG. The 65 best health & fitness apps of 2014. Available at: http://greatist.com/fitness/best-health-fitness-apps. Accessed August 8, 2014.

      8. Duffy J. The 100 best iPhone apps of 2014. Available at: http://www.pcmag.com/article2/0%2c2817%2c2393847%2c00.asp. Accessed August 8, 2014.

      9. Eddy M. The 100 best android apps of 2014. Available at: http://www.pcmag.com/article2/0,2817,2393101,00.asp. Accessed August 8, 2014.

      10. Rosenzweig F. 15 Best iPhone fitness apps for 2014. Available at: http://www.active.com/fitness/articles/15-best-iphone-fitness-apps-for-2014. Accessed August 8, 2014.

      11. Barroso M, Walkiewicz S. The top 10 fitness apps for 2014. Available at: http://www.mensfitness.com/life/gearandtech/the-top-10-fitness-apps-for-2014. Accessed August 8, 2014.

      12. Borison R. RANKED: the 13 best health and fitness apps. Available at: http://www.businessinsider.com/13-best-health-and-fitness-apps-2014-7?op=1. Accessed August 8, 2014.

        • Bort-Roig J.
        • Gilson N.D.
        • Puig-Ribera A.
        • et al.
        Measuring and influencing physical activity with smartphone technology: a systematic review.
        Sports Med. 2014; 44: 671-686
        • Recio-Rodriguez J.I.
        • Martin-Cantera C.
        • Gonzalez-Viejo N.
        • et al.
        Effectiveness of a smartphone application for improving healthy lifestyles, a randomized clinical trial (EVIDENT II): study protocol.
        BMC Public Health. 2014; 14: 254
        • Fanning J.
        • Mullen S.P.
        • McAuley E.
        Increasing physical activity with mobile devices: a meta-analysis.
        J Med Internet Res. 2012; 14: e161
        • Glynn L.G.
        • Hayes P.S.
        • Casey M.
        • et al.
        Effectiveness of a smartphone application to promote physical activity in primary care: the SMART MOVE randomised controlled trial.
        Br J Gen Pract. 2014; 64: e384-e391
        • Carter M.C.
        • Burley V.J.
        • Nykjaer C.
        • et al.
        Adherence to a smartphone application for weight loss compared to website and paper diary: pilot randomized controlled trial.
        J Med Internet Res. 2013; 15: e32
        • Boulos M.N.
        • Yang S.P.
        Exergames for health and fitness: the roles of GPS and geosocial apps.
        Int J Health Geogr. 2013; 12: 18
        • Wohlers E.M.
        • Sirard J.R.
        • Barden C.M.
        • et al.
        Smart phones are useful for food intake and physical activity surveys.
        Conf Proc IEEE Eng Med Biol Soc. 2009; 2009: 5183-5186
        • Ashrafian H.
        • Toma T.
        • Harling L.
        • et al.
        Social networking strategies that aim to reduce obesity have achieved significant although modest results.
        Health Aff (Millwood). 2014; 33: 1641-1647
        • Abraham C.
        • Michie S.
        A taxonomy of behavior change techniques used in interventions.
        Health Psychol. 2008; 27: 379-387
        • Conn V.S.
        • Hafdahl A.R.
        • Mehr D.R.
        Interventions to increase physical activity among healthy adults: meta-analysis of outcomes.
        Am J Public Health. 2011; 101: 751-758
        • Foster C.
        • Richards J.
        • Thorogood M.
        • et al.
        Remote and web 2.0 interventions for promoting physical activity.
        Cochrane Database Syst Rev. 2013; : CD010395
        • Direito A.
        • Dale L.P.
        • Shields E.
        • et al.
        Do physical activity and dietary smartphone applications incorporate evidence-based behaviour change techniques?.
        BMC Public Health. 2014; 14: 646
        • Lyons E.J.
        • Lewis Z.H.
        • Mayrsohn B.G.
        • et al.
        Behavior change techniques implemented in electronic lifestyle activity monitors: a systematic content analysis.
        J Med Internet Res. 2014; 16: e192
        • King A.C.
        • Ahn D.K.
        • Oliveira B.M.
        • et al.
        Promoting physical activity through hand-held computer technology.
        Am J Prev Med. 2008; 34: 138-142
        • Wharton C.M.
        • Johnston C.S.
        • Cunningham B.K.
        • et al.
        Dietary self-monitoring, but not dietary quality, improves with use of smartphone app technology in an 8-week weight loss trial.
        J Nutr Educ Behav. 2014; 46: 440-444
        • Al Ayubi S.U.
        • Parmanto B.
        • Branch R.
        • et al.
        A persuasive and social mHealth application for physical activity: a usability and feasibility study.
        JMIR Mhealth Uhealth. 2014; 2: e25
        • Zheng Y.L.
        • Ding X.R.
        • Poon C.C.
        • et al.
        Unobtrusive sensing and wearable devices for health informatics.
        IEEE Trans Biomed Eng. 2014; 61: 1538-1554
      13. Centers for Disease Control and Prevention. Division of Nutrition, Physical Activity, and Obesity. Overcoming barriers to physical activity. Available at: http://www.cdc.gov/physicalactivity/everyone/getactive/barriers.html. Accessed August 8, 2014.

        • Nakhasi A.
        • Shen A.X.
        • Passarella R.J.
        • et al.
        Online social networks that connect users to physical activity partners: a review and descriptive analysis.
        J Med Internet Res. 2014; 16: e153
      14. Khan A. What to look for in a fitness app. Available at: http://health.usnews.com/health-news/health-wellness/articles/2014/07/18/what-to-look-for-in-a-fitness-app. Accessed August 8, 2014.

        • Richards J.
        • Thorogood M.
        • Hillsdon M.
        • et al.
        Face-to-face versus remote and web 2.0 interventions for promoting physical activity.
        Cochrane Database Syst Rev. 2013; : CD010393
        • Visser B.J.
        • Buijink A.W.
        Need to peer-review medical applications for smart phones.
        J Telemed Telecare. 2012; 18: 124
        • Lubans D.R.
        • Smith J.J.
        • Skinner G.
        • et al.
        Development and implementation of a smartphone application to promote physical activity and reduce screen-time in adolescent boys.
        Front Public Health. 2014; 2: 42
        • Lepp A.
        • Barkley J.E.
        • Sanders G.J.
        • et al.
        The relationship between cell phone use, physical and sedentary activity, and cardiorespiratory fitness in a sample of U.S. college students.
        Int J Behav Nutr Phys Act. 2013; 10: 79
        • Backinger C.L.
        • Augustson E.M.
        Where there's an app, there's a way?.
        Am J Prev Med. 2011; 40: 390-391
        • Conroy D.E.
        • Yang C.H.
        • Maher J.P.
        Behavior change techniques in top-ranked mobile apps for physical activity.
        Am J Prev Med. 2014; 46: 649-652
        • Vandelanotte C.
        • Kirwan M.
        • Rebar A.
        • et al.
        Examining the use of evidence-based and social media supported tools in freely accessible physical activity intervention websites.
        Int J Behav Nutr Phys Act. 2014; 11: 105
        • Rabin C.
        • Bock B.
        Desired features of smartphone applications promoting physical activity.
        Telemed J E Health. 2011; 17: 801-803
        • Grindrod K.A.
        • Li M.
        • Gates A.
        Evaluating user perceptions of mobile medication management applications with older adults: a usability study.
        JMIR Mhealth Uhealth. 2014; 2: e11
        • Willcocks L.
        • Lester S.
        Beyond the IT productivity paradox.
        European Management Journal. 1996; 14: 279-290
        • Mobasheri M.H.
        • Johnston M.
        • King D.
        • et al.
        Smartphone breast applications–what's the evidence?.
        Breast. 2014; 23: 683-689
        • Becker S.
        • Miron-Shatz T.
        • Schumacher N.
        • et al.
        mHealth 2.0: experiences, possibilities, and perspectives.
        JMIR Mhealth Uhealth. 2014; 2: e24
        • Sunyaev A.
        • Dehling T.
        • Taylor P.L.
        • et al.
        Availability and quality of mobile health app privacy policies.
        J Am Med Inform Assoc. 2015; 22: e28-e33
      15. Farr C, Nayak M. New health apps, games reward patients who take their meds. Available at: http://in.reuters.com/article/2014/08/15/mobilephone-health-idINKBN0GF02L20140815. Accessed August 8, 2014.

      Linked Article

      • Suicide Prevention by Smartphone
        The American Journal of MedicineVol. 129Issue 8
        • Preview
          Beyond the benefit of apps for promoting health and fitness,1 smartphone-based life-alert technology might be adapted to reduce suicide, which is the only cause of death among the top 10 in the US for which age-adjusted mortality rates increased between 2005 and 2012.2 The recently identified higher frequency of suicide following discharge from inpatient psychiatric treatment warrants approaches beyond those in usual and customary practice.3-6
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