Development of ‘Twazon’: An Arabic App for Weight Loss

Background Weight gain and its related illnesses have become a major public health issue across the world, with Saudi Arabia and other Gulf countries seeing dramatic increases in obesity and overweight, and yet there is very little information on how to intervene with this demographic due to cultural and linguistic barriers. As the use of smartphones and apps has also increased in the region, information communication technologies could be a cost-effective means of facilitating the delivery of behavior-modification interventions directly to the target population. Although there are existing apps that offer lifestyle-modification tools, they do not give consideration to the evidence-based practices for weight management. This offers an opportunity to create an Arabic language weight loss app that offers localized content and adheres to evidence-informed practices that are needed for effective weight loss. Objective This paper describes the process of developing an Arabic weight loss app designed to facilitate the modification of key nutritional and physical activity behaviors among Saudi adults, while taking into consideration cultural norms. Methods The development of the Twazon app involved: (1) reviewing all available Arabic weight loss apps and compared with evidence-based practices for weight loss, (2) conducting a qualitative study with overweight and obese Saudi women to ascertain their preferences, (3) selecting which behavioral change strategies and guidelines to be used in the app, (4) creating the Saudi Food Database, (5) deciding on graphic design for both iPhone operating system and Android platforms, including user interface, relational database, and programming code, and (6) testing the beta version of the app with health professionals and potential users. Results The Twazon app took 23 months to develop and included the compilation of an original Saudi Food database. Eight subjects gave feedback regarding the content validity and usability of the app and its features during a pilot study. The predominant issue among the group was the lack of information explaining how to use the app. This has since been resolved through the implementation of a tutorial. No other changes were required to be made. Conclusions Information communication technologies, such as smartphone apps, may be an effective tool for facilitating the modification of unhealthy lifestyle habits in Saudi; however, consideration must be given to the target population, cultural norms, and changing trends in the global market. The effectiveness of the app will be better determined during a 6-month intervention with 200 overweight and obese Saudi women.

Shaping Knowledge: 4.1 Advise or agree on how to perform the behaviour.
Provides all information in the Arabic language with localized content in a culturally sensitive manner, allowing for the users to understand advice on how to lose weight. Motivational tools, positive reinforcement, professional advice, support and social networking. Provides feedback and motivation to users through the social network regarding other´s perception of their posts. For example they can receive "likes" for posting what they consumed for breakfast.
Messages which congratulate and motivate users appear on screen when step counter goals are achieved. Additionally a green palm tree is shown to users when all the necessary weight loss documentation is complete to meet their goals over a two week period.
Users are encouraged to consider themselves as role model for their children or family members.
Positive reinforcement and professional advice is provided through the app by sending messages to the user encouraging them to continue to meet their goals and giving information about health. . App messages are considered as a credible source as it is an evidence based app.
Professional advice for how to best apply evidence informed practices offered throughout all tips and notifications of the app. Professional information about the health consequences of abdominal obesity and unhealthy food choices are provided to users.
Advice is offered to users to support Remove access to the reward: 7.4 Advise or arrange for the person to be separated from situations in which unwanted behavior can be rewarded in order to reduce the behavior Advice is offered to replace behaviours which are likely to contribute to obesity with healthier life choices.
Professional advice for how to restructure users´ living environment to support the ease of making healthy decisions is provided in the app.
App advises users to restructure their social environment through recommending connecting with others in the weight loss community, spending time playing with children, etc. in order to facilitate weight loss.
Suggestions are given to rehearse new healthy habits in place of unhealthy habitual behaviours.
Provides an app-specific message board allowing users to share their experiences and provide one another with counselling and encouragement as they work towards their individual goals.
App allows users share practical weight-loss ideas with other users inside the app´s social network or through other social networks.
Message board and social network links are integrated to allow users to give and receive emotional support as they are able to privately share experiences, weight loss goals achieved, and photos with other users.

Dietary and physical activity tools
Goal-setting behavior: 1.1 Set or agree on a goal in terms of the Weight-loss goals of .5 Kg per week are set with users as an outcome of following app advice.
Reminders are regularly sent to users to encourage the correct amount of steps taken, water consumption, and physical activity. A warning is also sent when total daily calories have been consumed encouraging users to stop eating.
Visual features in App are displayed to users to demonstrate discrepancies between their current behaviors and the guidelines that should be followed to meet weightloss goals.
Graded weight loss goals are included in the app as well as a graded step counter tool which increases the amount of steps over time.
Instructs users how to read nutritional labels to minimise the need to memorise which foods are healthy for them and make healthy choices regularly. Additionally provides an extensive food calorie guide which users can use as a quick reference for calorie counting. Physical activity is promoted throughout the App. Utilizing step counter to promote physical activity. User is asked to weigh themselves every two weeks and record their weight to update application setting.
App gives information to users about how many calories are lost during various physical activities.
Feedback messages are adjusted after every 2 week assessment.
Messages are tailored to individuals behavior and reduced when user has demonstrated success in performing the behaviour. User-friendly interface.
Shaping Knowledge: 4.1 Advise or agree on how to perform the behaviour.
Behaviour Change Techniques have been integrated in the App with a user-friendly interface in order to assist users in understanding the necessary steps they must take in losing weight.

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What the app should provide, arrange or do based on the qualitative study: What Overweight Women Want From a Weight Loss App: A Qualitative Study on Arabic Women [15].