A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/245728
Review Bariatric Times • January 2014 Augmenting Weight Loss Using Technology by JENNIFER ARUSSI, MS, RD 9 You Exer r Food a TOD cise Tra nd Lunc AY'S ME cker ALS Gard h: • Aru en Salad tomo gula, yel light to, olive low pepp s, olive er oil d 1Tbsp. , ress TOD ing Walk AY'S EX Calo ing: 3 m ERCISE ries i Burn les. ed: 3 00 Bariatric Times. 2014;11(1):9–11. ABSTRACT Comparison studies have shown a significant association between the practice of selfmonitoring 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. KEYWORDS weight loss, bariatric surgery, postoperative, self-monitoring, behavior modification, technology, obesity Conitued from page 1 A meta-analysis published in the Journal of American Dietetic Association reviewed the effectiveness of dietary selfmonitoring 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 selfmonitoring 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 correctly14; 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 al20 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 selfmonitored 80 to 90 percent of the time, compared to their paper recorder counterparts who selfmonitored 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 selfmonitoring compliance shows promise and parallels perfectly with our technology-focused culture. Once patients learn how to selfmonitor 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 al24 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