An innovative eHealth program to reduce chronic disease risk in Australian adolescents

June 2018

Chronic diseases, such as cardiovascular diseases, diabetes and mental disorders, are the leading cause of death and disability in Australia and are associated with significant costs and harms[1, 2]. For example, in 2008-09, cardiovascular disease alone had direct health-care costs of almost $8 billion[1]. Fortunately, much of this burden can be reduced by addressing key behavioural risk factors.

It is well established that the major chronic diseases share four main risk factors: poor diet, physical inactivity, smoking and alcohol use[3]. More recently, recreational screen time (leisure time spent doing seated electronic activities e.g. watching TV, using smartphones) and poor sleep have also emerged as key risk factors. For example, research has also demonstrated associations between screen time and markers of adiposity and cardiometabolic disease risk[4], mental health[5] and quality of life[6] in adolescents. In terms of sleep, sleep duration, poor quality and sleep timing (late bedtime or wake-up time) have been associated with poor health outcomes, such as obesity, among children and adolescents[7, 8] and risk for later disease in adulthood[9, 10]. This suggests that there are now six important risk factors (the “Big 6”) for chronic disease.

Although the majority of young people are free of chronic disease, far fewer are free of their risk factors. In fact, the prevalence of the Big 6 among Australians (aged 12-17yrs) is alarmingly high[11-14]:

Risk behaviours in adolescence

Adolescence is a time where many key risk factors emerge and develop, and young people have greater autonomy over their lifestyle choices while exposure to risk behaviours, such as substance use, increases. Importantly, risk behaviours commonly cluster, or co-occur, as people engage in multiple risk behaviours concurrently[15]. Once the Big 6 are established they are more likely to persist, than improve, over the life course and they also grow in multiplicity over time. For example, in one study only 8% of 12-13 year-olds had two or more risk factors, however this increased to 33% of 14-17 year-olds and 50% in 18-21 year-olds[16].

In our recent study among young Australians[17], we found that lifestyle risk behaviours were prevalent among a sample of more than 800 18-year-olds (Table 1). These findings reinforce the notion that risk behaviours are well-established by emerging adulthood, and that prevention and early intervention need to be implemented early in life to promote the adoption of healthy behaviours.

Table 1: Proportion of sample engaging in the Big 6 risk behaviours among 18-year olds (n=853)

Risk behaviour


Insufficient vegetable intake


Risky alcohol use


Insufficient fruit intake


Sedentary Behaviour




Physical inactivity


Source: Champion et al., (2018). Frontiers in Public Health. 6(135).

Engaging in multiple lifestyle risk behaviours not only increases the risk of chronic disease and mortality in adulthood, but in the short term it is associated with mental health problems, such as depression, anxiety and distress[17] and obesity. Therefore, early and effective prevention is needed to improve current physical and mental health, and to reduce later disease risk.

Our Solution: The Health4Life Initiative 

Launched on the 25 May 2018, Health4Life is an innovative solution to the increasing burden of chronic disease. The initiative utilises established frameworks for primary and secondary prevention to reduce or delay the risk factors for chronic disease, and intervene early where signs of risk factors have already emerged.

Led by Professor Maree Teesson AC, Director of the NHMRC Centre of Research Excellence in Mental Health and Substance Use at NDARC, and Associate Professor Nicola Newton (CREMS, NDARC), this study represents an exciting partnership with the Paul Ramsay Foundation. With representatives from eight research institutions, at five universities across Australia (UNSW Sydney, University of Newcastle, University of Queensland, and Curtin University), and in the United States (Northwestern University), the Health4Life Team* comprises multidisciplinary researchers, spanning the fields of addiction, mental health, dietetics, exercise physiology, and behaviour change.

Developed for high school students, Health4Life seeks to reduce the risk of developing chronic diseases, and to empower Australian adolescents to improve their physical and mental health, by addressing key lifestyle risk behaviours. The Health4Life Initiative is evidence-based, interactive through online cartoon storylines and personalised feedback, and aligned with the Health and Physical Education curriculum. The intervention consists of three components:

  1. Health4Life school-based program: A universal online program delivered to all Year 7 students during health and education classes at school, to provide education about the Big 6.
  2. Health4Life smartphoneapplication (‘app’): Provided to all students to reinforce material taught in class, and encourage youth adopt and maintain healthy behaviours via self-monitoring and goal-setting.
  3. Health4Life booster app: An early intervention app, based on cognitive behaviour therapy and motivation enhancement principles, delivered to students who remain ‘at-risk’ of chronic disease as they progress throughout high school.

This will be the first eHealth intervention that concurrently target the “Big 6” risk factors among secondary schools students, prior to the onset of chronic disease. It has the potential to not only improve the health of young Australians in the short term, but also to enhance their capacity to lead healthy lives as adults later in life.

Next Steps

To evaluate the Health4Life program, we will conduct a cluster randomised controlled trial in 80 schools (8000 Year 7 students) across New South Wales, Western Australia and Queensland, beginning in mid-2019.

We are currently seeking expressions of interest from high schools who are interested in participating in the Health4Life Initiative. For more information or to register your interest in the Health4Life Initiative:

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The "Big 6"

It is well established that the major chronic diseases share four main risk factors: poor diet, physical inactivity, smoking and alcohol use[3]. More recently, recreational screen time (leisure time spent doing seated electronic activities e.g. watching TV, using smartphones) and poor sleep have also emerged as key risk factors. 


  1. Australian Institute of Health and Welfare (AIHW), Australia's health 2014. 2014, AIHW: Canberra.
  2. Wilcox, S., Chronic diseases in Australia: Blueprint for preventive action. 2015, Mitchell Institute.
  3. Ezzati, M. and E. Riboli, Behavioral and dietary risk factors for noncommunicable diseases. New England Journal of Medicine, 2013. 369(10): p. 954-964.
  4. Saunders, T.J., J.-P. Chaput, and M.S. Tremblay, Sedentary Behaviour as an Emerging Risk Factor for Cardiometabolic Diseases in Children and Youth. Canadian Journal of Diabetes, 2014. 38(1): p. 53-61.
  5. Hoare, E., et al., The associations between sedentary behaviour and mental health among adolescents: a systematic review. International Journal of Behavioral Nutrition and Physical Activity, 2016. 13(1): p. 108.
  6. Gopinath, B., et al., Physical Activity and Sedentary Behaviors and Health-Related Quality of Life in Adolescents. Pediatrics, 2012. 130(1): p. e167.
  7. Cappuccio, F.P., et al., Meta-Analysis of Short Sleep Duration and Obesity in Children and Adults. Sleep, 2008. 31(5): p. 619-626.
  8. Chaput, J.-P. and C. Dutil, Lack of sleep as a contributor to obesity in adolescents: impacts on eating and activity behaviors. International Journal of Behavioral Nutrition and Physical Activity, 2016. 13(1): p. 103.
  9. Cappuccio, F.P., et al., Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. European Heart Journal, 2011. 32(12): p. 1484-1492.
  10. Ding, D., et al., Traditional and Emerging Lifestyle Risk Behaviors and All-Cause Mortality in Middle-Aged and Older Adults: Evidence from a Large Population-Based Australian Cohort. PLoS Med, 2015. 12(12): p. e1001917.
  11. Schranz, N.K., et al., Results From Australia’s 2016 Report Card on Physical Activity for Children and Youth. Journal of Physical Activity and Health, 2016. 13(11 Suppl 2): p. S87-S94.
  12. Hillman, D.R. and L.C. Lack, Public health implications of sleep loss: the community burden. Med J Aust, 2013. 199(8): p. S7-S10.
  13. Australian Institue of Health and Welfare (AIHW), Australia's health 2014. 2014, AIHW: Canberra.
  14. White, V. and T. Williams, Australian secondary school students’ use of tobacco, alcohol, and over-the counter and illicit substances in 2014. 2016, Cancer Council Victoria
  15. Spring, B., A.C. Moller, and M.J. Coons, Multiple health behaviours: overview and implications. Journal of Public Health, 2012. 34 Suppl 1(suppl 1): p. i3-10.
  16. Brener, N.D. and J.L. Collins, Co-occurrence of health-risk behaviors among adolescents in the United States. Journal of Adolescent Health, 1998. 22(3): p. 209-213.
  17. Champion, K.E., et al., Clustering of multiple risk behaviors among a sample of 18-year-old Australians and associations with mental health outcomes: A latent class analysis. Frontiers in Public Health, 2018. 6(135).