Online Journal of Nursing Informatics (OJNI) Spring 2008 Volume 12, Number 1
ISSN # 1089-9758 Indexed in CINAHL © 2008
Shay, L. (February, 2008). Self-monitoring and weight management. Online Journal of Nursing Informatics (OJNI), 12, (1) [Online]. http://ojni.org/12_1/shay.html
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Keeping track of food intake and exercise plays an important role in any weight management program. A number of studies in the literature clearly show a direct relationship between consistent self-monitoring and weight loss. Earlier studies were performed using food/exercise diaries written on paper. Newer technologies now being used for self-monitoring include software with large databases containing nutrition and exercise information that can be down loaded into Personal Digital Assistants PDAs or used via Web-based interfaces. Little is known about the effect these newer technologies have on weight management. The purpose of this article is to build upon prior reviews that have addressed self-monitoring methods used in weight management, focusing on outcomes associated with self-monitoring and on recommendations for further inquiry.
New technologies are now being used in weight management to assist patients in keeping track of their energy intake and output. These technologies include software with large databases containing nutrition information on thousands of food items including many restaurant items and exercise information that can be down loaded into portable hardware such as personal digital assistants (PDAs) or used via Web-based interfaces. Each of these technologies allows for quick access to nutrition and exercise information that can be easily entered and stored into a diary that calculates and displays daily caloric consumption and expenditure. Is seems apparent that these technologies would have an advantage over the gold standard paper diary in improving weight management outcomes, but do they? If these newer technologies are more effective is it because they improve accuracy, or is it because they are easier to use and therefore used more consistently or is due to both improved accuracy and consistency? Many clinicians assume that they are better than the gold standard paper diaries however there has been little research in this area to determine if this assumption is true.
We do know that the keeping of detailed records on specific behaviors or self-monitoring, is considered one of the most essential features of behavior therapy (Baker & Kirschenbaum, 1993; Berkel, Poston, Reeves, & Foreyt, 2005; Fabricatore, 2007). Some of the earliest research on the behavioral effects of self-monitoring was conducted by Dr. Richard M. McFall. (Gottman & McFall, 1972; McFall, 1970; McFall & Hammen, 1971; Sieck & McFall, 1976) whose work was triggered by the phenomenon that a subject's awareness of data collection during a study often caused a reactive process that influenced the behavior being observed (Gottman & McFall, 1972). In terms of weight management, self-monitoring of dietary intake is consistently associated with adherence to dietary measures, (Schnoll & Zimmerman, 2001; Yancy & Boan, 2006) however accuracy is generally poor (Goris, Westerterp-Plantenga, & Westerterp, 2000; Schaefer et al., 2000; Stone, Shiffman, Schwartz, Broderick, & Hufford, 2003). This inaccuracy has been observed in many well controlled clinical trials measuring doubly labeled water results against self-reported food diaries (Black et al., 1993; Clark et al., 1994; Goris et al., 2000; Hise, Sullivan, Jacobsen, Johnson, & Donnelly, 2002; Livingstone & Black, 2003; Livingstone et al., 1990; Martin et al., 1996; Rothenberg, 1994; Seale & Rumpler, 1997; Tomoyasu, Toth, & Poehlman, 1999, 2000). Accuracy does not appear to improve even when individuals have access to software containing a large nutrition databases. A recent study found that participants keeping a diet record using nutrition software down loaded into a personal digital assistant (PDA), did not improve accuracy (Yon, Johnson, Harvey-Berino, & Gold, 2006).
Does self-monitoring need to be accurate in order to positively influence a behavior? Early studies on self-monitoring in relation to weight management used paper diaries. Baker & Kirschenbaum (1993) found in their research that the more consistently participants self-monitored the more weight they lost and that the accuracy of the information was not as important as self-focusing attention on the behavior. This positive effect is seen throughout the literature--self-monitoring of food intake is associated with a decrease in food intake and subsequent weight loss (Blundell & Gillett, 2001; Boutelle & Kirschenbaum, 1998; Boutelle, Kirschenbaum, Baker, & Mitchell, 1999; Goris et al., 2000; Guare et al., 1989; Kruger, Blanck, & Gillespie, 2006; Rosenthal & Marx, 1983; Sandifer & Buchanan, 1983; Sperduto, Thompson, & O'Brien, 1986; Stalonas & Kirschenbaum, 1985). Therefore, when it comes to weight management, consistent self-monitoring seems to contribute to the desired outcome of weight loss more than accurate self-monitoring.
The purpose of this article is to build upon a review published by Burke et al, (Burke et al., 2005) which provides an overview of self-monitoring of dietary intake that emphasizes relative strengths and limitations of paper diaries versus PDA diaries. This paper will focus on the outcomes associated with the current methods used for weight management and make recommendations for further inquiry.
Devices to self-monitor blood sugar and blood pressure have been used by patients for many years. Outcomes associated with use of these devices has been well reported in the literature (Appel & Stason, 1993; Blonde & Karter, 2005; Cappuccio, Kerry, Forbes, & Donald, 2004; Deiss et al., 2006; Franciosi et al., 2001; Halme, Vesalainen, Kaaja, & Kantola, 2005; Harris, 2001; Kennedy, 2001; Murata et al., 2003; Schutt et al., 2006; Schwedes, Siebolds, & Mertes, 2002; Staessen et al., 2004; Wilde & Garvin, 2007; Yarows, Julius, & Pickering, 2000). Some of these studies have had mixed results (Appel & Stason, 1993; Harris, 2001; Kennedy, 2001; Staessen et al., 2004; Yarows et al., 2000) others clearly demonstrate positive outcomes (stable blood sugars and decreased blood pressures) associated with using such devices (Blonde & Karter, 2005; Cappuccio et al., 2004; Deiss et al., 2006; Franciosi et al., 2001; Halme et al., 2005; Murata et al., 2003; Schutt et al., 2006; Schwedes et al., 2002; Staessen et al., 2004). Recent studies have also shown positive outcomes associated with patients using devices that monitor International Normalized Ration (INR) to self-manage their oral anticoagulant dose (Ferretti et al., 2007; Heneghan et al., 2006).
Several studies have compared the use of handheld electronic diaries with paper diaries. Johannes et al.(2000) conducted a pilot study comparing a paper diary with ProCycle, an electronic handheld diary with software designed to record menstrual bleeding, medications, and health symptoms for 25 regularly cycling women for 3 months. The electronic diary was more efficient and accurate. Missing data were less frequent with the ProCycle and seventy percent of the users preferred the ProCycle; nine percent preferred the paper diary. Jamison et al. ( 2001, 2002) compared the use of a handheld electronic device to the standard paper diary for monitoring pain medication. Group one (n = 24) used a handheld electronic device and a paper diary and Group 2 (n = 16) used only the paper version. All participants were asked to monitor their pain, mood, activity, medication and side effects for one year. Group 1 made significantly more data entries into the handheld electronic device than paper diary entries made by both groups (261 days verses 65 days).
It has been reported that the use of handheld electronic food/exercise diaries avoids the problems of poor adherence associated with paper diaries (Kerkenbush & Lasome, 2003). Burke, Warziski, and Starrett (2005) report that electronic diaries provide the following benefits over paper diaries: (1) They may be learned by individuals without prior computer experience; (2) Poor handwriting is not an issue; (3) They provide immediate feedback, because the user can see current intake next to their daily goals; and (4) Subtotals and totals are automatically calculated (Burke et al., 2005).
To date, few published studies have evaluated outcomes associated with using electronic food/exercise diaries in weight management (Burke et al., 2005; Jerome & Frederiksen, 1992). A pilot test of DietMate,® a handheld computer containing nutrition information software developed by Health Innovations, Inc. (HII), was conducted using a pretest-posttest treatment design on 24 participants. The 21 participants who completed the 12-week trial showed statistically significant reductions in weight (M = 10 lbs., SD = 6.7) (Jerome & Frederiksen, 1992). Glanz et al. (2006) conducted a pilot study to test real-time diet monitoring and a feedback system using a hand-held computer. A convenience sample of 33 women was selected from the Women's Health Initiative Diet Modification Trial to test the use of a PDA device (Palm Pilot Vx) containing nutrition information software with over 300 food items. The women were instructed to use the system to record and monitor their food intake throughout the day for at least 3 days a week for one month. Data from the PDA dietary entries, a short baseline survey and end-of-study survey, and a base line and follow-up Food Frequency Questionnaire (FFQ) were analyzed. Participants entered their food choices into the PDAs on average five days per week with half entering data six to seven days per week. Analysis of the time-date stamps demonstrated that most of the food entries appeared to be entered close to the time the meal was eaten rather than all at once at the end of a day. Comparison of baseline and follow-up FFQs showed a trend toward lower mean caloric intake, significant decreases in total daily fat grams, and percent energy from fat. Self-reports of adherence and self-monitoring before and after the study period indicated a significant increase in both. Overall participants significantly increased the frequency of self-monitoring and reported the PDA to be convenient, easy to use, informative and reinforcing with 90% reporting that they would continue to use the PDA if they had one.
Burke et al (2005). conducted a feasibility study to evaluate use patterns for a handheld PDA device (Palm Tungston/E). This study was conducted on seven participants who had completed an 18-month behavioral and nutrition intervention program for weight management. The software used was DietMatePro, a program based on the USDA nutrient database which holds 6,000 food items, including brand name and restaurant foods. Participants were instructed to use the PDA as much as possible over a 16-week period and determine whether it would help them monitor their eating. Adherence ranged from 10.6% to 65.4%. The participants who were less conscientious in using paper diaries during the 18-month weight management intervention were also less conscientious in their use of the PDA. No participant withdrew from the study because of inability to use the device or because they found the device too burdensome.
A number of commercially available Web-based food/exercise diaries can be accessed through the Internet using a personal computer: CalorieKing.com, WeightWatchers.com, MyFoodDiary.com, and My-Calorie-Counter.com, to name a few. These programs contain large databases of nutrition information and exercise information. Many studies have been published on the effect of Web-based weight management programs,(Gold, Burke, Pintauro, Buzzell, & Harvey-Berino, 2007; Harvey-Berino et al., 2002; Harvey-Berino, Pintauro, Buzzell, & Gold, 2004; Kirk et al., 2003; Messecar, Salveson, & Monkong, 2002; Tate, Jackvony, & Wing, 2003; Veverka et al., 2003; Wing, Tate, Gorin, Raynor, & Fava, 2006; Womble et al., 2004; Yeh et al., 2003). None of the studies have strictly explored the use of a Web-based food/exercise diary as the self-monitoring method in a traditional weight management program that incorporates self-monitoring, diet, exercise and counseling, and none has compared the web-based food/exercise diary to the paper diary or handheld PDA diary.
Based on this brief review, self-monitoring has been shown to have a positive impact on behavior, even if inaccuracies in recording occur. Self-monitoring of dietary intake and exercise plays an essential role in any weight management program. Currently the methods used to self-monitor dietary intake and exercise are the paper food/exercise diary and the handheld PDA food/exercise diary. Web based food/exercise diaries are also available often within an Internet based weight management program. The question remains whether or not one method is more effective than the others. Few published studies have compared the effect of these newer technologies against traditional paper diaries, and no published studies have compared all three of these self-monitoring methods in the same weight management program.
A study by the Uniformed Services University of Health Sciences Graduate School of Nursing is currently exploring this question. The title is A Study to Evaluate the Effect of Self-Monitoring on Weight Management in Active Duty Military. Funding is provided by the National Naval Medical Center Graduate Education and Research. The participants are randomly assigned to one of three groups: (1) a paper food/exercise diary group, (2) an Internet Web-based food/exercise diary group, or (3) a handheld PDA food/exercise diary group. All groups participate in the standard 6-week Ship Shape Navy weight management program at National Naval Medical Center, which is taught by a registered dietitian. All participants are asked to return for one additional follow-up session at week 12, after they have been self-monitoring for six weeks. Outcome measures include: weight, BMI, waist circumference, estimated % body fat, adherence patterns, and self-efficacy. Results from this study may provide insight into whether or not one of these methods used to self-monitor dietary intake and exercise is more effective than the others as an adjunct to a standardized weight management program (Shay & Pagliara, 2005).
One should note that other factors associated with self-monitoring have not been fully explored. Early research by Baker & Kirshenbaum (1993) attempted to answer two important questions: (1) Does the monitoring of certain variables (e.g., food, where food is consumed, mood, with whom food is consumed) have a greater relation to weight control than other variables?; (2) Does self-monitoring cause weight loss, or are those who consistently self-monitor more likely to succeed for other reasons (e.g., better coping skills, stronger commitments)? In addressing these questions, Baker & Kirshenbaum (1993) concluded that more work is needed to improve methods for self-monitoring. Therefore, it is important to note that these questions remain unanswered.
The literature review confirms that self-monitoring is an essential component of any weight management program. It is clear that consistent self-monitoring correlates with weight loss. However, little is known about the effect of other self-monitoring variables (e.g., keeping track of mood, where food is consumed, with whom food is consumed). In addition, newer self-monitoring technologies such as handheld PDAs and Internet Web-based programs are being integrated into weight management programs and research studies, but little is known about their effect. It is not known whether these newer technologies help or hinder self-monitoring or whether they work as well as a paper diary if they are used consistently. It is also not known whether different learning styles or levels of literacy impact how well these methods are used, or if additional monitoring variables such as mood and social patterns would enhance their effect. While it is important to find new and creative ways to self-monitor; equally important is having well controlled research studies that carefully look at the effect these new self-monitoring methods have on weight management outcomes. This research will determine which methods are most effective and will provide vital information needed to develop better ways to self-monitor.
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Laura Shay PhD(c), C-ANP
Captain Laura E. Shay is a nurse practitioner who is a Commissioned Corps Officer in the United Stated Public Health Service. She is currently a Ph.D. candidate working on her Ph.D. in Nursing at the Uniform Services University in Bethesda Maryland. Her area of research is on the effect of self-monitor methods in weight management in the active duty military population.