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Technology to support health and wellbeing

Technology to support health and wellbeing

"Today’s technology has the power to connect us, but it can also isolate us. It promises to make our lives easier but can erode our physical and mental well-being if we’re not mindful." - Arianna Huffington

This article was updated in December 2024.

In our article Physical activity: the science and environment, we highlight that technology has engineered movement out of our lives.

Our article on Longevity: exploring the blue zones identifies that, in the geographical areas with the greatest longevity, the majority of people still live traditionally; physical activity is built into their lives, whether that be walking or cycling to get around, and they wash their clothes by hand. Their lack of technology seems to be protective!

In our Nutrition in the primary care consultation and Ultra-processed food articles, we explain how modern food technology has transformed our nutritional intake, and how this has contributed to the current tsunami of long-term conditions.

You may be thinking that an article on how technology can support our health may be rather short!

But what about the technology aimed at improving health? It can act as both a barrier and a solution to healthy lifestyles.

Here, we explore key technological hardware and software which may be changing the landscape of health and wellbeing. This includes:

Hardware:

• Wearable biometric monitoring devices.
• Continuous glucose monitors.
• Artificial pancreas.

Software:

• Mobile applications.
• Behaviour change.
• Nutrition and weight management.
• Mental wellbeing.
• Sleep.
• Gamification.
• Video-conferencing exercise interventions.

The first piece of wearable medical technology was back in 1962. Can you guess what it was? The Holter monitor for cardiac monitoring!

Since then, technology has brought us devices that can sense oxygen saturation, sleep quality and numerous other physiological parameters. It can assess these and feedback to the user and their healthcare professional. To see how wearable technology has transformed over the years, have a look at this infographic published in Nature.

The COVID-19 pandemic led to rapid advancements in using medical technology to monitor people remotely, and we in primary care experienced that more than most. 

But will such medical devices improve patient outcomes or change clinical practice? Will they just cause mass panic? (My watch tells me my O₂ sats are pretty much always 91%!) Is it a fad that will pass, like so many consumer devices? 

One of the biggest uses of wearable monitoring devices is to track and encourage us to be physically active. But do they actually help us get moving?

A large systematic review and meta-analysis of 121 studies looked at outcomes for using physical activity monitors in a mixed population of adults (BMJ 2022;376:e068047). The trials were generally small and very heterogenous so there was only low-to-moderate certainty of evidence.

The review found that, in those using wearable technology:

• Physical activity increased by around 1200 steps a day.
• Vigorous activity increased by around 48 minutes per week.
• Sedentary time reduced by around 10 minutes per day.

A systematic review and meta-analysis of 36 randomised controlled trials (including 6 studies from the UK and 9 from the USA) assessed whether wearable technology resulted in increased physical activity in adults with at least one cardiometabolic condition (BMJ 2020;369:m877). It included over 5000 patients, and looked at the use of pedometers/accelerometers in adults with at least one of:

• Type 2 diabetes/risk factors for type 2 diabetes.
• Overweight/obese.
• Cardiovascular disease.

Pedometer-based interventions combined with face-to-face consultations with a healthcare professional showed the greatest improvement in physical activity levels; the effect was smaller for accelerometer studies. Without clinician support, pedometers had a small positive effect on physical activity, while accelerometers were ineffective. The use of these devices did not impact on the secondary outcomes of glucose levels, blood pressure, cholesterol or BMI.

As well as tracking our physical activity, devices such as watches, headbands and wristbands have been equipped with a growing number of sensors, including:

• O₂ saturation.
• Respiratory rate.
• Temperature.
• Blood pressure.
• ECG.
• EEG.
• Glucose.
• Galvanic skin response (electrical changes in the skin in response to sweating).

These can either be inbuilt or connected wirelessly to an external device.

Wearable biometric monitoring devices have the potential to revolutionise randomised controlled trials by transitioning from sporadic measurements at predetermined intervals to continuous and comprehensive data collection (JMIR Mhealth Uhealth. 2021;9:e25138).

The use of AI is becoming more prominent in various industries, and healthcare is no exception, with a report from the National Academy of Medicine in the US stating that it provided “unprecedented opportunities”.

Using biometric wearable devices to help track several lifestyle behaviours will produce a great deal of data. In fact, over 300 million books worth! (Clin Transl Sci. 2021;14:86).

AI can help analyse and interpret this data, allowing the professional to communicate the results to the user to help support health behaviour change. An example of this is machine learning algorithms which can interpret multiple data inputs (e.g. heart rate variability, galvanic skin response, movements during sleep) to calculate the stress levels of the users (Cogn Comput 2024;16:455).

A scoping review found that most studies exploring the use of wearable technology in assessing stress resulted in positive outcomes (Healthcare (Basel) 2023;11:2369). Devices can then be programmed to support the patient to make the necessary steps to manage their stress – so these devices are for both investigation and management!

Sleep assessment is another area targeted by biometric monitoring devices. We delve into this further in our article on Sleep.

Of all the additional biometrics now being monitored, continuous glucose monitoring has taken the world by storm. Or at the very least my Instagram feed... Let’s explore this in more detail.

Continuous glucose monitoring (CGM) is now the preferred glucose monitoring method for those with diabetes which requires insulin. Its use is included in several national guidelines, including NICE (BMJ 2023;380:e072420, NICE 2023 QS208). The device measures glucose in the interstitial fluid, which does result in a short delay in identifying changes, but accuracy is comparable to capillary glucose testing (finger prick).

There are 3 main types:

• Real-time CGM (rtCGM): transmits glucose data continuously and provides real-time alerts, e.g. Dexcom ONE® (licensed aged 2y or above).
• Intermittently-scanned CGM (isCGM, previously known as ‘flash’ glucose monitoring): provides glucose data when scanned by a receiver or smart device, e.g. FreeStyle Libre® 2 (licensed aged 4y or above).
• A longer-term implantable CGM: can also be combined with an insulin pump to create a hybrid closed-loop system; more on that later.

However, diabetic patients on insulin must continue to have the means to check a BM (capillary glucose) because this delay may not pick up rapid rises or falls in glucose. For more information on CGMs, see our article Technology in diabetes.

You may have noticed an increasing number of people without diabetes using CGMs (Obes Res Clin Pract. 2021;15:431) – mainly because they seem to post their blood sugar levels on social media after every meal !

Despite CGMs initially being designed for those with diabetes, commercial marketing and the growing demand for personalised approaches to medicine and lifestyle means there is now huge interest among a wider population. There has also been a recent surge in the use of CGMs for clinical and research purposes to assess the impacts of lifestyle interventions and to help support behaviour change (Obes Res Clin Pract. 2021;15:431, Nutrients. 2020;12:475). Many of us already monitor our weight, steps and heart rate. Will we soon be monitoring our glucose, hormone and electrolyte levels? Many companies are eager for that to be the case, but is there any evidence of real benefit? 

Not much!

• One study found that overweight or obese sedentary individuals without diabetes who used a CGM device and activity tracker for 10 days after a counselling session on physical activity effects reported increased motivation to exercise (Cancer Epidemiol Biomarkers Prev 2020;29:761).
• In a study of 153 non-diabetic individuals, around 96% exhibited normal or near-normal blood sugar levels; in fact, most readings out of range were considered anomalous (J Clin Endocrinol Metab 2019;104:4356).
  • Some believe that we should be mindful of our blood glucose swings, even if within the normal range. Commercial operators highlight a VERY small study a while back in type 2 diabetics, which found that high-normal glucose fluctuations post-meal triggered oxidative stress (JAMA. 2006;295:1681).
  • A meta-analysis looked at non-diabetic populations and found that hyperglycaemia in this population was a risk factor for cardiovascular disease (Arch Intern Med. 2004;164:2147). However, we were unable to find evidence of improved health outcomes related to their use in non-diabetic populations.

Some manufacturers have shared non-peer-reviewed studies on their websites that report improved blood sugar profiles among healthy users. However, they lack critical details and examine arbitrary blood sugar ranges, meaning the true impact on health, including metabolic health outcomes or hospitalisations, remains unknown.

At Red Whale, we could find no published studies that conclusively linked monitoring to improved health outcomes.

There is a growing concern among critics of CGM that oversimplification of nutrition to purely glucose spikes may result in users cutting out otherwise healthy foods, and may even fuel eating disorders in vulnerable users.

For most of us, the only way to get an idea of our patient’s body composition is to grab our tape measure and calculate their waist-to-height ratio. This is crude, but a better tool than body mass index (BMI). BMI does not consider the composition of mass, and struggles at the extremes of muscle mass, in particular sarcopenia, which is more common in the UK population than you think (5.3%) and more prevalent in those with type 2 diabetes (J Cachexia Sarcopenia Muscle. 2020;11:62). This loss of mass muscle may mask more severe adiposity, which is why NICE asks us to calculate waist-to-height ratio when our patient’s BMI is <35  (NICE (2014, updated 2022) CG189).

Because body composition is an important factor for health and longevity (and is associated with a greater risk of cardiometabolic disease, several types of cancer and early mortality), more patients and health clinics are starting to use technology to help calculate it (Nutrients. 2021;13:2493). Let’s look through the different bits of kit out there!

These are aimed at supporting patients in behaviour change to reduce the risk of developing or worsening long-term conditions (NHS England Health innovation network). One example is the Holly Health app, which has been approved by the NHS. When assessing its impact over 8 weeks:

• 86% of users reported starting new habit/s.
• 33% of users reported that they accessed their GP less frequently.
• There was a 19% average increase in physical activity.
• There was a 23% average improvement in anxiety.

In my PCN, we have used it alongside group lifestyle consultations to help support the patients in maintaining their goals. It gives clinicians the ability to track their patient's progress (with their consent, of course!).

Several popular apps have been designed to support nutrition. Most are targeted at weight loss, e.g. MyFitnessPal, while others help users implement new nutrition plans such as intermittent fasting, e.g. Simple.

NHS Digital launched a 12-week online behavioural and lifestyle programme designed to support adults with a BMI ≥30 (reduce this by 2.5 for those from South Asian, Chinese, other Asian, Middle Eastern, Black African or African Caribbean family backgrounds). The criteria for referral is a diagnosis of type 2 diabetes, hypertension or both.

An interesting study compared this NHS digital weight management programme with a commercial option (Healthy Weight Programme) and an active control group. All three groups were given access to a gym and physical activity guidelines, but received no formal support or training (BMC Public Health 2019;19:1732):

• NHS app: –4.19 ± 5.49kg (n = 21).
• Commercial app: − 5.17 ± 4.22kg (n = 18).
• Gym control: –1.17 ± 3.00kg (n = 24).

So, digital support achieved greater reductions in weight compared with merely signposting, educating and providing access to healthy behaviours.

A review explored various mobile applications targeted at weight loss, and found them to be a cost-effective method of supporting patients to lose weight. However, it did highlight the need for research to identify the long-term impacts and how to support hard-to-reach populations (Curr Cardiovasc Risk Rep 2023;17:83).

With the emergence of GLP-1 medications in the management of weight loss, NICE evaluated digital weight-management technologies for delivering multidisciplinary (MDT) care remotely, with the intention of addressing high costs and long wait times in tier 3 and 4 services (NICE 2024, HTE14).

Approved NHS technologies:

• For prescribing medication: seven technologies (including Gro Health W8Buddy, Liva, Oviva and Second Nature) were approved with conditions for evidence generation.
• Non-prescribing MDT services: nine technologies (including Counterweight and Weight Loss Clinic) were approved without prescribing capabilities.

Effectiveness:

• Comparable weight loss to in-person services over two years.
• Broader access to care, especially for underserved groups.
• Reduced waiting times: potential cost-effectiveness (it notes that further data is required).

Limitations:

• Insufficient evidence on long-term outcomes, adherence and adverse event monitoring.
• Risks of misuse or disordered eating highlight the need for safeguarding systems and psychological support.

The health technology evaluation highlighted that digital MDT teams should still include dietitians, psychologists and surgical expertise when necessary, and that digital solutions must be tailored, engaging and informed by patient feedback.

As understanding of the impact of stress on long-term health grows, mobile apps such as Headspace and Calm have become increasingly popular. But do they work?

A systematic review found 14 randomised control trials for Headspace but only 1 for Calm:

• There was improved depression in 75% of studies.
• Changes in mindfulness, wellbeing, stress and anxiety were varied.
• Users were provided with the highest-level membership for free.
• Many participants were company employees!!

In conclusion, the authors felt there were some promising results with Headspace, but overall study quality and conflicts of interest meant stronger evaluations of effectiveness were not possible.

Computerised CBT-i (CCBT-i) has been shown to improve sleep efficiency, fatigue, mood and overall daytime functioning. It can be considered in mild to moderate cases of insomnia due to its low cost and easy availability; in many areas, patients can self-refer to access digital therapy such as Sleepio or Sleepstation. However, face-to-face CBT-i  has a consistently greater treatment effect than CCBT-i in terms of both the immediate improvement of insomnia and the duration of the therapeutic benefits (BMJ 2016;354:i2123). There may also be a lower uptake of computerised treatments for insomnia compared with face-to-face therapies (Lancet 2023;402:940).

In 2022, NICE published medical technologies guidance (MTG70) on Sleepio digital therapy (available via a website or app) as a cost-saving option for people who would otherwise be offered drugs or sleep hygiene advice. It made this recommendation because evidence suggests that Sleepio reduces insomnia compared with both drugs and sleep hygiene. The document acknowledges the concerns around evidence of efficacy compared with face-to-face CBT-i, but points out that face-to-face care is more challenging to provide to the population at scale. Sleepio is currently available to those receiving Macmillan Cancer Support; on the NHS in all of Scotland and some areas of England; and to all NHS staff.

Gaming suggests sitting in a dimly-lit room, realising you are hours past your bedtime and that what has felt like an hour has been six! For many, it can lead to social isolation and sedentary behaviour. You may be surprised that we are bringing it up in a health article. But that same addictive power to keep people sedentary can act as a catalyst for positive behaviour change if applied to promoting health through the power of 'gamification'.

Gamification involves integrating game-like elements into non-game situations to enhance engagement, motivation and overall user experience. Key tools include points, badges, leaderboards, challenges, competition and rewards. The objective is to encourage participation, collaboration and achievement across diverse fields, including business, education, marketing, medicine and lifestyle. For instance, fitness apps leverage these elements to motivate users to achieve specific health and fitness objectives (Lancet Reg Health West Pac 2023;35:100528).

A meta-analysis of 16 studies (2407 participants) confirmed that gamifying physical activity helped promote movement in different population groups. Increased activity and pleasure of movement persisted after the follow-up period, indicating that the user had increased engagement even after the novelty wore off; this is in contrast to non-gamified physical activity interventions (J Med Internet Res. 2022;24:e26779).

Examples of successful gamification:

• Pokémon Go: launched in 2016 and has been downloaded over 500 million times! But did it increase physical activity in its users (J Med Internet Res 2016;18:e315)?:
  • Users increased their activity by 1473 steps/day on average.
  • This was a >25% increase from baseline.
  • It is estimated to have resulted in 144 billion additional steps in the US alone.
  • Most interestingly, it increased activity levels regardless of gender, age, weight, socioeconomic status or prior activity level.
• Betterpoints:
  • Council-funded app in some areas of the UK, promoting healthier lifestyle choices.
  • Users are rewarded with coupons and gym passes for engaging in active travel.
• Good Boost:
  • Originating as a community health research initiative, GoodBoost uses augmented reality exercise games within public swimming pools.
  • By gamifying strength and neuromuscular exercises, it aims to create lasting behaviour change (Audit review of Good Boost AI decision 2019).
• Zwift:
  • A popular gamification platform for virtual cycling and running.
  • Takes a community-driven approach.
  • Social identity leadership within the Zwift community, expressed through norms and behaviours, enhances a sense of belonging and motivation (Eur. J. Public Health 2023;33:133).

Red Whale explored the world of medical gamification in discussion with Ben Wilkins (CEO of Good Boost). See the link in our useful resources at the end of this article to view this extended video byte.

A systematic review and meta-analysis found that video-conferencing exercise interventions were effective, safe and feasible in those with long-term health conditions. However, disappointingly, engagement with the programmes tailed off despite participants recording a high desire at baseline (Br J Sports Med 2024;0:1).

The British Society of Lifestyle Medicine defines lifestyle medicine as a “low-tech approach to health”. Should that put us off using technology?

Often, it is not the tool that is the problem, but how it is applied. Interventions should appeal to patient preferences in order to foster engagement, and guard against exacerbation of health inequalities due to unfair access across society.

I am just hoping that, one day, I will be able to use a medical tricorder from Start Trek in real life. Before writing this article, I would have said that was science fiction. Now, I am confident that our doctor's bag will have something that closely resembles it! Live long and prosper...

Technology to support health and wellbeing Technology has the power to both worsen and improve health outcomes. Wearable technology has been used within healthcare since 1962, but its advancement and use have accelerated over the past 15 years. Continuous glucose monitors are transformative for diabetic populations. There is minimal data to support use of continuous glucose monitoring in non-diabetic populations. Technology has the potential to exacerbate health inequalities if its provision is unfairly distributed in society.

Useful resources: Videos (all resources are hyperlinked for ease of use in Red Whale Knowledge) Red Whale Knowledge: Physical activity: gamification Podcasts Health Points - health gamification (putting leading researchers, designers, thinkers and business leaders behind the mic to talk all things health gamification)