An App to Improve Eating Habits of Adolescents and Young Adults (Challenge to Go): Systematic Development of a Theory-Based and Target Group–Adapted Mobile App Intervention

Background Due to the widespread use of mobile phones, dietary mobile apps are promising tools for preventing diet-related noncommunicable diseases early in life. However, most of the currently available nutrition apps lack scientific evaluation and user acceptance. Objective The objective of this study was the systematic design of a theory-driven and target group–adapted dietary mobile app concept to promote healthy eating habits with a focus on drinking habits as well as consumption of fruits and vegetables in adolescents and young adults, especially from disadvantaged backgrounds. Methods The design process was guided by the behavior change wheel (BCW). The development process comprised 3 stages. In stage 1, the target behavior was specified, and facilitators and barriers were identified. Furthermore, important insights into target group interests, needs, and values in the field of nutrition and apps were revealed. To this end, 2 empirical studies were conducted with the target group. In stage 2, results of stage 1 were translated into behavior change techniques (BCTs) and, finally, into app functionalities and features. Consequently, in stage 3, the concept was evaluated and optimized through expert interviews. Results Facilitators and barriers for achieving the target behavior were psychological capabilities (eg, self-efficacy), reflective motivation (eg, fitness), automatic motivation, social support, and physical opportunity (eg, time). Target group interests, needs, and values in the field of nutrition were translated into target group preferences for app usage, for example, low usage effort, visual feedback, or recipes. Education, training, incentives, persuasion, and enablement were identified as relevant intervention functions. Together with the target group preferences, these were translated via 14 BCTs, such as rewards, graded tasks, or self-monitoring into the app concept Challenge to go (C2go). The expert evaluation suggested changes of some app features for improving adherence, positive health effects, and technical feasibility. The C2go concept comprises 3 worlds: the (1) drinking, (2) vegetable, and (3) fruit worlds. In each world, the users are faced with challenges including feedback and a quiz. Tips were developed based on the health action process approach and to help users gain challenges and, thereby, achieve the target behavior. Challenges can be played alone or against someone in the community. Due to different activities, points can be collected, and levels can be achieved. Collected points open access to an Infothek (information section), where users can choose content that interests them. An avatar guides user through the app. Conclusions C2go is aimed at adolescents and young adults and aims to improve their fruit and vegetable consumption as well as drinking habits. It is a theory-driven and target group–adapted dietary mobile intervention concept that uses gamification and was systematically developed using the BCW.

[1]  E. Pearson,et al.  Goal setting as a health behavior change strategy in overweight and obese adults: a systematic literature review examining intervention components. , 2012, Patient education and counseling.

[2]  J. Manson,et al.  Quantity and variety in fruit and vegetable intake and risk of coronary heart disease. , 2013, The American journal of clinical nutrition.

[3]  Elise Dusseldorp,et al.  Combinations of techniques that effectively change health behavior: evidence from Meta-CART analysis. , 2014, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[4]  K. Brownell,et al.  Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. , 2007, American journal of public health.

[5]  Moderator Tom Baranowski,et al.  Effective Feedback Procedures in Games for Health. , 2013, Games for health journal.

[6]  B. Renner,et al.  Colourful = healthy? Exploring meal colour variety and its relation to food consumption , 2018 .

[7]  Margaret Allman-Farinelli,et al.  Development of Smartphone Applications for Nutrition and Physical Activity Behavior Change , 2012, JMIR research protocols.

[8]  S. Michie,et al.  Designing interventions to change eating behaviours , 2015, Proceedings of the Nutrition Society.

[9]  P. Scarborough,et al.  Cardiovascular disease in Europe 2014: epidemiological update. , 2014, European heart journal.

[10]  Arlene E. Chung,et al.  Tweeting to Health , 2017, Clinical pediatrics.

[11]  A. Bergland,et al.  The Effectiveness of Smartphone Apps for Lifestyle Improvement in Noncommunicable Diseases: Systematic Review and Meta-Analyses , 2018, Journal of medical Internet research.

[12]  Rhys Tague,et al.  Effectiveness of a Web- and Mobile Phone-Based Intervention to Promote Physical Activity and Healthy Eating in Middle-Aged Males: Randomized Controlled Trial of the ManUp Study , 2014, Journal of medical Internet research.

[13]  S. Michie,et al.  The behaviour change wheel: A new method for characterising and designing behaviour change interventions , 2011, Implementation science : IS.

[14]  Gudrun Sproesser,et al.  Describing the Process of Adopting Nutrition and Fitness Apps: Behavior Stage Model Approach , 2018, JMIR mHealth and uHealth.

[15]  W. Nseir,et al.  Soft drinks consumption and nonalcoholic fatty liver disease. , 2010, World journal of gastroenterology.

[16]  Gert B. M. Mensink,et al.  [Fruit and vegetable consumption by children and adolescents in Germany: Results of KiGGS wave 1]. , 2015, Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz.

[17]  T. Conner,et al.  The development and effectiveness of an ecological momentary intervention to increase daily fruit and vegetable consumption in low-consuming young adults , 2017, Appetite.

[18]  Sudakshina Lahiri,et al.  Targeting Parents for Childhood Weight Management: Development of a Theory-Driven and User-Centered Healthy Eating App , 2015, JMIR mHealth and uHealth.

[19]  Maya B. Mathur,et al.  Mobile Technology for Vegetable Consumption: A Randomized Controlled Pilot Study in Overweight Adults , 2016, JMIR mHealth and uHealth.

[20]  Peter R. Giacobbi,et al.  Childhood obesity and adult cardiovascular disease risk factors: a systematic review with meta-analysis , 2017, BMC Public Health.

[21]  R. Oostendorp,et al.  How to promote healthy behaviours in patients? An overview of evidence for behaviour change techniques , 2010, Health promotion international.

[22]  K. Tucker,et al.  Coronary heart disease prevention: nutrients, foods, and dietary patterns. , 2011, Clinica chimica acta; international journal of clinical chemistry.

[23]  F. Sniehotta,et al.  Association of behaviour change techniques with effectiveness of dietary interventions among adults of retirement age: a systematic review and meta-analysis of randomised controlled trials , 2014, BMC Medicine.

[24]  A. Prestwich,et al.  How can self-efficacy be increased? Meta-analysis of dietary interventions , 2014, Health psychology review.

[25]  Y. Chae,et al.  Evaluation of a mobile phone-based diet game for weight control , 2010, Journal of Telemedicine and Telecare.

[26]  S. Lorkowski,et al.  Dietary mobile apps - acceptance among young adults : a qualitative study , 2017 .

[27]  Gert B. M. Mensink,et al.  [Food consumption of children and adolescents in Germany. Results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]. , 2007, Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz.

[28]  Sara LeGrand,et al.  Epic Allies: Development of a Gaming App to Improve Antiretroviral Therapy Adherence Among Young HIV-Positive Men Who Have Sex With Men , 2016, JMIR serious games.

[29]  M. Carter,et al.  Adherence to a Smartphone Application for Weight Loss Compared to Website and Paper Diary: Pilot Randomized Controlled Trial , 2013, Journal of medical Internet research.

[30]  B. Bunting,et al.  Psychological Determinants of Consumer Acceptance of Personalised Nutrition in 9 European Countries , 2014, PloS one.

[31]  Geir Egil Eide,et al.  Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses , 2017, International Journal of Behavioral Nutrition and Physical Activity.

[32]  Karel M. Stokking,et al.  Framing of feedback impacts student’s satisfaction, self-efficacy and performance , 2015, Advances in health sciences education : theory and practice.

[33]  M. Lima,et al.  Formative research on HAPA model determinants for fruit and vegetable intake: target beliefs for audiences at different stages of change. , 2013, Health education research.

[34]  C. Brombach,et al.  Food consumption of adults in Germany: results of the German National Nutrition Survey II based on diet history interviews , 2015, The British journal of nutrition.

[35]  G. Bray Energy and Fructose From Beverages Sweetened With Sugar or High-Fructose Corn Syrup Pose a Health Risk for Some People12 , 2013, Advances in nutrition.

[36]  Julian Wienert,et al.  Effectiveness of a Web-Based Computer-Tailored Multiple-Lifestyle Intervention for People Interested in Reducing their Cardiovascular Risk: A Randomized Controlled Trial , 2016, Journal of medical Internet research.

[37]  S. Michie,et al.  Are interventions theory-based? Development of a theory coding scheme. , 2010, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[38]  Gert B. M. Mensink,et al.  Lebensmittelverzehr bei Kindern und Jugendlichen in Deutschland , 2007, Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz.

[39]  Yael Benn,et al.  Does monitoring goal progress promote goal attainment? A meta-analysis of the experimental evidence. , 2016, Psychological bulletin.

[40]  Ulf Schrader,et al.  Fostering Sustainable Nutrition Behavior through Gamification , 2016 .

[41]  J. Breda,et al.  Using Mobile Apps to Promote a Healthy Lifestyle Among Adolescents and Students: A Review of the Theoretical Basis and Lessons Learned , 2016, JMIR mHealth and uHealth.

[42]  M. Sevick,et al.  The Effect of Electronic Self‐Monitoring on Weight Loss and Dietary Intake: A Randomized Behavioral Weight Loss Trial , 2011, Obesity.

[43]  A. King,et al.  Iterative development of Vegethon: a theory-based mobile app intervention to increase vegetable consumption , 2016, International Journal of Behavioral Nutrition and Physical Activity.

[44]  D. Mozaffarian,et al.  Association Between Dietary Factors and Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United States , 2017, JAMA.

[45]  D. Thombs,et al.  Efficacy of a Brief Image-Based Multiple-Behavior Intervention for College Students , 2008, Annals of behavioral medicine : a publication of the Society of Behavioral Medicine.

[46]  Adam Drewnowski,et al.  Does social class predict diet quality? , 2008, The American journal of clinical nutrition.

[47]  E. Robinson,et al.  Development and feasibility testing of a smart phone based attentive eating intervention , 2013, BMC Public Health.

[48]  J. Brug,et al.  The effects of tailored and threatening nutrition information on message attention. Evidence from an event-related potential study , 2011, Appetite.

[49]  Kevin G Volpp,et al.  Financial incentive-based approaches for weight loss: a randomized trial. , 2008, JAMA.

[50]  J. Montani,et al.  Sugary drinks in the pathogenesis of obesity and cardiovascular diseases , 2008, International Journal of Obesity.

[51]  Lucy Yardley,et al.  Opportunities and Challenges for Smartphone Applications in Supporting Health Behavior Change: Qualitative Study , 2013, Journal of medical Internet research.

[52]  Nicole L. Nollen,et al.  Development and functionality of a handheld computer program to improve fruit and vegetable intake among low-income youth. , 2013, Health education research.

[53]  C. Brombach,et al.  Nationale Verzehrsstudie II. Ergebnisbericht, Teil 2: Die bundesweite Befragung zur Ernährung von Jugendlichen und Erwachsenen , 2008 .

[54]  R. Schwarzer,et al.  The role of action control and action planning on fruit and vegetable consumption , 2015, Appetite.

[55]  Ralf Schwarzer,et al.  Mechanisms of health behavior change in persons with chronic illness or disability: the Health Action Process Approach (HAPA). , 2011, Rehabilitation psychology.

[56]  A. Schienkiewitz,et al.  Übergewicht und Adipositas im Kindes- und Jugendalter in Deutschland – Querschnittergebnisse aus KiGGS Welle 2 und Trends , 2018 .

[57]  A. Pakpour,et al.  A cluster randomised controlled trial of an intervention based on the Health Action Process Approach for increasing fruit and vegetable consumption in Iranian adolescents , 2017, Psychology & health.

[58]  Maya B. Mathur,et al.  Effect of a mobile app intervention on vegetable consumption in overweight adults: a randomized controlled trial , 2017, International Journal of Behavioral Nutrition and Physical Activity.

[59]  Shiyi Cao,et al.  Consumption of fruit and vegetable and risk of coronary heart disease: a meta-analysis of prospective cohort studies. , 2015, International journal of cardiology.

[60]  Gert B. M. Mensink,et al.  Konsum zuckerhaltiger Erfrischungsgetränke bei Kindern und Jugendlichen in Deutschland – Querschnittergebnisse aus KiGGS Welle 2 und Trends , 2018 .