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Sustained Weight Loss during 20 Months using a Personalized Interactive Internet Based Dietician Advice Program in a General Practice Setting

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Obesity is an increasing drain on the resources of general practitioners, who have few effective options for treatment other than surgery and (often prohibitively expensive) personal dietician advice. This pilot project investigated the weight loss efficacy and the cost of an interactive internet-based weight loss program in a Danish medical center setting. The study comprised an initial weight loss period of approximately 4 months, consisting of frequent online consultations with a dietician and an exercise coach supported by electronic diaries and establishment of an online community, where the patients exchanged experiences with other users of the program. This was followed by a 16-month maintenance treatment providing less intensive counseling. Of 46 obese patients offered participation, 32 patients were enrolled in the study and 21 completed the full course. The mean weight at inclusion was 104 kg with a BMI of 36.4 kg/m 2 . After 4 months of treatment and an average of 17 consultations the participants lost on average 7.0 kg, p<0.001. During the 16-month maintenance period, the average weight did not change and 81% of the participants retained or increased their initial weight loss. The cost of the initial treatment was calculated as 165 DKK (approx. €22) per kg weight lost. These results indicate that e-mail consultations can produce comparable weight loss as conventional weight loss treatments in general practice at a lower cost, particularly for sustaining the weight loss over a longer period of time. The results of this preliminary uncontrolled study with few participants indicate that future randomized clinical trials with more participants comparing the e-consultations with relevant conventional practices are justified, in order to quantify effect and long-term cost-efficiency of e-consultations as an intervention against obesity.
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Sustained Weight Loss during 20 Months using a Personalized Interactive Internet
Based Dietician Advice Program in a General Practice Setting
Vibeke Brandt
University of Southern Denmark
Odense, Denmark
e-mail: vibra@student.sdu.dk
Carl J. Brandt
Stenstrup gehus
Svendborg, Denmark
e-mail: carl_brandt@get2net.dk
Dorte Glintborg
Department of Endocrinology M
Odense University Hospital
Odense, Denmark
e-mail: dorte.glintborg@dadlnet.dk
Cecilia Arendal
Clinical Dietician
Nyborg, Denmark
e-mail: cia-erik@adslhome.dk
Søren Toubro
Reduce
Roskilde, Denmark
e-mail: st@reduce.dk
Kirsten Brandt
Human Nutrition Research Centre, School of Agriculture,
Food and Rural Development
Newcastle University
Newcastle upon Tyne, United Kingdom
e-mail: kirsten.brandt@newcastle.ac.uk
AbstractObesity is an increasing drain on the resources
of general practitioners, who have few effective options for
treatment other than surgery and (often prohibitively
expensive) personal dietician advice. This pilot project
investigated the weight loss efficacy and the cost of an
interactive internet-based weight loss program in a Danish
medical center setting. The study comprised an initial weight
loss period of approximately 4 months, consisting of frequent
online consultations with a dietician and an exercise coach
supported by electronic diaries and establishment of an online
community, where the patients exchanged experiences with
other users of the program. This was followed by a 16-month
maintenance treatment providing less intensive counseling. Of
46 obese patients offered participation, 32 patients were
enrolled in the study and 21 completed the full course. The
mean weight at inclusion was 104 kg with a BMI of 36.4 kg/m
2
.
After 4 months of treatment and an average of 17 consultations
the participants lost on average 7.0 kg, p<0.001. During the 16-
month maintenance period, the average weight did not change
and 81% of the participants retained or increased their initial
weight loss. The cost of the initial treatment was calculated as
165 DKK (approx. 22) per kg weight lost. These results
indicate that e-mail consultations can produce comparable
weight loss as conventional weight loss treatments in general
practice at a lower cost, particularly for sustaining the weight
loss over a longer period of time. The results of this
preliminary uncontrolled study with few participants indicate
that future randomized clinical trials with more participants
comparing the e-consultations with relevant conventional
practices are justified, in order to quantify effect and long-
term cost-efficiency of e-consultations as an intervention
against obesity.
Keywords-obesity; internet community; treatment; preventive
medicine
I. INTRODUCTION
Obesity is a growing problem, resulting in an increasing
demand for efficient weight loss treatments suitable for use
in general practice settings [1]. According to the
Framingham study, obesity shortens life by 3 to 8 years for a
40-year-old person [2] demonstrating the urgent need for
effective ways to reduce obesity.
Form and content of communication are important in
order to modify life style factors [3], which is the general
recommendation to obtain a sustainable weight reduction.
Several Cochrane reviews infer that advice from general
practitioners (GPs) by itself does not have a long-term effect
on weight loss compared to placebo [4]. Dietician guidance
and the establishment of group meetings have a significant
effect in the short term, but only few long-term studies are
available [4][5]. Surgical intervention is an effective long-
term weight loss option, but in Denmark it is reserved for
very obese patients [5]. Consequently no documented
effective non-surgical weight loss offers are available to the
GPs of the Danish National Health Service for patients with
simple overweight [6].
There is now a vast literature on how the internet can be
integrated as a consultation tool [5][7][8][9]. For example,
several studies suggest that interaction over the internet with
experts in an internet based community is the most effective
way to lose weight [10][11]. Recent studies suggest that
online contacts are an economically attractive contact form
for optimizing guidance on diet and exercise and in keeping
the patients motivated [12][13][14]. The internet furthermore
substantially facilitates the use of motivational tools such as
self-monitoring, which has been used successfully in other
approaches of internet based weight loss interventions [16].
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In Denmark, 86 % of the population has internet access at
home [15], which makes it possible to reach out to most of
the patients by online intervention.
Conventional dietician advice is costly, therefore it is
important to ensure that resources are being used in the best
way possible. In Denmark it is now possible to employ
dieticians in general practice and health care centers.
However many practices experience difficulties to organize
the activities in a way that makes it economically feasible to
offer diet treatment to patients within the rates provided by
the Danish National Health Service.
The present paper reports on the methods used and
results achieved in a preliminary uncontrolled prospective
survey of weight loss and weight maintenance among obese
patients, who received advice and support about diet and
exercise using a personalized interactive internet-based
dietician advice program in a clinical practice setting.
II. METHOD AND SUBJECTS
A. Patients
One medical center with primary care participated in the
study. In May 2008, new patients and patients who were
already enrolled in weight stabilization courses were offered
the opportunity to participate. Initially 46 patients attended a
consultation with a dietician, of which 32 patients agreed to
participate in the full study and signed the informed consent
form. Patients then received information on how they could
log on to the program. Before attending the dietician, the
patients filled out name, address and e-mail address. The
study was approved by the South Danish regional committee
on biomedical ethics.
Figure 1. Screenshot of dietary notations on a daily basis from one of the
participants using the website.
B. Study design
The pilot study was designed as an uncontrolled
prospective survey of the efficacy of using an existing
commercial weight loss program [17] for obese patients in a
general practice setting. At the first login, patients filled out a
comprehensive 16-page medical history with information
regarding their health, education and medicine intake.
Completing the forms gave e-access to consultations with a
dietician and an exercise coach.
E-access also allowed e-mail chats with the other patients
participating in the study.
During the first week the patients recorded a diet and
exercise history on a day-to-day basis (see Figure 1). Based
on these records, the patients received a diet plan, weekly
advice from a dietitian (see figure 2) as well as an exercise
plan and advice from an exercise coach once a month.
Treatment principles in both online and physical
consultations were based on the Danish Board of Health's
recommendations from "The 8 dietary guidelines" [6].
The aim was to enhance the daily intake of vegetables
and fruits, choose whole-grain options for bread and other
cereal products, replace products rich in fat with lean
alternatives and distribute food intake into several smaller
meals throughout the day.
The treatment consisted of providing simple and
manageable guidelines and tools that gave the patients
substantial freedom in planning their meals while the
dietitian could supervise and advise each patient individually
on where improvements could be achieved. Patients who
according to the dietician’s professional assessment needed
face-to-face consultation with the dietician during the study
period, were seen by a dietician in the medical center 2 to 3
months into the study period. Only one dietitian was
connected to the project, which means that the patients were
met by the same dietician at the medical center as online.
Figure 2. Screenshot of personal advice from the dietician as a response to
the information in Figure 1.
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The internet tools in the program encouraged the patients
to record their exact dietary intake on a day-to-day basis,
enabling the dieticians at the face-to-face consultation to
focus more on serving the patient’s needs and spend less
time to simply clarify recent food intake. The patients could
also write about any complication or worry that they might
have during a day, as illustrated in the example in Figure 1.
Dietary notes and commentaries from the patients were used
by the dietician, the exercise coach as well as peers (other
users of the program) to intervene and relate to problems
when they appeared.
The patients were supported by their peers on the website
by using an internet community (presented as ‘forums for
debate), consisting of all users of the internet based program,
both the patients enrolled in the study and other users who
pay for the service privately to lose weight in a non-clinical
setting. The members of this internet community were
encouraged to contact each other for support, as seen in the
example in Figure 3.
The internet community was very intimate as only
patients with a weight problem had access. The patients
could communicate via discussion forums and internet chat
forums. Communication was also available in specially
designed inboxes on the website, as comments to food and
exercise records or via personal pictures.
To illustrate this we have chosen some typical
comments from the patients: “I know I don’t use as many
fiber rich vegetables in my salad as I would like, but there is
no room when I eat my regular salad that I love…” “…the
weather makes it difficult for me to exercise because of my
gout. What can I do?” or “my dog died. I’m so sad…”. The
dietician would get to know every participant individually,
and be able to guide them in a way that suited their lifestyle,
as seen in Figure 2.
Figure 3. Screenshot of participants using the debate forums from the
internet community.
Waist and hip measurement, weight and clinical analysis
values were obtained at baseline and after 4 month initial
treatment. These assessments were performed by the study
team at physical consultations, see table 1. The following
approx. 16 months (maintenance period) most of the patients
continued to use the program, but only received internet
consultations when requested by the patient or by the
dietician, and weight measurements were recorded whenever
the patients attended the health centers for other reasons.
Results were analyzed as a one-sample t-test for the
hypothesis that the weight loss or other change from one
time point to the next was different from 0.
III. RESULTS
The datasets from 22 of the 32 enrolled patients were
sufficiently complete to be included in the outcome
calculations. Of the remaining 10 patients, 2 only registered
starting weight and the remaining 8 never logged on. All 22
completed the initial treatment period and 21 the
maintenance treatment. One patient only completed a 12-
month period due to pregnancy; we used the last observation
carried forward. Baseline data and details of treatment for the
22 patients who participated in the are given in Table 1.
The average weight loss after the initial intensive
treatment period of 115 days (95% CI: 101; 121),was 7.0 kg,
with a standard error of the mean of 1.1 (95% CI: 4.6, 9.3),
P<0.001. Nine participants achieved a weight loss of 5-10 kg
and 4 participants lost more than 10 kg. There were no
significant correlations between weight loss and duration of
treatment period or between weight loss and number of
consultations. Clinical and anthropomorphic data of patients
enrolled are listed in Table 1. The mean age at inclusion was
43 years and the mean weight 104 kg with a BMI of 36.4
kg/m
2
.
Figure 4. Average weight of the participants at baseline, after 4 months and
after 20 months follow up.
85#
90#
95#
100#
105#
110#
115#
'4# 0# 4# 8# 12# 16# 20# 24#
Weight'(Kg)'
Time'from'start'of'intervention'
(Months)'
Changes'in'average'weight'
Female#
Male#
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Data presented as mean value (95% confidence interval)
* p<0.05 vs. before related to same sex
** p<0.001 vs. before related to same sex
*** Two patients were excluded due to pregnancy and absence; we used last observation carried forward (one after 4 months and one after 10 months)
The mean weight loss from baseline after the
maintenance period, a total of approx. 20 months, 595 days
(95% CI: 519; 671), was still 7.0 kg. 15 out of 21 achieved a
weight loss between 5 and 29 kg. 4 lost between 0.3 and 2.2
kg, and the last 3 patients gained between 0.1 and 4.7 kg.
One patient became pregnant and 1 patient was absent for
the approx. 20 month assessment, they were excluded and
we used the last observation carried forward. Seventeen out
of the 21 i.e. 81% of the participants managed to sustain a
weight loss of more than 1 kg after 20 months.
The dietician and some of the patients were interviewed
about their experience with the program. Both parties agreed
that one of the most important parts of the program was the
continuity. The dietician was always available over the
internet, which created an ongoing motivation for lifestyle
changes instead of a short-term diet change. The patients also
found that continuous emotional support and practical advice
from peers had been very important during the study.
Some patients found the internet community equally
important as the dietician, as illustrated by a comment: I
spend most of my time on the internet community, I like to
see how the others are doing and whether they have the same
problems as me.”
Feedback from the doctors and staff in the medical center
indicated that they were satisfied with the cooperation with
the dietician. It was seen as a benefit to offer dietician advice
close to the patients without requiring frequent visits to the
medical center. The main challenge mentioned by this group
was the technical integration with the existing e-journal
system of the Danish National Health Service.
The total cost of the initial weight loss treatment,
including the personal (face-to-face) consultations and
clinical assessments, was estimated to a total of
approximately 35,000DKK. Without the cost of the study
assessments the cost would have been approximately 25,700
DKK. This estimate corresponds to 165 DKK (22) per kg
weight lost for the treatment provided.
TABLE 1. Clinical and anthropomorphic data for the patients. Full set of data at baseline and after the initial treatment period, only weight measurements
after the approx. 20 months maintenance period.
Females (n=17)
Males (n=5)
Age(years)
42 (39-46)
43 (37-50)
Start
4 months
20 months
Start
4 months
20 months
E-mail cons.
0
17 (14-20)
57 (45-70)
0
17 (12-21)
29(18-39)
Period
(days)
111 (97-126)
568 (485-650)
130 (119-140)
683 (649-717)
Weight (kg)
101
(94-108)
93
(85-100)**
94***
(85-102)**
113
(108-117)
111
(105 -116)*
107
(101-113)*
BMI
(kg/m
2
)
35.6
(32.9-38.2)
32.6
(29.9-35.3)**
32.9
(29.9-36.0)**
39.1
(38.0-40.2)
38.4
(37.1-39.8)
37.3
(33.0-41.6)
Waist (cm)
103.2
(97.3-109.2)
95.4
(90.2-100.)*
122.7
(119.9-125.5)
120.3
(116.6-124.1)
Hip (cm)
119
(112.1-125.8)
109.4
(104.2-114.6)*
113.5
(112.5-114.5)
113.5
(112.5-114.5)
WHR
0.86
(0.82-0.93)
0.86
(0.82-0.93)
1.10
(1.07-1.13)
1.09
(1.04-1.13)
Total
cholesterol
5.2
(4.6-5.7)
4.9
(4.4-5.3)
5.8
(5.6-6.0)
5.0
(4.5-5.5)
LDL
(mmol/l)
3.1
(2.5-3.6)
3.0
(2.5-3.4)
3.3
(3.0-3.5)
3.5
(3.3-3.7)
HDL
(mmol/l)
1.7
(1.1-1.4)
1.7
(1.1-1.4)
1.0
(0.8-1.1)
1.1
(1.0-1.1)
TG
(mmol/l)
1.7
(1.3-2.1)
1.3
(1.0-1.6)
4.2
(3.3-5.1)
2.2
(1.6-2.7)
HbA1c (%)
5.0
(5.3-6.8)
5.2
(5.2-6.3)
8.0
(6.6-8.7)
7.0
(6.0-7.8)
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The cost to the Danish National Health Service of an e-mail
consultation was 49.68DKK, compared with 211.14DKK for
a consultation in the medical center with the aim of assisting
the patient to change lifestyle. The average price per patient
for the 4-month weight loss process in this implementation
study was 1165 DKK. Data on costs are not available for the
subsequent maintenance period, but they were substantially
lower than during the initial treatment period.
IV. DISCUSSION
In the present study we used a combination of the expertise
available to a Danish health center with an interactive e-
consultation delivery tool and an internet community to
accomplish a sustainable weight loss amongst obese Danes.
Using this method we achieved an average weight loss of 7.0
kg during the first 4 months, which is comparable to other
conventional treatments [10]. A maintained average weight
loss of 7.0 kg after 20 months follow up is a strong indicator
that this might be a way to efficiently and cost-effectively
reduce weight for a large population. However a
randomized controlled trial would be necessary to determine
whether the results are reproducible.
Bennett et al recently reported on a randomized clinical
trial of another web-based weight loss program in primary
care in the USA, with a similar study population (baseline
BMI 34.6 and age 54.4). This study showed a comparable
efficacy with a 3.05 kg greater weight loss amongst cases
compared with usual care. The trial period was 12 weeks and
one of their conclusions was that trials of longer duration are
necessary [16].
This study however displayed several differences from
ours, i.e. they tried to create adherence to the program by
offering the possibility of winning money and their internet
program did not include facilitated peer support (online
community). Since many of the patients used the community
frequently during our study and found it very beneficial this
may be an important difference. Also the patients in our
study corresponded with the same dietician over the internet
and during the counseling in general practice, in contrast to
the study of Bennett et al [16], where the program was not
designed to provide individual counseling. Using the
patient’s interaction with the community and e-mails from
the patient, the dietician could follow the patients' progress
and provide more accurate and effective advice, since she
had the opportunity to build a greater understanding of every
individual. Together with the longer weight loss period this
might be a reason why our study appeared to show a larger
weight loss, while their results are more significant due to a
higher number of participants and more relevant due to the
comparison with a control group. However in combination
these two studies strongly indicate that as a concept internet
based weight loss programs can be successful in the short
term, may be useful in longer term maintenance of weigh
loss and can be effectively introduced in health care.
Several studies suggest that keeping the patients in the
program is as effective as frequent follow-up but cheaper [5].
In the present study, the low number of dropouts among
those who progressed beyond the first week was remarkable;
according to the patients this was mainly due to the
community, where they established relationships with other
patients. The low dropout rate could also be affected by the
fact that the patients all received advice from the same
dietician, and she could possibly be very good at keeping the
patients motivated. It would be interesting to further
investigate specifically the efficacy of the internet
community, since the Bennet et al. study showed that the
more patients were using the internet program, the greater
their weight loss [16], even though no such correlation was
found with the small number of participants in the present
study. Future developments of the program could focus on
the community and make it more attractive. We may achieve
greater and in particular more sustained weight loss results if
we could get the patients more involved in the program
through the internet community.
The use of self-monitoring provided by the online
program had both advantages and disadvantages. The
patients were able to follow their own progress using the
website, which can help keep motivation, and the data that
the patients provided were essential as tools for the dietitian
to achieve the very cost-effective provision of advice. In
contrast, the self-reported data could not be used for,
evaluation of the intervention outcome, due to potential bias
such as under- or over-estimations or recall bias. Therefore
only data from measurements that were carried out at the
medical center by the dietician or a nurse are presented in the
present paper.
Web-based interventions have the disadvantage that the
participants must be fairly proficient at using the internet and
have the required writing and reading skills for using the
program, in addition to the obvious requirement for
convenient internet access. In our study, 14 patients who
were offered participation failed to go through the enrollment
progress, and some of these could be due to lack of computer
or writing skills.
Feedback from doctors and secretaries involved in the
study was very positive. It was agreed that the program could
potentially help to better utilize the scarce dietician resources
by decreasing the need for consulting face to face. In relation
to the implementation in the medical centers, it was
important that there should be a technical integration that
makes the internet portal an integrated part of the electronic
journal system used by the Danish National Health Service.
Communication between the medical center and dieticians
could become an integrated part of the doctors daily work
tool. It is especially necessary to establish a technical
integration with billing and information exchange, to
minimize the need for intervention by the other staff at the
medical center.
With a total of 500 licensed dieticians in Denmark and
approximately 50 newly educated every year, faced with the
needs of 4000 medical centers to provide relevant treatment
offers to ever increasing numbers of obese patients, the
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present pilot trial indicates the potential usefulness of this
type of effective and economically attractive individual
internet treatment for the large part of the population in need
of dietary advice.
V. CONCLUSION AND FUTURE WORK
The study showed that the internet based interactive weight
management program may be a cost-effective way to
produce a significant and sustained weight loss among
patients with obesity in general practice. The internet can be
used as a communication tool for lifestyle changes and
provide a community for the patients to support them to
maintain weight loss and healthier life style. We have
developed a protocol for a randomized controlled trial to
further investigate the efficacy of this weight-loss program in
a more controlled setting, comparing the intervention with
usual care [18]. Furthermore, we are working on a
refinement of the internet platform to record how much each
of the participants use the internet community, as a tool to
assess the importance of this feature.
ACKNOWLEDGMENT
Thanks to medical student Mathilde Pedersen, University
of Southern Denmark and to political science student Sara
Katrine Brandt for editorial contributions to this paper.
Thanks to the staff at Stenstrup gehus, Nyenstadlægerne
and Marstal gehus for making this study possible. Thanks
to Region Syddanmark and the KEU fund for input and
financial support.
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... A number of studies show that empathy by the healthcare professional (HCP) providing the lifestyle coaching is of paramount importance for in-person coaching [6,7]. Previously, we reported on a collaborative eHealth solution that resulted in long-term behavioural change: weight loss of 7.0 kg over 20 months using eHealth coaching in a general practice setting [8]. The same findings were observed in a municipality setting with diabetic men, where patients stated that an initial in-person meeting with the dietician seemed important for their future web-based interaction [9]. ...
... HCPs conducted eHealth coaching using the collaborative eHealth solution LIVA [17] in a hybrid manner, combining face to face meetings with eHealth coaching. LIVA is a refinement of the former 4 [8] and mydietician.org.uk [9], which were used and described in detail in two previously reported studies [8,9]. ...
... LIVA is a refinement of the former 4 [8] and mydietician.org.uk [9], which were used and described in detail in two previously reported studies [8,9]. The five participating municipalities have offered this eHealth tool to patients for 6 to 12 months and have each included 100 to 400 patients. ...
... A user-driven approach to the design of both the user and coach interfaces has enabled ease of use and has eased communication flow [20], allowing for tailored communication between the health coaches and the end users at all steps of the weight loss program [21]. An important feature of the intervention continues to be the initial establishment of an empathic relationship between the user and the health coach, who delivers effective remote digital coaching based on the user's own registration. ...
... Afshin et al concluded in 2016 that a direct interaction between a user and a health coach enhances the effectiveness of lifestyle interventions [3]. By establishing a personal relationship outside the digital environment, which is maintained through the platform with backend follow-ups, we believe that we are able to facilitate tailored care and sustained participant engagement over time with limited continued health coach input in the process of successfully changing and sustaining a lifestyle change [8,21]. ...
... With version 1.0 of the collaborative eHealth tool, we found that personal eHealth lifestyle coaching combined with various BCTs, such as tailored information, self-monitoring, lifestyle coaching, personal feedback, reminders, and face-to-face support, led to relevant weight loss during a 20-month period [21]. These results were confirmed in an English RCT in a municipality setting, showing weight loss of 5.4 kg among men with type 2 diabetes compared with weight loss of 2.8 kg in a control group receiving standard care [8]. ...
Article
Full-text available
Background: Obesity is linked to a number of chronic health conditions, such as type 2 diabetes, heart disease, and cancer, and weight loss interventions are often expensive. Recent systematic reviews concluded that app and web-based interventions can improve lifestyle behaviors and weight loss at a reasonable cost, but long-term sustainability needs to be demonstrated. Objective: This study protocol is for a 2-year randomized controlled trial that aims to evaluate the clinical and economic effects of a primary care, anchored, collaborative, electronic health (eHealth) lifestyle coaching program (long-term Lifestyle change InterVention and eHealth Application [LIVA] 2.0) in obese participants with and without type 2 diabetes. The program's primary outcome is weight loss. Its secondary outcome is the hemoglobin A1c (HbA1c) level, and its tertiary outcomes are retention rate, quality of life (QOL), and cost effectiveness. Analytically, the focus is on associations of participant characteristics with outcomes and sustainability. Methods: We conduct a multicenter trial with a 1-year intervention and 1-year retention. LIVA 2.0 is implemented in municipalities within administrative regions in Denmark, specifically eight municipalities located within the Region of Southern Denmark and two municipalities located within the Capital Region of Denmark. The participants are assessed at baseline and at 6-, 12-, and 24-month follow-ups. Individual data from the LIVA 2.0 platform are combined with clinical measurements, questionnaires, and participants' usage of municipality and health care services. The participants have a BMI ≥30 but ≤45 kg/m2, and 50% of the participants have type 2 diabetes. The participants are randomized in an approximately 60:40 manner, and based on sample size calculations on weight loss and intention-to-treat statistics, 200 participants are randomized to an intervention group and 140 are randomized to a control group. The control group is offered the conventional preventive program of the municipality, and it is compared to the intervention group, which follows the LIVA 2.0 in addition to the conventional preventive program. Results: The first baseline assessments have been carried out in March 2018, and the 2-year follow-up will be carried out between March 2020 and April 2021. The hypothesis is that the trial results will demonstrate decreased body weight and that the number of patients who show normalization of their HbA1c levels in the intervention group will be much higher than that in the control group. The participants in the intervention group are also expected to show a greater decrease in their use of glucose-lowering medication and a greater improvement in their QOL when compared with the control group. Operational costs are expected to be lower than standard care, and the intervention is expected to be cost-effective. Conclusions: This is the first time that an app and web-based eHealth lifestyle coaching program implemented in Danish municipalities will be clinically and economically evaluated. If the LIVA 2.0 eHealth lifestyle coaching program is proven to be effective, there is great potential for decreasing the rates of obesity, diabetes, and related chronic diseases. Trial registration: ClinicalTrials.gov NCT03788915; https://clinicaltrials.gov/ct2/show/NCT03788915. International registered report identifier (irrid): DERR1-10.2196/19172.
... LIVA 1.0 was a browser-based solution. With LIVA 1.0, we found that, in a Danish setting, personal eHealth lifestyle coaching combined with various BCTs, such as self-monitoring, reminders, tailored information, personal feedback, and face-to-face support, led to a relevant weight loss of 5.1 kg during a 20-month period [19]. These results have been confirmed in a British municipality setting [9]. ...
... The current version of LIVA 2.0 was developed based on experiences from the Danish and British studies [9,19], as well as experiences of approximately 140,000 individuals who had used LIVA 1.0 in Denmark and Britain over a 15-year period. Its development was also based on three qualitative interview studies with a. patients who had been using LIVA 1.0 [20], b. general practitioners (GPs) [21], and c. eHealth coaches [22] who had used the first prototype of LIVA 2.0. ...
Article
Long-term weight loss can reduce the risk of type 2 diabetes for people living with obesity and reduce complications for patients diagnosed with type 2 diabetes. We investigated whether a telehealth lifestyle-coaching program (Liva) leads to long-term (24 months) weight loss compared to usual care. In a randomized controlled trial, n = 340 participants living with obesity with or without type 2 diabetes were enrolled and randomized via an automated computer algorithm to an intervention group ( n = 200) or to a control group ( n = 140). The telehealth lifestyle-coaching program comprised of an initial one-hour face-to-face motivational interview followed by asynchronous telehealth coaching. The behavioural change techniques used were enabled by individual live monitoring. The primary outcome was a change in body weight from baseline to 24 months. Data were assessed for n = 136 participants (40%), n = 81 from the intervention group and n = 55 from the control group, who completed the 24-month follow-up. After 24 months mean body weight and body mass index were reduced significantly for completers in both groups, but almost twice as much was registered for those in the intervention group which was not significant between groups −4.4 (CI −6.1; −2.8) kg versus −2.5 (CI −3.9; −1.1) kg, P = 0.101. Haemoglobin A1c was significantly reduced in the intervention group −3.1 (CI −5.0; −1.2) mmol/mol, but not in the control group −0.2 (CI −2.4; −2.0) mmol/mol without a significant between group difference ( P = 0.223). Low completion was partly due to coronavirus disease 2019. Telehealth lifestyle coaching improve long-term weight loss (> 24 months) for obese people with and without type 2 diabetes compared to usual care.
... LIVA 1.0 was a browser-based solution. With LIVA 1.0, we found that, in a Danish setting, personal eHealth lifestyle coaching combined with various BCTs, such as self-monitoring, reminders, tailored information, personal feedback, and face-to-face support, led to a relevant weight loss of 5.1 kg during a 20-month period [19]. These results have been confirmed in a British municipality setting [9]. ...
... The current version of LIVA 2.0 was developed based on experiences from the Danish and British studies [9,19], as well as experiences of approximately 140,000 individuals who had used LIVA 1.0 in Denmark and Britain over a 15-year period. Its development was also based on three qualitative interview studies with a. patients who had been using LIVA 1.0 [20], b. general practitioners (GPs) [21], and c. eHealth coaches [22] who had used the first prototype of LIVA 2.0. ...
... LIVA 1.0 was a browser-based solution. With LIVA 1.0, we found that, in a Danish setting, personal eHealth lifestyle coaching combined with various BCTs, such as self-monitoring, reminders, tailored information, personal feedback, and face-to-face support, led to a relevant weight loss of 5.1 kg during a 20-month period [19]. These results have been confirmed in a British municipality setting [9]. ...
... The current version of LIVA 2.0 was developed based on experiences from the Danish and British studies [9,19], as well as experiences of approximately 140,000 individuals who had used LIVA 1.0 in Denmark and Britain over a 15-year period. Its development was also based on three qualitative interview studies with a. patients who had been using LIVA 1.0 [20], b. general practitioners (GPs) [21], and c. eHealth coaches [22] who had used the first prototype of LIVA 2.0. ...
Article
Full-text available
The goal of this trial was to investigate whether an eHealth lifestyle coaching programme led to significant weight loss and decreased Haemoglobin A1c (HbA1c) in patients with type 2 diabetes. In an RCT, 170 patients were enrolled from 2018 to 2019 for intervention or control. Inclusion criteria were diagnosed with type 2 diabetes, BMI 30–45 kg/m2, and aged 18–70 years. Exclusion criteria were lacks internet access, pregnant or planning a pregnancy, or has a serious disease. Primary and secondary outcomes were a reduction in body weight and HbA1c. At six months, 75 (75%) patients in the intervention group and 53 (76%) patients in the control group remained in the trial. The mean body weight loss was 4.2 kg (95% CI, −5.49; −2.98) in the intervention group and 1.5 kg (95% CI, −2.57; −0.48) in the control group (p = 0.005). In the intervention group, 24 out of 62 patients with elevated HbA1c at baseline (39%) had a normalized HbA1c < 6.5% at six months, compared to 8 out of 40 patients with elevated HbA1c at baseline (20%) in the control group (p = 0.047). The eHealth lifestyle coaching programme can lead to significant weight loss and decreased HbA1c among patients with type 2 diabetes, compared to standard care.
... LIVA 1.0 was a browser-based solution. With LIVA 1.0, we found that, in a Danish setting, personal eHealth lifestyle coaching combined with various BCTs, such as self-monitoring, reminders, tailored information, personal feedback, and face-to-face support, led to a relevant weight loss of 5.1 kg during a 20-month period [19]. These results have been confirmed in a British municipality setting [9]. ...
... The current version of LIVA 2.0 was developed based on experiences from the Danish and British studies [9,19], as well as experiences of approximately 140,000 individuals who had used LIVA 1.0 in Denmark and Britain over a 15-year period. Its development was also based on three qualitative interview studies with a. patients who had been using LIVA 1.0 [20], b. general practitioners (GPs) [21], and c. eHealth coaches [22] who had used the first prototype of LIVA 2.0. ...
Preprint
BACKGROUND Lifestyle interventions can delay and reverse the onset of type 2 diabetes (T2D) and decrease morbidity and mortality. Studies suggest that digital coaching based on real-time monitoring can lead to clinically relevant weight loss, as well as decreased or normalized hemoglobin A1c (HbA1c) for a significant number of patients. OBJECTIVE To assess whether an eHealth lifestyle coaching program (LIVA 2.0) for patients with T2D who are motivated for lifestyle changes leads to significant weight loss and decreased HbA1c, compared to usual care. METHODS In a randomized controlled single-blinded trial, 170 patients with T2D were enrolled from March 2018 to March 2019 and randomized to the intervention (100) and control (70) groups. Patients were recruited via their general practitioners, the Danish diabetes organization, and social media. The intervention comprised an initial face-to-face motivational interview followed by digital coaching. The same healthcare professional coach provided synchronous and asynchronous multimodal feedback and used digital behavioral change techniques enabled by an app providing live monitoring of lifestyle behaviors. Primary outcome was body weight. Secondary outcomes were changes in HbA1c, body composition, lipids, and quality of life at 6 months. RESULTS At 6 months, 75 patients (75%) in the intervention group and 53 patients (76%) in the control group remained in the study. Mean body weight loss was 4.2 kg (95% CI, 5.5- 3.0) in the intervention group vs 1.5 kg (95% CI, 2.57- 0.48) in the control group (P = .005). In the intervention group, 36 (52%) patients lost > 3% body weight, compared to 12 (32%) patients in the control group. Mean HbA1c was lower in both groups at 6 months, with reductions of 8.2% (95% CI, 11.01 to 5.29) and 5.5% (95% CI, 8.75 to 2.76) for the intervention and control groups, respectively (P = .203). In the intervention group, 24 (32%) had an HbA1c <6.5% at 6 months, compared to 8 (15%) in the control group (P = .03). CONCLUSIONS Reduction in body weight and remission rate for HbA1c, as well as improved body composition can be enhanced by using digital lifestyle coaching for patients with T2D. CLINICALTRIAL Trial Registration: Clinicaltrials.gov NCT03788915 https://clinicaltrials.gov/ct2/show/NCT03788915 International Registered Report Identifier (IRRID): DERR2-10.2196/19172 INTERNATIONAL REGISTERED REPORT RR2-10.2196/19172
... Recent systematic reviews conclude that Web-based and mobile digital eHealth solutions can improve lifestyle behaviours [3][4][5][6][7][8], however also stress that there is a lack of "…available weight loss interventions suitable to the real-world PC setting, with most research and guideline formulation conducted inside academic silos…" [5] as well as there is a "…need for long-term interventions to evaluate sustainability" [4]. The authors have previously found that eHealth lifestyle coaching providing various Behavioural Change Techniques (BCT) such as tailored information, self-monitoring, lifestyle coaching, in-person feedback, reminders, and person-to-person support based on a strong personal relationship led to a significant weight loss of 7,0 kg during a 20 months' period [9]. A refinement of this eHealth intervention (LIVA) was implemented in eight Danish municipalities between summer 2016 until summer 2018 on the basis of a number of qualitative studies [10] [11]. ...
... The intervention provides various BCT's evidenced to be effective for changing lifestyle such as tailored information, self-monitoring, lifestyle coaching, in-person feedback, reminders, and peer-to-peer support [17]. By establishing a personal relationship initially in a face-to-face meeting, which is then continued digitally through the eHealth intervention, the intervention enables tailored care and sustained patient engagement over time with a minimal of HCP input in the process of successfully changing lifestyle and sustaining this change [6,9,16]. Goal setting is based on the SMART model: Specific, Measurable, Attainable, Relevant and Timely according to a predefined guideline structure, described in Table 1. ...
Article
Full-text available
Background Internet and mobile interventions aiming to promote healthy lifestyle have attracted much attention because of their scalability and accessibility, low costs, privacy and user control, potential for use in real-life settings, as well as opportunities for real-time modifications and interactive advices. A real-life electronic health (eHealth) lifestyle coaching intervention was implemented in 8 Danish municipalities between summer 2016 and summer 2018. Objective The aim of this study was to assess the effects associated with the eHealth intervention among diabetes patients in a real-life municipal setting. The eHealth intervention is based on an initial meeting, establishing a strong empathic relationship, followed by digital lifestyle coaching and collaboration supported by a Web-based community among patients. Methods We conducted an observational study examining the effect of an eHealth intervention on self-reported weight change among 103 obese diabetes patients in a real-life municipal setting. The patients in the study participated in the eHealth intervention between 3 and 12 months. A weight change was observed at 6, 9, and 12 months. We used regression methods to estimate the impacts of the intervention on weight change. Results We found that the eHealth intervention significantly reduced weight among diabetes patients, on average 4.3% of the initial body mass, which corresponds to 4.8 kg over a mean period of 7.3 months. Patients who were in intervention for more than 9 months achieved a weight reduction of 6.3% or 6.8 kg. Conclusions This study brings forward evidence of a positive effect of a real-life eHealth lifestyle intervention on diabetes patients’ lifestyle in a municipal setting. Future research is needed to show if the effect is sustainable from a long-term perspective.
... Recent systematic reviews conclude that Web-based and mobile digital eHealth solutions can improve lifestyle behaviours, however results on how to maintain the effect are more variable [3][4][5][6][7][8]. We have previously found that eHealth lifestyle coaching providing various Behavioural Change Techniques (BCT) such as tailored information, self-monitoring, lifestyle coaching, in-person feedback, reminders, and person-to-person support led to a significant weight loss during a 12 and 20 months' periods [9]. A refinement of this eHealth solution was implemented in eight Danish municipalities between summer 2016 until summer 2018 on the basis of a number of qualitative studies [10] [11]. ...
Preprint
BACKGROUND Internet and mobile interventions aiming to promote healthy lifestyle have attracted much attention due to their potential for scalability and accessibility, low costs, privacy and user-control, use in municipal settings as well as opportunities for real time modifications and interactive advices. An eHealth lifestyle coaching intervention was implemented in 8 Danish municipalities between summer 2016 until summer 2018. OBJECTIVE The aim of this study is to assess the effectiveness of the eHealth lifestyle coaching among diabetes patients in a municipal setting, based on the evidence from the collaborative eHealth tool facilitating lifestyle coaching implemented in 8 Danish municipalities. METHODS An observational study examining the effect of eHealth lifestyle coaching on self-reported weight change among 103 obese diabetes patients, in a municipal setting. The patients in the study have used the collaborative eHealth tool from 3 to 12 months. RESULTS We found that the use of a collaborative eHealth tool significantly reduced weight among diabetes patients, on average 4.3% of the initial body mass, which corresponds to 4.8 kg over mean period of 7.3 months. The patients that have used the eHealth tool for over 9 months have achieved a weight reduction of 6.3% or 6.8 kg. CONCLUSIONS This study brings forward evidence of a positive effect of a running municipal secondary preventive offer targeted diabetes patients and gives a model that can be used for other similar interventions. Future research is needed to show if the effect is sustainable in a long-term perspective.
... We have previously described a collaborative electronic health (eHealth) solution that supported lifestyle coaching by establishing a relationship and providing behavioral change (weight loss of 7.0 kg for 20 months) through monitoring and empathic, relevant, and individualized feedback in a general practice setting [6]. These findings were replicated in a later version of the solution in a municipality setting in the region of North East England in Durham and Darlington County for men with type 2 diabetes in a pilot randomized controlled trial where patients lost an average of 5.4 kg compared with a control group that received usual care and lost 2.8 kg. ...
Article
Full-text available
Background: Wearables, fitness apps, and patient home monitoring devices are used increasingly by patients and other individuals with lifestyle challenges. All Danish general practitioners (GPs) use digital health records and electronic health (eHealth) consultations on a daily basis, but how they perceive the increasing demand for lifestyle advice and whether they see eHealth as part of their lifestyle support should be explored further. Objective: This study aimed to explore GPs' perspectives on eHealth devices and apps and the use of eHealth in supporting healthy lifestyle behavior for their patients and themselves. Methods: A total of 10 (5 female and 5 male) GPs were recruited by purposive sampling, aged 38 to 69 years (mean 51 years), of which 4 had an urban uptake of patients and 6 a rural uptake. All of them worked in the region of Southern Denmark where GPs typically work alone or in partnership with 1 to 4 colleagues and all use electronic patient health records for prescription, referral, and asynchronous electronic consultations. We performed qualitative, semistructured, individual in-depth interviews with the GPs in their own office about how they used eHealth and mHealth devices to help patients challenged with lifestyle issues and themselves. We also interviewed how they treated lifestyle-challenged patients in general and how they imagined eHealth could be used in the future. Results: All GPs had smartphones or tablets, and everyone communicated on a daily basis with patients about disease and medicine via their electronic health record and the internet. We identified 3 themes concerning the use of eHealth: (1) how eHealth is used for patients; (2) general practitioners' own experience with improving lifestyle and eHealth support; and (3) relevant coaching techniques for transformation into eHealth. Conclusions: GPs used eHealth frequently for themselves but only infrequently for their patients. GPs are familiar with behavioral change techniques and are ready to use them in eHealth if they are used to optimize processes and not hinder other treatments. Looking ahead, education of GPs and recognizing patients' ability and preference to use eHealth with regard to a healthy living are needed.
Preprint
BACKGROUND The increasing prevalence and economic impact of chronic diseases challenge health care systems globally. Digital solutions can potentially improve efficiency and quality of care, but these initiatives struggle with non-usage attrition. OBJECTIVE This study seeks to gain insight into the causes of attrition to build predictive models that can identify patients in a digital lifestyle intervention at high risk of dropout by analyzing several predictor variables applied in different models. METHODS Data from 2,684 patients using an eHealth platform was iteratively analyzed using logistic regression, decision trees, and random forest models. The dataset was split into an 80% training and cross-validation set and a 20% hold-out test set. Trends in activity patterns were analyzed to assess engagement over time. RESULTS Patients in the test dataset were classified as dropouts with an 89% precision using a random forest model and 11 predictor variables. The most significant predictors were the provider of the intervention, two weeks inactivity, and the number of advice received from the health coach. CONCLUSIONS Dropouts from eHealth lifestyle interventions can be predicted using various data mining methods. The best performing model was found to be the random forest.
Article
Full-text available
Obesity is an increasing drain on the resources of general practitioners, who have few effective options for treatment other than surgery and (often prohibitively expensive) personal dietician advice. A study has been designed to investigate the effects of internet-based dietary advice compared with a placebo non-interactive web-support to conventional practice during 24 months. Using data from a previous pilot project for the power calculation, by recruiting 300 patients we will obtain sufficient power to reliably detect a long-term weight loss of 2.5 kg, or, if this figure is higher, to obtain more detailed information about criteria distinguishing patients more or less likely to benefit from this type of Internet based weight loss program.
Article
Full-text available
Overweight and obesity in adulthood are linked to an increased risk for death and disease. Their potential effect on life expectancy and premature death has not yet been described. To analyze reductions in life expectancy and increases in premature death associated with overweight and obesity at 40 years of age. Prospective cohort study. The Framingham Heart Study with follow-up from 1948 to 1990. 3457 Framingham Heart Study participants who were 30 to 49 years of age at baseline. Mortality rates specific for age and body mass index group (normal weight, overweight, or obese at baseline) were derived within sex and smoking status strata. Life expectancy and the probability of death before 70 years of age were analyzed by using life tables. Large decreases in life expectancy were associated with overweight and obesity. Forty-year-old female nonsmokers lost 3.3 years and 40-year-old male nonsmokers lost 3.1 years of life expectancy because of overweight. Forty-year-old female nonsmokers lost 7.1 years and 40-year-old male nonsmokers lost 5.8 years because of obesity. Obese female smokers lost 7.2 years and obese male smokers lost 6.7 years of life expectancy compared with normal-weight smokers. Obese female smokers lost 13.3 years and obese male smokers lost 13.7 years compared with normal-weight nonsmokers. Body mass index at ages 30 to 49 years predicted mortality after ages 50 to 69 years, even after adjustment for body mass index at age 50 to 69 years. Obesity and overweight in adulthood are associated with large decreases in life expectancy and increases in early mortality. These decreases are similar to those seen with smoking. Obesity in adulthood is a powerful predictor of death at older ages. Because of the increasing prevalence of obesity, more efficient prevention and treatment should become high priorities in public health.
Article
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A primary focus of self-care interventions for chronic illness is the encouragement of an individual's behavior change necessitating knowledge sharing, education, and understanding of the condition. The use of the Internet to deliver Web-based interventions to patients is increasing rapidly. In a 7-year period (1996 to 2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies." The use and effectiveness of Web-based interventions to encourage an individual's change in behavior compared to non-Web-based interventions have not been substantially reviewed. This meta-analysis was undertaken to provide further information on patient/client knowledge and behavioral change outcomes after Web-based interventions as compared to outcomes seen after implementation of non-Web-based interventions. The MEDLINE, CINAHL, Cochrane Library, EMBASE, ERIC, and PSYCHInfo databases were searched for relevant citations between the years 1996 and 2003. Identified articles were retrieved, reviewed, and assessed according to established criteria for quality and inclusion/exclusion in the study. Twenty-two articles were deemed appropriate for the study and selected for analysis. Effect sizes were calculated to ascertain a standardized difference between the intervention (Web-based) and control (non-Web-based) groups by applying the appropriate meta-analytic technique. Homogeneity analysis, forest plot review, and sensitivity analyses were performed to ascertain the comparability of the studies. Aggregation of participant data revealed a total of 11,754 participants (5,841 women and 5,729 men). The average age of participants was 41.5 years. In those studies reporting attrition rates, the average drop out rate was 21% for both the intervention and control groups. For the five Web-based studies that reported usage statistics, time spent/session/person ranged from 4.5 to 45 minutes. Session logons/person/week ranged from 2.6 logons/person over 32 weeks to 1008 logons/person over 36 weeks. The intervention designs included one-time Web-participant health outcome studies compared to non-Web participant health outcomes, self-paced interventions, and longitudinal, repeated measure intervention studies. Longitudinal studies ranged from 3 weeks to 78 weeks in duration. The effect sizes for the studied outcomes ranged from -.01 to .75. Broad variability in the focus of the studied outcomes precluded the calculation of an overall effect size for the compared outcome variables in the Web-based compared to the non-Web-based interventions. Homogeneity statistic estimation also revealed widely differing study parameters (Q(w16) = 49.993, P < or = .001). There was no significant difference between study length and effect size. Sixteen of the 17 studied effect outcomes revealed improved knowledge and/or improved behavioral outcomes for participants using the Web-based interventions. Five studies provided group information to compare the validity of Web-based vs. non-Web-based instruments using one-time cross-sectional studies. These studies revealed effect sizes ranging from -.25 to +.29. Homogeneity statistic estimation again revealed widely differing study parameters (Q(w4) = 18.238, P < or = .001). The effect size comparisons in the use of Web-based interventions compared to non-Web-based interventions showed an improvement in outcomes for individuals using Web-based interventions to achieve the specified knowledge and/or behavior change for the studied outcome variables. These outcomes included increased exercise time, increased knowledge of nutritional status, increased knowledge of asthma treatment, increased participation in healthcare, slower health decline, improved body shape perception, and 18-month weight loss maintenance.
Conference Paper
Obesity is according to WHO one of the greatest health challenges of our time. The aim of the pilot project was to investigate the weight loss efficacy and the cost of individual dietetic internet-based consultations in a Danish medical centre in combination with an internet community. A total of 46 obese patients in general practice were offered participation in a cohort study during May 15th to December 1st 2008. Patients from three different health centers were included. 32 patients gave informed consent to participate and were given access to weekly e-mail consultations with a dietician and access to an advanced internet community. The weight was objectively decided by inclusion and conclusion of the study. 22 (17 women and 5 men) completed the study. The average age was 41 years, the weight was 103 kg and the BMI was 36.7 kg/m2. After four months (42-168 days) of treatment and averagely 17 consultations the participants accomplished an average weight loss of 6.3 kg, p
Article
The objectives of this systematic review are to evaluate the effectiveness of web-based interventions on weight loss and maintenance and identify which components of web-based interventions are associated with greater weight change and low attrition rates. A literature search from 1995 to April 2008 was conducted. Studies were eligible for inclusion if: participants were aged >or=18 years with a body mass index >or=25, at least one study arm involved a web-based intervention with the primary aim of weight loss or maintenance, and reported weight-related outcomes. Eighteen studies met the inclusion criteria. Thirteen studies aimed to achieve weight loss, and five focused on weight maintenance. Heterogeneity was evident among the studies with seven research questions examined across interventions of varying intensity. Seven studies were assessed for effectiveness based on percentage weight change, with four studies deemed effective. Although the four meta-analyses suggest meaningful weight change, it is not possible to determine the effectiveness of web-based interventions in achieving weight loss or maintenance due to heterogeneity of designs and thus the small number of comparable studies. Higher usage of website features may be associated with positive weight change, but we do not know what features improve this effect or reduce attrition.
Article
Evidence is lacking regarding effective and sustainable weight loss approaches for use in the primary care setting. We conducted a 12-week randomized controlled trial to evaluate the short-term efficacy of a web-based weight loss intervention among 101 primary care patients with obesity and hypertension. Patients had access to a comprehensive website that used a moderate-intensity weight loss approach designed specifically for web-based implementation. Patients also participated in four (two in-person and two telephonic) counseling sessions with a health coach. Intent-to-treat analysis showed greater weight loss at 3 months (-2.56 kg; 95% CI -3.60, -1.53) among intervention participants (-2.28 +/- 3.21 kg), relative to usual care (0.28 +/- 1.87 kg). Similar findings were observed among intervention completers (-3.05 kg; 95% CI -4.24, -1.85). High rates of participant retention (84%) and website utilization were observed, with the greatest weight loss found among those with a high frequency of website logins (quartile 4 vs. 1: -4.16 kg; 95% CI -1.47, -6.84). The intervention's approach promoted moderate weight loss at 12 weeks, though greater weight loss was observed among those with higher levels of website utilization. Efficacious web-based weight loss interventions can be successfully offered in the primary care setting.
Article
The dietary habits of Americans are creating serious health concerns, including obesity, hypertension, diabetes, cardiovascular disease, and even some types of cancer. While considerable attention has been focused on calorie reduction and weight loss, approaches are needed that will not only help the population reduce calorie intake but also consume the type of healthy, well-balanced diet that would prevent this array of medical complications. To design an Internet-based nutrition education program and to explore its effect on weight, blood pressure, and eating habits after 12 months of participation. We designed the DASH for Health program to provide weekly articles about healthy nutrition via the Internet. Dietary advice was based on the DASH diet (Dietary Approaches to Stop Hypertension). The program was offered as a free benefit to the employees of EMC Corporation, and 2834 employees and spouses enrolled. Enrollees voluntarily entered information about themselves on the website (food intake), and we used these self-entered data to determine if the program had any effect. Analyses were based upon the change in weight, blood pressure, and food intake between the baseline period (before the DASH program began) and the 12th month. To be included in an outcome, a subject had to have provided both a baseline and 12th-month entry. After 12 months, 735 of 2834 original enrollees (26%) were still actively using the program. For subjects who were overweight/obese (body mass index > 25; n = 151), weight change at 12 months was -4.2 lbs (95% CI: -2.2, -6.2; P < .001). For subjects with hypertension or prehypertension at baseline (n = 62), systolic blood pressure fell 6.8 mmHg at 12 months (CI: -2.6, -11.0; P < .001; n = 62). Diastolic pressure fell 2.1 mmHg (P = .16). Based upon self-entered food surveys, enrollees (n = 181) at 12 months were eating significantly more fruits, more vegetables, and fewer grain products. They also reduced consumption of carbonated beverages. Enrollees who had visited the website more often tended to have greater blood pressure and weight loss effect, suggesting that use of the DASH for Health program was at least partially responsible for the benefits we observed. We have found that continued use of a nutrition education program delivered totally via the Internet, with no person-to-person contact with health professionals, is associated with significant weight loss, blood pressure lowering, and dietary improvements after 12 months. Effective programs like DASH for Health, delivered via the Internet, can provide benefit to large numbers of subjects at low cost and may help address the nutritional public health crisis.
Article
Rapid increases in access to the Internet have made it a viable mode for public health intervention. No controlled studies have evaluated this resource for weight loss. To determine whether a structured Internet behavioral weight loss program produces greater initial weight loss and changes in waist circumference than a weight loss education Web site. Randomized, controlled trial conducted from April to December 1999. Ninety-one healthy, overweight adult hospital employees aged 18 to 60 years with a body mass index of 25 to 36 kg/m(2). Analyses were performed for the 65 who had complete follow-up data. Participants were randomly assigned to a 6-month weight loss program of either Internet education (education; n = 32 with complete data) or Internet behavior therapy (behavior therapy; n = 33 with complete data). All participants were given 1 face-to-face group weight loss session and access to a Web site with organized links to Internet weight loss resources. Participants in the behavior therapy group received additional behavioral procedures, including a sequence of 24 weekly behavioral lessons via e-mail, weekly online submission of self-monitoring diaries with individualized therapist feedback via e-mail, and an online bulletin board. Body weight and waist circumference, measured at 0, 3, and 6 months, compared the 2 intervention groups. Repeated-measures analyses showed that the behavior therapy group lost more weight than the education group (P =.005). The behavior therapy group lost a mean (SD) of 4.0 (2.8) kg by 3 months and 4.1 (4.5) kg by 6 months. Weight loss in the education group was 1.7 (2.7) kg at 3 months and 1.6 (3.3) kg by 6 months. More participants in the behavior therapy than education group achieved the 5% weight loss goal (45% vs 22%; P =.05) by 6 months. Changes in waist circumference were also greater in the behavior therapy group than in the education group at both 3 months (P =.001) and 6 months (P =.005). Participants who were given a structured behavioral treatment program with weekly contact and individualized feedback had better weight loss compared with those given links to educational Web sites. Thus, the Internet and e-mail appear to be viable methods for delivery of structured behavioral weight loss programs.