EAL

AWM: New Technology and Telenutrition (2013)

Citation:

Harvey-Berino J, Pintauro S, Buzzell P, DiGiulio M, Casey Gold B, Moldovan C, Ramirez E. Does using the Internet facilitate the maintenance of weight loss? Int J Obes Relat Metab Disord. 2002; 26(9): 1,254-1,260.

PubMed ID: 12187404

Study Design:

Randomized Controlled Trial

Class:

A - Click here for explanation of classification scheme.

Quality Rating:

POSITIVE: See Quality Criteria Checklist below.

Research Purpose:

To investigate the effectiveness of a weight maintenance program conducted over the Internet.

Inclusion Criteria:

Age over 18 years
Body mass index 25kg/m² or more
Computer with at least 16 Megabytes of RAM, Windows 95 or 98 as a computer operating system and a 28.8kbps Internet connection.

Exclusion Criteria:

History of major medical or psychiatric problems
Planned a pregnancy within the next 18 months
Unable to participate in an exercise program.

Description of Study Protocol:

Recruitment

Recruited through newspaper advertisements.

Design

Randomized clinical behavioral weight loss trial.

Blinding Used

Implied with measurements.

Intervention

Six-month in-person behavioral obesity treatment followed by a 12-month maintenance program conducted both in person (frequent in-person support; F-IPS, minimal in-person support; MIPS) and over the Internet (Internet support; IS)
Frequent in-person support: This group met in person on a biweekly basis for 52 weeks. Subjects turned in their self-monitoring diaries, got weighed and participated in a discussion facilitated by a group therapist. On the weeks when the group was not meeting, subjects received a phone call from the group therapist and submitted their self-monitoring data (energy intake, exercise energy expenditure and body weight) via postcards supplied by the investigators. Subjects also participated in a social-influence peer support program.
Internet support: All participants in the IS condition attended an initial technical orientation session led by one of the study co-authors. Participants were taught the basic procedures for logging in to the study website, how to access the electronic self-monitoring forms and dietary analysis program. Subjects attended biweekly maintenance meetings in the form of an Internet chat session. Subjects entered the chat room at a prearranged time and the discussion was facilitated by the group therapist.
Minimal in-person support: Participants randomized to the M-IPS condition continued to meet in-person monthly for the first six months of the 12-month weight maintenance condition. At these meetings, weight was measured and subjects attended an hour-long weight maintenance support group.

Statistical Analysis

Data were examined using both an intent-to-treat analysis (N=122) and with those having complete data for all measures (N=90)
There were no differences in results between these two methods, thus data are presented as the results of analysis with a complete data set
Repeated measures analysis of variance was used to assess changes in weight, energy intake and energy expended in physical activity
Chi-squared analysis was used to assess differences between groups in computer ability, enjoyment of computers and acceptability of assigned condition
Differences in attendance, self-monitoring and number of peer-support contacts was analyzed using analysis of variance
The significance level was set at comparisons when the ANOVA was significant
All analyses were performed using the Statistical package for the Social Sciences SPSS for Windows version 10.05.

Data Collection Summary:

Timing of Measurements

All subjects were seen for assessment measures at baseline, six, 12 and 18 months.

Dependent Variables

Body weight measured at baseline, six months, 12 months and 18 months on a balance beam scale with participants in their street clothes, without shoes. Height was self-reported.
Energy intake was measured using the Block Food Frequency questionnaire and analyzed using the National Cancer Institute Dietary Analysis System
Energy expended in physical activity was measured at zero, six, 12 and 18 months using the Paffenberger Physical Activity Questionnaire.

Independent Variables

Six-month in-person behavioral obesity treatment followed by a 12-month maintenance program conducted both in person (frequent in-person support; F-IPS, minimal in-person support; MIPS) and over the Internet (Internet support; IS)
Frequent in-person support: This group met in person on a biweekly basis for 52 weeks. Subjects turned in their self-monitoring diaries, got weighed and participated in a discussion facilitated by a group therapist. On the weeks when the group was not meeting, subjects received a phone call from the group therapist and submitted their self-monitoring data (energy intake, exercise energy expenditure and body weight) via postcards supplied by the investigators. Subjects also participated in a social-influence peer support program.
Internet support: All participants in the IS condition attended an initial technical orientation session led by one of the study co-authors. Participants were taught the basic procedures for logging in to the study website, how to access the electronic self-monitoring forms and dietary analysis program. Subjects attended biweekly maintenance meetings in the form of an Internet chat session. Subjects entered the chat room at a pre-arranged time and the discussion was facilitated by the group therapist.
Minimal in-person support: Participants randomized to the M-IPS condition continued to meet in person monthly for the first six months of the 12-month weight maintenance condition. At these meetings, weight was measured and subjects attended an hour-long weight maintenance support group.
- At baseline, subjects were asked to choose one of the following statements to describe their computer ability:
  - Novice with little or no computer experience
  - Comfortable with basic software applications
  - Comfortable with basic software applications to the Internet
  - Hobbyist with more advanced understanding of software and hardware
  - Computer professional.
- Attendance at group meetings was recorded
- Adherence to self-monitoring was assessed by calculating the number of weeks subjects in the F-IPS and IS groups submitted self-monitoring records
- The acceptability of both the F-IPS and IS conditions was assessed at six and 12 months by having subjects rate their level of agreement with the statement, "I would prefer being in the group that meets over the Internet/in person" on a five-point scale where one is strongly agree and five is strongly disagree
- Peer support was assessed by counting the number of peer-support contacts initiated by group members in both the F-IPS and IS conditions.

Description of Actual Data Sample:

Initial N: 122 (40 Internet group, 41 minimal in-person support group, 41 frequent in-person support group)
Attrition (final N): 90 subjects (73%) had complete data for all measures. Attrition was 18% after six months of treatment and 24% over 18 months of evaluation
Age: Between the ages of 26 and 77 years
Ethnicity: White
Anthropometrics: Mean body mass index 32.2±4.5kg/m². There were no significant differences between groups for any of the dependent variables.
Location: Vermont.

Summary of Results:

Key Findings

Results showed that weight loss did not differ by condition during treatment (8.0kg±5kg vs. 11kg±6.5kg vs. 9.8gk±5.9kg, P=0.27) for IS, M-IPS and F-IPS, respectively)
The IS condition gained significantly more weight than the F-IPS group during the first six months of weight maintenance (2.2kg±3.8kg vs. 0kg±4kg, P<0.05) and sustained a significantly smaller weight loss than both in-person support groups at the one-year follow-up (-5.7kg±5.9kg vs. -10.4kg±9.3kg vs. -10.4kg±6.3kg, P<0.05 for IS, M-IPS and F-IPS respectively)
Attendance at maintenance meetings was greater for the F-IPS than the IS condition over the one-year maintenance program (54% vs. 39%, P=0.04)
Acceptability of assigned condition was higher for subjects in the F-IPS than IS condition.

Author Conclusion:

In conclusion, the weight change, attendance patterns and stated preference for group assignments strongly suggest that the Internet is not more effective than face-to-face communication for facilitating long-term weight loss. It is not clear whether components of an Internet program can be used to successfully augment a face-to-face intervention on whether there are specific individual characteristics that might predict success with an Internet-mediated weight loss program.

Funding Source:

Government:

USDA Hatch Act Funds (HA 593)

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.)	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	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
	3.4.	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)?	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)?	Yes
	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?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	Yes
	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