ALIVE!

Chronic diseases such as coronary heart disease, cancer, and diabetes are responsible for five of the top six leading causes of death, as well as for decreases in quality of life. The important role of diet and physical activity in reducing the burden of chronic disease and obesity is well-established; however, the majority of Americans do not meet dietary and physical activity guidelines. For example, fewer than 50% of the population engage in physical activity at the minimal level recommended for health benefits, fewer than 25% consume five or more fruits and vegetables per day, and 59% eat more than the recommended intake of saturated fat. Diets high in saturated and trans fats contribute substantially to coronary heart disease and to cancers of the colon, breast, and prostate. Low fruit and vegetable intake is associated with increased risk of 14 specific cancer types. Physical inactivity is strongly associated with coronary heart disease, Type II diabetes, colon cancer, and possibly breast cancer. Thus, improvements in dietary habits and physical activity can reduce the risk of obesity and of many chronic diseases. 

Many interventions have significantly improved diet and physical activity, at least in the short run, but the need still exists for cost-effective interventions capable of reaching large segments of the population.

ALIVE! is designed to assist individuals to increase their physical activity and fruit and vegetable intake, and decrease their intake of saturated and trans fats and added sugars. ALIVE! is a tailored computerized program delivered entirely by email. Potential participants may be invited to try ALIVE! through a batch email sent by the leaders of a business or organization to its employees or members. First, participants complete the initial health risk assessments on diet and physical activity and receive immediate on-line feedback on their levels of those behaviors, regardless of whether they decide to participate further. If they decide to participate in the full program, participants choose one of three health-behavior modules or paths to work on for the next 3 months: (1) increasing physical activity, (2) increasing fruits and vegetables, or (3) decreasing saturated and trans fats and added sugars. 

Each week, participants receive a personally tailored email suggesting four to six small-step goals relevant to the characteristics the participant identified in the initial health risk assessment (i.e., lifestyle constraints, physical activity preferences, stage of change, current diet and physical activity). Participants are asked to commit to one or two of these goals to work on for the following week, such as "I will have a salad with lunch 2 days this week" or "I will walk 20 minutes at lunch time." Upon choosing a goal in the email, the participant is automatically taken to his or her "personal home page." This personalized Web page contains tips for achieving the goal(s) the participant has chosen, tips on overcoming barriers mentioned in the initial assessment, a goal tracker, an interactive simulation tool, health information, and links to other sites for additional information. A brief email reminder about the goals is sent midweek. A total of 25 personalized program-initiated email contacts occur over the 3-month intervention period for each module. Participants can choose to re-enroll for one or two additional 3-month intervention periods to cover the remaining topics.  Since all participants from a given organization would be enrolled in an organization-specific group, group data, such as means, (but no data on individuals) can be provided to the organization.

The use of ALIVE! in the evaluation reported here differed slightly from the standard ALIVE! program. In the evaluation, participants chose one module to work on with no subsequent re-enrollment, the intervention lasted for 4 months, and emails were sent weekly in the first 2 months and every other week in the final 2 months. 

Participants first take an on-line health risk assessment (HRA) that takes approximately 15 minutes to complete. The ALIVE! program itself consists of 25 personalized program-initiated email contacts over a 3-month period for each of the three modules.  Administrative efforts are minimal and include providing a link to potential participants.

ALIVE! is intended for adults aged 18 and over.

ALIVE! is administered through email and provides suggestions for dietary changes and activities that can be done at home or at work. Participants can be recruited through work wellness programs or through other types of organizations.

ALIVE! is an email-based intervention that can be purchased by individuals, employers, or other organizations by visiting http://www.nutritionquest.com.  The program developers offer two pricing schedules. One is based on the number of individuals who sign up for the program; the other is based on the number of individuals to whom the program is offered. Contact NutritionQuest to discuss options.

Approximately 8,000 regional employees of Northern California Kaiser Permanente for whom the investigators had email addresses were sent an electronic diet and physical activity assessment tool. Those who completed the assessment received instantaneous feedback regarding their current diet and physical activity in relation to national guidelines, details about the study, an informed consent document, and a second baseline questionnaire that was used for tailoring subsequent intervention messages and assessing secondary study outcomes. A total of 797 respondents from 192 different departments provided informed consent. These respondents were randomized by department, after stratification by department size, to either the intervention (ALIVE!) or control group. Ten individuals were excluded from analyses because of a randomization error, leaving a final sample size of 787. 

The average age of the participants was 44.2 years. The sample was 74.3% female, 25.7% male, 7.4% African American, 8.5% Asian, 4.1% Latino, 38.0% White, and 42.6% mixed/unknown race/ethnicity. 

The following self-report questionnaires were administered at baseline, posttest (4 months after baseline), and follow-up (4 months after the intervention ended):

-- Physical Activity Questionnaire (PAQ), containing 34 activities divided into 6 areas: walking, biking and other transportation, care-giving and household chores, conditioning exercises, dance and sports, and other leisure activities. Respondents indicated days per week and minutes per day they participated in each of the activities in a typical week in the past 4 months. Each activity was assigned a MET value (a measure of energy expenditure where 1 MET is equivalent to the energy required for sitting quietly) according to the Compendium of Physical Activities, multiplied by frequency and duration, and summed over all relevant activities to create summary variables: total activity, moderate physical activity (MPA), vigorous physical activity (VPA), walking, and sedentary behavior. 

-- Diet questionnaire, developed for this study using the same data-based approach used in the Block Food Frequency Questionnaire. The survey included 35 items asking about usual intake, including both frequency and portion size. Foods were identified for inclusion based on analyses of the National Health and Nutrition Examination Survey (NHANES), with separate analyses for African Americans, Whites, and Hispanics to ensure inclusion of foods appropriate for those ethnic groups. Fruits and vegetables were measured in cup-equivalents per day, and saturated and trans fats were measured in grams per day.

-- SF-8 Health Survey, a set of quality-of-life measures, consisting of eight questions representing eight domains of physical and mental health. Items were scored on 5-point Likert scale, with the exception of self-assessed health status, which was scored on a 6-point scale. 

Primary outcomes of interest included change in physical activity, saturated and trans fats intake, sugar intake, and consumption of fruits and vegetables. Secondary outcomes included change in health-related quality of life, presenteeism (reduced worker productivity resulting from mental and physical conditions, despite being present on the job), self-efficacy, and stage of readiness for change.  The study used intent-to-treat analyses that set change in non-responders to the followup questionnaires to zero. 

Effects on Physical Activity

• Intent-to-treat analyses at posttest showed that relative to the control group, the intervention group as a whole had significant increases in MET minutes per week of total activity (p=.004), moderate physical activity (p=.0002), vigorous physical activity (p=.03), and walking (p=.0003) and a significant decrease in sedentary behavior (p=.05).
   
• The change in physical activity was most evident among participants who chose to follow the physical activity path, and was even more pronounced when non-responders were excluded from the analysis. For example, among the responders in the physical activity path, time spent walking increased by 27.3 minutes per week (p=.003) relative to the control group, and time in sedentary behavior decreased by 121.7 minutes per week (p=.01).
   
• The effect of ALIVE! was greatest among responders in the physical activity path who did not meet the recommendation for the minimal amount of physical activity needed for health benefits at baseline. For example, moderate physical activity increased by almost 1 hour per week relative to the control group (p=.0005), and sedentary behavior decreased by more than 2 hours per week (p=.03). In contrast, the changes in both of these behaviors in those who did meet the recommendations at baseline were not significantly different from those in the control group.

Effects on Diet

• Intent-to-treat analyses at posttest showed that relative to the control group, the intervention group as a whole had significant decreases in the consumption of saturated (p=.01) and trans fats (p=.02) and increases in the consumption of fruits and vegetables (p=.03).  A decline in the consumption of added sugars in the intervention group was marginally different from that reported by the control group (ns).
   
• Change in the consumption of saturated and trans fats was most evident in the fats/sugars path, and the change in the consumption of fruits and vegetables was most evident in the fruits/vegetables path. These findings were even more pronounced when nonresponders were excluded from the analyses. Among responders in the fats/sugars path, the consumption of saturated fats decreased by 1.56 grams per day (p=.02); among responders in the fruits/vegetables path, the consumption of fruits and vegetables increased by 0.45 cup-equivalents per day (p=.03).

• Models that stratified by whether or not participants met dietary recommendations at baseline suggested that the effect of the intervention was greatest among those not meeting recommendations to begin with. For example, among the responders in the fats/sugars path, those not meeting recommendations regarding dietary fat at baseline reported significantly decreased consumption of trans fats (p=.03), while those who did meet the recommendations at baseline did not. The same pattern was also observed among the responders in the fruits/vegetables path: the intake of fruits and vegetables increased significantly in those not meeting fruit and vegetable recommendations at baseline (p=.004) but not in those who did. 

Additional Findings

• The effect of ALIVE! was significant for health-related quality of life. Change in the physical and mental summary scores of the SF-8 was significantly greater in the intervention group compared to the control group (p=.02).
   
• Intervention participants were 1.47 times more likely than the control group to report improvement in the ability to concentrate and accomplish work tasks (p=.02).
   
• Intervention participants had significantly greater improvement than the control group in confidence in their ability to change their diet. For physical activity, confidence did not improve significantly in the intervention group compared to the control group when all subjects were included in the analysis, including those indicating they were "very confident" at baseline. However, when the analysis was limited to participants in the physical activity path who were not already "very confident", a significant improvement in confidence was seen (p=.037).
   
• Significant forward movement in stage of readiness for change was seen in all domains among "at risk" participants needing improvement at baseline (fat, p=.05; fruits/vegetables, p<.001; added sugars, p<.001; and physical activity, p=.02).