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Self-Monitoring: Review of the Literature. Lora E. Burke, PhD, MPH, FAHA, FAAN Obesity Researchers Journal Club University of Pittsburgh October 21, 2008. Overview of Review. Self-monitoring – why Historical review of studies, 1980s – present using paper diaries
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Self-Monitoring: Review of the Literature Lora E. Burke, PhD, MPH, FAHA, FAAN Obesity Researchers Journal Club University of Pittsburgh October 21, 2008
Overview of Review • Self-monitoring – why • Historical review of studies, 1980s – present using paper diaries • Internet and electronic diary studies • What have we learned, where do we need to go
Self-Monitoring in Weight Loss • Is the systematic recording of one’s eating or physical activity behaviors • Purpose is to increase one’s awareness of eating behaviors • Should occur in real time, throughout day
Abbreviations • Behavioral weight loss program = BWLP • Physical activity = PA • Self-monitoring = SM • Intervention = Tx
“First” study of Self-Monitoring in Wt Loss (1) • Study involved 16 groups of 11 adults in a BWLP at a fee-for-service clinic for obesity; 15 weekly 1-hr meetings • 1/2 of groups given target behavior monitoring forms – 9 behaviors related to eating & PA, frequency count • # of times/day behavior was engaged in compared to total # of eating episodes = % compliance; graphed behavior; rec’d feedback Sperduto et al., 1986
“First” study of Self-Monitoring in Wt Loss (2) • Combining the 8 groups that used SM forms, mean wt loss = 15.9 ± 3.9 lbs vs. 9.7 ± 1.9 lbs for comparison group at end of Tx (15 wks), p <.005 • At 3-mos f/u difference was 6.4 lbs, p <.005 • Completion rate was higher among SM group, 74.4% vs. 56.8%, p <.05 • Implications: Need to begin to focus on eating behaviors, not outcome of wt loss Sperduto et al., 1986
Self-Monitoring and Weight Change: Cross-sectional Study • N = 56 obese adults previously Tx; agreed to participate in SM study • Given new booklet each week to record all foods, calories • Focus: examine relationship between SM and weight change • Result: Great diversity in percentage of Ss who SM and in type & frequency of variables monitored Baker & Kirschenbaum, 1993
Percentage of Days All Foods Were Monitored Baker & Kirschenbaum, 1993
Conclusions and Recommendations • 6 variables correlated significantly with wt change after 12 wks, e.g., SM any or all foods eaten, time eaten, quantity, gms. of fat • Ss in the highest level of SM lost sig more wt than those at the lower levels • Consistency/quality of SM in initial wks of Tx predicted wt loss over 6-mos period • Important to view SM not only as a process that mediates wt control but also an important outcome; focus more on behaviors that produce wt loss than on the wt loss • Need to develop means of sustaining SM Baker & Kirschenbaum, 1993
Further Support for Consistent SM • Study replicated Baker & Kirschenbaum’s 1993 study re: relationship between SM and wt control; N = 59 women in long-term BWLP; asked to participate in SM study for 8 wks • 26.3% SM all foods eaten on <50% of days • Most consistent SMs lost more wt, Ss lost more wt during time of consistent SM • Conclusion: Ss should SM at least 75% of the days; if SM <50% of days unlikely to succeed Boutelle and Kirschenbaum, 1998
Self-Monitoring and the Holidays • 2 studies (N = 32 & 57) examined effect of SM on weight gain among adults who had been in long-term Tx for weight loss • Findings: • Holidays were high risk period • Only the highly consistent SM quartile averaged any wt loss over 10-wk holiday period; least consistent SM gained wt • 2nd study showed that Ss SM more consistently during the pre-holiday period than during the holidays or post-holiday period; consistency was correlated with wt change (r = -.35, p = .007) Baker & Kirschenbaum, 1998;Boutelle et al., 1999
Comparison of 2 SM Approaches • 16-wk correspondence BWLP compared 2 methods of SM: traditional paper diary (n = 21, 45% retention) vs. traditional paper diary with transition to abbreviated diary with checklists at 8 wks (n = 21, 57% retention) • Results: Sig diff in # of diaries ret’d among completers (14.0 ± 2.0 detailed vs. 15.2 ± 1.4 transition group, p =.04) • No sig diff between groups in wt loss Helsel, Jakicic, & Otto, 2007
Number of Diaries by Groups Helsel, Jakicic, & Otto, 2007
Wt Loss in Two SM Groups TSM = transitioned to abbreviated SM, DSM = detailed SM Helsel, Jakicic, & Otto, 2007
Self-Monitoring Physical Activity • 6-mon BWLP, N = 40 obese, sedentary adults, 85% retention at 6 mos • Instructed to complete daily PA diary describing exercise type/duration; collected every 4-5 wks during 21-wk Tx • Examined association between SM exercise and wt loss and PA • Results: 8 drop outs + 5 Ss did not complete diaries; on average, 27 Ss completed 15.8 ± 6.2 wks of SM; greater SM assoc with wt loss (r = .44, p <.05), weekly PA (r = .52, p <.01) Carels et al., 2005
Differences Between Consistent & Inconsistent SM of Exercise • Insert figure 1 from Carels et al article Carels et al., 2005
Phase I of Wt Loss Maintenance Trial • 4-center, one group BWLP lasting 6 mos.; N = 1685, 44% minority; 92% retention at 6 mos. • Results: Ss completed 3.7 daily food records per wk.; men completed more diaries than women (p <.004) • After adjusting for race, gender & initial wt, greater wt loss with greater attendance, SM records & min of PA • Association between # FR kept per wk & wt loss greater for non-AA compared to AA regardless of gender Hollis, Gullion, Stevens et al., 2008
Effect of No. of FRs/Wk on Wt Change Hollis, Gullion, Stevens et al., 2008
Self-Monitoring in Internet Studies (1) • Study compared structured Internet BWLP to a weight loss education Web site; N = 91, 71% retention at 6 mos. • SM diaries submitted online, individualized feedback provided e-mail • Results: wt loss -4.1 ± 4.5 vs. -1.6 ± 3.3 kg • Ss submitted 13.65 ± 6.4 diaries during 24 wks, >50% of diaries submitted in 1st 3 mos. • Total # of diaries submitted related to wt loss, r = .50, p = .001 Tate, Wing & Winett, 2001
Self-Monitoring in Internet Studies (2) • Study compared Internet wt loss program alone to Internet wt loss + behavioral counseling via e-mail for 12 mos; N = 92, 84% retention at 12 mos. • Ss instructed to submit daily diaries for 1st month, thereafter option of daily or weekly diary, individualized feedback provided e-mail • Results: wt loss -2.0 ± 5.7 vs. -4.4 ± 6.2 kg • Logins to Web site sig greater in behavioral e-couns group (p <.05); logins correlated with wt loss, r = -0.47, p =.003 • Not clear if logins same as submitting diary Tate, Jackvony & Wing, 2003
Logins to Web Site Tate, Jackvony & Wing, 2003
Improving SM Adherence with Hand-Held Computers: A Pilot Study • Diet Modification arm of WHI, N = 33 • Personal digital assistant (PDA) system used for 1 month; Ss received immediate & weekly tailored feedback • Results: Ss significantly increased SM, improved attitudes toward SM, met dietary goals more often, reduced fat intake Glanz, Murphy, Moylan et al., 2005
Use of Technology in Self-Monitoring • Quasi-exp design, 6-mos BWLP compared paper diary (n = 115, 81% retention in a previous study) vs. PDA with Calorie King Diet software (n = 61, 93% retention) for SM and effect on wt loss • Results: No sig difference between groups in wt loss, SM, adherence; 32% of wt loss was explained by frequency of SM, p <.001 Yon, Johnson, Harvey-Berino et al., 2007
Adherence to Tx by PDA vs. Control Yon, Johnson, Harvey-Berino et al., 2007
PDA-Based SM in ENHANCE • 2-group RCT testing 6-mon behavioral Tx for self-mgmt of type 2 diabetes vs. attention control; N = 151, 85% retention at 6 mos. • Results: Adherence based on assumption of 3 meals + snack/day – entered 43% of expected meals; assuming 3 meals/day entered 58% of meals • End of study assessment revealed good acceptability of PDA: 88% understood usefulness of SM, 85% entering foods was easy, 70% could interpret graphs Sevick, Zickmund, Korytkowski et al., 2008
Summary of PDA Studies • Software variable • Adherence defined and measured differently • SM occurred ~ 52-62% of days • Yon et al. (2006) reported that validity of energy intake did not improve with PDA; 41% of Ss categorized as low energy reporters • Software does not track date & time of SM
Use of Instrumented Paper Diary • Purpose of study: To examine and describe the actual patterns of self-monitoring among participants in a weight loss intervention study, using an instrumented paper diary* (IPD) *Stone, A, et al. 2002 • Conducted as an ancillary study to PREFER trial – 12-mon BWLP with 6-mon maintenance phase (n = 35, 13, 16 across 3 phases) Burke, Sereika, Choo et al., 2006
Method of Self-Monitoring Used • Instrumented paper diary (IPD) • Pages contained w/in a canvas binder • Photosensors are unobtrusively embedded in spine of binder • Circuit board is enclosed in back pocket • Photosensors detect when the binder is opened and closed; date-and-time stamped each action
Instrumented Paper Diary Photosensor detects opening & closing of binder Unobtrusive instrumentation records time/date -circuit board in right pocket Plastic ties lock rings closed invivodata, inc., Pittsburgh, PA
Card Reader to Upload IPD Data invivodata, inc., Pittsburgh, PA
Adherence Definitions • Reportedadherence – based on time Ss report recording • Conservative – record w/in 2 hrs. of eating • Liberal – record w/in 6 hrs. of eating • Actual adherence – based on measure of the IPD opening and closing • Faked adherence – difference between self-reported time and IPD recording • Hoarding – no recording of IPD open/closing yet there are diary pages that are completed
Adherent: IPD Report Time Day of Monitoring Period
Adherent: IPD Report and Self-Report of Eating Time Day of Monitoring Period
Adherent: IPD Report and Self-Report of Eating and Recording Time Day of Monitoring Period
Hoarding: IPD Report Time Day of Recording
Hoarding: IPD Report and Self-Report of Eating Time Day of Recording
Hoarding: IPD Report and Self-Report of Eating and Recording Time Day of Recording
Correlations of Recording and Weight Change Baseline – 6 Months
Summary of Findings • Majority of time little concordancebetween self-reported and electronicallydocumented data • Data provide first evidence of actual patterns of self-monitoring among weight loss study subjects