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The e ec i eness and applicabili y o di e en li es yle in e en ions o enhancing
wellbeing: he s udy design o a andomized con olled ial o pe sons wi h
me abolic synd ome isk ac o s and psychological dis ess
Lappalainen, Raimo; Sai anen, Essi; Jä elä, Elina; Ran ala, Sanni; Ko pela, Rii a;
Pu onen, Sampsa; Kujala, U ho; Myllymäki, Te o; Peuhku i, Ka i; Ma ila, Elina;
Kaipainen, Ki sikka; Ah inen, Aino; Ka hunen, Leila; Pihlajamäki, Jussi; Jä ne el , Heli;
Lai inen, Jaana; Ku inlah i, Eija; Saa elma, Osmo; E mes, Miikka; Kolehmainen,
Ma jukka
Lappalainen, R., Sai anen, E., Jä elä, E., Ran ala, S., Ko pela, R., Pu onen, S., Kujala,
U., Myllymäki, T., Peuhku i, K., Ma ila, E., Kaipainen, K., Ah inen, A., Ka hunen, L.,
Pihlajamäki, J., Jä ne el , H., Lai inen, J., Ku inlah i, E., Saa elma, O., E mes, M., &
Kolehmainen, M. (2014). The e ec i eness and applicabili y o di e en li es yle
in e en ions o enhancing wellbeing: he s udy design o a andomized con olled
ial o pe sons wi h me abolic synd ome isk ac o s and psychological dis ess.
BMC Public Heal h, 14(310). h ps://doi.o g/10.1186/1471-2458-14-310
2014
STUDY PROTOCOL Open Access
The e ec i eness and applicabili y o di e en
li es yle in e en ions o enhancing wellbeing:
he s udy design o a andomized con olled ial
o pe sons wi h me abolic synd ome isk ac o s
and psychological dis ess
Raimo Lappalainen
1*
, Essi Sai anen
1†
, Elina Jä elä
2†
, Sanni Ran ala
3†
, Rii a Ko pela
3
, Sampsa Pu onen
4
,
U ho M Kujala
5
, Te o Myllymäki
1
, Ka i Peuhku i
3
, Elina Ma ila
6
, Ki sikka Kaipainen
6
, Aino Ah inen
6
, Leila Ka hunen
2
,
Jussi Pihlajamäki
2
, Heli Jä ne el
4
, Jaana Lai inen
4
, Eija Ku inlah i
7
, Osmo Saa elma
7
, Miikka E mes
6
and Ma jukka Kolehmainen
2
Abs ac
Backg ound: Obesi y and s ess a e among he mos common li es yle- ela ed heal h p oblems. Mos o he cu en
disease p e en ion and managemen models a e no sa is ac o ily cos -e ec i e and ha dly each hose who need hem
he mos . The e o e, no el e idence-based con olled in e en ions a e necessa y o e alua e models o p e en ion and
ea men based on sel -managemen . This andomized con olled ial examines he e ec i eness, applicabili y, and
accep abili y o di e en li es yle in e en ions wi h indi iduals ha ing symp oms o me abolic synd ome and
psychological dis ess. The o e ed in e en ions a e based on cogni i e beha io al app oaches, and a e designed
o enhancing gene al well-being and suppo ing pe sonalized li es yle changes.
Me hods/Design: 339 obese indi iduals epo ing s ess symp oms we e ec ui ed and andomized o ei he (1) a
minimal con ac web-guided Cogni i e Beha io al The apy-based (CBT) in e en ion including an app oach o heal h
assessmen and coaching me hods, (2) a mobile-guided in e en ion comp ising o mind ulness, accep ance and
alue-based exe cises, (3) a ace- o- ace g oup in e en ion using mind ulness, accep ance and alue-based app oach,
o (4) a con ol g oup. The pa icipan s we e measu ed h ee imes du ing he s udy (p e = week 0, pos = week 10,
and ollow-up = week 36). Psychological well-being, li es yles and habi s, ea ing beha io s, and use expe iences we e
measu ed using online su eys. Labo a o y measu emen s o physical well-being and gene al heal h we e pe o med
including e.g. li e unc ion, hy oid glands, kidney unc ion, blood lipids and glucose le els and body composi ion
analysis. In addi ion, a 3-day ambula o y hea a e and 7-day mo emen da a we e collec ed o analyzing s ess,
eco e y, physical ac i i y, and sleep pa e ns. Food in ake da a we e collec ed wi h a 48 -hou die ecall in e iew
ia elephone. Di e ences in he e ec s o he in e en ions would be examined using mul iple-g oup modeling
echniques, and e ec -size calcula ions.
(Con inued on nex page)
* Co espondence: [email p o ec ed]
†
Equal con ibu o s
1
Depa men o Psychology, Uni e si y o Jy äskylä, Ylis önmäen ie 33, P. O.
Box 35, 40014 Jy äskylä, Finland
Full lis o au ho in o ma ion is a ailable a he end o he a icle
© 2014 Lappalainen e al.; licensee BioMed Cen al L d. This is an Open Access a icle dis ibu ed unde he e ms o he
C ea i e Commons A ibu ion License (h p://c ea i ecommons.o g/licenses/by/4.0), which pe mi s un es ic ed use,
dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly c edi ed. The C ea i e Commons Public
Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his
a icle, unless o he wise s a ed.
Lappalainen e al. BMC Public Heal h 2014, 14:310
h p://www.biomedcen al.com/1471-2458/14/310
(Con inued om p e ious page)
Discussion: This s udy will p o ide addi ional knowledge abou he e ec s o h ee low in ensi y in e en ions o
imp o ing gene al well-being among indi iduals wi h obesi y and s ess symp oms. The s udy will show e ec s o
wo echnology guided sel -help in e en ions as well as e ec o an accep ance and alue–based b ie g oup in e -
en ion. Those who migh bene i om he a o esaid in e en ions will inc ease knowledge base o be e unde -
s and wha mechanisms acili a e e ec s o he in e en ions.
T ial egis a ion: Cu en Clinical T ials NCT01738256, Regis e ed 17 Augus , 2012.
Keywo ds: Li es yle, Well-being, Obesi y, S ess, Accep ance and Commi men The apy, Cogni i e beha io al he apy,
Mobile applica ion, Web-based in e en ion, Technology-aided in e en ions
Backg ound
Obesi y is inc easing globally and is co ela ed wi h a a -
ie y o heal h p oblems. Consequences o being o e weigh
migh esul in he me abolic synd ome, which is a se o
medical ea u es such as impai ed glucose me abolism,
dyslipidaemia and hype ension ha a e isk ac o s o
ca dio ascula disease and ype-II diabe es [1,2]. Li es yle
changes ha e p o en o be an e icien way o coun e obes-
i y and ela ed diso de s [3,4], howe e i is challenging o
achie e long- e m li es yle changes using limi ed esou ces
in eal-li e heal h ca e sys ems.
Indi iduals ha ing p oblems ela ed o o e weigh also
expe ience addi ional heal h issues such as s ess. Psycho-
logical s ess is known o be ela ed wi h inc eased body
mass. In addi ion psychological s ess also con ibu es o
weigh gain [5-7]. The ou h Eu opean Su ey o Wo king
Condi ions epo ed ha 22% o wo king Eu opean indi id-
uals su e s om s ess. I is impo an o no e ha he
annual inancial cos o wo k- ela ed s ess wi hin he EU
was es ima ed a €20,000 million [8].
Much o exis ing heal h se ice models ha e p oblems
in suppo ing long- e m li es yle changes equi ed o
managing o weigh and s ess. In addi ion, exis ing
disease p e en ion and managemen models a e no cos
e ec i e and do no necessa ily each hose indi iduals
who need hem he mos . A la ge numbe o s udies
indica e ha li es yle changes could be p omo ed by using
di e en ypes o In e ne -based echnologies [9-14]. A ail-
able li e a u e p o ides signi ican e idence ha suppo s
he e ec i eness o web-based in e en ions o li es yle and
beha io al changes [15,16], howe e wha ype/s o web-
based in e en ions could be bene icial o indi iduals wi h
ch onic heal h diso de s is aguely epo ed and need u -
he in es iga ion. In addi ion, li le is known abou he
ele ance o low in ensi y p og ams using no el in e ac i e
echnologies o e ing minimal con ac o hose epo ing
bo h obesi y and s ess.
Addi ional con olled s udies a e necessa y o e alua e
di e en ypes o low in ensi y in e en ion models o
p e en ion and ea men s based on sel -managemen .
The e a e se e al op ions o acili a e de elopmen o
low in ensi y sel -managemen app oaches o li es yle-
ela ed ch onic condi ions, o example, use o In e ne -
adminis a ed assessmen , online heal h sc eening and
coaching app oaches based on cu en knowledge o
Cogni i e Beha io al The apies (CBT). Low in ensi y
CBT-based in e en ions use a minimum le el o in e -
en ion essen ial o enhance men al heal h and well-
being [17]. Much o he low in ensi y in e en ions use
no el in e ac i e communica ion echnologies. They
migh suppo long- e m li es yle changes because hey
deli e swi and easy access o ea ly in e en ion and
p e en i e p og ams.
In addi ion o in es iga ing he e ec o low in ensi y
web-based heal h sc eening and coaching applica ion, we
wan ed o explo e he e ec o hi d wa e CBT me hods by
applying mind ulness and accep ance-based in e en ions
o indi iduals wi h obesi y and s ess. The e has been an
inc easing in e es owa ds hese no el app oaches
la ely wi h an aim o imp o e psychological lexibili y
o p omo ing li e s yle changes. I has been p oposed
ha psychological lexibili yisoneo hekey equisi es
o psychological heal h [18]. Psychological lexibili y
is e lec ed by how a pe son: adap s o inconsis en si -
ua ions, econ igu es men al esou ces, modi ies iew-
poin s, and balances compe ing desi es and needs. Fo
example, in e en ions ha include componen s o
psychological lexibili y ha e demons a ed signi ican
bene i s when compa ed wi h con olled condi ions on
measu es o dep ession and anxie y [19]. Addi ionally,
he e is e idence sugges ing ha lowe psychological
lexibili y and bu nou inc ease he isk o uns able
emo ional s a e o mind and ad e se ea ing habi s [20].
These esul s among o he s indica e ha imp o emen
o psychological lexibili y is undoub edly bene icial o
indi iduals su e ing om obesi y and/o s ess.
Mind ulness, accep ance and alue-based me hods
a ge ing psychological lexibili y include psychological
in e en ions such as Accep ance and Commi men The -
apy (ACT) [21]. The e a e ew s udies ha ha e in es i-
ga ed he e ec o no el mind ulness and accep ance-based
in e en ions such as ACT o ch onic heal h condi ions
[22,23]. An inc easing numbe o s udies indica e ha ACT
is concei ably e ec i e o a wide ange o psychological
Lappalainen e al. BMC Public Heal h 2014, 14:310 Page 2 o 16
h p://www.biomedcen al.com/1471-2458/14/310
and heal h diso de , such as ch onic pain, smoking,
diabe es, epilepsy and wo k- ela ed s ess [24,25]. Ye
u he s udies a e desi able o p o e he e ec i eness
o ACT-based in e en ions such as mind ulness and
accep ance p ac ices in imp o ing de e io a ed me abolic
indica o s, such as dyslipidemia, low-g ade in lamma ion o
de iciencies in glucose me abolism.
ACT has mainly been in es iga ed using ace- o- ace in-
e en ions, and he e a e only ew s udies ha ha e s udied
he e ec o ACT-based app oaches o heal h diso de s
using web o mobile-based in e en ions. Web-based ACT
in e en ions ha e been de eloped e.g. o inni us dis ess
[26], ch onic pain [27], and psychological s ess [28]. Fu -
he mo e, ACT-based mobile apps ha e been s udied on
small scale [29,30]. To he bes o ou knowledge, he e a e
e y ew con olled ials ha ha e been conduc ed o
in es iga e he e ec i eness o ACT-based mobile in e en-
ions [29]. O e all, he e a e a limi ed numbe o con olled
s udies ha ha e in es iga ed he e ec s and easibili y o
sma phone solu ions o ch onic heal h diso de [31].
Aim and main hypo heses
The o e all aim o he p esen s udy was o in es iga e
he e ec o h ee no el low in ensi y psychological in e -
en ions o me abolic synd ome isk ac o s, psychological
lexibili y and gene al well-being among obese indi iduals
expe iencing s ess. The pu pose was o s udy (a) he e ec s
o minimal con ac web-based CBT in e en ion including
an app oach o heal h assessmen and coaching me hods
(In e ne ), (b) he e ec s o mobile-based in e en ion con-
aining mind ulness, accep ance and alue-based exe cises
(Mobile), and (c) he e ec s o ace- o- ace g oup in e en-
ion using mind ulness, accep ance and alue-based ap-
p oaches (Face- o-Face) in a con olled s udy design, whe e
con ol (Con ol) ecei ed no ea men , bu he same mea-
su emen s we e comple ed o all he g oups. Thus, bo h
echnology-based low in ensi y sel -help in e en ions o -
e ed minimal con ac , and hey we e compa ed o a b ie
g oup in e en ion. Mo eo e , we we e in e es ed in s udy-
ing accep abili y, applicabili y, pe cei ed bene i s, use expe-
iences, and usage o he said in e en ions.
The h ee in e en ions g oups, and he con ol g oup
we e compa ed based on changes in li es yle measu es (e.g.
ood and nu i ion in ake, meal pa e ns, physical ac i i y,
sleeping habi s), psychological measu es (e.g. psychological
lexibili y, pe cei ed s ess, dep ession symp oms, quali y o
li e, pe cei ed quali y and quan i y o sleep), clinical and
biochemical a iables (e.g. BMI, body composi ion, ci cula -
ing glucose, insulin, lipids, s ess and in lamma ion indica-
o s), o he physiological measu emen s (e.g. objec i e sleep
measu emen s, hea a e a iabili y-based eco e y om
s ess), and use expe iences (e.g. expe iences wi h he in-
e en ions, ac ual usage, ealiza ion o exe cises p esen ed
in in e en ions). We o mulized he ollowing hypo heses:
H1: Pa icipan s who ecei e any o he h ee in e -
en ions would show imp o emen s in li es yle and
psychological measu es, and clinical, biochemical, and
physiological a iables ascompa ed o hecon ol
g oup. Each in e en ion g oup is compa ed wi h he
con ol condi ion sepa a ely.
H2: Pa icipan s who ecei e any o he h ee in e en-
ions will show equal posi i e changes in li es yle, and
psychological measu es, and clinical, biochemical, and
physiological a iables when he in e en ions a e com-
pa ed wi h each o he .
We also wan ed o examine demog aphics and psycho-
logical a iables ha could p edic change o e ime
(P e, Pos and Follow-up) including age, gende , ini ial
BMI, physical ac i i y, psychological lexibili y, s ess and
dep essi e mood and psychological symp oms. Fu he ,
we would examine po en ial media o s on he e ec o
he in e en ions including psychological lexibili y and
mind ulness skills. Seconda y objec i es include analyses
o he use expe iences and alidi y o used measu e-
men and in e en ion me hods.
Me hods/Design
S udy design
This s udy was a andomized con olled ial (RCT)
(Figu e 1). Main ou come measu es we e psychological
lexibili y, weigh , die quali y, ea ing beha io , pe cei ed
s ess, dep ession symp oms, and sleeping habi s. Se e al
o he a iables associa ed wi h li es yle changes, psycho-
logical and physiological heal h was assessed du ing he
s udy. We we e also in e es ed in use expe iences o he
h ee no el in e en ions. The in e en ions a e desc ibed
below in de ail.
The s udy was pe o med a h ee ci ies in Finland
(Helsinki, Jy äskylä, and Kuopio) by he local uni e si ies
(Uni e si y o Helsinki, Uni e si y o Jy äskylä, and
Uni e si y o Eas e n Finland, Kuopio). In addi ion,
VTT Technical Resea ch Cen e o Finland (Tampe e,
Finland), Finnish Ins i u e o Occupa ional Heal h (Helsinki
and Oulu), and companies Duodecim Medical Publica-
ionsL d.(Helsinki,Finland), Fi s bea Technologies
L d. (Jy äskylä, Finland), Vi ago L d. (Espoo, Finland),
Finnish Red C oss Blood Se ice (Helsinki, Finland),
and Valio L d. (Helsinki, Finland) pa icipa ed in pe -
o ming he s udy. The s udy was app o ed by he
e hics commi ee o he Cen al Finland Heal h Ca e
Dis ic , and egis e ed wi h ClinicalT ials.go wi h he
iden i ie NCT01738256.
The s udy was ca ied ou in wo phases. The i s
phase s a ed in Sep embe 2012 and he second phase
in Janua y 2013. The s udy included p e-measu emen s
be o e he 8-week in e en ions, pos -measu emen s
10 weeks a e he p e-measu emen s, and ollow-up
measu emen s six mon hs a e he pos measu emen s
Lappalainen e al. BMC Public Heal h 2014, 14:310 Page 3 o 16
h p://www.biomedcen al.com/1471-2458/14/310
(36 weeks om p e-measu emen ). The las measu e-
men s we e collec ed in Decembe 2013.
S udy popula ion
The ec ui ed pa icipan s (n = 339, Figu e 1) we e
ei he o e weigh o obese and epo ed psychological
s ess symp oms. The inclusion c i e ia we e: 1) Body
Mass Index (BMI) 27–34.9 kg/m
2
, 2) pe cei ed psycho-
logical s ess (a leas 3/12 poin s in Gene al Heal h
Ques ionnai e [32], and 3) he possibili y o use com-
pu e wi h in e ne connec ion. The exclusion c i e ia
we e: diagnosed se e e ch onic illness (symp oma ic
ca dio ascula disease, Type I o II diabe es, se e e
psychia ic condi ions o subs ance abuse), medical
su ge y wi hin he pas 6 mon hs, hea a ack/s oke
wi hin pas 6 mon hs, kidney disease equi ing dialy-
sis o o he disabili ies/illnesses a ec ing subs an ially
physiological o men al heal h, egula use o co isone
pills, pacemake , ea ing diso de (bulimia), disabili y
pension o psychological easons, p egnancy o b eas -
eeding wi hin he pas 6 mon hs, shi wo k (in h ee
shi s) o nigh wo k, psycho he apy o o he psycho-
logical o men al ea men a leas wice a mon h, and
pa icipa ion in o he in e en ion s udies du ing he
p esen s udy.
P ocedu e o ec ui men , andomiza ion and alloca ion
The pa icipan s we e ec ui ed by using ad e isemen s
in local newspape s. All he pa icipan s ook pa in he
s udy on olun ee basis. The ini ial exclusion c i e ia
we e assessed h ough phone calls and by using elec onic
ques ionnai e o epo ed dis ess. The pa icipan s who
passed he ini ial sc eening we e andomly alloca ed in o
one o he h ee in e en ion g oups (In e ne , Mobile,
Face- o-Face), o in o a con ol g oup. A e andomiza ion,
pa icipan s wi h p ede e mined abno mali ies in base-
line labo a o y examina ions we e excluded om he
s udy(seeFigu e1).A hebaseline isi o hes udy
cen e he blood samples we e d awn o de e mining
heal h s a us and excluding olun ee s wi h unknown/
undiagnosed ch onic disease o o he heal h p oblem.
The measu emen s o li e , hy oid glands and kidney
unc ion as well as glucose and lipid me abolism we e
aken. I he e was a alue ou side e e ence alues, he
pa icipan was excluded be o e s a ing he ac ual in-
e en ions. W i en in o med consen was ob ained
du ing he labo a o y examina ion. Randomiza ion was
done by a uni e si y s a is ician using a able o an-
dom numbe s (in ba ches o ou ). An independen
pe son ou side o he esea ch g oup p epa ed en e-
lopes con aining he andomiza ion numbe , s udy
ID and g oup numbe by cen e . The en elopes we e
Assessed o eligibili y (n=645)
Excluded (n=306)
No mee ing inclusion c i e ia
Declined o pa icipa e
O he easons
Randomized (n=339)
Los o pos in e en ion measu emen (n=3)
Reasons:
noncompliance (n=2),
medical condi ion (n=1)
Los o pos in e en ion measu emen (n=8)
Reasons:
noncompliance (n=5),
medical condi ion (n=3)
Pa icipa ed in he ollow up measu emen
(n=60)
Los o ollow up measu emen (n=2)
Reasons:
noncompliance (n=1),
medical condi ion (n=1)
Pa icipa ed in he ollow up measu emen
(n=73)
Los o ollow up measu emen (n=2)
Reasons:
noncompliance (n=2)
Pa icipa ed in he ollow up measu emen
(n=64)
Los o ollow up measu emen (n=6)
Reasons:
noncompliance (n=4),
medical condi ion (n=2)
Pa icipa ed in he ollow up measu emen
(n=67)
Los o ollow up measu emen (n= 1)
Reasons:
medical condi ion (n=1)
Follow up measu emen (week 36)
Pos in e en ion measu emen (week 10)
Los o pos in e en ion measu emen (n=2)
Reasons:
noncompliance (n=1),
medical condi ion (n=1)
Los o pos in e en ion measu emen (n=6)
Reasons:
noncompliance (n=6)
Mobile (n=85)
Recei ed alloca ed in e en ion (n=78)
Did no ecei e alloca ed in e en ion
(n=7):
Reasons:
no mee ing inclusion c i e ia (n=5),
noncompliance (n=2)
In e ne (n=85)
Recei ed alloca ed in e en ion (n=78)
Did no ecei e alloca ed in e en ion
(n=7):
Reasons:
no mee ing inclusion c i e ia (n= 1),
noncompliance (n=5),
medical condi ion (n=1)
Con ol (n=85)
Pa icipa ed in he con ol g oup (n=70)
Did no pa icipa e in he con ol g oup
(n=15):
Reasons:
no mee ing inclusion c i e ia (n=7),
noncompliance (n=7),
medical condi ion (n=1)
Face- o- ace (n=84)
Recei ed alloca ed in e en ion (n=68)
Did no ecei e alloca ed in e en ion
(n=16):
Reasons:
no mee ing inclusion c i e ia (n=6),
noncompliance (n=10)
Alloca ion and p e in e en ion measu emen (week 0)
Figu e 1 Flow cha o he s udy design.
Lappalainen e al. BMC Public Heal h 2014, 14:310 Page 4 o 16
h p://www.biomedcen al.com/1471-2458/14/310

opened in he o de pa icipan s passed he ini ial sc eening
ollowing ‘concealmen o alloca ion’p inciple.
In e en ions
In e ne -based coaching
The In e ne -based in e en ion (Table 1) consis ed o a
12-week p og am wi hou any ace- o- ace con ac
(Duodecim Vi ual Heal h Check and Coaching p o-
g am). The in e en ion combined he assessmen o
psychological esou ces and heal h ela ed beha io o
p o ide use s wi h a comp ehensi e iew o hei heal h
and li e si ua ion and ways o imp o e i . Wi h he suppo
o he assessmen , he use s could choose be ween coaching
p og ams o imp o e posi i e li e skills and o change
heal h ela ed beha io s.
In he Heal h Check, he use s illed ou a heal h ques-
ionnai e assessing key heal h de e minan s, li es yle ac-
o s, emo ional well-being, and pe o mance (Figu e 2).
On he basis o he assessmen , he use s ecei ed es ima-
ions, including a p ognosis o a e age li e expec ancy,
co ona y hea disease, s oke and diabe es isk, as well as a
desc ip ion o hei habi s and beha io s impac ing
hei heal h (Figu e 3). The ques ionnai e and algo-
i hms assessing heal h isks we e based on he Finnish
heal h check and ollow-up s udy Fin iski, ha ing up o
30 yea s ollow-up da a on a popula ion sample mo e
han 10 000 people [33].
On he basis o he heal h check eedback, use s could
choose op ional coaching p og ams o weigh manage-
men , heal hy die , exe cise, sleep imp o emen , alcohol
consump ion managemen , smoking cessa ion, and men al
well-being (s ess managemen , g a i ude, o gi eness, good
ac ions, op imism, posi i e in e ac ion in ela ionships and
esol ing con lic s in ela ionship). Pa icipan s we e none-
heless commended o choose p ima ily om he ollowing
h ee p og ams: S ess and li e managemen , Nu i ion, and
Exe cise. The p og ams we e designed o suppo imp o e-
men s in he heal h and well-being habi s and beha io s.
In he coaching p og am, use s ecei ed a weekly coach-
ing message including in o ma ion abou he chosen opic
and a link o u he in o ma ion. In addi ion, he message
con ained ad ice o exe cise, h ough which an indi idual
could imp o e awa eness o his/he beha io and p ac ice
skills o de elop habi s ha suppo wellbeing. The weekly
message also included eedback based on en ies made by
he espec i e use . The use s had an op ion o eco d
ollow-up in o ma ion abou hei li es yles (weigh , phys-
ical ac i i y, nu i ion, alcohol consump ion and smoking).
Du ing he p og am, use s could moni o hei p og ess
h ough g aphs, make new heal h checks, and choose new
coaching p og ams (Figu e 4).
Coaching p og ams o weigh managemen , sleep
imp o emen , exe cise, alcohol consump ion manage-
men , and smoking cessa ion we e based on cogni i e-
beha io al p ac ices on li es yle changes [34-37]. The
es and coaching p og ams o men al well-being ha e
been de eloped along he ou lines desc ibed by se e al
au ho s [38-40] showing ha he cogni i e beha io al
coaching p og am o de elop op imism, g a i ude
and o he li e skills a e e ec i e in adi ional w i ing
exe cise and web-based coaching p og ams [38,41].
The alidi y o he a iables has been es ed in a la ge
Table 1 Con en o he In e ne in e en ion
Con en Key poin s
Heal h ques ionnai e Es ima e o li e expec ancy, co ona y hea disease, s oke and diabe es isk. Desc ip ion o one’s li e habi s and beha io s
impac ing on heal h and ways o in luence hem
Coaching p og ams
Each p og am includes a weekly message.
In weigh managemen , heal hy die , exe cise, sleep imp o emen and alcohol use managemen p og ams he use has an op ion o eco d
ollow-up in o ma ion abou ele an beha io o pa ame e :
a) Weigh managemen Messages consis o in o ma ion, p ac ical ad ice and exe cises on weigh managemen (e.g. managing appe i e,
ea ing, po ion size, buying ood), and link o u he eadings.
b) Heal hy die Messages abou heal hy die and p ac ical ad ice o imp o emen , and also links o u he eadings.
c) Exe cise Messages include in o ma ion abou heal h ela ed physical ac i i y and link o u he eadings. Message con ains also
ad ice o p ac ice.
d) S ess and li e
managemen
Op ional: S ess managemen , Good deeds, Op imism, Human ela ions, Social ela ions, Posi i e in e ac ion in
ela ionships, Resol ing con lic s in ela ionships, Coaching exe cises o amilies wi h child en. The weekly coaching
message includes in o ma ion, p ac ical ad ice, and exe cise abou s ess o li e managemen and link o u he eadings.
Op ional:
e) Sleep imp o emen In o ma ion, p ac ical ad ice and exe cises on good sleep (e.g. sleep hygiene, en i onmen , elaxa ion) and link o u he
eadings. Message con ains also ad ice o p ac ice.
) Alcohol use
managemen
Cogni i e beha io al p og am o analyze easons and si ua ions o alcohol use and ad ice o a oid excess use.
g) Smoking cessa ion Cogni i e beha io al p og am o analyze easons and si ua ions o smoking, men al exe cise, and suppo o qui ing.
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c oss-sec ional s udy whe e mo e han 130 000 Finns
comple ed he ques ionnai e [42].
Mobile-based in e en ion
The pa icipan s in he Mobile-based in e en ion we e
in i ed in a g oup mee ing ha consis ed o a b ie o e -
iew o Accep ance and Commi men The apy (ACT)
p inciples. In he mee ing, he pa icipan s we e gi en
And oid sma phones ha we e p e-ins alled wi h a
s and-alone men al wellness aining applica ion called
Oi a. They we e ins uc ed o use Oi a o he upcom-
ing 8 weeks a hei own. The applica ion con ained
sho exe cises ha augh ACT skills o be applied in
daily li e. The mobile applica ion deli e ed an ACT-
based in e en ion p og am simila o he Face- o-Face
g oup. P io o he p esen ial, he applica ion had
been pilo ed in a easibili y s udy wi h a sample o o ice
wo ke s wi h s ess symp oms [29].
The con en o he applica ion was di ided in o ou
in e en ion pa hs: Mind ul Mind, Wise Mind, Values,
and Heal hy Body (Table 2). The i s h ee pa hs dem-
ons a e co e p ocesses o ACT and he ou h pa h ap-
plies ACT-based app oach on physical well-being. The
applica ion con ained al oge he 46 exe cises in ex and
audio o ma s, as well as in oduc ion ideos o each
pa h and sec ion. The p og am did no include psycho-
educa ion on heal hy die o physical ac i i y, only a
hype link o a public nu i ional websi e was p o ided.
Figu e 5 p esen s examples o he use in e ace o he
applica ion. The main sc een (Figu e 5a) con ained a
lowe -shaped menu h ough which di e en pa hs could
be accessed. The main sc een also p o ided access o a
dia y (Figu e 5b), lis o a o i e exe cises, and in oduc ion
o he applica ion in ex and ideo o ma s (Figu e 5c).
Each pe al ep esen s one o he pa hs, which we e num-
be ed acco ding o hei ecommended o de . Each pa h
consis ed o 1–4 subsec ions (“s eps”), which included 5–8
exe cises (Figu e 5d). The e was an in oduc ion in ex and
ideo o ma s o each pa h and s ep, in o ming use s abou
he p ocesses and skills.
Mos o he exe cises we e sho and ook abou 1–
3 minu es o be comple ed (Figu e 5e-h). This aimed a
making exe cises easy o pe o m in any si ua ion. Each
exe cise began wi h an in oduc ion p esen ing he pu pose,
du a ion and ins uc ions o he exe cise (Figu e 5e). The
use s could choose o exe cise by lis ening (Figu e 5 ) o by
eading (Figu e 5g). A e each exe cise, a e lec ion sc een
(Figu e 5h) summa ized he skills lea ned om he exe cise
andenableduse s ow i eno esand e lec ionsin hei
dia y(Figu e5b).Theno eswe esa edin hedia yand
could be accessed la e . The applica ion smoo hly guided
use s h ough he in e en ion p og am wi hou es ic ing
ee na iga ion. Pa hs, s eps, and exe cises we e numbe ed
Figu e 2 Sc eensho s o he in e ne applica ion.
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in he ecommended o de and he nex sugges ed
i em was dynamically highligh ed (Figu e 5a and d).
Howe e , all pa hs and exe cises we e accessible om
he e y beginning.
Face- o- ace g oup in e en ion (Face- o-Face)
The ACT-based ace- o- ace g oup in e en ion con-
sis ed o six g oup sessions du ing 8-week pe iod o
ime, wi h each session las ing o abou 90 minu es (see
Table 3). Each g oup consis ed o 6–12 pa icipan s and
was ins uc ed by a psychologis . Th ee psychologis s
ac ed as coaches. All o hem we e ained in ACT ap-
p oach, had expe ience in ACT in e en ions, and had a
manual o he p og am o ollow. The pa icipan s we e
gi en a wo kbook ha con ained sho desc ip ions o
he sessions, exe cises, and indi idual e lec ions and
no es.
The in e en ion p og am aimed o suppo li es yle
changes and o enhance well-being h ough commi ed
and conc e e ac ions based on he pe sonally impo an
alues – he mos impo an di ec ions in li e. The p o-
g am s a ed wi h an analysis o own li e si ua ion and
e lec ions abou alues and impo an hings in li e.
A e he alue cla i ica ion, he pa icipan s made con-
c e e ac ion plans and de ined hei own goals. The
emphasis was placed on small and easible ac ions ha
lead o be e li e acco ding o pe sonally chosen alues.
In o de o achie e he se goals, he pa icipan s we e
augh accep ance and mind ulness skills and new ways
o deal wi h he ba ie s o ac ion. The pu pose o each-
ing accep ance and mind ulness skills was o inc ease
Figu e 3 Sc eensho s o he in e ne applica ion.
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Figu e 4 Sc eensho s o he in e ne applica ion.
Table 2 Con en o he ou pa hs in he mobile in e en ion
Topic o he pa h Con en Key poin s
Mind ul mind Fi e mind ulness exe cises Con ac wi h he p esen momen .
Focusing ully on one’s inne o ou e expe iences.
Ac ing mind ully.
Wise mind Obse a ion: six exe cises Obse ing hough s wi hou being caugh up in hem.
Accep ance: ou exe cises Making oom o unpleasan eelings, sensa ions, u ges, and o he p i a e
expe iences; allowing hem o come and go wi hou s uggling wi h hem.
Values Values: se en exe cises How I use my ime in my cu en li e?
How mind ulness-skills can imp o e wellbeing?
Wha a e he mos impo an alues o me?
Am I li ing acco ding o my alues?
Value based ac ions: se en exe cises Wha a e my speci ic goals and ac ions ha suppo my alued beha io ?
Heal hy body Relaxa ion: six exe cises Relaxing and lis ening o my body.
Mind ul ea ing: six exe cises Exe cising mind ul ea ing. Wha is my ypical meal hy hm?
Physical ac i i y: i e exe cises E e yday physical ac i i y in small s eps.
Ele en gymnas ic ideo clips
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doi:10.1186/1471-2458-14-310
Ci e his a icle as: Lappalainen e al.:The e ec i eness and applicabili y
o di e en li es yle in e en ions o enhancing wellbeing: he s udy
design o a andomized con olled ial o pe sons wi h me abolic
synd ome isk ac o s and psychological dis ess. BMC Public Heal h
2014 14:310.
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