Sarah’s Story: Six Months of Determination, Health Coaching and Observations of Daily Living

Katherine Kim, M.P.H., MBA, iN Touch Principal Investigator, San Francisco State University

Sarah* was a 214-pound, pre-diabetic high school student who hated comments her peers made about her appearance. When she first met the iN Touch health coach, Sarah shared that she regularly ate fast food, drank soda and cut class. She wanted to focus on eating healthier and exercising. Sarah and the coach discussed different types of exercises and worked together to create backup plans in case she was unable to do her intended exercise.

Sarah planned to record her observations of daily living (ODLs) about her food, exercise, socializing and mood in TheCarrot.com’s iN Touch application a few times a week. She began recording her ODLs and found it was easy enough to do. She also used the notes section to intensively journal about her path to a healthier life. Sarah texted the health coach and took advantage of in-person coaching visits to talk about her challenges, strategies and progress. She also continued to see her regular physicians and nurses.

By the third month of participation she reported that she was cutting fewer classes. She now regularly power walks with hand weights and started taking dance classes over the summer. She has eliminated fast food, chips and sodas from her diet. Instead, she carries healthy snacks in her purse and drinks only water. At the end of 6 months of participation, Sarah has lost more than 20 pounds.

Sarah is one of the first wave of participants to complete the study this month. While we wait to collect our complete set of evaluation data, we looked at frequency of usage of the technology to see if we could find clues to Sarah’s success. To date, 33 participants have entered 1,794 ODLs, not including notes. (Note: most participants have not yet completed their six months.) Recording frequency varied, and individuals ranged from one ODL recorded to 230 ODLs recorded with an average of 54 ODLs recorded. Sarah recorded 117.

Sarah’s size is not the only change. “I have confidence,” she says,  “I feel this is my year. Now if people want to come at me with drama, I’m just like, ‘I don’t care.’ I’m going across that stage. I’m going to a 4-year college. Twelfth grade is my serious year.”  She says she plans to continue using her iPod Touch and free TheCarrot.com application to improve her health.

*Not her real name.

Staying iN Touch: Community-engaged Research with Insiders and Outsiders

By Janelle Charles, Graduate Student Researcher and Katherine Kim, Principal Investigator, iN Touch, San Francisco State University

Read all iN Touch blog posts.

We first conceived of iN Touch two years ago at a local conference on innovation in health care services. One of the speakers talked about health care being stuck in the old paradigm of building large, complex, Cadillac solutions that require long implementation and training cycles in order to be effective. The new paradigm is just the opposite: building small, simple portable solutions that are intuitive and immediately valuable.
 
And so, the idea for iN Touch emerged—a small, simple portable way to help low-income youth with overweight/obese and anxiety/depression track their health and share that information with the care team to improve collaborative health management.
 
Here at the Health Equity Institute, we ascribe to several tenets including innovative research, community engagement and equal access to health.  For iN Touch, we had a real opportunity and obligation to engage community. But that meant admitting we didn’t know everything and letting go of a little control. The first was easier than the second.  
 
We as the research team are “outsiders.” We aren’t youth, although we all used to be. We aren’t low income, although some of us used to be. We aren’t anxious or depressed, but some of us wish we could lose weight. We need “insiders” to inform and direct our research. So, we created the Youth Advisory Board (YAB). We will meet with them six times over the course of the project to gain insider information about the future participant pool and prepare us for the myriad challenges unique to our study.

We have already gleaned several key insights from the YAB. In their own words:

Feelings of guilt and reluctance to report on eating patterns (via photos) and  mood, to health care providers.   

“…since it’s your doctor and they’re watching… your health, you might feel guilty about [taking pictures of your food]… ‘all I eat is McDonald’s… they’re gonna see that I eat a lot of bad food, so I’m going to lie and not send them my picture.’”

Trust between the patient and care team

“… a really good idea… [is] acknowledgement that there [are] gonna be days when you’re not eating healthy, then they know… like ‘oh, we know and so just tell us,” you know, it’s not a secret…” 

How much time would you spend on a daily basis collecting… information? 

“When I collect the date, I don’t want any… more than like five touches.  I don’t care about the time, but… it better be like real quick, like five [touches]. Five is my limit, pushing it.”

 
These open dialogues with youth will help us get to know our target population and avoid silly mistakes: like contracting a health coach who cannot relate to youth or developing a complicated application that requires teens to use more than “five touches” on a mobile device. Although we will undoubtedly encounter obstacles over the course of our study, YAB will keep us iN Touch.

A Balancing Act - Tackling Teen Obesity and Depression

By Katherine Kim, San Francisco State University, iN Touch Principal Investigator.

Our project is in full swing and that means we are increasingly clear about the promise that lies ahead if we are successful. As often happens, the more we talk about the project, the more we find others working on similar issues.

Last week, I met Professor Karl-Walter Kohlmann, a German health psychologist who was visiting San Francisco State.  He kindly sent me two recent papers from his research group. The first paper highlighted the high rates of anxiety and depression among children and teens who are overweight or obese. The other paper showed a difference in negative coping strategies (overeating, social isolation, computer and television use, etc.) used by children who saw themselves as overweight/obese vs. those who saw themselves as not (even if their BMI was in the overweight/obese range). It heightened my awareness of how thoughtfully and carefully we must interact with youth in our project so as not to perpetuate the problem by over-identifying them with a clinical label.  We want to protect their identity and esteem while we help them realistically change their health behavior. 

The paper recommended that treatment components for youth include nutrition, physical activity and behavioral skills (e.g. stress management, self-regulation and evaluation skills, and social support). I think we are on the right track with iN Touch by helping the patient manage activities related to all three components. I do have a question though. Might the use of the iPhone/iPod Touch increase the positive social integration of our population of teens by giving them another means of communication and another supportive person to engage with, the health coach?  Or, will the device end up like the TV and computer, an enabler of sedentariness and isolation. 

I’d love to hear what you think.

Staying iN Touch with Youth with Obesity and Depression

This post is the third in a series that will introduce you to our five new grantee teams.

By Katherine Kim, San Francisco State University, iN Touch Principal Investigator

Obesity and depression
Overweight and obese youth are suffering from chronic illnesses at younger and younger ages. The iN Touch project is reaching out to youth who are dealing with or are at risk for obesity and depression. Here at San Francisco State University’s Health Equity Institute (SF State) we believe we need to manage both of these conditions to have healthier youth. 

iN Touch
To tackle this issue we have partnered with clinicians from San Francisco General Hospital’s Teen Clinic (SFGH) to integrate smartphone technology with a health coaching model of care to help youth say in touch with their health, in touch with the factors in their environment that impact their health, and in touch with their care team. With an iPhone or an iPod Touch, San Francisco teens will be able to track observations of daily living (ODLs) such as food choices, physical activity, social networks, moods and information about the environment they live in that they feel is relevant to managing their physical and mental health. But, access to information and tracking of ODLs is only a first step. Taking action based on the information is critical. That’s where health coaching comes in.

The SFGH health coaching model centers around the patient. The primary care team includes the physician, therapist, and health coach who work together to support the patient. For example, a health assessment will be done by the physician that identifies medical issues. The health coach will then meet with the patient to help them develop an action plan—one that states the patient’s specific health goal, steps she will take to work towards that goal, and commitments around tracking, communication, and follow through. The smartphone technology supports the daily engagement with the action plan and allows the patient to interface with the health coach as often as they want. It also helps the care team identify medical and mental health issues as they arise, not waiting until the next visit which might be weeks or months away. In this way, we hope to enable an integrated and comprehensive approach to well-being that helps patients and their providers work together.

The iN Touch Team
I am the principal investigator from SF State and work with co-PI Christina Sabee from SF State’s Communications Studies Department. We are collaborating with the SFGH team which includes co-PI (and UC San Francisco faculty) Dr. Tom Bodenheimer, medical director Dr. Hali Hammer, Teen Clinic attending Dr. Aisha Mays, Department of Public Health psychiatric social worker David Guldmann, and iN Touch program manager Amireh Ghorob. We also have great research assistants: health education graduate student Ed Young and communications studies graduate students Joven Chacon and Holly Logan.

We are very excited about our project and hope you'll visit our webpage for updates and follow our progress through the blog!