This Academy member benefit temporarily has been made public to allow all practitioners access to content that may assist in patient care during the national pandemic response. Click here for information on joining the Academy. 

NC: Behavior Change Strategies (2007-2008)

Citation:

Streit KJ, Stevens NH, Stevens VJ, Rossner J. Food records: A predictor and modifier of weight change in a long-term weight loss program. J Am Diet Assoc. 1991; 91 (2): 213-216.

PubMed ID: 1991935
 
Study Design:
Time Study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
This study focused on food record patterns of participants in a large-scale weight loss program and examined the role of self-prescribed and self-managed food records in achieving weight loss.
Inclusion Criteria:

Subjects were required to pay an entry fee of $135 and a monthly enrollment fee of $35 as long as they remained active, ie, attended weekly group meetings.

Exclusion Criteria:

Not available

Description of Study Protocol:

Recruitment
From 1982 to 1986, more than 2,000 people enrolled in Freedom from Fat. Participants were not excluded on the basis of weight requirements or medical conditions. All were required to pay an entry fee of $135 and a monthly enrollment fee of $35 as long as they remained active, i.e, attended weekly group meetings.

Design
Self-evaluation reports describing the number of food records kept, average daily caloric intake, and average percentage of calories from fat were submitted each week. 

Blinding used
No

Intervention (if applicable)
All participants were enrolled in a comprehensive, weight management program that integrated self-management and social skills, moderate exercise and gradual transition to an eating pattern consistent with the US Dietary Goals.

During the first four weeks in the program, participants were asked to keep an increasing number of food records (at least two during the first week) increased to five in the fourth week. During subsequent weeks, participants set goals for the number of records they would keep during the week. Learning to set realistic and achievable goals in both dietary management and exercise was a primary objective of the program. There were no explicit minimal behavioral standards for continued participation. Data were retrieved from the self-reports submitted by participants at weekly meetings. The number of food records reported reflected the number of days in which the participant kept complete records.

Food records were reviewed periodically by an FFF dietitian and returned to participants. Only positive and constructive written comments are made on returned food records.

Statistical Analysis
Only means were calculated. Statistical analysis are not clear.

Data Collection Summary:

Timing of Measurements

Months one, two, three, four, five, six, seven, eight, nine, 10, 11 and 12 months.

Dependent Variables

  • Food records
  • Weight change
  • Food record pattern
  • Calorie content, percent calorie content from fat
  • Food record adherence.

Independent Variables

  • Bodyweight
  • Body mass index
  • Weight loss.

Control Variables

 

Description of Actual Data Sample:

 

Initial N
2,022

Attrition (final N)
298 (women, 86.8%) (85% attrition)

Approximately one half of all participants remained active in the program for five months and about one fifth for one year. There were no notable differences between men and women in attrition rates.

Age
Range: 18 to 84 years

Ethnicity
Not available

Other relevant demographics
Not available

Anthropometrics
Mean BMI: 34.4; Average weight was 95.7kg (range 54.2 to 215.5kg; average age at enrollment was 44.7 years

Location
Not available

 

Summary of Results:

 

Mean weight loss (or gain) in each month by food record patterns during that month of program participation

                                                                             Number of food records per weeka
Month
0 One-Two Three-Four Five+
Percentage of Members
Weight Loss, kg
Percentage of Members
Weight Loss, kg
Percentage of Members
Weight Loss, kg
Percentage of Members
Weight Loss, kg
1
4
0.5
32
1.3
41
0.9
23
2.5
2
13
0.5
19
0.5
26
0.9
42
1.6
3
21
0.2
20
0.5
24
0.6
35
1.4
4
28
(0.1)
22
0.1
19
0.4
31
1.0
5
30
0.1
21
0.1
21
0.1
28
0.9
6
34
(0.4)
22
0.1
17
0.2
27
0.7
7
31
(0.3)
21
(0.1)
20
(0.1)
28
0.5
8
35
0.1
16
(0.3)
21
0.1
28
0.6
9
33
(0.5)
25
(0.6)
18
0.1
24
0.3
10
37
(0.4)
22
(0.1)
20
0.3
21
0.1
11
36
(0.3)
20
(0.3)
17
(0.1)
27
0.3
12
39
(0.3)
21
(0.5)
16
(0.2)
24
0.2

a Mean number of food records kept per week during the indicated month

Other Findings

  • Participants kept food records less consistently the longer they stayed in the program, with a decrease from a mean of more than three records per week at the beginning of their participation to a mean of less than three if they remained active for more than three months
  • Individual patterns ranged from refusal to keep any records to keeping records seven days a week
  • Project staff members observed a strong apparent relationship between food record patterns and weight loss
  • The longer participants remained active in the program the more weight they lost, but those keeping five ore more food records per week consistently lost the most weight
  • Approximately 1.5% of participants were in this category, with the remaining 85% reporting less than five food records per week
  • Cumulative weight loss was surprisingly consistent when food record patterns were related to the length of enrollment. With the exception of month 10, weight loss increased as the number of food records increased.
  • For the first 10 months of the program those participants who kept at least five food records per week experienced twice the weight loss of those who kept two or fewer food records per week.
  • During months one and two more than 60% of participants kept at least three food records per week.
  • After an initial learning period of a few weeks, most FFF participants found that keeping food records required no more than five to 10 minutes per day
  • FFF participants found that keeping food records helped them manage their eating habits and achieve weight loss found that the most successful training exercise was to have participants practice recording sample meals in a group setting, followed by evaluation by the dietitan
  • Successful practice in group classes demonstrated how quickly a food record could be completed, and this often resulted in an increased number of food records being kept in the next week
  • It was found that teaching participants to estimate the percentage from fat in their daily food records often led to better adherence than simply tallying total calories, which could be discouraging or anxiety producing. Focusing on the percentage of calories from fat facilitated maintenance of a lower level of fat and, thus, total calories.
  • During the first month of the FFF program, notable weight loss resulted for participants who kept as few as one to two days of records per week. After a pattern of keeping food records has been established, the weekly goal can be increased gradually.
  • FFF participants kept graphic records of exercise and weight change and were also encouraged to note on their graphs the days on which they kept records
  • An alternative was to mark a calendar showing days on which food records were kept. Some participants also charted total calories and percent of calories from fat on their graphs. The visual display emphasizes the correlation between exercise, caloric intake, and weight loss. 

 

Author Conclusion:
  • The results of the study show that food records are a strong predictor of weight loss
  • Although a correlation study such as this one cannot prove a causal relationship between keeping food records and subsequent weight loss, both our clinical impression and the data support this hypothesis
  • The strong linear relationship between food record patterns and weight loss in this conservative weight loss program suggests, but does not prove, that keeping food records has value as a behavior change too regardless of the precision of the record.
Funding Source:
Industry:
kaiser permanente
Other:
Reviewer Comments:
  • The results of the study show that food records are a strong predictor of weight loss
  • This study is not providing information on food records has value as a behavior change too regardless of the precision of the record
  • This is a self reported assessments not quantitative assessments
  • Significant drop in the subjects active participation at 12 months (22%). This reduces the quality of the significance of the results.

     

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? ???
  1.3. Were the target population and setting specified? ???
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) ???
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? No
  4.1. Were follow-up methods described and the same for all groups? ???
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? ???
  4.4. Were reasons for withdrawals similar across groups? No
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? ???
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? ???
  5.5. In diagnostic study, were test results blinded to patient history and other test results? ???
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? ???
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? ???
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? ???
  6.6. Were extra or unplanned treatments described? ???
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? ???
7. Were outcomes clearly defined and the measurements valid and reliable? ???
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? ???
  7.6. Were other factors accounted for (measured) that could affect outcomes? ???
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? ???
  8.1. Were statistical analyses adequately described and the results reported appropriately? ???
  8.2. Were correct statistical tests used and assumptions of test not violated? N/A
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? No
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? No
  8.6. Was clinical significance as well as statistical significance reported? ???
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? No
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes