The App That is Tackling Type 2 Diabetes in Finland One Healthy Habit at a Time

For anyone creating health tracking mobile apps today (including us!), the StopDia type 2 diabetes prevention project and its BitHabit app are fantastic sources of inspiration.

StopDia type 2 diabetes risk assessment survey.

StopDia is a research and public engagement project that is tackling prevention of type 2 diabetes in Finland, through simple and daily lifestyle health interventions. The University of Eastern Finland, Finland’s National Institute for Health and Welfare, the VTT Technical Research Institute of Finland and regional healthcare organizations in Finland have teamed up to conduct one of the largest population risk screenings ever completed for type 2 diabetes, and to evaluate a technology-mediated intervention for at-risk individuals.

LifeOmic chatted with several StopDia researchers this week to learn more about the project and its web app for healthy habit formation. At LifeOmic, we are currently developing a robust health tracking and precision health mobile app — LIFE Extend — that will apply lessons from the best health intervention and research tools out there, within a cloud platform framework that can drive insights for researchers, healthcare providers and patients alike.

An infographic representation of the StopDia project for type 2 diabetes prevention in Finland

StopDia began with a large-scale recruitment effort in which the citizens of Finland were encouraged to fill out an online diabetes risk assessment, now known around the world as FINDRISC. Over 200,000 individuals in Finland have completed the assessment, which incorporates risk factors such as age, family history, daily physical activity, vegetable and fruit intake, blood sugar control and blood pressure.

Based on their responses to the FINDRISC questionnaire, individuals across three participating counties who score at a moderate or high risk for type 2 diabetes are recruited to participate in the StopDia research project. Active research participants receive a range of clinical tests related to diabetes risk (blood pressure measurements, fasted insulin response tests, etc.) before being randomly assigned to an experimental or control study arm for 12 months. Individuals in the experimental study arms are directed to use a health tracking web app, called BitHabit, that theoretically will move them toward healthier daily behaviors to prevent type 2 diabetes.

“We have now more than 3,000 people with high risk of developing type 2 diabetes participating in the study,” said Riia Järvenpää, a communications development manager at the National Institute for Health and Welfare in Finland. At StopDia, Riia is working to improve research participant recruitment via novel methods. “The intervention will last for two years, so we will have the final results next year. So far the findings seem promising; people are adhering well to the app.”

The project is still in research phase, but StopDia researchers are now analyzing preliminary data on user engagement with the app and health outcomes.

StopDia’s Tiny Approach to Healthy Habits for Diabetes Prevention

“When we started to discuss and design the concept for this app, the BitHabit, we used other health coaching apps as our starting point. But we felt that we didn’t want to replicate apps with coaching approaches to health, because we know from research that the long-term adherence to these types of apps is very low,” said Dr. Pilvikki Absetz, a researcher at the University of Eastern Finland and sole owner of Collaborative Care Systems Finland, an organization that specializes in research, consultancy and training in health promotion and disease prevention. Pilvikki has over 15 years of experience designing, disseminating and implementing behavioral interventions with a strong element of community engagement in different “real world” settings.

“Very few participants, relatively, can stick with health coaching apps long term,” Pilvikki said. “There are also a lot of commercial health tracking apps out there, for tracking behaviors such as exercise, diet, etc. Users have high expectations for these apps as consumer-facing products, and we didn’t want to or feel that we could compete with these apps.”

In Goldilocks fashion, the researchers and designers behind BitHabit landed somewhere in between. They went for a web app that combines features of health coaching apps with a habit creation approach to health behavior tracking. They chose to create a web app in particular so that any recruited research participants are able to easily participate in the StopDia research project, regardless of the type of mobile device they use at home.

“Our target population isn’t tech geeks, Pilvikki said. “It was apparent to us that our target research participants wouldn’t have the tools and resources to search app stores and download/install a complicated app.”

Each StopDia research participant receives a personalized link that associates their app data with their participant ID. Impressively, StopDia researchers report that over 99% of research participants who have agreed to participate in the project have been able to open the app, and only 7% of the app users haven’t chosen any “bithabits” to practice and track for health.

Could Preventing Type 2 Diabetes Be as Easy as Online Shopping?

“Everybody has health behaviors that they engage in every once in a while,” said Pilvikki, a behavioral scientist and a leading expert in real-world implementation of type 2 diabetes prevention and lifestyle change programs. Pilvikki has a doctorate degree in health psychology and has put many of the principles of this field to work in BitHabit. “But how do we support creation of habits out of these isolated instances of healthy behavior? We set out to foster healthy behavior habit creation with BitHabit.”

BitHabit web app.

Pilvikki and colleagues took their inspiration from online shopping. Everyone knows how to shop for products online. It’s intuitive and rewarding. What if engaging in healthy habits on a daily basis, like flossing, walking 150 minutes per day or going to sleep at your ideal bedtime, were as easy as online shopping?

“We envisioned a library or store of defined, context-specific behaviors, which we call ‘bithabits,’ that have an evidence-based link with prevention of type 2 diabetes,” Pilvikki said. “Imagine the online store, and then imagine the different departments you can browse through. In each department, you have products — in our app, these products are bithabits that participants can browse, select and track over time.”

The BitHabit app prompts users to select healthy behaviors that they feel will work best for them. It’s as easy as putting healthy products into your online “shopping cart.” The goal is for users of the app to report daily on their performance of the bithabits they’ve selected.

“It’s quite simple,” Pilvikki said. The app and its bithabit approach to health behaviors is inspired by the work of Wendy Wood, a social psychologist who studies habit theories, and B.J. Fogg, a researcher who leads the Persuasive Technology Lab at Stanford University and has created a model for human behavior that relies on motivations to act, ability to act and triggers.

“In this model (FBM), behavior is a product of three factors: motivation, ability, and triggers, each of which has subcomponents. The FBM asserts that for a person to perform a target behavior, he or she must (1) be sufficiently motivated, (2) have the ability to perform the behavior, and (3) be triggered to perform the behavior. These three factors must occur at the same moment, else the behavior will not happen.” — B.J. Fogg, A Behavior Model for Persuasive Design

“The easiest way to change behavior is to create paths out of dots, such that single, isolated behaviors (the dots) start to span longer periods of time. In other words, they become habit-like,” Pilvikki said. “The idea is to give people a sense of self-efficacy and perceived control over health promoting behaviors.”