Apps and monitors for patient health

The 2009 Institute of Medicine recommendations for amount and rate of weight gain during pregnancy indicate that practitioners should discuss "diet and exercise" with their patients.¹ Although most of us have not had formal nutrition training, it is safe to assume that a discussion of a healthy diet (ie, caloric intake, sugars, and saturated fats) is relatively straightforward. In fact, for many of us who follow patients with gestational diabetes, demonstrating the effect of certain foods on blood sugar is a powerful educational tool for helping patients understand the importance of adhering to a diet.

Yet when it comes to discussing exercise, it seems that many of us are at a loss for words. What kind of exercise should I recommend? How much exercise is enough? How much is too much? How do I know that my patient is actually exercising? How do I prescribe exercise?

According to the US Department of Health and Human Services, US adults should engage in moderately intense physical activity for a minimum of 150 minutes each week; this is equivalent to 30 minutes a day, 5 days per week.² While it is relatively easy to keep track of the duration and frequency of exercise, it is much more difficult to quantify the intensity of an activity, let alone ensure that the activity is "moderate" for the entire 30 minutes. In fact, in a 2008 study of women's understanding of "moderate-intensity" physical activity as presented in the popular media, the authors found that it is not enough to simply hear and read a description of physical activity, but that it requires practice.³

Using data to measure health and fitness

So, what are we to do? Should we have our patients log their daily activities? Should we have our patients show us sign-in sheets from the local gym? It turns out that the dilemma of how to quantify physical activity has been a hot topic of discussion for more than 50 years. In 1965 a Japanese doctor developed the first pedometer to give people the opportunity to meet measurable goals and thus increase their physical activity. The device was called the Manpo-kei (meaning "10,000-steps meter"). It was based on research by Dr. Yoshiro Hatano that demonstrated that 10,000 steps a day allowed for a proper balance between the traditional Japanese caloric intake and the caloric expenditure of walking approximately 5 miles per day (the average person's stride length is approximately 2.5 ft long, therefore 2,000 steps/mile).⁴

The validity of the 10,000-steps model for Americans has been questioned by many researchers, since today’s American diet is far more calorie-rich than the 1965 Japanese diet and 5 miles of walking per day may be too much for the average person. A 2004 study that attempted to answer the question "How many steps/day are enough?" reported that:⁵

Walking <5000 steps/day indicates a “sedentary lifestyle”

Walking 5000-7499 steps/day is typical of daily activity excluding sports/exercise and may be considered “low active”

Walking 7500-9999 steps/day likely includes some volitional activities (and/or elevated occupational activity demands) and may be considered “somewhat active”

Walking ≥10,000 steps/day indicates that an individual is “active”

Walking >12,500 steps/day is “highly active”

All this leads back to the original question of how physicians can effectively prescribe exercise to our patients and then assess their compliance. Well, as you can imagine, there are apps for this!

Nike+ is one of the most popular running apps (free, iOS/Android), tracking distance, pace, time, and calories burned using the device's GPS.

It also provides users with audio feedback (such as encouragement, statistics, and heart rate) as they run. The app can also be programmed to automatically upload workout information to a website, nikeplus.com, where users can track their running routes, elevations, and progress. Furthermore, when synced with a Facebook account, users can alert their Facebook friends at the start of their workouts so they can receive real-time “cheers" for each "like" or comment they receive. Although this app is running focused, any walking or running motion is recorded. http://nikeplus.nike.com/plus/products/gps_app/

RunKeeper (free, iOS/Android) is another popular running app.

Like the Nike+ app, RunKeeper uses GPS-derived data to track fitness performance. Although the name suggests a running focus, this app can be used to monitor all sorts of physical activity, including running, walking, and cycling. Furthermore, RunKeeper can sync with a number of third-party accessories such as heart-rate monitors and Internet-linked syncing scales to let users collect and analyze their fitness data and monitor their performance. Other highlights of RunKeeper include the ability to see detailed pace, distance, and time stats; in-ear (headphone) coaching that gives live stats; progress through built-in audio cues; on-demand notification of new personal bests and milestones; and most importantly, the ability to follow detailed plans to help patients follow specific (personal or prescribed) fitness objectives. http://runkeeper.com/

Fitbit goes beyond apps that only use native smartphone technology, syncing  to the Internet via smartphone to monitor your physical activity.

A popular manufacturer, Fitbit was one of the first companies to allow consumers to measure not only their daily physical activity but also their sleep-related motion, which is associated with sleep efficacy. Their most popular model, the Fitbit One, is $99.99 and works with iOS and Android devices. Its matchbook-sized clip-on monitor has the ability to measure the number of steps walked or run (distance is calculated by a calibrated step), floors climbed, and calories burned, and to track sleep statistics (hours slept, number of times woken, sleep efficiency). The device is designed to be worn 24 hours a day, which is why it is sweat-, rain-, and splash-proof and can be worn in the shower. Fitbit is also about to release a bracelet-style monitor called the Fitbit Flex that has all the features of the Fitbit One. Fitbit also manufactures a Wi-Fi-enabled scale that tracks body weight, body fat percentage, and body mass index, allowing users to create pictures of their long-term progress. It also wirelessly syncs stats with online graphing and mobile tools to help users integrate their fitness data. http://www.fitbit.com/

UP is a popular bracelet-styled device made by the famed Bluetooth headset manufacturer Jawbone.

The Jawbone UP has many of the features of the Fitbit products and is also designed to work with a smartphone device (iOS or Android). The strength of the Jawbone app is that UP not only offers users easily understood data on their sleep performance (how long did it take to fall asleep; how long did they have light sleep and deep sleep; how long were they awake during the night; how long were they in bed; did they reach their sleep goal) but it also uses that data to turn a user’s phone into a smart alarm that wakes the user at the right point in the sleep cycle. For example, the power nap monitor wakes the user after 26.5 minutes of sleep, the optimal length of a nap.

Those who may have a propensity to be idle or need a reminder to be active (ie, those who work at a desk for hours on end) can set an alarm as a reminder to take a break and move around. Lastly, the app has a built-in food and drink tracker that allows the user to take a photo of food, scan a barcode, browse the image gallery in UP, or search the ingredient database to record what he or she is eating and drinking. The app will then calculate the daily nutritional intake and display the calories consumed compared to the calories burned. Among devices with custom alerts, UP definitely stands out. https://jawbone.com/up

Pear Sports is a smartphone-based training app unlike any other.

Sold at Apple Store locations and online, the $99.99 kit comes with a proprietary Bluetooth wireless heart-rate monitor and secure earphones. After downloading the app and syncing the heart-rate monitor to the device, the user performs a sample workout to calibrate the device. Once calibrated, the Pear app tells the user when to speed up or slow down, provides useful tips to improve form, explains the purpose and benefits of the workout, and keeps motivating the user through in-ear coaching cues. The app ultimately “learns” the user's fitness level and creates custom heart-rate zones to ensure that each subsequent workout is at the right intensity. Of course, Pear can also display workout-by-workout statistics in graphical and numerical charts to show the user’s progress. http://pearsports.com/pear-mobile-gear

Pear has partnered with a number of famous workout coaches to create custom plans that users can purchase in the app to help them achieve certain goals. These include the 30 Minute Functional Strength Circuit Workout for Runners, 30 Minute Fat Burn Run, Zero to Running Plan, 5K Training Plan Level 2, and the Half Marathon Plan.

We physicians have known for a very long time that diet and exercise are the keys to fitness success. If the sum of the calories burned is greater than the sum of calories consumed, by definition a person should lose weight. However, as discussed above, quantifying the quality and character of caloric output is challenging. This is why it is important to recognize these consumer-level products. In concert with demonstrable app-derived data it is now feasible not only to recommend a specific exercise program but also to advise patients about improving their activity.

It is not unreasonable to envision a day when we not only write a prescription for a medication but also prescribe an application. “Download two of these and call me in the morning . . . .”

References

1. Rasmussen KM, Yaktine AL; Institute of Medicine, National Research Council Committee to Reexamine IOM Pregnancy Weight Guidelines. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: National Academies Press; 2009.

2. US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. ODPHP publication no. U0036. www.health.gov/paguidelines/pdf/paguide.pdf. Published October 2008. Accessed April 10, 2013.

3. Rice KR, Heesch KC, Dinger MK, Fields DA. Effects of 2 brief interventions on women’s understanding of moderate-intensity physical activity. J Phys Act Health. 2008;5(1):58–73.

4. Tudor-Locke C. Manpo-kei: The Art and Science of Step Counting. Victoria, British Columbia: Trafford Publishing; 2003.

5. Tudor-Locke C, Bassett DR Jr. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med. 2004;34(1):1-8.