New and Emerging Weight Management Strategies for Busy Ambulatory Settings
A Scientific Statement From the American Heart AssociationEndorsed by the Society of Behavioral Medicine
Recent data from the Centers for Disease Control and Prevention show that a staggering 68% of American adults are either overweight or obese, and 34% are obese.1 Although there is evidence that its prevalence is stabilizing, obesity remains an extremely serious public health problem. It is a major risk factor for a wide range of medical (eg, type 2 diabetes mellitus), social (eg, discrimination in employment and education settings), and psychological (eg, depression) conditions.2
Although the effectiveness of different obesity treatments has been evaluated systematically,3 rational, safe, and effective treatments from which the majority of overweight and obese patients can benefit remain elusive. New medications are emerging, but their impact on weight loss has been modest, and their long-term adverse effects are uncertain.4 Bariatric surgery is effective but expensive and is appropriate only for a small proportion of patients in whom the benefits outweigh the risks. Effective and safe commercial and noncommercial behavior modification programs are scarce. Changes in public policy and the “built environment”5 may curb obesity, but such changes take a long time to bring about, and the magnitude of their impact has yet to be established clearly. A recent review, for example, concluded that soft drink taxes have only a small impact on a population's average body mass index (BMI).6
It is widely acknowledged that no single strategy will solve the obesity problem and that effective public health initiatives to prevent and treat obesity will require the involvement of multiple stakeholders, including patients, employers, health plans, governments at all levels, the food and beverage industries, and healthcare providers.7,8 Among these healthcare providers are those who deliver care in busy ambulatory settings, including primary care physicians, nurse practitioners, nurses, registered dietitians, and others. Screening and counseling for obesity in such settings is widely recommended.9,10 Unfortunately, there is ample evidence that physicians and other healthcare professionals are poorly equipped to tackle the problem. A survey conducted in 2006 revealed, for example, that only 65% of obese patients were advised to lose weight by their physicians.11 A lack of knowledge, skills, and practical tools have all been identified repeatedly as barriers to the identification and management of obesity by healthcare professionals.12–14
The purpose of this statement is to provide an overview of new and emerging tools and strategies for discussing weight and assisting overweight and obese patients. Only tools and strategies that can be used practically in busy ambulatory settings are included. The goal is to provide clinicians with evidence-based strategies to tackle the problem of obesity in settings in which patients are seen for a wide variety of problems. Before using such strategies, of course, it is important to assess patients for overweight and obesity, a critical step that is addressed in another pending American Heart Association scientific statement on assessment of adiposity.14a On the basis of our literature review, we have divided strategies into 3 categories: (1) appropriate ways of discussing body weight with patients (including readiness to change); (2) approaches that involve multidisciplinary collaboration among healthcare professionals; and (3) strategies that make use of information technology to deliver weight management programs. Although many weight management approaches that make use of technology have not been evaluated in busy ambulatory settings, we believe technological approaches should be included in the present statement because they have the potential to impact large numbers of participants and are relatively easy to recommend, administer, or refer to in such settings.
1. Discussing Weight With Patients
This section includes a review of existing evidence about (1) acceptable methods for raising and discussing the issue of weight, (2) practical methods of assessing readiness to change and motivation for attaining a healthier weight, and (3) practical strategies for assessment of eating and physical activity behaviors in busy settings.
We searched for articles that explicitly described strategies for discussing weight with patients. Search terms including “physician-patient relations” OR “primary care” etc AND “communication” OR “counseling” etc were used in combination with “obesity” OR “weight loss” to identify relevant studies in the following databases: PubMed, EMBASE, CINAHL, PsycINFO, Cochrane CENTRAL, and the New York Academy of Medicine Grey Literature Collection. We searched only for reports published from 2002 through November 2010.
We retrieved 157 unique citations from PubMed and 59 from EMBASE, with no other unique citations indentified in the other databases. The vast majority of these reports were not relevant. Citations not reviewed included descriptive studies of the perspectives and practices of providers (eg, perceived barriers to weight management in primary care, patients' recall about receiving weight management advice). Other reports not reviewed described strategies for discussing weight that we considered too time consuming and impractical for busy clinical settings. We reviewed 23 reports in depth (Table 1).
Raising and Discussing Weight: Studies of Patient Preferences
Several studies reported patient preferences for discussing weight management. Patients described the need for empathy, nonjudgmental interactions, and specific personalized recommendations.15,18,23,31 A descriptive survey of 25 female family medicine clinic patients found that when physicians demonstrated more empathy, as rated by 2 independent coders on a scale of 1 (low) to 7 (high), patients were significantly more likely to report changing their exercise behaviors 1 month later.23 In general, published reports emphasized the need for communication between the provider and patient to be nonjudgmental to avoid feelings of blame and stigma.18 Some patients associate even the word “obese” with discrimination.31 A survey of patients seeking weight loss treatment asked respondents to rate the desirability of 12 terms to describe excess weight.32 Physicians were asked to report which of the terms they most often used during clinical encounters. Patients rated “‘weight” as the most desirable term, and “fatness” as the most undesirable term. Fortunately, physicians were most likely to use “weight” and least likely to use “fatness.” Dutton et al32 concluded that the use of desirable and respectful terms and the avoidance of terms known to be offensive improves the quality of communication about obesity and weight loss. Patients also express a preference for clinicians taking time to deliver weight loss counseling, rather than offering weight loss advice as an afterthought as they leave the room.31 The importance of verbally recognizing patients' small weight losses as well as their unsuccessful weight management efforts was also noted, because nonrecognition by providers was seen as a judgment that the patient did not care or was not making an effort toward weight loss.31
Patients expressed an interest in hearing about how their weight was affecting their specific medical conditions (or risk for conditions) and an interest in receiving specific recommendations from the individual provider on how to lose weight rather than just broad statements about the need to lose weight.15,18,31 Finally, physician recommendations related to diet and physical activity were more effective (ie, associated with greater likelihood of patient behavior change) if patients were given the chance to reflect on causes of their overweight during counseling visits and their own perceptions about weight management were incorporated into the recommendations.29
Studies Describing Specific Strategies for Discussing Weight
Beginning a conversation about weight is challenging. The discussion may be especially difficult if there are no readily available and affordable resources for patients genuinely interested in losing weight. The US Preventive Services Task Force recommends a framework for counseling known as the 5 A's (ask, advise, assess, assist, and arrange) to assist physicians in primary care to effectively begin the conversation about health behavior change and provide assistance.33 Use of this paradigm by physicians has been shown to improve patient outcomes in smoking cessation in part by noting the behavior as a health risk and advising that the patient take action to stop smoking.34 An adaptation of the 5 A's for obese patients includes assessment of patient health risk, assessment of current behavior and readiness to change, advising the patient to change specific behaviors, agreeing about the behaviors and collaboratively setting goals, assisting patients in addressing barriers and securing support, and arranging for follow-up.27,33 In a recently published randomized controlled trial (RCT), internal medicine residents were randomized either to receive training in the 5 A's obesity counseling curriculum or not and then to utilize the strategy with obese patients.33 Results revealed that the majority of obese patients of residents who received training acknowledged that they had been counseled. Evaluation of the counseling provided, however, revealed that residents in the intervention group did not address most of the 5 A's. Furthermore, there were no actually significant differences in obesity counseling rates between residents in the intervention and control groups. This result may indicate the impracticality of the 5 A's when implemented in a manner that relies entirely on physicians without infrastructure supports or help from other professionals. Counseling about obesity is likely more complex and time-consuming than smoking cessation counseling. Even among studies that demonstrate the effectiveness of the 5 A's paradigm for smoking cessation counseling by primary care physicians, physicians were more likely to complete the “ask” and “advise” steps and less likely to complete the remaining steps.35
A descriptive study by Scott et al26 supported the usefulness of encouraging patients themselves to make weight management a priority with their physicians. In 633 clinical encounters, excess weight was mentioned in 17% of visits with overweight and obese adults, and weight loss counseling occurred with 11% of overweight and obese adults. In encounters that included counseling, patients formulated weight management as a problem by making it a reason for the visit or explicitly or implicitly asking for help with the weight loss, or physicians framed weight as a medical problem itself or one that contributed to another existing medical problem. The authors concluded that strategies that increase the likelihood of patients themselves identifying weight as a problem or that provide clinicians with a way to “medicalize” the patient's weight are most likely to increase the frequency of weight loss counseling in primary care visits.
Assessing Readiness to Change and Motivation
A qualitative study of 43 obese blacks revealed that patients believe providers should ask whether they want to lose weight and whether they believe they are ready to make changes to promote weight loss.31 Methods for assessing patients' readiness to address weight management behaviors were described in several studies16,17,19,21,23,24 and were based on Prochaska and DiClemente's stages of change: precontemplation, contemplation, preparation, action, and maintenance.38 A simple 5-item questionnaire was used in a descriptive study of 210 patients attending 2 primary care clinics in Louisiana, in which patients were asked to choose which of 5 statements best described their readiness for weight loss: “I have not really thought about it” (precontemplation), “I mean to lose weight but I don't actually get around to it” (contemplation), “From time to time, I go on a diet/exercise, but then I stop after a few days” (preparation), “I have been working on losing weight for the past 6 months” (action), or “I have been working on losing weight for over 6 months, or I have kept my weight I lost off for over 6 months” (maintenance).21 Patients who were in the latter 4 stages of readiness were more likely to recall having received counseling for weight loss than those in the precontemplation stage. Similar results have been found by Simkin-Silverman and colleagues.24 These findings suggest that although assessing readiness to change adds an extra step in caring for overweight and obese adults, it is a useful indicator of whether any accompanying weight loss counseling will be recalled by the patient. A patient who at least recalls weight loss counseling is better equipped to take steps toward weight loss than one who does not.
Motivational interviewing is a brief, evidence-based intervention derived from a social cognitive theoretical framework. It is designed to increase a patient's motivation to change problematic and often long-standing health behaviors. Motivational interviewing strategies have been adapted for use in healthcare settings and are designed to work with the stages-of-change framework.39,40 There is evidence for the efficacy of motivational interviewing in promoting weight loss.41 What follows is a general description of the strategy. Depending on a patient's self-reported readiness to change (based on the questions above or alternatively on a 10-point scale), there are predetermined steps a clinician can take to increase motivation and encourage change. For example, the goal for a provider with a precontemplative patient is to increase the patient's awareness of the need to change by providing personalized information and feedback about weight and health risks. An additional aim is to encourage the patient to continue to think about making some changes and, with the patient's permission, arrange for a follow-up visit to continue the conversation. For patients in the contemplation stage, the provider's goal is to enhance patient motivation and sense of self-efficacy about his or her efforts to change. Self-efficacy is defined as people's beliefs about their capabilities to produce designated levels of performance that exert influence over events that affect their lives.42 The patient's self-efficacy can be enhanced by eliciting perceived benefits of change, exploring concerns and fears about change, clarifying misconceptions, offering information with permission, and expressing empathy and support. Once a patient has moved into the preparation, action, or maintenance stage, recognition of their effort and success is very important, as is relating weight loss to improvements in indicators of health such as blood pressure or blood sugar.
Assessing Eating and Physical Activity Behaviors
Efficient and accurate assessment of eating and physical activity behaviors in busy clinical settings is necessary to guide weight management. Tools such as 24-hour dietary recalls, food frequency questionnaires, and food/exercise diaries have been used to assess diet and activity, especially in research studies.28,36,43 These tools, however, are generally not practical for fast-paced settings because they are time consuming to administer and analyze and sometimes require specially trained personnel. Greenwood and colleagues20 developed a 14-item questionnaire for use in the clinical setting to screen patients' eating and physical activity behaviors. Domains of the questionnaire relate to restaurant and fast food consumption, sugar-added beverage intake, fruit and vegetable intake, breakfast intake, restaurant meal portion size consumption, and whether physical activity (defined as at least moderate-intensity activity for ≥30 minutes) in the past week and a typical week took place.20 The validity of the tool is supported by strong associations between specific behaviors and obesity. Among 261 majority female (54%) and white (80%) family medicine clinic patients, typical consumption of sugar-sweetened beverages was associated with a higher BMI, eating a full-size portion of a restaurant meal was associated with the likelihood of being obese, and the odds of obesity and overweight were lower with at least 30 minutes a day of moderate-intensity activity and consumption of vegetables and/or fruits >3 times a day.20
Other practical tools to assess diet include the 8-item Eating Pattern Questionnaire recommended by the American Medical Association,44,45 the 8-item Starting the Conversation tool,22 the 17-item Quick WAVE (Weight, Activity, Variety, and Excess) Screener,37 and the 16-item Rapid Eating Assessment for Participants–Short Version (REAP-S).25 The Eating Pattern Questionnaire assesses behaviors such as how an individual's food is typically prepared (eg, baked, broiled), frequency of eating outside the home, favorite snack foods, and typical daily frequency of starches, fruits, vegetables, dairy, meat, fats, and sweets.44 The Starting the Conversation tool is a brief screening tool developed for nondietitian professionals and asks about, for example, consumption of fast foods, fruits and vegetables, regular soda, margarine or butter, and desserts over the previous few months. It correlates significantly with the National Cancer Institute's Percent Energy From Fat screener and is available in English or Spanish.22 The Quick WAVE Screener was initially developed as a pocket guide. The WAVE uses items in the Behavioral Risk Factor Surveillance System and the Paffenbarger Physical Activity Questionnaire46 to address 4 key assessment areas (weight, physical activity, dietary variety, and excess)47 and has evolved into a 17-item tool that can be completed in 5 to 10 minutes. The assessment of these 4 areas includes questions about, for example, where excess body weight is concentrated, sedentary and activity behaviors, the variety of healthful (eg, fruits and vegetables) and unhealthful (eg, candy bars, sugared sodas) foods consumed, and excess food consumption during stressful times.37 Written at a fifth-grade reading level, the REAP-S was designed to help providers quickly assess dietary behaviors as part of the routine history and physical examination and includes items to evaluate intake of whole grains, foods high in calcium, vegetables and fruits, fat and cholesterol, sugar, sodium, and alcohol.48 The REAP-S has been validated with the Block 1998 Food Frequency Questionnaire.49 It is a shorter and lower literacy version of a 31-item questionnaire that also asked about physical activity.44
Initial discussions about weight management with patients should be respectful, nonjudgmental, and delivered in an unhurried fashion. The term “weight” should be used rather than “obese” or objectionable terms such as “fatness.” Counseling should always include a description of the medical consequences of obesity. The 5 A's paradigm for delivering counseling is simple and practical but has not yet been successfully incorporated into busy clinical settings in a way that improves the quality of counseling.
A patient's stage of readiness to change can be assessed with a simple 5-item questionnaire. Assessment should be accompanied by systematic motivational interviewing, the content of which is tailored for the individual patient's readiness to change.
Several simple tools are available for the accurate assessment of diet and physical activity behaviors that contribute to obesity. These include 8- to 17-item questionnaires that can be completed by patients in a limited amount of time.
2. Collaborative Approaches
We defined a collaborative approach as a strategy or set of strategies to help patients achieve and/or maintain a healthy weight that involve collaboration among healthcare professionals in at least 2 different disciplines (eg, physicians and dieticians) for the delivery of weight management interventions. We considered interventions that do not significantly disrupt the usual processes of health care in busy practices and that included at least 1 meaningful outcome such as change in dietary behavior or change in weight.
Terms including “cooperative behavior,” “collaborative intervention,” and “chronic care model” in combination with the terms “obesity” or “obese” were used to search the following databases: PubMed, EMBASE, CINAHL, PsycINFO, Cochrane CENTRAL, and the New York Academy of Medicine Grey Literature. Only articles published from 2002 through November 2010 were reviewed.
One hundred thirty-four citations were retrieved, the vast majority of which did not meet our inclusion criteria. Many reports described approaches that were not truly collaborative (eg, physicians simply referring to a weight management program, with no joint responsibility for providing or coordinating obesity care) or involved interventions that we considered too time consuming, expensive, and inconvenient for busy clinical settings. Only 4 reports met our criteria (Table 2).
The Counterweight Programme is a centrally planned, locally implemented primary care weight management program developed in the United Kingdom.54 Sixty-two primary care practices were recruited initially. Seven weight management advisors facilitated implementation. The program included 4 phases: audit and needs assessment; practice support and training; patient intervention; and evaluation. General practitioners and practice nurses both received training and collaborated to deliver the program. General practitioners were responsible for raising the issue of weight, assessing motivation, and monitoring progress, as well as prescribing medications when needed. Practice nurses completed an extensive 6- to 8-hour training program that included skills in goal setting and assisting patients with self-monitoring, stimulus control, cognitive restructuring, nutrition education, and relapse management. Practice nurses were encouraged to see patients for six 10- to 30-minute appointments for the first 3 months followed by quarterly visits. A recent evaluation of the program revealed a mean weight change for participants of −3 kg after 12 months and −2.3 kg after 24 months. The cost to deliver the program was roughly $90 per participant.50 The program has not been systematically compared with a control intervention.
Feigenbaum et al51 described a 6-month, 3-arm program in which (A) patients received counseling by a family physician and dietician every 2 weeks along with orlistat, or (B) monthly meetings with a family physician only with orlistat treatment, or (C) monthly meetings with a dietician only with no drug treatment. Physicians received training in obesity management. All patients received a personal diet and individualized nutrition and physical activity goals at each visit. Patients in arm A met first with a family physician who described the program, then with a dietician. In follow-up sessions, the physician and dietician met jointly with each patient. Counseling by physicians was limited to discussing the use of orlistat and its side effects. Fifty-one percent of patients in arm A lost at least 5% of their starting weight compared with 13% and 9% of patients in arms B and C, respectively. Patients in arms A and B also demonstrated significant improvement in triglyceride and low-density lipoprotein cholesterol levels.
The Reasonable Eating and Activity to Change Health (REACH) trial was a 24-month, randomized 2-armed study performed in 15 primary care practices.52 Participants in the augmented usual-care group were asked to provide dietary and exercise data every 6 months. They received 10 minutes of dietary counseling at each visit. Participants assigned to the transtheoretical model/chronic disease group received the same care as the augmented usual-care group together with formal assessments for anxiety, depression, and binge eating every 6 months and “stages of change” assessment of physical activity, portion control, dietary fat, and fruit and vegetable consumption every 2 months. Assessments were reviewed by a weight loss advisor who provided individualized telephone counseling monthly. Physicians received reports that summarized the progress of patients in the transtheoretical model/chronic disease group, as well as training on how to make use of the stages-of-change profiles and a stages-of-change flip chart for counseling during patients' routine visits. After 24 months, there was no appreciable mean weight loss in either group and no statistically significant mean change in weight between the 2 groups.
Ely et al53 performed a 6-month, 2-armed trial in 3 rural practices in which a usual-care arm was compared with a strategy that included elements of the chronic care model. Chronic care model elements included clinical information systems in the form of an electronic registry that updated physicians on patients' progress and readiness to change behaviors. Physicians also received decision support in the form of National Institutes of Health obesity guidelines. Self-management support took the form of weight loss materials, pedometers, and diet/activity diaries. The primary counseling intervention used motivational interviewing and was delivered by trained counselors by telephone. Topics included relationship with food and body image, as well as dietary and physical activity behaviors. Each patient received 8 calls over 6 months. Patients in the chronic care model arm lost a mean of 4.3 kg after 180 days compared with 0.95 kg in the usual-care arm (P=0.01).
Only a small number of reports described practical collaborative approaches for busy settings. Strategies that included central planning and training, the chronic care model, and counseling in combination with medications demonstrated positive results.
3. Use of the Internet and Other Technologies
Great interest has emerged in technologies that have the potential to overcome the time and resource barriers that primary care clinicians face when trying to disseminate weight management interventions to large numbers of people. Few technology-supported weight loss interventions have actually been tested in the primary care setting, but there is hope that providers will one day be able to provide patients with effective weight loss interventions delivered via the Internet, mobile phone, or other devices. Our review includes published RCTs of Internet-based behavioral weight loss and weight maintenance studies. We also reviewed a small number of studies that make use of other technological tools.
Our search strategy included the terms “computer assisted instruction” OR “Internet” OR “cellular phone” OR “handheld” (among many others) in combination with “obesity” OR “obese.” We searched the following databases: PubMed, CINAHL, PsycINFO, EMBASE, Cochrane CENTRAL, IEEE Xplore, and the New York Academy of Medicine Grey Literature Collection. Only papers published from 2002 to the present were reviewed.
For Internet-based and other technology-based studies, the present review was limited to RCTs that compared behavioral interventions for obesity delivered via the Internet with a control condition. Only studies that provided pretreatment and posttreatment data for ≥1 weight loss indices, including change in body weight, BMI, or waist circumference, were selected for review.
A total of 227 abstracts were identified. A total of 24 studies met our inclusion criteria and were included in the present review (18 weight loss trials and 6 weight maintenance trials). These studies are summarized inTable 3.
Of the Internet trials reviewed, intervention components included the following: (1) education about diet, physical activity, weight loss, and weight maintenance; (2) self-monitoring for a variety of health behaviors (ie, diet intake, physical activity) and outcomes (ie, body weight, BMI, and waist circumference); (3) individual goal setting for health behavior change; (4) motivation enhancement (typically facilitated online or through electronic communication by a counselor); and/or (5) peer social support.
Nine of the 18 trials55–57,59–58–62,70,72 reported significantly greater weight loss among participants randomized to Internet conditions than a control condition. Of these 9, however, 1 study reported findings only from participants who had fully completed the interventions (ie, not intention-to-treat analyses),61 and another reported outcomes for only 20% to 30% of participants because of extremely high attrition.59 The 7 remaining positive trials reported that successful Internet intervention conditions contained elements of human contact (eg, e-mail or online discussion with a behavioral coach) and involved participants who were primarily obese rather than just overweight. Participants in 2 positive trials were relatively homogenous (>80% female and white),56,60 whereas participants in 2 others were more diverse (eg, ≈50% male and 50% white).55,57 An additional 7 of the 18 trials reported no significant differences in weight loss between the Internet and control conditions,58,63–67,71 and the final 2 trials reported significantly greater weight loss among participants randomized to the control condition. The superior control condition was a self-directed weight loss manual in 1 study68 and face-to-face counseling in another study.69
With respect to the 6 trials of weight maintenance interventions, the authors of 3 trials reported no significant differences between Internet and control conditions.73,74,76 Results of the 3 other trials showed significantly greater weight maintenance among participants randomized to a face-to-face counseling program than those using Internet programs.76–78
Our review of Internet-based studies suggests that under certain conditions, Internet interventions may be effective in facilitating weight loss among obese individuals. Several imitations were identified in the reviewed studies. First, although samples composed of at least 50% men were used in 5 trials,55,57,58,62,64 most studies enrolled a large majority of women. Further research is needed to determine whether weight loss and weight maintenance can be achieved via the Internet among men. Second, positive trials reported completer rather than intention-to-treat analyses.61,63,71,65 This compromises the value of randomization. Third, attrition rates in some studies were high. Twelve trials reported attrition rates greater than 20% (ranging from 24% to 80%),56,58–60,62,63,65,66,68,71,74,75 which compromises the power of the studies and the certainty with which any conclusions can be drawn. Finally and most importantly, a considerable amount of heterogeneity existed among the intervention components included in these trials. The Internet is not an intervention; it is a vehicle through which behavioral interventions can be delivered. It holds considerable promise because it enables individuals to have access to empirically supported interventions that may not otherwise be available in their community. We are unable, however, to draw causal inferences from these data about the specific behavioral mechanisms that are responsible for facilitating weight loss in Internet-based interventions. Future research that is guided by relevant behavioral theory may shed light on the optimal manner in which to deliver intensive behavioral interventions via the Internet.
Handheld and Other Devices for Use in Behavioral Weight Loss Interventions
We defined handheld devices as personal digital assistants (PDAs), mobile phones, pedometers, accelerometers, and armbands that record energy expenditure. Thirteen studies were identified, and of these, 4 met our inclusion criteria (Table 3). Studies were excluded because they did not report weight loss outcomes (n=3),82–84 did not use a randomized controlled design (n=4),85–88 or the phones used were standard landline phones (n=2).49,89 All 4 studies enrolled primarily white women and were conducted in the community.
Two studies used mobile phones.79,80 One study, conducted in Finland, compared a smart phone text-messaging–delivered weight loss intervention to a control group that received no intervention.79 Based on a dieter's daily weight and weight loss targets, the program sent text messages designed to promote weight loss by informing patients of weight and daily calorie goals and by providing general advice, such as limiting the consumption of high-fat foods, high-sugar foods, and alcohol and increasing physical activity. Although the experimental group lost more weight than the control group (4.5 versus 1.1 kg) over 12 months, analysis was performed only on study completers. Attrition was high at 27% and 35% of the experimental and control groups, respectively.
Patrick and colleagues80 described a 16-week RCT that compared the provision of written material monthly with an intervention that included personalized Short Message Service and Multimedia Message Service. The Short Message Service was augmented by printed materials focused on behavioral strategies for weight loss and brief monthly phone calls from a health counselor. Tailoring of the Short Message Service messages involved adjusting the frequency and timing of message delivery according to the participants' preferences. Adherence, measured by subject response to the messages, was 100% the first week and declined to ≈66% by week 16. At 16 weeks, the intervention group lost a statistically significant 3.16% of baseline weight compared with 1.01% in the control group.
Burke and colleagues30 conducted a 24-month RCT of a standard behavior intervention for weight loss in which 210 participants (85.3% women and 80.3% white) were randomized to 1 of 3 approaches to self-monitoring: paper record, PDA with dietary and exercise software (PDA), and a PDA with the same software plus delivery of a daily message (feedback) tailored to what had been entered in the PDA (PDA plus feedback). After 6 months, 63% of PDA-plus-feedback group participants had achieved a 5% weight loss compared with 46% of the paper record group and 49% of the PDA group. The differences between the PDA-plus-feedback and the paper and PDA groups were significant, but the differences between the PDA and paper groups were not. Adherence to self-monitoring was statistically significantly higher in the PDA groups than in the paper group. These findings suggest that mobile devices may be useful tools for self-monitoring as part of standard behavior interventions for weight loss.
We reviewed 1 study that used the SenseWear Pro Armband, a device that tracks energy expenditure.81 This 3-group, 12-week RCT of 57 subjects compared standard in-person behavior treatment with continuous or intermittent use of the armband to monitor energy expenditure, along with an Internet program to monitor energy intake. The group that used the armband continuously lost significantly more weight on average (6.2 kg) than the group that used it intermittently (3.4 kg) or the control group that received standard in person-treatment (4.1 kg). The armband device shows promise in self-monitoring and encouragement of physical activity, but it needs to be evaluated among more patients and for a longer duration as a tool for managing obesity.
With the exception of the PDA study, the studies of technologies other than the Internet were pilot or feasibility studies and thus had limited sample size and were of limited duration. Although the findings are promising, longer studies with a larger and more diverse sample are needed before definitive conclusions can be drawn. Two of the studies are being replicated on a large scale at present.80,81
The use of electronic health records is becoming more widespread.90 We did not, however, find studies that met our inclusion criteria that made explicit use of electronic health records to deliver obesity interventions.
The Internet shows promise as a tool to promote weight loss among obese individuals (BMI >30 kg/m2). Further research is needed to determine its relative effectiveness in other specific segments of the population, including men. The available data do not support the use of Internet interventions for weight maintenance.
It is premature to draw conclusions about the effectiveness of mobile phones as a weight loss tool. There is some evidence for the usefulness of mobile devices (including PDAs) to promote self-monitoring of diet and physical activity habits and weight loss. The effectiveness of both technologies in promoting weight loss needs further study.
4. Conclusions, Recommendations, and Future Directions
In general, more evidence is needed to support specific strategies for discussing weight, incorporating collaborative approaches for weight management, and using technological tools, including the Internet. We also believe in general that because many weight management interventions involve understanding and applying detailed and sometimes complex information by patients, the health literacy of patients should be taken into account in the design and selection of interventions. Our recommendations are based on the limited evidence we found:
Discussions of weight should be performed in a nonjudgmental, respectful, and unhurried manner.
Readiness and self-efficacy to change behaviors should be assessed before weight loss strategies are initiated, and this information should be factored into decisions about what type of approach to use.
Validated tools such as the Eating Pattern Questionnaire, the Starting the Conversation tool, and the WAVE and REAP-S tools should be used to assess behaviors that contribute to excess body weight gain.
Central planning and training should be incorporated into collaborative approaches that involve physicians, nurses, or other providers.
Studies of Internet and other technologies for weight loss have shown promise, but at this time, there is insufficient evidence to make recommendations about their use in busy clinical settings.
We have prioritized areas for future research based on significant gaps in the literature:
There is a need for larger studies, both those that include technologically based interventions and those that do not, that enroll a diverse spectrum of overweight and obese patients in terms of sex, race, and socioeconomic status. Latino subjects and men, in particular, are underrepresented in obesity studies to date. There is also a need to investigate the specific features of technologically based interventions (eg, content, format, device) that make such interventions successful in promoting weight loss.
Because attrition rates from technology-based studies are very high, there is a need to develop effective strategies to keep patients engaged in using technology tools for the long-term.
Further evaluation of collaborative approaches (eg, approaches involving centralized planning, approaches involving nurses in intervention delivery) in general is needed. In particular, larger studies of longer duration are needed to evaluate the effectiveness of the chronic care model as a framework for weight management interventions.
Use of electronic health records is increasing, and there is a need to explore the use of these valuable tools, not only for identification and assessment of obesity but also for the delivery of obesity interventions. The STOP (Strategies to Overcome and Prevent) Obesity Alliance research team has also emphasized the usefulness of electronic health records in the care of obese patients.91
We wish to acknowledge the invaluable help of Jing Wang, PhD, for her careful review and editing of the manuscript. We also wish to acknowledge Mary Lou Klem, PhD, for her extremely helpful assistance in locating relevant evidence, and Anjali Pandit, MPH, for her helpful suggestions.
Endorsed by the Society of Behavioral Medicine
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on June 13, 2011. A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail .
The American Heart Association requests that this document be cited as follows: Rao G, Burke LE, Spring BJ, Ewing LJ, Turk M, Lichtenstein AH, Cornier M-A, Spence JD, Coons M; on behalf of the American Heart Association Obesity Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Clinical Cardiology, Council on Cardiovascular Nursing, Council on the Kidney in Cardiovascular Disease, and Stroke Council. New and emerging weight management strategies for busy ambulatory settings: a scientific statement from the American Heart Association. Circulation. 2011;124:1182–1203.
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- © 2011 American Heart Association, Inc.
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