Augmenting Weight Loss Using Technology

| January 22, 2014

by Jennifer Arussi, MS, RD

Jennifer Arussi, MS, RD, is from Cedars-Sinai Medical Center/Center of Weight Loss, Los Angeles, California.
This article contains a Reader Handout: View and download it HERE.

Funding: No funding was provided.
Disclosures: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2014;11(1):9–11.

ABSTRACT
Comparison studies have shown a significant association between the practice of self-monitoring and increased weight loss in patients with obesity. A self-monitoring strategy includes any activity that makes an individual pay closer attention to their behaviors, specfically eating and exercise in this patient population. In this article, the author reviews research on both electronic tracking and remote behavioral counseling and discusses the benefits of implementing this paradigm in both pre- and post-bariatric surgery patients.

The United States Preventative Services Task Force is recommending that clinicians refer individuals with obesity to “intensive, multicomponent behavioral interventions.”[1] Consequently, it is a mandate under the Affordable Care Act.[2,3] Additionally, the Centers for Medicare and Medicaid Services (CMS) recently added a provision calling for “intensive behavioral counseling” for seniors with obesity.[4] As a result of these national changes, healthcare provider’s familiarizing themselves with the fundamentals of behavioral therapy is apropos and necessary.

One overriding feature of behavioral therapy is helping patients develop specific strategies, such as self-monitoring, to facilitate their goal of weight loss. This practice of food and activity journaling is considered a mainstay of many weight loss programs and interventions.[5–7] Encouraging this exercise to both pre- and post-surgical patients should be considered, as preliminary results reveal that dietary self monitoring may help prevent weight regain in individuals who have undergone bariatric surgery.[8,9]
Albert Bandera, the father of social cognitive theory (SCT), asserts that self-monitoring is a process that forces us to pay attention to our own behavior. SCT assumes that without this focus, un-desired actions, such as eating the doughnut that was sitting in the break-room, cannot be modified. Ultimately, self-monitoring promotes self-regulation.[10]

A meta-analysis published in the Journal of American Dietetic Association reviewed the effectiveness of dietary self-monitoring and its effects on weight loss in 15 studies. While there were limitations to the some of studies reviewed, such as self-report or a nonheterogeneous sample, a significant association between self-monitoring and weight loss was consistently found.

As one might estimate, enhanced weight losses correlate with more frequent and thorough food records.[11,12] Self-monitoring nonadherence is unequivocal and not unique to other essential health behaviors. However, self monitoring nonadherence is unequivocal and not unique to other essential health behaviors. It is estimated that 80 percent of people do not follow the advice of their healthcare provider.[13] Possible causes of nonadherence are multi-factorial and include: a knowledge deficit, as it is estimated that only one-third of Americans know the primary driver of weight gain is excess calories and less than 15 percent of Americans estimate the calories they need per day correctly[14]; and the “behavioral fatigue” phenomenon.[15,16]

Dietary Self-Monitoring using Technology
While self-monitoring is powerful, providers need strategies to increase performance of this fundamental behavior. Self-monitoring using technologies, mainly apps and software, is one recently recognized strategy. Recent studies have observed accelerated weight losses as a result of technology being integrated into behavioral interventions.[17–19]

Burke et al[20] discovered increased food recording adherence using Personal Digital Assistants (PDAs). This advantage was noted to be of most benefit in the first six months of the study, where PDA users self-monitored 80 to 90 percent of the time, compared to their paper recorder counterparts who self-monitored 55 percent of the time.

The greatest adherence and weight losses were witnessed in the group that received personalized feedback messages through the PDA platform. PDA messages were tailored to the individual and included reminders, such as, “Taking a few minutes to record will help you meet your goals” or “Watch portion sizes to control calories.” All study groups (paper method, PDA, and PDA with feedback) experienced some weight regain in the second year of the study, with the least amount in the PDA with feedback.

The authors suggested that the weight regain experienced in all groups may be due in part to the reduced frequency of group meetings. Furthermore, the superior results were thought to be the result of the additive technological “coaching.”

A similar study published in the Journal of Internal Medicine randomized predominately male subjects from a Midwestern Virginia hospital into a technological or “standard” intervention group.[21] The technology group was advised to record their foods throughout the day using their PDA; received behavioral counseling through “coaching calls;” and attended behavioral classes led by a psychologist, dietitian, or physician. The standard group did not receive coaching calls, but tracked their food via the paper method and attended group meetings. The technology group achieved and sustained significantly greater weight losses compared to the standard group, even after cessation of the coaching calls for the remainder of the study (7–12 months). The authors speculated that the coaching calls combined with tracking technology was the catalyst for enhanced weight losses.

Using technology to increase self-monitoring compliance shows promise and parallels perfectly with our technology-focused culture. Once patients learn how to self-monitor using specific apps and software, most report feeling relieved at the ease of entering their food. They have access to a large database of foods, foods are subtotaled as they are entered, and the ability to reach calorie and protein goals are concretely assessed on a day-to-day basis. Additional benefits include easy retraction of frequently eaten meals and portability of the “paperless notebook” when a smart phone or tablet is used.

According to SCT, not all patients possess the behavioral capability to perform effectual self-monitoring. This process of skills training may need to be part of in-clinic consultations or group meetings.

Another strategy to increase compliance with self-monitoring (and behavior change in general) may be reminding patients they do not have to be perfect. Patients hold themselves to very high standards and this “perfectionist” mentality may often be a barrier to change. In a study by Burke et al,[22] subjects that adhered to food recording 30 to 59 percent of the time (instead of 100%) were still able to lose a significant amount of weight. Consistency with self-monitoring should ultimately be the focus; however, let us remember that all is not lost when our patients have not been as adherent as we may have hoped.
Communicate to your patients to give their best effort to self monitor early on in treatment, as early adherence was predictive of long term weight losses demonstrated in the POUNDS (Prevention of Obesity Using Novel Dietary Strategies) LOST study.[23]

Remote Support
Technology is furthermore applicable to internet usage, e-mail, and telephone coaching. Appel et al[24] recently found remote support equally effective at producing clinically significant weight losses in obese subjects when compared with in person behavioral treatment. Both the in-person and remote support patients attended follow-up visits at 6, 12, and 24 months with the primary care physician (PCP) where they were weighed and provided guidance on their computer generated report accessed from the website. Trained weight loss coaches worked in collaboration with the PCP in delivering group or individual sessions to the in-person intervention, while the remote support intervention were counseled via telephone. The delivery of the behavioral counseling, not the frequency, was the defining characteristic between the two interventions.

At the conclusion of two years, the weight change from baseline was 1.1 percent in the control group, 5 percent in the group receiving remote support, and 5.2 percent in the group receiving in person treatment. These results demonstrate that remote behavioral counseling can be just as effective as face-to-face counseling in achieving clinically significant weight losses.

Internet behavioral counseling was also compared to standard internet treatment. All participants were asked to submit their weight and food records via a web-based diary. E-mail reminders were submitted weekly for the entire 12 months of the study. The behavioral counseling group received feedback on their food records, reinforcement for identified behaviors and recommendations for change, while the standard group received no such treatment. At 12 months, the addition of e-counseling doubled the percentage of initial weight loss from 2.2 to 4.8 percent.[25]

The paradigm of remote counseling with reinforcement has far-reaching implications. Consider the patient’s reduced burden from missing time from work, finding and paying for a parking space, and cost of commuting.

Summary
Providers need strategies to increase weight loss momentum in their patients. This is especially true before bariatric surgery and at the conclusion of the “honeymoon phase.” While more studies are needed to confirm its effectiveness, electronic tracking and remote counseling incorporated into a standard practice shows promise in augmenting weight losses.

References
1.    National Heart, Lung, and Blood Institute and the North American Association for the Study of Obesity. 2000. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. National Institutes of Health. Bethesda, Maryland.
2.    Moyer VA, U.S. Preventive Services Task Force. Screening for and management of obesity in adults. U.S. Preventative Services Task Force recommendation statement. Ann Intern Med. 157:373–378.
3.    Morton JM. The Affordable Care Act: key elements and what it means for bariatric surgery. Bariatric Times. 2013;10(1):8.
4.    Centers for Medicaid and Medicare Services. Decision memo for behavioral therapy for obesity (CAG-00423N). November 29, 2011. http://www.cms.gov/medicare-coverage dbase/details/ncadecisionmemo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&bc=ACAAAAAAIAAA&NCAId=253
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10.    Bandura A. Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes. 1991;50:248–187.
11.    Burke LE, Wang J. Self-monitoring in weight loss: a systematic review of the literature. J Am Diet Assoc. 2011;(111):92–102.
12.    Streit KJ, Steven NH. Food records: a predictor and modifier of weight change in a long-term weight loss program. J Am Diet Assoc. 1991(2):213–216.
13.    Constance A, Sauter, C. Inspiring and Supporting Behavior Change: A Food and Nutrition Professional’s Counseling Guide. American Dietetic Association; 2011.
14.    Food & Health Survey; Consumer Attitudes toward Food Safety, Nutrition & Health. International Food Information Council Foundation. 2013
15.    Burke LE, Sereika SM, Music E, Warziski M, Styn MA, Stone A. Using instrumented paper diaries to document self-monitoring patterns in weight loss. Contemporary Clinical Trials. 2008(29): 182–193.
16.    Guare JC, Wing RR, Marcus MD, et al. Analysis of changes in eating behavior and weight loss in type II diabetic patients. Which behaviors to change. Diabetes Care. 1989; 12(7):500–503.
17.    Pellegrini CA, Verba SD, et al. The comparison of a technology-based system and an in person behavioral weight loss intervention. Obesity (Silver Spring). 2012:20(2):356–363.
18.    Shuger SL, Barry VW, et al. Electronic feedback in a diet- and physical activity based lifestyle intervention for weight loss: a randomized controlled trial. Int J Behav Nutr Phys Act. 2011; 8:41.
19.    Harvey-Berino J, West D, et al. Internet delivered behavioral obesity treatment. Prev Med. 2010; 51(2):123–128.
20.    Burke LE, Styn MA, et al. Using mHealth technology to enhance self monitoring for weight loss: a randomized trial. Am J Prev Med. 2012; 43(1):20–26.
21.    Spring B, Duncan JM, et al. Integrating technology into a standard weight loss treatment. JAMA Intern Med. 2013. 173(2): 105–111.
22.    Burke LE, Styn MA, et al. Using mHealth technology to enhance self monitoring for weight loss: a randomized trial. Am J Prev Med. 2012. 43(1): 20–26.
23.    Williamson DA, Anton SD, Han H, Champagne, C, Allen R, LeBlanc E, Ryan D, Rood J, McManus K, Laranjo N, Carey VJ, Loria CM, Bray GA, Sacks FM. Early behavioral adherence predicts short and long-term weight loss in the POUNDS LOST study. J Behav Med. 2010. 33(4): 305-314.
24.    Appel, LJ, Clark, JM, et al. Comparative effectiveness of weight loss interventions in clinical practice. N Eng J Med. 2011; (365):1959–1968.
25.    Tate DF, Jackvony EH, Wing RR. Effects of internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. JAMA. 2003;289(14);1833–1836.

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