Adult Weight Management

AWM: New Technology and Telenutrition (2013)

Citation:

Harvey-Berino J, Pintauro S, Buzzell P, Gold EC. Effect of internet support on the long-term maintenance of weight loss. Obes Res. 2004; 12(2): 320-329.

PubMed ID: 14981225
 
Study Design:
Randomized Controlled Trial
Class:
A - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To test a novel approach to sustaining long-term contact with individuals after participation in a structured behavioral weight loss program. The hypothesis is that individuals randomized to an Internet condition would maintain more weight loss than individuals in a comparable in-person condition.

Inclusion Criteria:
  • Age over 18
  • BMI 25kg/m2 or more
  • Computer with at least 32 MB of RAM, a sound card, a CD-ROM drive, 200 MHz, and 22 kps actual connection speed
  • Provided informed consent.
Exclusion Criteria:
  • History of major medical or psychiatric problems
  • Planned a pregnancy within the next 18 months
  • Unable to participate in an exercise program
  • Agreed not to participate in other weight loss treatment programs for 18 months.
Description of Study Protocol:

Recruitment

Recruited through newspaper advertisements placed in 10 different locations throughout the state.

Design

Randomized controlled trial.

Blinding Used

Implied with measurements.

Intervention:

  • Six-month behavioral weight loss intervention followed by randomization into one of three maintenance groups
  • Subjects were treated over interactive television for behavioral weight loss. The program focused on the modification of eating and exercise habits through the use of behavioral strategies and self-management skills. Subjects met weekly for one hour and printed lessons were given out to reinforce the weekly sessions. Subjects were instructed to reduce their caloric intake to 4,186kJ to 10,465kJ per day depending on their baseline body weight.
    • Graded goals for activity were used throughout the program and patients were encouraged to expend at least 1,000 calories per week in physical activity
    • Subjects were instructed to record their dietary intake and the amount of energy expended in physical activity daily
    • Self-monitoring diaries and advice was given on strategies for lowering caloric intake while maintaining a nutritionally balanced diet.
  • After the weight loss program, subjects were randomized to one of three maintenance groups for 12 months: Internet Support (IS), frequent in person support (F-IPS) and minimal in person support (M-IPS)
    • Subjects were told to continue with their diet and exercise prescriptions
    • The primary study therapist was a Master's-level dietitian trained in behavioral weight control techniques
    • F-IPS group met in person at the local ITV studio on a biweekly basis, turned in their self-monitoring diaries, got weighed, participated in a discussion facilitated by the group therapist and participated in a social-influence peer-support program
    • IS group attended biweekly maintenance meetings in the form of an Internet chat session facilitated by the group therapist and participated in a social-influence peer-support program
    • M-IPS group met in person at the local ITV studio monthly for the first six months, got weighed, attended a one-hour long weight maintenance support group and were encouraged to self-monitor even though diaries were not reviewed. There was no contact during the remaining six months.

Statistical Analysis

  • All data entry and analysis were completed by staff that was blinded to subject condition
  • Data were analyzed using SPSS version 10.05 software
  • Comparisons of baseline data were performed using a one-way ANOVA
  • The a priori hypotheses were examined using a two-factor (group x time) repeated measures ANOVA and additional analyses were performed using a one-way ANOVA
  • A X2 test was used to assess demographic and distribution patterns for subjects who dropped out and for those who achieved intervention goals
  • Statistical significance was defined as P≤0.05
  • All data were analyzed using intention-to-treat analysis unless otherwise specified
  • A power analysis based on weight loss at 18 months was conducted before recruitment
  • Using an alpha level of 0.05 and a power of 87%, a sample size of 60 individuals per group was needed to detect a 2kg difference between groups.
Data Collection Summary:

Timing of Measurements

Measurements made at zero, six, 12 and 18 months at the ITV studios.

Dependent Variables

  • Body weight was measured on a beam-balance scale with participants in their street clothes and without shoes, height was self-reported at baseline
  • Energy intake was measured using the Block food frequency questionnaire and analyzed using the National Cancer Institute Dietary Analysis System software program
  • Energy expended in physical activity was measured using the Paffenberger Physical Activity Questionnaire
  • Mediators of weight loss included computer experience and comfort, attendance at group meeting and chat sessions, adherence to self-monitoring by calculating the number of weeks in the F-IPS and IS groups and social influence.

Independent Variables

  • Six-month behavioral weight loss intervention followed by randomization into one of three maintenance groups
  • Subjects were treated over interactive television for behavioral weight loss. The program focused on the modification of eating and exercise habits through the use of behavioral strategies and self-management skills. Subjects met weekly for one hour and printed lessons were given out to reinforce the weekly sessions. Subjects were instructed to reduce their caloric intake to 4,186kJ to 10,465kJ per day depending on their baseline body weight.
    • Graded goals for activity were used throughout the program and patients were encouraged to expend at least 1,000 calories per week in physical activity
    • Subjects were instructed to record their dietary intake and the amount of energy expended in physical activity daily
    • Self-monitoring diaries and advice was given on strategies for lowering caloric intake while maintaining a nutritionally balanced diet.
  • After the weight loss program, subjects were randomized to one of three maintenance groups for 12 months: Internet Support (IS), frequent in person support (F-IPS) and minimal in person support (M-IPS):
    • Subjects were told to continue with their diet and exercise prescriptions
    • The primary study therapist was a Master's-level dietitian trained in behavioral weight control techniques
    • F-IPS group met in person at the local ITV studio on a biweekly basis, turned in their self-monitoring diaries, got weighed, participated in a discussion facilitated by the group therapist and participated in a social-influence peer-support program
    • IS group attended biweekly maintenance meetings in the form of an Internet chat session facilitated by the group therapist, and participated in a social-influence peer-support program
    • M-IPS group met in person at the local ITV studio monthly for the first six months, got weighed, attended an one-hour-long weight maintenance support group and were encouraged to self-monitor even though diaries were not reviewed.  There was no contact during the remaining six months.
Description of Actual Data Sample:
  • Initial N: 255 (209 women and 46 men) enrolled and 232 were randomized, 77 to the F-IPS group, 77 to the IS group, 78 to the M-IPS group
  • Attrition (final N): 194 completed the 12-month follow-up (83%), 68 in the F-IPS group, 59 in the IS group, and 67 in the M-IPS group
  • Age: Mean baseline age 45.8±8.9years
  • Other relevant demographics: Education at baseline was:
    • 24 high school
    • 73 some college
    • 75 college degree
    • 83 graduate school
  • Anthropometrics: Mean BMI at baseline 31.8±4.1kg/m2. There were no significant differences between groups at baseline.
  • Location: Vermont.
Summary of Results:

Key Findings

There were no significant differences among the groups in weight loss (mean ±SD) from baseline to 18 months (7.6kg±7.3kg vs. 5.5kg±8.9kg vs. 5.1kg±6.5kg, P=0.23 for the IS, M-IPS, and F-IPS respectively).

 

 

Author Conclusion:

The results from this study showed that an Internet weight maintenance program could sustain comparable long-term weight loss compared with a similar program conducted in person and over the phone.

Funding Source:
Government: National Institute of Health Grant DK56746
Reviewer Comments:
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
  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
  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
  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
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
  1. Was the research question clearly stated? Yes
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.1. 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? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
  1.3. Were the target population and setting specified? Yes
  2. Was the selection of study subjects/patients free from bias? Yes
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
  2.1. 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
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? 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
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
  3. Were study groups comparable? 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
  3.1. 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
  3.2. 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.) Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  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
  3.4. 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
  3.5. 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
  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? Yes
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  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%.) Yes
  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%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
  5. Was blinding used to prevent introduction of bias? Yes
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? No
  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.) Yes
  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.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? 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? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
  6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  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
  6.3. 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
  6.4. 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? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  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? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
  7. Were outcomes clearly defined and the measurements valid and reliable? Yes
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  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
  7.2. 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
  7.3. 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
  7.4. 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? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
  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? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  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
  8.4. 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)? Yes
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
  9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
  10. Is bias due to study's funding or sponsorship unlikely? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes
  10.2. Was the study free from apparent conflict of interest? Yes