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Mobile Health Approach Promotes Sleep to Prevent Childhood Obesity
Insufficient sleep is a serious public health concern among children and adolescents in the United States. Whether due to early school start times, screen-related distractions, or other external pressures, nearly 50% of American children ages 6 to 12 get less than the nine hours per night recommended by pediatricians. And that lack of Zzz's can lead to behavioral and health problems, including obesity, a chronic disease with escalating effects over time.
Consistent epidemiological evidence shows short sleep is an adolescent obesity risk factor, including studies by Jonathan Mitchell, PhD, an investigator at Children's Hospital of Philadelphia. Putting this research to task, the American Academy of Pediatrics recommends pediatricians promote sleep as part of their obesity prevention efforts. Although the primary care setting has enormous potential to promote sleep, a lack of time at the point of care is a key barrier.
Enter Dr. Mitchell and a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The Mitchell Lab is engineering a mobile health platform for the pediatric care setting to promote longer sleep duration for childhood obesity prevention.
"The problem is there's a very short amount of time to get into the nuts and bolts of sleep health problems at an office visit," Dr. Mitchell said. "So the idea is to develop a mobile health approach to amplify the care delivered at an office visit by delivering it in the home setting and the actual environment where the child is sleeping and perhaps give a bigger dose of sleep promotion guidance beyond the point of care."
Optimizing Intervention Components
The Mitchell Lab uses digital tools to measure physical activity and sleep patterns, and the team designs mobile health interventions to promote physical activity and sleep in children. By focusing on behavior in early life, the lab's overarching goal is to help children and adolescents achieve optimal growth and help prevent chronic diseases in later life.
With this grant, the research team aims to identify an optimal set of intervention components to increase sleep duration and prevent excess weight gain, with equitable effectiveness across sociodemographic backgrounds. Their work is guided by the Multiphase Optimization Strategy (MOST), a research framework for determining the most efficient and effective version of an intervention. This study represents the first application of the MOST framework to engineer a mobile health platform to promote sleep for obesity prevention that will be equitable across sociodemographic groups.
The researchers will test four candidate components: sleep goal, digital messaging, parent-directed incentive, and personalized feedback. Each component will have two settings which can be turned on or off, for example, sleep guidance with and without a call from a sleep psychologist.
"We have all these great ideas, but we may not need all our components," Dr. Mitchell said. "Because we're doing this factorial experiment and following the MOST framework, we can remove ineffective components and keep in the most effective components with respect to sleep duration."
With MOST as the guiding framework, the researchers will be able to determine what works well together and what does not, helping to determine if optimal settings for sleep promotion lead to lesser gains in fat mass index. They will measure total energy intake and the timing and composition of meals to gain mechanistic insights. The investigators will determine if optimal settings for sleep promotion are comparable across individual- and neighborhood-level sociodemographic factors.
Sleep Duration and Body Mass Index (BMI)
The study aims to enroll 325 typically developing children between the ages of 8 and 12 who are identified as short sleepers, meaning they fall below the recommended sleep duration level for their given age. Based on a previous study led by Dr. Mitchell that showed short sleep is associated with higher BMI, specifically in the 50th percentile or above, they will be targeting children with a BMI between the 50th and 95th percentile.
Based on their observational data, this is where sleep seems to have the most action in terms of changing weight trajectories. If they are able to increase the sleep of the children enrolled, perhaps they will be able to offset their weight gain trajectory and help prevent them from crossing that 95th BMI percentile threshold, which is used to define obesity in childhood.
"Our idea is not to treat obesity — it's to help prevent obesity," Dr. Mitchell said.
Track, Text, and Talk to Sleep
After an initial study visit in CHOP's Center for Human Phenomic Science Nutrition Assessment Unit, participants will wear a sleep tracker, similar to a smartwatch, day and night for six months. The tracker features an accelerometer, a sensor that provides a measure of arm movement, considered an objective way to assess the wearer's sleep duration because it does not rely on recalling bed and wake times. Algorithms applied to the sensor data can infer bed and wake times and night awakenings based on the slowing and speeding up of arm movements overnight. It also measures the wearer's physical activity during the waking hours.
During the six-month intervention period, participants' caregivers will receive sleep guidance messaging via short, snappy, visually appealing texts messages such as, "Don't use screens in the bedroom," or "Keep going, you're doing well sticking with your bedtime setting." The idea is for parents and caregivers to share and talk with the children about the messages to help them achieve their sleep goal.
In order to assess if these one-way text messages are enough, a randomized group will receive calls from a sleep expert along with the text messages. Ariel Williamson PhD, DBSM, a psychologist and diplomat in behavioral sleep science at CHOP, will lead this part of the intervention and train other psychologists to hit upon key behavioral sleep medicine aspects in their phone conversations. There will be up to three phone calls with the intention of providing more one-on-one sleep guidance. These conversations can be tailored and will be unique to a given family's circumstance. The calls will be strategically placed: early, mid, and later in the six-month intervention period, with the last one intended to set them up for success with encouragement to keep implementing the skills learned when the messages are turned off.
The study has a six-month follow-up phase during which the researchers will continue to measure sleep after the daily messaging stops. The participants will return for six- and 12-month study visits at CHOP.
The researchers will administer the study via Way to Health (W2H), a web-based platform that provides technology infrastructure for sustainable behavior change interventions. W2H is supported by the Center for Health Care Innovation and the University of Pennsylvania Center for Health Incentives and Behavioral Economics.
"This innovative research shifts attention from the problem of insufficient sleep to a solution for insufficient sleep," Dr. Mitchell said. "Our research has the potential to greatly advance the field of behavioral sleep medicine and reimagine how insufficient sleep duration and obesity are prevented in pediatric healthcare."