Adherence and weight loss outcomes associated with food-exercise diary preference in a military weight management program

Impact of a diabetes-designed meal delivery service on changes in hemoglobin A1c and quality of life in patients with diabetes

BACKGROUND

Over 34 million Americans have diabetes, and nutrition therapy is essential in self-management.

AIMS

The primary aim of the study was to evaluate the impact of meals designed for patients with type 2 diabetes (T2D) through a meal delivery program. The primary outcome was a 3-month change in hemoglobin A1c (HbA1c). Secondary outcomes included a 3-month change in weight, blood pressure, high-density lipoprotein, low-density lipoprotein, and triglycerides. Furthermore, the study aimed to evaluate the impact of the meal delivery program on the participants' quality of life.

METHODS

In this randomized crossover clinical trial, patients were allocated in a 1:1 fashion to treatment sequence AB or treatment sequence BA. In Phase 1, participants allocated to sequence AB received 10 meals per week for 3 months, followed by a 3-month washout period and a 3-month standard intervention period with no meals. Participants allocated to sequence BA received 3 months of standard intervention with no meals followed by a 3-month washout period and a 3-month period with 10 meals per week. A quality-of-life survey was obtained during weeks 0, 12, 24, and 36.

RESULTS

The mean 3-month change in HbA1c (primary outcome) was nearly a half point lower with meal delivery (-0.44% [95% CI: -0.85%, -0.03%]; P = 0.037). The estimated mean 3-month change in quality of life was approximately 2 points lower (better) with meal delivery (-2.2 points [95% CI: -4.2, -0.3]; P = .027). There were no statistically significant differences in secondary outcomes with meal delivery (all P ≥ 0.15).

CONCLUSIONS

A meal delivery system for patients with T2D improves glycemic control and quality of life.

Analyzivng Demand for Customized Obesity Prevention and Management Across Adult Age Groups Using Focus Group Interview

With the increasing obesity rates, many studies on obesity prevention and management have been implemented. However, few studies focused on obesity in adulthood and different perceptions of obesity between life cycles. Thus, this study aimed to investigate the demand for customized obesity prevention and management (OPM) strategies across adult age groups. Focus group interviews were conducted to gather insights from three age groups: young adults (20-34 years), middle-aged adults (35-49 years), and seniors (50-64 years). A total of 17 participants took part in the study, with 5 participants in Group 1, 6 participants in Group 2, and 6 participants in Group 3. Thematic analysis and the use of NetMiner version 4.4.3 facilitated data categorization and scrutiny. The study employed qualitative methods to explore perceptions of obesity and preferences for personalized OPM strategies among participants. Diverse perspectives on obesity as a health threat were found among the age groups. While all stressed the importance of personalized OPM, preferences for strategies varied. Diet and exercise combination emerged as a common preference. This study highlighted the need for customized OPM approaches aligned with age-specific preferences.

A Review of Digital Innovations for Diet Monitoring and Precision Nutrition

This article provides an up-to-date review of technological advances in 3 key areas related to diet monitoring and precision nutrition. First, we review developments in mobile applications, with a focus on food photography and artificial intelligence to facilitate the process of diet monitoring. Second, we review advances in 2 types of wearable and handheld sensors that can potentially be used to fully automate certain aspects of diet logging: physical sensors to detect moments of dietary intake, and chemical sensors to estimate the composition of diets and meals. Finally, we review new programs that can generate personalized/precision nutrition recommendations based on measurements of gut microbiota and continuous glucose monitors with artificial intelligence. The article concludes with a discussion of potential pitfalls of some of these technologies.

Compact food bar improves cardiopulmonary function in men military athletes: A randomized, placebo-controlled, single-blind clinical trial

BACKGROUND

This study aimed to evaluate the effects of compact food bar (CFB) designed on cardiopulmonary function in men athletes who serve in military service.

MATERIALS AND METHODS

In this randomized, single-blind, controlled clinical trial, 46 men of military staff were arranged into 2 groups and studied for 28 days; one branch used 3 packs daily, 700 kcal each, of CFB with Functional compounds (Caffeine and L-arginine) and the other group used regular food during training course. Maximal oxygen uptake (VO₂ Max) in vitro with cardiopulmonary exercise test, body composition, and physical activity were assessed and recorded at baseline and end of the study period.

RESULTS

VO₂ Max (P = 0.05) significantly increased in CFB group compared with baseline. Moreover, VO₂ Max (P = 0.01), VO₂/HR (P = 0.04), oxygen uptake/heart rate (VO₂/HR) (P = 0.03), and ventilation per minute/oxygen uptake (VE/VO₂) (P = 0.03) significantly increased in CFB group compared with control group. In comparison, there was no significant difference in mean ventilation per minute/carbon dioxide production (VE/VCO₂) (P = 0.41), ventilation per minute (VE) (P = 0.69), and breathing frequency (P = 0.056). No significant effect of CFB was found on weight, body mass index (P = 0.23), lean body mass (P = 0.91), and body fat mass (P = 0.91).

CONCLUSION

Our results show that intervention with CFB is more effective than regular diet in improving cardiopulmonary function in men athletes who serve in military service.

Predicting the macronutrient composition of mixed meals from dietary biomarkers in blood

Diet monitoring is an essential intervention component for a number of diseases, from type 2 diabetes to cardiovascular diseases. However, current methods for diet monitoring are burdensome and often inaccurate. In prior work, we showed that continuous glucose monitors (CGMs) may be used to predict the macronutrients in a meal (e.g., carbohydrates, protein, and fat) by analyzing the shape of the post-prandial glucose response. The objective of this study was to examine a number of additional dietary biomarkers in blood by their ability to improve the prediction of meal macronutrients, compared to using CGMs alone. As our experimental method, we conducted a nutritional study where (n=10) participants consumed nine different mixed meals with varied but known macronutrient amounts, and we analyzed the concentration of 33 dietary biomarkers (including amino acids and their combinations, insulin, triglycerides, and 3 independent measures of glucose) at various times post-prandially. As our computational method, we built machine learning models to predict the macronutrient amounts from (1) individual biomarkers and (2) their combinations. The major result from this work is that the additional blood biomarkers provide complementary information, and more importantly, achieve higher prediction performance for the three macronutrients in terms of normalized root mean squared error (carbohydrates: 22.9%; protein: 23.4%; fat: 32.3%) than CGMs alone (carbohydrates: 28.2%, p = 0.08; protein: 42.9%, p<0.001; fat: 41.4%, p<0.05}). Our main conclusion is that augmenting CGMs to measure these additional dietary biomarkers improves macronutrient prediction performance, and may ultimately lead to the development of automated methods to monitor monitor nutritional intake. This work is significant to biomedical research as it provides a potential solution to the long-standing problem of diet monitoring, facilitating new interventions for a number of diseases.

Weight-Related Information Avoidance Prospectively Predicts Poorer Self-Monitoring and Engagement in a Behavioral Weight Loss Intervention

BACKGROUND

Self-monitoring is a key component of behavioral weight loss (BWL) interventions. Past research suggests that individuals may avoid self-monitoring in certain contexts (e.g., skipping self-weighing after higher-than-usual calorie intake). However, no studies have attempted to quantify individuals' inclination to avoid information about their weight control ("weight-related information avoidance"; WIA) or prospectively examined its implications for treatment engagement and outcomes in BWL programs.

PURPOSE

Characterize WIA using a validated questionnaire among adults enrolled in BWL treatment and examine whether WIA prospectively predicts self-monitoring adherence, session attendance, treatment discontinuation, or weight loss.

METHODS

Participants (N = 87; MBMI = 34.9 kg/m2, 83% female) completed a measure of WIA prior to starting a 12 week, group-based BWL intervention. Participants were given digital self-monitoring tools and instructed to self-monitor their food intake daily, physical activity daily, and body weight weekly (Weeks 1-10) and then daily (Weeks 11-12). Session attendance and treatment discontinuation were recorded. Weight was measured in-clinic pretreatment and posttreatment.

RESULTS

While mean WIA was low (M = 2.23, standard deviation [SD] = 0.95; potential scale range: 1-7), greater WIA predicted poorer attendance (r = -.23; p = .03) and poorer self-monitoring of physical activity (r = -.28; p = .009) and body weight (r = -.32; p = .003). WIA did not predict food monitoring (p = .08), treatment discontinuation (p = .09), or 12 week weight loss (p = .91).

CONCLUSIONS

Greater WIA, as assessed via a brief questionnaire, may place individuals at risk for poorer self-monitoring and treatment engagement during BWL. Further research on the implications of WIA in the context of weight management is warranted, including evaluation of correlates, moderators, and mechanisms of action of WIA.

CLINICAL TRIAL REGISTRATION

NCT03337139.

Randomized trial of a novel lifestyle intervention compared with the Diabetes Prevention Program for weight loss in adult dependents of military service members

BACKGROUND

Lifestyle interventions are the first-line treatment for obesity, but participant weight loss is typically low.

OBJECTIVES

We evaluated the efficacy of an alternative lifestyle intervention [Healthy Weight for Living (HWL)] compared with a modified Diabetes Prevention Program (m-DPP). HWL was based on a revised health behavior change model emphasizing hunger management and the development of healthy food preferences. m-DPP was a standard Diabetes Prevention Program implemented with counselor time matched to HWL. Participants were adult dependents of military personnel and had overweight or obesity.

METHODS

Participants were randomly assigned to HWL (n = 121) or m-DPP (n = 117), delivered primarily by group videoconference with additional midweek emails. The primary outcome was 12-mo weight change. Secondary outcomes included 6-mo changes in cardiometabolic risk factors and diet. Intention-to-treat (ITT) and complete case (CC) analyses were performed using linear mixed models.

RESULTS

Retention did not differ between groups (72% and 66% for HWL and m-DPP at 12 mo, respectively; P = 0.30). Mean ± SE adjusted 12-mo weight loss in the ITT cohort was 7.46 ± 0.85 kg for HWL and 7.32 ± 0.87 kg for m-DPP (P = 0.91); in the CC cohort, it was 7.83 ± 0.82 kg for HWL and 6.86 ± 0.88 kg for m-DPP (P = 0.43). Thirty-eight percent of HWL and 30% of m-DPP completers achieved ≥10% weight loss (P = 0.32). Improvements in systolic blood pressure, LDL cholesterol, triglycerides, fasting glucose, general health, sleep, and mood were similar across groups; improvements in diastolic blood pressure were greater in m-DPP. Adjusted group mean reductions in energy intake were not significantly different between groups, but HWL participants were more adherent to their dietary prescription for lower glycemic index and high fiber and protein (P = 0.05 to <0.001 for ITT).

CONCLUSIONS

HWL and m-DPP showed equivalent and clinically impactful mean weight loss with cardiometabolic benefits. These results identify an alternative approach for behavioral treatment of overweight and obesity.This trial was registered at clinicaltrials.gov as NCT02348853.

Preference, Expected Burden, and Willingness to Use Digital and Traditional Methods to Assess Food and Alcohol Intake

We conducted an online survey to examine the preference, expected burden, and willingness of people to use four different methods of assessing food and alcohol intake such as food/drink record, 24-h recall, Remote Food Photography Method© (RFPM, via SmartIntake^® app), and a novel app (PortionSize^®) that allows the in-app portion size estimation of foods/drinks by the user. For food (N = 1959) and alcohol (N = 466) intake assessment, 67.3% and 63.3%, respectively, preferred the RFPM/SmartIntake^®, 51.9% and 53.4% preferred PortionSize^®, 48.0% and 49.3% the food records, and 32.9% and 33.9% the 24-h recalls (difference in preference across all methods was p < 0.001 for food and alcohol intake). Ratings of burden and preference of methods were virtually superimposable, and we found strong correlations between high preference and low expected burden for all methods (all ρ ≥ 0.82; all p < 0.001). Willingness (mean (SD)) to use the RFPM/SmartIntake^® (food: 6.6 (2.0); alcohol: 6.4 (2.4)) was greater than PortionSize^® (food: 6.0 (2.2); alcohol: 6.0 (2.4); all p < 0.001) and 24-h recalls (food: 6.1 (2.2); alcohol: 5.7 (2.7); p < 0.001), but not different from food records (food: 6.6 (2.0); alcohol: 6.5 (2.3); all p ≥ 0.33). Our results can be used in conjunction with existing data on the reliability and validity of these methods in order to inform the selection of methods for the assessment of food and alcohol intake.

Feasibility and Convergent Validity of an Activity Tracker for Low Back Pain Within a Clinical Study: Cross-sectional Study

BACKGROUND

Low back pain (LBP) is a highly prevalent condition affecting individuals of all ages. To manage the symptoms and prevent recurrences and flare-ups, physical activity in conjunction with self-management education is recommended. Tools such as diaries and questionnaires have been the gold standard for tracking physical activity in clinical studies. However, there are issues with consistency, accuracy, and recall with the use of these outcome measures. Given the growth of technology in today's society, consumer-grade activity monitors have become a common and convenient method of recording physical activity data.

OBJECTIVE

The aim of this study is to test the feasibility and convergent validity of a Garmin Vivofit 3 activity tracker in evaluating physical activity levels in a clinical trial of patients with LBP.

METHODS

We recruited 17 individuals with nonspecific LBP referred from health care professionals or self-referred through advertisements in the community. The participants entered into a 12-week physical activity and self-management program. Physical activity was assessed using a self-reported questionnaire and the Garmin activity tracker. Activity tracker data (eg, steps taken, distance walked, and intensity minutes) were extracted weekly from the Garmin Connect online platform. Outcomes of pain and activity limitation were assessed weekly using a mobile app. A linear regression was conducted to evaluate if demographic factors (ie, age, gender, pain level) affected the adherence rates to the activity monitor. We also used Pearson correlations to evaluate the convergent validity of the Garmin activity tracker with the physical activity questionnaire.

RESULTS

The mean daily adherence rate for activity monitors was 70% (SD 31%) over the 26 weeks of study. The mean response rate for the weekly physical activity measures using REDCap for the first 12 weeks of the study was 91% (SD 17%). None of the hypothesized variables or questionnaires were predictors of response rate.

CONCLUSIONS

The majority of participants were compliant with wearing the tracker, and demographic factors were not found to be predictors of adherence to wearing the device. However, there were poor correlations between the modified International Physical Activity Questionnaire Short Form (IPAQ-SF) and the activity monitor, demonstrating problems with convergent validity.

Binge eating predicts adherence to digital self-monitoring during behavioral weight loss

OBJECTIVE

Consistent self-monitoring of dietary intake, weight, and physical activity predicts better outcomes during behavioral weight loss, but the factors that influence self-monitoring adherence are not well understood. This study attempted to fill gaps in the existing literature by examining whether pre-treatment eating behaviors predict adherence to digital self-monitoring during a behavioral weight loss program.

METHOD

Participants (N = 77) reported on binge eating, uncontrolled eating, and emotional eating at baseline, and were instructed to self-monitor their food intake, weight, and physical activity using digital devices (food logging app, Fitbit, and wireless "smart" scale) throughout the 12-week treatment. Adherence to self-monitoring was assessed using data captured from these devices.

RESULTS

Greater baseline binge eating severity predicted greater adherence to self-monitoring of weight (ρ = 0.25, p = .03) and eating (ρ = 0.25, p = .03), but not self-monitoring of physical activity. Uncontrolled eating and emotional eating did not significantly predict self-monitoring adherence.

CONCLUSIONS

In contrast to previous research, this study found that participants with greater pre-treatment binge eating severity had better adherence to self-monitoring of eating, and for the first time established a relationship between binge eating severity and digital self-monitoring of weight in behavioral weight loss. Individuals with greater pre-treatment binge eating may exhibit characteristics, such as motivation or rigidity, that are beneficial during the initial period of weight loss. Future studies should determine if there are features of analogue versus digital self-monitoring that may explain this pattern of findings, and examine these associations longitudinally.

Revising Diabetes Programming for Black Men and Their Families

Type-2 diabetes has increased 160% for African American males in the United States. This two-part study's purpose was to apply social marketing theory to understand the Type-2 diabetes education needs of men in Iowa. Study One was a preference assessment of Type-2 diabetes education strategies. Four African American men participated in a series of four focus groups and indicated that they were interested in diabetes prevention programming with their families but not in having it labeled as diabetes education. Participating men would rather increase their physical activity as opposed to tracking their food intake. As a follow-up to this study, nine other African American males took part in Study Two, which used cooking demonstrations and recipe taste-testing with the men to examine their relationship to food in the context of managing their Type-2 diabetes. The findings of both studies, which provided insight into these African American men's lifestyle as related to their Type-2 diabetes, could be useful for nursing professionals who have a critical role in navigating cultural, gender, and family norms while developing care plans, offering patient education, and promoting quality of life.

Digital self-monitoring: Does adherence or association with outcomes differ by self-monitoring target?

OBJECTIVE

Digital self-monitoring of eating, physical activity, and weight is increasingly prescribed in behavioural weight loss programmes. This study determined if adherence rates or associations with outcomes differed according to self-monitoring target (ie, self-monitoring of eating versus physical activity versus weight).

METHODS

Participants in a 3-month, group-based weight loss programme were instructed to use an app to record food intake, wear a physical activity sensor, and use a wireless body weight scale. At post-treatment, weight loss was measured in clinic and moderate-to-vigorous physical activity (MVPA) was measured by research-grade accelerometer.

RESULTS

Adherence to self-monitoring decreased significantly over time for eating and weight but not physical activity. Overall, adherence to self-monitoring of weight was lower than that of eating or physical activity. Greater adherence to self-monitoring of eating, physical activity, and weight each predicted greater weight loss. Only greater adherence to self-monitoring of eating was associated with greater bouted minutes of MVPA.

CONCLUSIONS

Findings from this study suggest that self-monitoring should be considered a target-specific behaviour rather than a unitary construct when conceptualizing adherence and association with treatment outcomes.

Strategies to reduce attrition in weight loss interventions: A systematic review and meta-analysis

The primary objective of the study was to identify the effect of intervention strategies on attrition within a weight loss programme among adults aged 18 to 65 years. The secondary objective of the study was to assess the impact of such intervention strategies among female-only weight loss programmes. The literature search was performed in Ovid (CINAHL Plus, MEDLINE, EMBASE, Cochrane [Cochrane Database of Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register], and PsycINFO). Studies must have identified weight loss as the main aim and compared the primary weight loss programme alone (control) with the primary weight loss programme coupled with an additional intervention strategy (intervention). Papers must have had a mean participant age between 18 and 65 years and available in English. Fifty-seven trials met the inclusion criteria and were included in the meta-analysis. Strategies that successfully reduced attrition included the incorporation of financial incentives (n = 8), a multicomponent approach (n = 13), and use of self-monitoring technology (n = 4). The majority of studies were of low to moderate methodological quality because of insufficient reporting. A limited number of female-only trials were found (n = 13). Implementation of financial incentives, multicomponent interventions, and self-monitoring technology help reduce attrition among adult weight loss programmes. Further studies are required to identify the impact of intervention strategies on attrition in women.

Effect of Treatment Preference in Randomized Controlled Trials: Systematic Review of the Literature and Meta-Analysis

BACKGROUND

A significant limitation of the traditional randomized controlled trials is that strong preferences for (or against) one treatment may influence outcomes and/or willingness to receive treatment. Several trial designs incorporating patient preference have been introduced to examine the effect of treatment preference separately from the effects of individual interventions. In the current study, we summarized results from studies using doubly randomized preference trial (DRPT) or fully randomized preference trial (FRPT) designs and examined the effect of treatment preference on clinical outcomes.

METHODS

The current systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies using DRPT or FRPT design were identified using electronic databases, including PubMed, Cochrane Library, EMBASE, and Google Scholar between January 1989 and November 2018. All studies included in this meta-analysis were examined to determine the extent to which giving patients their preferred treatment option influenced clinical outcomes. The following data were extracted from included studies: study characteristics, sample size, study duration, follow-up, patient characteristics, and clinical outcomes. We further appraised risk of bias for the included studies using the Cochrane Collaboration's risk of bias tool.

RESULTS

The search identified 374 potentially relevant articles, of which 27 clinical trials utilized a DRPT or FRPT design and were included in the final analysis. Overall, patients who were allocated to their preferred treatment intervention were more likely to achieve better clinical outcomes [effect size (ES) = 0.18, 95% confidence interval (CI) 0.10-0.26]. Subgroup analysis also found that mental health as well as pain and functional disorders moderated the preference effect (ES = 0.23, 95% CI 0.11-0.36, and ES = 0.09, 95% CI 0.03-0.15, respectively).

CONCLUSIONS

Matching patients to preferred interventions has previously been shown to promote outcomes such as satisfaction and treatment adherence. Our analysis of current evidence showed that allowing patients to choose their preferred treatment resulted in better clinical outcomes in mental health and pain than giving them a treatment that is not preferred. These results underline the importance of incorporating patient preference when making treatment decisions.

Exploring the Experiences of Iranian Women Regarding Obesity Self-Management: A Qualitative Study

BACKGROUND

Despite the high and growing prevalence of obesity in Iran and a variety of interventions by the healthcare providers control the problem, and it is still a prevalent health problem among Iranian women.

AIM

The aim of this study is to explore the perspective of obese Iranian women in the process of self-management regarding the facilitating factor in self-management of obesity.

METHODS

In a qualitative study, the participants were selected through purposeful sampling, and the data were collected using semi-structured interviews and focus group (n = 25) between July 2017 and September 2018. All the interviews were transcribed verbatim and the data were analysed using constant comparative method.

RESULTS

Supporting the umbrella was the main category found in the present study. The participating obese individuals found "support" as the main factor with an outstanding effect on motivating, incentivising and keeping diet in long-term. This category contains subcategories: self-help; family, friends, and peers' support; and medical team's support.

CONCLUSION

The findings suggested the critical role of support in obesity self-management process. This critical factor improves our perception of the multi-aspect and complicated nature of obesity self-management. Moreover, policymakers and providers of health services can utilise this finding in the design of care plans with higher chance of success.

Defining Adherence to Mobile Dietary Self-Monitoring and Assessing Tracking Over Time: Tracking at Least Two Eating Occasions per Day Is Best Marker of Adherence within Two Different Mobile Health Randomized Weight Loss Interventions

BACKGROUND

Mobile dietary self-monitoring methods allow for objective assessment of adherence to self-monitoring; however, the best way to define self-monitoring adherence is not known.

OBJECTIVE

The objective was to identify the best criteria for defining adherence to dietary self-monitoring with mobile devices when predicting weight loss.

DESIGN

This was a secondary data analysis from two 6-month randomized trials: Dietary Intervention to Enhance Tracking with Mobile Devices (n=42 calorie tracking app or n=39 wearable Bite Counter device) and Self-Monitoring Assessment in Real Time (n=20 kcal tracking app or n=23 photo meal app).

PARTICIPANTS/SETTING

Adults (n=124; mean body mass index=34.7±5.6) participated in one of two remotely delivered weight-loss interventions at a southeastern university between 2015 and 2017.

INTERVENTION

All participants received the same behavioral weight loss information via twice-weekly podcasts. Participants were randomly assigned to a specific diet tracking method.

MAIN OUTCOME MEASURES

Seven methods of tracking adherence to self-monitoring (eg, number of days tracked, and number of eating occasions tracked) were examined, as was weight loss at 6 months.

STATISTICAL ANALYSES PERFORMED

Linear regression models estimated the strength of association (R²) between each method of tracking adherence and weight loss, adjusting for age and sex.

RESULTS

Among all study completers combined (N=91), adherence defined as the overall number of days participants tracked at least two eating occasions explained the most variance in weight loss at 6 months (R²=0.27; P<0.001). Self-monitoring declined over time; all examined adherence methods had fewer than half the sample still tracking after Week 10.

CONCLUSIONS

Using the total number of days at least two eating occasions are tracked using a mobile self-monitoring method may be the best way to assess self-monitoring adherence during weight loss interventions. This study shows that self-monitoring rates decline quickly and elucidates potential times for early interventions to stop the reductions in self-monitoring.

Dietary, physical activity, and weight management interventions among active-duty military personnel: a systematic review

BACKGROUND

Research has been conducted to assess the effectiveness of weight management, dietary and physical activity interventions in military settings. However, a recent and comprehensive overview is lacking. The aim of this systematic review is to examine the evidence and describe key components of effective interventions in terms of improving body composition, dietary behaviors, and physical activity among active-duty military personnel.

METHODS

PubMed, PsycInfo, and CINAHL were searched on the 17th of November 2017 to identify interventions that promoted diet and/or physical activity among active-duty military personnel. Studies were included if they assessed outcomes related to anthropometric measurements, dietary behaviors, or fitness/physical activity levels. There were no restrictions regarding publication date, follow-up duration, and sex. After screening, a total of 136 studies were eligible. Of these studies, 38 included an educational and/or behavioral change component, and 98 had only physical or fitness training as part of basic military training. Only studies that included an educational and/or behavioral change component were assessed for quality using the Effective Public Health Practice Project tool and included in the qualitative synthesis of the results.

RESULTS

Based on consistent evidence from studies that were rated as moderate or strong, there is good evidence that military weight management interventions are effective in improving body composition for durations of up to 12 months. Effective interventions are more likely to be high intensity (have a greater number of sessions), are more often delivered by specialists, and use theoretical base/behavioral change techniques and a standardized guideline. Dietary interventions can potentially reduce total fat and saturated fat intake. Dietary interventions that target the kitchen staff and/or increase the availability of healthy food are more likely to be effective in the short term. The results regarding military physical fitness interventions were inconclusive.

CONCLUSION

Despite limitations such as the diversity and heterogeneity of the included interventions, outcome measurements, and follow-up duration, this systematic review found good evidence that weight management interventions are effective, especially in terms of weight loss. More studies are needed to acquire solid evidence for effectiveness for durations longer than 12 months and to identify key components of the effective dietary and physical activity educational and/or behavioral change interventions, especially in countries outside Europe and the US.

Mobile health, physical activity, and obesity: Subanalysis of a randomized controlled trial

BACKGROUND

Recent studies on physical activity were analyzed by randomizing participants into either the intervention or control group. It is necessary to classify each intervention and control groups according to physical activity using the International Physical Activity Questionnaire (IPAQ).

METHODS

This was a pilot project for SmartCare Services. The intervention group received obesity management services using a smartphone for 24 weeks, while the control group did not receive the interventions. Six anthropometric indices were analyzed: weight, body mass index (BMI), waist circumference, body fat, systolic blood pressure (SBP), and diastolic blood pressure (DBP). Five laboratory tests, including fasting blood sugar (FBS), glycosylated hemoglobin (HbA1c), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC), and triglycerides (TGs), were also assessed. The final 324 participants were categorized using the IPAQ questionnaire, and anthropometric indices and laboratory tests were analyzed for within-group and between-group changes from baseline to final visit.

RESULTS

Statistically significant decreases in the intervention group compared with the control group were observed in terms of insufficient activity (IA) (-1.6 ± 3.03 vs -0.1 ± 1.94 kg) and moderate activity (MA) (-2.5 ± 3.81 vs -0.3 ± 2.24 kg) for weight, IA (-0.7 ± 1.14 vs -0.2 ± 0.93 kg/m) and MA (-0.9 ± 1.30 vs -0.2 ± 0.86 kg/m) for BMI, and health-enhancing physical activity (HEPA) (-1.6 ± 3.69% vs -0.1 ± 3.15%) for body fat. For HbA1c, HEPA in the intervention group showed significant decreases (-0.2 ± 0.67 vs 0.0 ± 0.34 mg/dL) compared with the control group.

CONCLUSION

Anthropometric indices and laboratory test results were improved in the smartphone-based intervention group. Especially, improvement of metabolic components in the group with more active physical activity was remarkable.

Racial and ethnic minority enrollment in randomized clinical trials of behavioural weight loss utilizing technology: a systematic review

Many racial and ethnic minority groups (minorities) are disproportionately affected by overweight and obesity; however, minorities are often under-represented in clinical trials of behavioural weight loss (BWL) treatment, potentially limiting the generalizability of these trials' conclusions. Interventions involving technology may be particularly well suited to overcoming the barriers to minority enrollment in BWL trials, such as demanding or unpredictable work schedules, caregiving responsibilities and travel burdens. Thus, this systematic review aimed to describe minority enrollment in trials utilizing technology in interventions, as well as to identify which form(s) of technology yield the highest minority enrollment. Results indicated relatively low enrollment of minorities. Trials integrating smartphone use exhibited significantly greater racial minority enrollment than trials that did not; trials with both smartphone and in-person components exhibited the highest racial minority enrollment. This review is the first to explore how the inclusion of technology in BWL trials relates to minority enrollment and can help address the need to improve minority enrollment in weight loss research.

Validation of a Tablet Application for Assessing Dietary Intakes Compared with the Measured Food Intake/Food Waste Method in Military Personnel Consuming Field Rations

The collection of accurate dietary intakes using traditional dietary assessment methods (e.g., food records) from military personnel is challenging due to the demanding physiological and psychological conditions of training or operations. In addition, these methods are burdensome, time consuming, and prone to measurement errors. Adopting smart-phone/tablet technology could overcome some of these barriers. The objective was to assess the validity of a tablet app, modified to contain detailed nutritional composition data, in comparison to a measured food intake/waste method. A sample of Canadian Armed Forces personnel, randomized to either a tablet app (n = 9) or a weighed food record (wFR) (n = 9), recorded the consumption of standard military rations for a total of 8 days. Compared to the gold standard measured food intake/waste method, the difference in mean energy intake was small (−73 kcal/day for tablet app and −108 kcal/day for wFR) (p > 0.05). Repeated Measures Bland-Altman plots indicated good agreement for both methods (tablet app and wFR) with the measured food intake/waste method. These findings demonstrate that the tablet app, with added nutritional composition data, is comparable to the traditional dietary assessment method (wFR) and performs satisfactorily in relation to the measured food intake/waste method to assess energy, macronutrient, and selected micronutrient intakes in a sample of military personnel.

A review of the physiological and psychological health and wellbeing of naval service personnel and the modalities used for monitoring

Naval cohorts rely heavily on personnel to ensure the efficient running of naval organisations. As such, the wellbeing of personnel is essential. In an occupational setting, naval service personnel experience a variety of physiological and psychological stressors. Most naval services arrange annual physical fitness and body composition tests to ensure the physical readiness of personnel. However, these tests only evaluate a small amount of physiological capabilities. Components such as aerobic and strength capabilities are assessed, however, other components of physical fitness such as speed, agility, anaerobic capacity and flexibility are not. In addition to the physical capabilities, personnel are impacted by fatigue, nutrition and psychological stressors such as copping in stressful situations or dealing with time away from family and friends. This review will discuss the physiological and psychological factors that affect personnel's wellbeing. In addition to this, it will also evaluate the methods that are used to assess both physiological and psychological wellbeing.

The Effect of Adherence to Dietary Tracking on Weight Loss: Using HLM to Model Weight Loss over Time

The role of dietary tracking on weight loss remains unexplored despite being part of multiple diabetes and weight management programs. Hence, participants of the Diabetes Prevention and Management (DPM) program (12 months, 22 sessions) tracked their food intake for the duration of the study. A scatterplot of days tracked versus total weight loss revealed a nonlinear relationship. Hence, the number of possible tracking days was divided to create the 3 groups of participants: rare trackers (<33% total days tracked), inconsistent trackers (33-66% total days tracked), and consistent trackers (>66% total days tracked). After controlling for initial body mass index, hemoglobin A_1c, and gender, only consistent trackers had significant weight loss (-9.99 pounds), following a linear relationship with consistent loss throughout the year. In addition, the weight loss trend for the rare and inconsistent trackers followed a nonlinear path, with the holidays slowing weight loss and the onset of summer increasing weight loss. These results show the importance of frequent dietary tracking for consistent long-term weight loss success.

Technology- and Phone-Based Weight Loss Intervention: Pilot RCT in Women at Elevated Breast Cancer Risk

INTRODUCTION

For women with an increased breast cancer risk, reducing excess weight and increasing physical activity are believed to be important approaches for reducing their risk. This study tested a weight loss intervention that combined commercially available technology-based self-monitoring tools with individualized phone calls.

DESIGN

Women were randomized to a weight loss intervention arm (n=36) or a usual care arm (n=18).

SETTING/PARTICIPANTS

Participants were women with a BMI ≥ 27.5 kg/m² and elevated breast cancer risk recruited from the mammography clinic at the Moores Cancer Center at the University of California San Diego.

INTERVENTION

Intervention participants used the MyFitnessPal website and phone app to monitor diet and a Fitbit to monitor physical activity. Participants received 12 standardized coaching calls with trained counselors over 6 months. Usual care participants received the U.S. Dietary Guidelines for Americans at baseline and two brief calls over the 6 months.

MAIN OUTCOME MEASURES

Weight and accelerometer-measured physical activity were assessed at baseline and 6 months. Data were collected in San Diego, CA, from 2012 to 2014 and analyzed in 2015.

RESULTS

Participants (n=54) had a mean age of 59.5 (SD=5.6) years, BMI of 31.9 (SD=3.5), and a mean Gail Model score of 2.5 (SD=1.4). At 6 months, intervention participants had lost significantly more weight (4.4 kg vs 0.8 kg, p=0.004) and a greater percentage of starting weight (5.3% vs 1.0%, p=0.005) than usual care participants. Across arms, greater increases in moderate-to-vigorous physical activity resulted in greater weight loss (p=0.01).

CONCLUSIONS

Combining technology-based self-monitoring tools with phone counseling supported weight loss over 6 months in women at increased risk for breast cancer.

Beyond the treatment effect: Evaluating the effects of patient preferences in randomised trials

The treatments under comparison in a randomised trial should ideally have equal value and acceptability – a position of equipoise – to study participants. However, it is unlikely that true equipoise exists in practice, because at least some participants may have preferences for one treatment or the other, for a variety of reasons. These preferences may be related to study outcomes, and hence affect the estimation of the treatment effect. Furthermore, the effects of preferences can sometimes be substantial, and may even be larger than the direct effect of treatment. Preference effects are of interest in their own right, but they cannot be assessed in the standard parallel group design for a randomised trial. In this paper, we describe a model to represent the impact of preferences on trial outcomes, in addition to the usual treatment effect. In particular, we describe how outcomes might differ between participants who would choose one treatment or the other, if they were free to do so. Additionally, we investigate the difference in outcomes depending on whether or not a participant receives his or her preferred treatment, which we characterise through a so-called preference effect. We then discuss several study designs that have been proposed to measure and exploit data on preferences, and which constitute alternatives to the conventional parallel group design. Based on the model framework, we determine which of the various preference effects can or cannot be estimated with each design. We also illustrate these ideas with some examples of preference designs from the literature.

Efficacy of an Intervention to Alter Skin Cancer Risk Behaviors in Young Adults

INTRODUCTION

Skin cancer is the most common cancer, and its incidence is increasing. Young adults expose themselves to large amounts of ultraviolet radiation (UV) and engage in minimal skin protection, which increases their risk. Internet interventions are effective in modifying health behaviors and are highly disseminable. The current study's purpose was to test an Internet intervention to decrease UV exposure and increase skin protection behavior among young adults.

STUDY DESIGN

RCT conducted in 2014, with data analyzed in 2015.

SETTING/PARTICIPANTS

A national sample of adults aged 18-25 years at moderate to high risk of developing skin cancer by a self-report measure was recruited online.

INTERVENTION

Participants were randomized to one of three intervention conditions: assessment only, the website of a skin cancer organization, or a tailored interactive multimedia Internet intervention program (UV4.me) based on the Integrative Model of Behavioral Prediction.

MAIN OUTCOME MEASURES

Self-reported overall UV exposure and skin protection assessed at 3 and 12 weeks after baseline. Secondary outcomes were self-reported intentional and incidental UV exposure, sunburns, sunscreen use, and skin cancer screening.

RESULTS

For the intervention arm, there were significant decreases in UV exposure and increases in skin protection at both follow-up time points compared with the assessment-only condition (p<0.001). The effect sizes (Cohen's d) comparing the experimental and assessment-only arm for exposure behaviors were 0.41 at 3-week follow-up and 0.43 at 12-week follow-up. The effect sizes for protection behaviors were 0.41 at 3-week follow-up and 0.53 at 12-week follow-up. The control condition was not significantly different from the assessment only condition. All three conditions exhibited decreased exposure and increased protection at both follow-ups (p<0.01), but the effect was much stronger in the intervention group. Secondary outcomes were generally also significantly improved in the intervention condition compared with the other conditions.

CONCLUSIONS

This is the first published report describing the results of an RCT of an Internet intervention to modify skin cancer risk behaviors among young adults. The UV4.me intervention significantly improved self-reported skin cancer prevention behaviors. Future research will investigate mechanisms of change and approaches for dissemination.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02147080.

An overview of the state of the art of automated capture of dietary intake information

Significant benefits arise from being able to capture dietary or nutritional intake information automatically or semi-automatically. These include the ability for individuals to know and understand their nutritional intake and hence improve their diet and health. To date, only highly manual processes such as 24-hour recall, food diaries, and food journals have been utilized which have been overly cumbersome for widespread adoption. Emerging informatics, computer vision, mobile computing, and sensor-based approaches are likely to play a role in further automating the capture of dietary intake information and these are becoming increasingly utilizable through such advents as the rapid and ubiquitous uptake of smartphones with built-in digital cameras and other sensors. In this paper, we review the state of the art of technologies for automatic capture of dietary intake information and identify significant outstanding research problems and promising directions.

A narrative review of the evaluation and selection of instruments which assess self-efficacy amongst patients with essential hypertension

Hypertension is a chronic disease that is mostly managed by the patients themselves inbetween consultation with their physicians. Self-efficacy, which is an individual’s belief in their capabilities to produce given attainments, is a desirable quality to enable the person to take charge of their health and any long-term illness. Assessment of self-efficacy is thus pivotal in developing a holistic patient-centric care plan to optimize their disease control. For hypertension, self-efficacy is associated with better self-care and outcomes of the disease.

This literature review aims to identify self-efficacy assessment instruments, evaluate their origin, quality and development, compare their strengths and limitations, and applicability in specific target population.

Searches performed using PubMed, Scopus and The Cochrane Library eventually yielded 34 relevant articles and 12 instruments. All instruments were validated in specific populations. Two instruments were specific to hypertension, two instruments measured multiple domains of self-management, while medication adherence was the most common single domain assessed. To select an appropriate instrument, one should take into consideration the clinical context and study design. An algorithm is proposed to facilitate the selection of instrument that is best suited for the specific purpose.

Effect of sexual diary keeping and self-evaluation on female sexual function and depression: A pilot study

OBJECTIVES

The aim of the trial was to assess the effect of self-evaluation and sexual diary keeping on female sexual function and depressive symptoms in women diagnosed with sexual dysfunction.

METHODS

A single-arm non-randomised trial included 30 women (53 ± 7 years of age) with female sexual dysfunction (Female Sexual Function Index [FSFI] < 27) and a stable partnership duration of 5-40 years. Female sexual function was assessed by sexual, psychological and gynaecological history taking and validated questionnaires including the FSFI, Female Sexual Distress Scale (FSDS) and Hamilton Depression Scale (HDS), before and after 4 weeks of sexual diary keeping.

RESULTS

A subjective improvement in communication of sexual problems was reported by 60% of participants; no participants reported any worsening of communication. FSFI and FSDS scores were, respectively, 18.0 ± 7.7 and 22.0 ± 10.0 at baseline and 20.2 ± 7.2 and 20.6 ± 11.5 after 4 weeks. HDS score decreased from 6.0 ± 4.0 at baseline to 4.4 ± 2.7 after 4 weeks (p = 0.042).

CONCLUSIONS

Self-evaluation and sexual diary keeping may improve aspects of sexual life, such as couple communication, without a direct effect on variables measured with validated questionnaires on different domains of sexual function.

When does personalized feedback make a difference? A narrative review of recent findings and their implications for promoting better diabetes self-care

Providing behavioral, biomarker, or disease risk feedback to patients is a key component of most behavioral interventions in diabetes, but it remains unclear what is necessary for such feedback to be truly engaging and effective. We sought to identify how personalized health-related feedback is most effectively designed and delivered, and how feedback may be tailored to meet the needs of individual patients with diabetes. To do so, we systematically reviewed recent findings concerning the effectiveness of feedback in eight health-related areas, including several specific to diabetes care (blood glucose monitoring and HbA1c) and others which touch on broader care dimensions (blood pressure, cholesterol, dietary intake, pedometer usage, self-weighing, and medical imaging). Five interdependent characteristics of health-related feedback were identified (clarity of the feedback message, personal meaningfulness of the feedback, frequency of feedback, guidance and support accompanying feedback, and interplay between feedback and patient characteristics) and applications for use in diabetes care were provided. Findings suggested that feedback will be most effective when it is easy for patients to understand and is personally meaningful, frequency of feedback is appropriate to the characteristics of the behavior/biomarker, guidance for using feedback is provided, and feedback is qualified by patient characteristics. We suggest that the effectiveness of feedback to promote better diabetes outcomes requires careful consideration of the feedback message, how it is delivered, and characteristics of the recipients.

Comparison of self-administered survey questionnaire responses collected using mobile apps versus other methods

BACKGROUND

Self-administered survey questionnaires are an important data collection tool in clinical practice, public health research and epidemiology. They are ideal for achieving a wide geographic coverage of the target population, dealing with sensitive topics and are less resource-intensive than other data collection methods. These survey questionnaires can be delivered electronically, which can maximise the scalability and speed of data collection while reducing cost. In recent years, the use of apps running on consumer smart devices (i.e., smartphones and tablets) for this purpose has received considerable attention. However, variation in the mode of delivering a survey questionnaire could affect the quality of the responses collected.

OBJECTIVES

To assess the impact that smartphone and tablet apps as a delivery mode have on the quality of survey questionnaire responses compared to any other alternative delivery mode: paper, laptop computer, tablet computer (manufactured before 2007), short message service (SMS) and plastic objects.

SEARCH METHODS

We searched MEDLINE, EMBASE, PsycINFO, IEEEXplore, Web of Science, CABI: CAB Abstracts, Current Contents Connect, ACM Digital, ERIC, Sociological Abstracts, Health Management Information Consortium, the Campbell Library and CENTRAL. We also searched registers of current and ongoing clinical trials such as ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform. We also searched the grey literature in OpenGrey, Mobile Active and ProQuest Dissertation & Theses. Lastly, we searched Google Scholar and the reference lists of included studies and relevant systematic reviews. We performed all searches up to 12 and 13 April 2015.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs), crossover trials and paired repeated measures studies that compared the electronic delivery of self-administered survey questionnaires via a smartphone or tablet app with any other delivery mode. We included data obtained from participants completing health-related self-administered survey questionnaire, both validated and non-validated. We also included data offered by both healthy volunteers and by those with any clinical diagnosis. We included studies that reported any of the following outcomes: data equivalence; data accuracy; data completeness; response rates; differences in the time taken to complete a survey questionnaire; differences in respondent's adherence to the original sampling protocol; and acceptability to respondents of the delivery mode. We included studies that were published in 2007 or after, as devices that became available during this time are compatible with the mobile operating system (OS) framework that focuses on apps.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies using a standardised form created for this systematic review in REDCap. They then compared their forms to reach consensus. Through an initial systematic mapping on the included studies, we identified two settings in which survey completion took place: controlled and uncontrolled. These settings differed in terms of (i) the location where surveys were completed, (ii) the frequency and intensity of sampling protocols, and (iii) the level of control over potential confounders (e.g., type of technology, level of help offered to respondents). We conducted a narrative synthesis of the evidence because a meta-analysis was not appropriate due to high levels of clinical and methodological diversity. We reported our findings for each outcome according to the setting in which the studies were conducted.

MAIN RESULTS

We included 14 studies (15 records) with a total of 2275 participants; although we included only 2272 participants in the final analyses as there were missing data for three participants from one included study.Regarding data equivalence, in both controlled and uncontrolled settings, the included studies found no significant differences in the mean overall scores between apps and other delivery modes, and that all correlation coefficients exceeded the recommended thresholds for data equivalence. Concerning the time taken to complete a survey questionnaire in a controlled setting, one study found that an app was faster than paper, whereas the other study did not find a significant difference between the two delivery modes. In an uncontrolled setting, one study found that an app was faster than SMS. Data completeness and adherence to sampling protocols were only reported in uncontrolled settings. Regarding the former, an app was found to result in more complete records than paper, and in significantly more data entries than an SMS-based survey questionnaire. Regarding adherence to the sampling protocol, apps may be better than paper but no different from SMS. We identified multiple definitions of acceptability to respondents, with inconclusive results: preference; ease of use; willingness to use a delivery mode; satisfaction; effectiveness of the system informativeness; perceived time taken to complete the survey questionnaire; perceived benefit of a delivery mode; perceived usefulness of a delivery mode; perceived ability to complete a survey questionnaire; maximum length of time that participants would be willing to use a delivery mode; and reactivity to the delivery mode and its successful integration into respondents' daily routine. Finally, regardless of the study setting, none of the included studies reported data accuracy or response rates.

AUTHORS' CONCLUSIONS

Our results, based on a narrative synthesis of the evidence, suggest that apps might not affect data equivalence as long as the intended clinical application of the survey questionnaire, its intended frequency of administration and the setting in which it was validated remain unchanged. There were no data on data accuracy or response rates, and findings on the time taken to complete a self-administered survey questionnaire were contradictory. Furthermore, although apps might improve data completeness, there is not enough evidence to assess their impact on adherence to sampling protocols. None of the included studies assessed how elements of user interaction design, survey questionnaire design and intervention design might influence mode effects. Those conducting research in public health and epidemiology should not assume that mode effects relevant to other delivery modes apply to apps running on consumer smart devices. Those conducting methodological research might wish to explore the issues highlighted by this systematic review.

Self-directed interventions to promote weight loss: a systematic review of reviews

Background

A wide range of self-directed weight-loss interventions are available, providing users with a variety of tools delivered through various formats to regulate weight-related behavior patterns. However, it is unclear how effective self-directed interventions are and how they promote weight loss and weight maintenance.

Objective

A systematic review of reviews was conducted to examine the effectiveness of such interventions and to identify intervention content associated with effectiveness.

Methods

MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Library for systematic reviews were searched from 2000-2012 for reviews of the effectiveness of self-directed interventions on weight loss and weight maintenance in adults. Two reviewers used predefined inclusion criteria to select relevant reviews and assess their quality using the Overview Quality Assessment Questionnaire (OQAQ). We extracted data on effectiveness and on relationships between intervention characteristics and effectiveness.

Results

Twenty reviews were included and quality assessed. Findings relevant to self-directed interventions, including interactive websites, smartphone applications, and text messaging (short message service, SMS) were summarized. Findings were mixed but promising. For example, one review of Internet-based interventions found that, when used in conjunction with standard weight loss programs, these interventions resulted in a significant average increase in weight loss of 1.5 kg over evaluation periods. Unfortunately, only 7 of 20 reviews were of high methodological quality according to OQAQ scores, and only 4 employed meta-analyses. Few reviews linked intervention content to effectiveness.

Conclusions

Current evidence suggests that self-directed interventions can independently promote weight loss and can augment interventions involving personal contact. Particular change techniques and delivery modes including individualized feedback, email counseling, and online social support appear to enhance effectiveness. Further reviews of the content of self-directed weight-loss intervention studies are needed to clarify which change techniques delivered through which delivery formats optimize intervention effectiveness.

Digital photography as an educational food logging tool in obese patients with type 2 diabetes: lessons learned from a randomized, crossover pilot trial

PURPOSE

The purpose of this pilot study is to investigate the utility of, and areas of refinement for, digital photography as an educational tool for food logging in obese patients with type 2 diabetes (T2DM).

METHODS

Thirty-three patients aged 18 to 70 with T2DM, body mass index at least 30 kg/m(2), and A1C 7.5% to 9% were recruited from an endocrinology clinic and randomized to a week of food logging using a digital camera (DC) or paper diary (PD), crossing over for week 2. Patients then viewed a presentation about dietary effects on blood glucose, using patient DC and blood glucose entries. Outcomes of adherence (based on number of weekly entries), changes in mean blood glucose and frequency of blood glucose checks, and patient satisfaction were compared between methods. Patient feedback on the DC intervention and presentation was also analyzed.

RESULTS

Thirty patients completed the study. Adherence was identical across methods. The mean difference in number of entries was not significant between methods. This difference increased and neared statistical significance (favoring DC) among patients who were adherent for at least 1 week (21 entries, with 2 entries per day for 5 of 7 days, n = 25). Mean blood glucose did not significantly decrease in either method. Patient satisfaction was similar between interventions. Feedback indicated concerns over photograph accuracy, forgetting to use the cameras, and embarrassment using them in public.

CONCLUSION

Although the DC method was comparable to PD in adherence, blood glucose changes, and patient satisfaction in this pilot trial, patient feedback suggested specific areas of refinement to maximize utility of DC-based food logging as an educational tool in T2DM.

The effect of a reminder diary on risk factors in patients with chronic hypertension attending a clinic at a hospital in Johannesburg, South Africa

Background

Poor adherence to lifestyle interventions and medication-taking is problematic, and there is some evidence that a diary may be useful in facilitating patients’ adherence to lifestyle modification in chronic disease.

Objectives

To compare changes in blood pressure, waist–hip ratio, body mass index, blood levels and exercise capacity between two experimental groups and one control group (CG) after a six month intervention, and at a further three month follow up.

Method

This was a longitudinal randomised control trial. All three groups underwent usual treatment. In addition, Experimental group one (EG1) received the diary as well as a once-a-month telephone call and Experimental group two (EG2) received only a once-a-month telephone call. Changes in measurements were established using an ANCOVA. The significance of the study was set at p = 0.05.

Results

The added intervention of the diary had no direct effect on blood pressure change greater than that achieved by the appropriate medication. All three groups showed a clinically significant drop in both systolic and diastolic blood pressure to accepted norms. There were marginal differences in EG1 for waist–hip ratios (p = 0.06) at six months. There were significant low density lipoprotein (LDL) reductions in both EG1 and EG2 at nine months compared with the CG (p = 0.02) Walking distances improved minimally in both EG1 and EG2.

Conclusion

The diary and telephone interventions showed some positive trends toward improvements in risk factors of patients with chronic hypertension.

Dietary assessment and self-monitoring with nutrition applications for mobile devices

Nutrition applications for mobile devices (e.g., personal digital assistants, smartphones) are becoming increasingly accessible and can assist with the difficult task of intake recording for dietary assessment and self-monitoring. This review is a compilation and discussion of research on this tool for dietary intake documentation in healthy populations and those trying to lose weight. The purpose is to compare this tool with conventional methods (e.g., 24-hour recall interviews, paper-based food records). Research databases were searched from January 2000 to April 2011, with the following criteria: healthy or weight loss populations, use of a mobile device nutrition application, and inclusion of at least one of three measures, which were the ability to capture dietary intake in comparison with conventional methods, dietary self-monitoring adherence, and changes in anthropometrics and/or dietary intake. Eighteen studies are discussed. Two application categories were identified: those with which users select food and portion size from databases and those with which users photograph their food. Overall, positive feedback was reported with applications. Both application types had moderate to good correlations for assessing energy and nutrient intakes in comparison with conventional methods. For self-monitoring, applications versus conventional techniques (often paper records) frequently resulted in better self-monitoring adherence, and changes in dietary intake and/or anthropometrics. Nutrition applications for mobile devices have an exciting potential for use in dietetic practice.

The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review

BACKGROUND

Mobile technologies could be a powerful media for providing individual level support to health care consumers. We conducted a systematic review to assess the effectiveness of mobile technology interventions delivered to health care consumers.

METHODS AND FINDINGS

We searched for all controlled trials of mobile technology-based health interventions delivered to health care consumers using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990-Sept 2010). Two authors extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and used random effects meta-analysis. We identified 75 trials. Fifty-nine trials investigated the use of mobile technologies to improve disease management and 26 trials investigated their use to change health behaviours. Nearly all trials were conducted in high-income countries. Four trials had a low risk of bias. Two trials of disease management had low risk of bias; in one, antiretroviral (ART) adherence, use of text messages reduced high viral load (>400 copies), with a relative risk (RR) of 0.85 (95% CI 0.72-0.99), but no statistically significant benefit on mortality (RR 0.79 [95% CI 0.47-1.32]). In a second, a PDA based intervention increased scores for perceived self care agency in lung transplant patients. Two trials of health behaviour management had low risk of bias. The pooled effect of text messaging smoking cessation support on biochemically verified smoking cessation was (RR 2.16 [95% CI 1.77-2.62]). Interventions for other conditions showed suggestive benefits in some cases, but the results were not consistent. No evidence of publication bias was demonstrated on visual or statistical examination of the funnel plots for either disease management or health behaviours. To address the limitation of the older search, we also reviewed more recent literature.

CONCLUSIONS

Text messaging interventions increased adherence to ART and smoking cessation and should be considered for inclusion in services. Although there is suggestive evidence of benefit in some other areas, high quality adequately powered trials of optimised interventions are required to evaluate effects on objective outcomes.

Interactive computer-based interventions for weight loss or weight maintenance in overweight or obese people

BACKGROUND

The World Health Organization (WHO) estimates that the number of obese or overweight individuals worldwide will increase to 1.5 billion by 2015. Chronic diseases associated with overweight or obesity include diabetes, heart disease, hypertension and stroke.

OBJECTIVES

To assess the effects of interactive computer-based interventions for weight loss or weight maintenance in overweight or obese people.

SEARCH METHODS

We searched several electronic databases, including CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS and PsycINFO, through 25 May 2011. We also searched clinical trials registries to identify studies. We scanned reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Studies were included if they were randomized controlled trials or quasi-randomized controlled trials that evaluated interactive computer-based weight loss or weight maintenance programs in adults with overweight or obesity. We excluded trials if the duration of the intervention was less than four weeks or the loss to follow-up was greater than 20% overall.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted study data and assessed risk of bias. Where interventions, control conditions, outcomes and time frames were similar between studies, we combined study data using meta-analysis.

MAIN RESULTS

We included 14 weight loss studies with a total of 2537 participants, and four weight maintenance studies with a total of 1603 participants. Treatment duration was between four weeks and 30 months. At six months, computer-based interventions led to greater weight loss than minimal interventions (mean difference (MD) -1.5 kg; 95% confidence interval (CI) -2.1 to -0.9; two trials) but less weight loss than in-person treatment (MD 2.1 kg; 95% CI 0.8 to 3.4; one trial). At six months, computer-based interventions were superior to a minimal control intervention in limiting weight regain (MD -0.7 kg; 95% CI -1.2 to -0.2; two trials), but not superior to infrequent in-person treatment (MD 0.5 kg; 95% -0.5 to 1.6; two trials). We did not observe consistent differences in dietary or physical activity behaviors between intervention and control groups in either weight loss or weight maintenance trials. Three weight loss studies estimated the costs of computer-based interventions compared to usual care, however two of the studies were 11 and 28 years old, and recent advances in technology render these estimates unlikely to be applicable to current or future interventions, while the third study was conducted in active duty military personnel, and it is unclear whether the costs are relevant to other settings. One weight loss study reported the cost-effectiveness ratio for a weekly in-person weight loss intervention relative to a computer-based intervention as USD 7177 (EUR 5678) per life year gained (80% CI USD 3055 to USD 60,291 (EUR 2417 to EUR 47,702)). It is unclear whether this could be extrapolated to other studies. No data were identified on adverse events, morbidity, complications or health-related quality of life.

AUTHORS' CONCLUSIONS

Compared to no intervention or minimal interventions (pamphlets, usual care), interactive computer-based interventions are an effective intervention for weight loss and weight maintenance. Compared to in-person interventions, interactive computer-based interventions result in smaller weight losses and lower levels of weight maintenance. The amount of additional weight loss, however, is relatively small and of brief duration, making the clinical significance of these differences unclear.

The effect of computers for weight loss: a systematic review and meta-analysis of randomized trials

BACKGROUND

The use of computers to deliver education and support strategies has been shown to be effective in a variety of conditions. We conducted a systematic review and meta-analysis to evaluate the impact of computer-based technology on interventions for reducing weight.

METHODS

We searched MEDLINE, CENTRAL, CINAHL, PsycINFO, Google Scholar and ClinicalTrials.gov (all updated through June 2010) for randomized controlled trials evaluating the effect of computer-based technology on education or support interventions aimed at reducing weight in overweight or obese adults. We calculated weighted mean differences (WMD) and 95% confidence intervals (CI) using random effects models.

RESULTS

Eleven trials with 13 comparisons met inclusion criteria. Based on six comparisons, subjects who received a computer-based intervention as an addition to the standard intervention given to both groups lost significantly more weight (WMD -1.48 kg, 95% CI -2.52, -0.43). Conversely, based on six comparisons, subjects for whom computer-based technology was substituted to deliver an identical or highly comparable intervention to that of the control group lost significantly less weight (WMD 1.47 kg, 95% CI 0.13, 2.81). Significantly different weight loss seen in "addition" comparisons with less than six months of follow-up (WMD -1.95 kg, 95% CI -3.50, -0.40, two comparisons) was not seen in comparisons with longer follow-up (-1.08 kg, 95% CI -2.50, 0.34, four comparisons). Analyses based on quality and publication date did not substantially differ.

CONCLUSIONS

While the addition of computer-based technology to weight loss interventions led to statistically greater weight loss, the magnitude (<1.5 kg) was small and unsustained.

Physical activity self-monitoring and weight loss: 6-month results of the SMART trial

INTRODUCTION

Weight loss has been associated with higher physical activity (PA) levels and frequent dietary self-monitoring. Less is known about how PA self-monitoring affects adherence to PA goals, PA levels, and weight change.

METHODS

The SMART Trial is a clinical weight loss trial in which 210 overweight adults were randomized equally to one of three arms: 1) paper record (PR), 2) personal digital assistant with self-monitoring software (PDA), and 3) PDA with daily tailored feedback message (PDA + FB). PA self-monitoring and adherence to PA goals were based on entries in weekly submitted diaries. PA levels were measured via self-report by the past 6-month Modifiable Activity Questionnaire at baseline and 6 months.

RESULTS

Data are presented on 189 participants with complete 6-month PA data (84% female, 77% white, mean age = 47.3 ± 8.8 yr, mean body mass index = 34.1 ± 4.5 kg·m(-2)). Median PA level was 7.96 MET·h·wk(-1) at baseline and 13.4 MET·h·wk(-1) at 6 months, with significant PA increases in all three arms. PDA + FB arm had a higher mean number of weekly self-monitoring entries than the PR arm (3.4 vs 2.4, P = 0.003) and were more likely to maintain high (i.e., 100%) adherence to PA goals over time than the PDA (P = 0.02) or PR arms (P = 0.0003). Both PA self-monitoring and adherence to PA goals were related to higher PA levels at 6 months. A higher mean rate of PA self-monitoring was associated with a greater percentage of weight decrease (ρ = -0.49, P < 0.0001) at 6 months.

CONCLUSIONS

PA self-monitoring and adherence to PA goals were more likely in participants in the PDA + FB arm and in turn predicted higher PA levels and weight loss.

Lose It!

Lose It! is a web-based, food and exercise diary application, assisting its users in weight control. It is part of a growing form of information technology developed to transform self-care through influencing individual care behaviors and impacting on lifestyle changes. Future implications for the development of such electronic tools require research into the connection of key variables dictated by the relevant theoretical body of knowledge and the translation of such knowledge to practice.

Self-monitoring in weight loss: a systematic review of the literature

Self-monitoring is the centerpiece of behavioral weight loss intervention programs. This article presents a systematic review of the literature on three components of self-monitoring in behavioral weight loss studies: diet, exercise, and self-weighing. This review included articles that were published between 1993 and 2009 that reported on the relationship between weight loss and these self-monitoring strategies. Of the 22 studies identified, 15 focused on dietary self-monitoring, one on self-monitoring exercise, and six on self-weighing. A wide array of methods was used to perform self-monitoring; the paper diary was used most often. Adherence to self-monitoring was reported most frequently as the number of diaries completed or the frequency of log-ins or reported weights. The use of technology, which included the Internet, personal digital assistants, and electronic digital scales were reported in five studies. Descriptive designs were used in the earlier studies whereas more recent reports involved prospective studies and randomized trials that examined the effect of self-monitoring on weight loss. A significant association between self-monitoring and weight loss was consistently found; however, the level of evidence was weak because of methodologic limitations. The most significant limitations of the reviewed studies were the homogenous samples and reliance on self-report. In all but two studies, the samples were predominantly white and women. This review highlights the need for studies in more diverse populations, for objective measures of adherence to self-monitoring, and for studies that establish the required dose of self-monitoring for successful outcomes.