Associations of Internet Website Use With Weight Change in a Long-term Weight Loss Maintenance Program

Background

The Weight Loss Maintenance Trial (WLM) compared two long-term weight-maintenance interventions, a personal contact arm and an Internet arm, with a no-treatment control after an initial six-month Phase I weight loss program. The Internet arm focused on use of an interactive website for support of long-term weight maintenance. There is limited information about patterns of website use and specific components of an interactive website that might help promote maintenance of weight loss.

Objective

This paper presents a secondary analysis of the subset of participants in the Internet arm and focuses on website use patterns and features associated with long-term weight maintenance.

Methods

Adults at risk for cardiovascular disease (CVD) who lost at least 4 kilograms in an initial 20-week group-based, behavioral weight-loss program were trained to use an interactive website for weight loss maintenance. Of the 348 participants, 37% were male and 38% were African American. Mean weight loss was 8.6 kilograms. Participants were encouraged to log in at least weekly and enter a current weight for the 30-month study period. The website contained features that encouraged setting short-term goals, creating action plans, and reinforcing self-management habits. The website also included motivational modules, daily tips, and tailored messages. Based on log-in and weight-entry frequency, we divided participants into three website use categories: consistent, some, and minimal.

Results

Participants in the consistent user group (n = 212) were more likely to be older (P = .002), other than African American (P = .02), and more educated (P = .01). While there was no significant difference between website use categories in the amount of Phase I change in body weight (P = .45) or income (P = .78), minimal website users (n = 75) were significantly more likely to have attended fewer Phase I sessions (P = .001) and had a higher initial body mass index (BMI) (P < .001). After adjusting for baseline characteristics including initial BMI, variables most associated with less weight regain included: number of log-ins (P = .001), minutes on the website (P < .001), number of weight entries (P = .002), number of exercise entries (P < .001), and sessions with additional use of website features after weight entry (P = .002).

Conclusion

Participants defined as consistent website users of an interactive behavioral website designed to promote maintenance of weight loss were more successful at maintaining long-term weight loss.

Trial Registration

{"type":"clinical-trial","attrs":{"text":"NCT00054925","term_id":"NCT00054925"}}NCT00054925; http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00054925","term_id":"NCT00054925"}}NCT00054925 (Archived by WebCite at http://www.webcitation.org/5rC7523ue)     

Efficacy of Standard Versus Enhanced Features in a Web-Based Commercial Weight-Loss Program for Obese Adults,Part 2: Randomized Controlled Trial

Background

Commercial Web-based weight-loss programs are becoming more popular and increasingly refined through the addition of enhanced features, yet few randomized controlled trials (RCTs) have independently and rigorously evaluated the efficacy of these commercial programs or additional features.

Objective

To determine whether overweight and obese adults randomized to an online weight-loss program with additional support features (enhanced) experienced a greater reduction in body mass index (BMI) and increased usage of program features after 12 and 24 weeks compared to those randomized to a standard online version (basic).

Methods

An assessor-blinded RCT comparing 301 adults (male: n=125, 41.5%; mean age: 41.9 years, SD 10.2; mean BMI: 32.2 kg/m², SD 3.9) who were recruited and enrolled offline, and randomly allocated to basic or enhanced versions of a commercially available Web-based weight-loss program for 24 weeks.

Results

Retention at 24 weeks was greater in the enhanced group versus the basic group (basic 68.5%, enhanced 81.0%; P=.01). In the intention-to-treat analysis of covariance with imputation using last observation carried forward, after 24 weeks both intervention groups had reductions in key outcomes with no difference between groups: BMI (basic mean –1.1 kg/m², SD 1.5; enhanced mean –1.3 kg/m², SD 2.0; P=.29), weight (basic mean –3.3 kg, SD 4.7; enhanced mean –4.0 kg, SD 6.2; P=.27), waist circumference (basic mean –3.1 cm, SD 4.6; enhanced mean –4.0 cm, SD 6.2; P=.15), and waist-to-height ratio (basic mean –0.02, SD 0.03; enhanced mean –0.02, SD 0.04, P=.21). The enhanced group logged in more often at both 12 and 24 weeks, respectively (enhanced 12-week mean 34.1, SD 28.1 and 24-week mean 43.1, SD 34.0 vs basic 12-week mean 24.6, SD 25.5 and 24-week mean 31.8, SD 33.9; P=.002).

Conclusions

The addition of personalized e-feedback in the enhanced program provided limited additional benefits compared to a standard commercial Web-based weight-loss program. However, it does support greater retention in the program and greater usage, which was related to weight loss. Further research is required to develop and examine Web-based features that may enhance engagement and outcomes and identify optimal usage patterns to enhance weight loss using Web-based programs.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) trial number: ACTRN12610000197033; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=335159 (Archived by WebCite at http://www.webcitation.org/6HoOMGb8j).     

Mindless Eating Challenge: Retention,Weight Outcomes,and Barriers for Changes in a Public Web-Based Healthy Eating and Weight Loss Program

Background

Most dietary programs fail to produce lasting outcomes because participants soon return to their old habits. Small behavioral and environmental changes based on simple heuristics may have the best chance to lead to sustainable habit changes over time.

Objective

To evaluate participant retention, weight outcomes, and barriers for changes in a publicly available web-based healthy eating and weight loss program.

Methods

The National Mindless Eating Challenge (NMEC) was a publicly available, online healthy eating and weight loss program with ongoing recruitment of participants. This volunteer sample consisted of 2053 participants (mean age 39.8 years, 89% female, 90% white/Caucasian, BMI mean 28.14). Participants completed an initial profiling survey and were assigned three targeted habit change suggestions (tips). After each month, participants were asked to complete a follow-up survey and then receive new suggestions for the subsequent month.

Results

In terms of overall attrition, 75% (1549/2053) of participants who completed the intake survey never returned to follow up. Overall mean weight loss among returning participants was 0.4% of initial weight (P=.019). Participants who stayed in the program at least three calendar months and completed at least two follow-up surveys (38%, 189/504) lost on average 1.8 lbs (1.0%) of their initial weight over the course of the program (P=.009). Furthermore, participants who reported consistent adherence (25+ days/month) to the suggested changes reported an average monthly weight loss of 2.0 lbs (P<.001). Weight loss was less for those who discontinued after 1-2 months or who did not adhere to the suggested changes. Participants who reported having lost weight reported higher monthly adherence to suggestions (mean 14.9 days, SD 7.92) than participants who maintained (mean 12.4 days, SD 7.63) or gained weight (mean 12.0 days, SD 7.50; F=14.17, P<.001). Common reported barriers for changes included personally unsuitable or inapplicable suggestions, forgetting or being too busy to implement changes, unusual circumstances, and emotional eating.

Conclusions

Because the bulk of the free and commercially available online diet and nutritional tools conduct no evaluation research, it is difficult to determine which aspects of a program are successful and what are reasonable expectations of results. The results of this study suggest that online interventions based on small changes have the potential to gradually lead to clinically significant weight loss, but high attrition from publically available or “free” programs still remains a challenge. Adherence to and effectiveness of small habit changes may be improved through further tailoring to individual circumstances and psychological needs.     

Determinants of Successful Weight Loss After Using a Commercial Web-Based Weight Reduction Program for Six Months: Cohort Study

Background

The Internet is widely available and commonly used for health information; therefore, Web-based weight loss programs could provide support to large parts of the population in self-guided weight loss. Previous studies showed that Web-based weight loss interventions can be effective, depending on the quality of the program. The most effective program tools are visual progress charts or tools for the self-monitoring of weight, diet, and exercises. KiloCoach, a commercial program currently available in German-speaking countries, incorporates these features. A previous investigation showed that the program effectively supports users in losing weight.

Objective

We investigated weight loss dynamics stratified by weight loss success after 6-month use of KiloCoach. Furthermore, we analyzed possible associations between intensity of program use and weight loss. The results are intended for tailoring user recommendations for weight-loss Internet platforms.

Methods

Datasets of KiloCoach users (January 1, 2008 to December 31, 2011) who actively used the platform for 6 months or more were assigned to this retrospective analysis. Users (N=479) were 42.2% men, mean age of 44.0 years (SD 11.7), with a mean body mass index (BMI) of 31.7 kg/m² (SD 3.2). Based on the weight loss achieved after 6 months, 3 success groups were generated. The unsuccessful group lost <5%, the moderate success group lost 5%-9.9%, and the high success group lost ≥10% of their baseline body weight. At baseline, the unsuccessful (n=261, 54.5%), moderate success (n=133, 27.8%), and high success (n=85, 17.8%) groups were similar in age, weight, BMI, and gender distribution.

Results

After 6 months, the unsuccessful group lost 1.2% (SD 2.4), the moderate success group lost 7.4% (SD 1.5), and the high success group lost 14.2% (SD 3.8) of their initial weight (P<.001). Multivariate regression showed that early weight loss (weeks 3-4), the total number of dietary protocols, and the total number of weight entries were independent predictors for 6-month weight reduction (all P<.001) explaining 52% of the variance in weight reduction. Sensitivity analysis by baseline carried forward method confirmed all independent predictors of 6-month weight loss and reduced the model fit by only 11%. The high success group lost weight faster and maintained weight loss more efficiently than the other groups (P<.001). Early weight loss was associated with weight maintenance after 1 year and 2 years (both P<.001). Weight dynamics did not differ between men and women over 6 months when adjusted for baseline and usage parameters (P=.91). The percentage of male long-term users was unusually high (42.2%).

Conclusions

Our results suggest that early weight loss and close program adherence (ie, 5 dietary protocols per week and weekly entering of current weight), especially in the early phase of program usage, can improve weight loss outcome.     

The Change in Eating Behaviors in a Web-Based Weight Loss Program: A Longitudinal Analysis of Study Completers

Background

Eating behaviors are essential components in weight loss programs, but limited research has explored eating behaviors in Web-based weight loss programs.

Objectives

The aim was to evaluate an interactive Web-based weight loss program on eating behaviors using the 18-item Three-Factor Eating Questionnaire Revised (TFEQ-R18) which measures uncontrolled eating, emotional eating, and cognitive restrained eating. Our Web-based weight loss program is comprised of information about healthy lifestyle choices, weekly chats with experts, social networking features, databases for recipe searches, and features allowing members to self-report and track their weight, physical activity, and dietary intake on the website.

Methods

On registering for the weight loss program, 23,333 members agreed to take part in the research study. The participants were then asked to complete the TFEQ-R18 questionnaire at baseline and after 3 and 6 months of participation. All data collection was conducted online, with no face-to-face contact. To study changes in TFEQ-R18 eating behaviors we restricted our study to those members who completed all 3 TFEQ-R18 questionnaires. These participants were defined as “completers” and the remaining as “noncompleters.” The relationships between sex, change in eating behaviors, and total weight loss were studied using repeated measures ANOVA and Pearson correlation coefficient.

Results

In total, 22,800 individuals participated (females: 19,065/22,800, 83.62%; mean age 39.6, SD 11.4 years; BMI 29.0 kg/m²; males: 3735/22,800, 16.38%; mean age 43.2, SD 11.7 years; BMI 30.8 kg/m²). Noncompleters (n=22,180) were younger and reported a lower score of uncontrolled eating and a higher score of cognitive restrained eating. Over time, completers (n=620) decreased their uncontrolled eating score (from 56.3 to 32.0; P<.001) and increased their cognitive restrained eating (from 50.6 to 62.9; P<.001). Males decreased their emotional eating (from 57.2 to 35.9; P<.001), but no significant change was found among females. The baseline cognitive restrained eating score was significantly and positively associated with weight loss for completers in both men (P=.02) and women (P=.002).

Conclusions

To our knowledge, this is the largest TFEQ sample that has been documented. This Web-based weight loss intervention suggests that eating behaviors (cognitive restrained eating, uncontrolled eating, and emotional eating) measured by TFEQ-R18 were significantly changed during 6 months of participation. Our findings indicate differences in eating behaviors with respect to sex, but should be interpreted with caution because attrition was high.     

Program completion of a web-based tailored lifestyle intervention for adults: differences between a sequential and a simultaneous approach

Background

Unhealthy lifestyle behaviors often co-occur and are related to chronic diseases. One effective method to change multiple lifestyle behaviors is web-based computer tailoring. Dropout from Internet interventions, however, is rather high, and it is challenging to retain participants in web-based tailored programs, especially programs targeting multiple behaviors. To date, it is unknown how much information people can handle in one session while taking part in a multiple behavior change intervention, which could be presented either sequentially (one behavior at a time) or simultaneously (all behaviors at once).

Objectives

The first objective was to compare dropout rates of 2 computer-tailored interventions: a sequential and a simultaneous strategy. The second objective was to assess which personal characteristics are associated with completion rates of the 2 interventions.

Methods

Using an RCT design, demographics, health status, physical activity, vegetable consumption, fruit consumption, alcohol intake, and smoking were self-assessed through web-based questionnaires among 3473 adults, recruited through Regional Health Authorities in the Netherlands in the autumn of 2009. First, a health risk appraisal was offered, indicating whether respondents were meeting the 5 national health guidelines. Second, psychosocial determinants of the lifestyle behaviors were assessed and personal advice was provided, about one or more lifestyle behaviors.

Results

Our findings indicate a high non-completion rate for both types of intervention (71.0%; n = 2167), with more incompletes in the simultaneous intervention (77.1%; n = 1169) than in the sequential intervention (65.0%; n = 998). In both conditions, discontinuation was predicted by a lower age (sequential condition: OR = 1.04; P < .001; CI = 1.02-1.05; simultaneous condition: OR = 1.04; P < .001; CI = 1.02-1.05) and an unhealthy lifestyle (sequential condition: OR = 0.86; P = .01; CI = 0.76-0.97; simultaneous condition: OR = 0.49; P < .001; CI = 0.42-0.58). In the sequential intervention, being male (OR = 1.27; P = .04; CI = 1.01-1.59) also predicted dropout. When respondents failed to adhere to at least 2 of the guidelines, those receiving the simultaneous intervention were more inclined to drop out than were those receiving the sequential intervention.

Conclusion

Possible reasons for the higher dropout rate in our simultaneous intervention may be the amount of time required and information overload. Strategies to optimize program completion as well as continued use of computer-tailored interventions should be studied.

Trial Registration

Dutch Trial Register NTR2168     

Acupuncture for ��frequent attenders�� with medically unexplained symptoms: a randomised controlled trial (CACTUS study)

Background

Medically unexplained physical symptoms (MUPS) are common and difficult to treat.

Aim

To investigate the effectiveness of adding five-element acupuncture to usual care in ‘frequent attenders’ with MUPS.

Design and setting

Randomised controlled trial in four London general practices.

Method

Participants were 80 adults with MUPS, consulting GPs ≥8 times/year. The intervention was individualised five-element acupuncture, ≥12 sessions, immediately (acupuncture group) and after 26 weeks (control group). The primary outcome was 26-week Measure Yourself Medical Outcome Profile (MYMOP); secondary outcomes were wellbeing (W-BQ12), EQ-5D, and GP consultation rate. Intention-to-treat analysis was used, adjusting for baseline outcomes.

Results

Participants (80% female, mean age 50 years, mixed ethnicity) had high health-resource use. Problems were 59% musculoskeletal; 65% >1 year duration. The 26-week questionnaire response rate was 89%. Compared to baseline, the mean 26-week MYMOP improved by 1.0 (95% confidence interval [CI] = 0.4 to 1.5) in the acupuncture group and 0.6 (95% CI = 0.3 to 0.9) in the control group (adjusted mean difference: acupuncture versus control –0.6 [95% CI = –1.1 to 0] P = 0.05). Other between-group adjusted mean differences were: W-BQ12 4.4 (95% CI = 1.6 to 7.2) P = 0.002; EQ-5D index 0.03 (95% CI = –0.11 to 0.16) P = 0.70; consultation rate ratio 0.90 (95% CI = 0.70 to 1.15) P = 0.4; and number of medications 0.56 (95% CI = 0.47 to 1.6) P = 0.28. All differences favoured the acupuncture group. Imputation for missing values reduced the MYMOP adjusted mean difference to –0.4 (95% CI = –0.9 to 0.1) P = 0.12. Improvements in MYMOP and W-BQ12 were maintained at 52 weeks.

Conclusion

The addition of 12 sessions of five-element acupuncture to usual care resulted in improved health status and wellbeing that was sustained for 12 months.     

Innovation in Weight Loss Programs: A 3-Dimensional Virtual-World Approach

Background

The rising trend in obesity calls for innovative weight loss programs. While behavioral-based face-to-face programs have proven to be the most effective, they are expensive and often inaccessible. Internet or Web-based weight loss programs have expanded reach but may lack qualities critical to weight loss and maintenance such as human interaction, social support, and engagement. In contrast to Web technologies, virtual reality technologies offer unique affordances as a behavioral intervention by directly supporting engagement and active learning.

Objective

To explore the effectiveness of a virtual-world weight loss program relative to weight loss and behavior change.

Methods

We collected data from overweight people (N = 54) participating in a face-to-face or a virtual-world weight loss program. Weight, body mass index (BMI), percentage weight change, and health behaviors (ie, weight loss self-efficacy, physical activity self-efficacy, self-reported physical activity, and fruit and vegetable consumption) were assessed before and after the 12-week program. Repeated measures analysis was used to detect differences between groups and across time.

Results

A total of 54 participants with a BMI of 32 (SD 6.05) kg/m² enrolled in the study, with a 13% dropout rate for each group (virtual world group: 5/38; face-to-face group: 3/24). Both groups lost a significant amount of weight (virtual world: 3.9 kg, P < .001; face-to-face: 2.8 kg, P = .002); however, no significant differences between groups were detected (P = .29). Compared with baseline, the virtual-world group lost an average of 4.2%, with 33% (11/33) of the participants losing a clinically significant (≥5%) amount of baseline weight. The face-to-face group lost an average of 3.0% of their baseline weight, with 29% (6/21) losing a clinically significant amount. We detected a significant group × time interaction for moderate (P = .006) and vigorous physical activity (P = .008), physical activity self-efficacy (P = .04), fruit and vegetable consumption (P = .007), and weight loss self-efficacy (P < .001). Post hoc paired t tests indicated significant improvements across all of the variables for the virtual-world group.

Conclusions

Overall, these results offer positive early evidence that a virtual-world-based weight loss program can be as effective as a face-to-face one relative to biometric changes. In addition, our results suggest that a virtual world may be a more effective platform to influence meaningful behavioral changes and improve self-efficacy.     

Longitudinal Accuracy of Web-Based Self-Reported Weights: Results From the Hopkins POWER Trial

Background

Websites and phone apps are increasingly used to track weights during weight loss interventions, yet the longitudinal accuracy of these self-reported weights is uncertain.

Objective

Our goal was to compare the longitudinal accuracy of self-reported weights entered online during the course of a randomized weight loss trial to measurements taken in the clinic. We aimed to determine if accuracy of self-reported weight is associated with weight loss and to determine the extent of misclassification in achieving 5% weight loss when using self-reported compared to clinic weights.

Methods

This study examined the accuracy of self-reported weights recorded online among intervention participants in the Hopkins Practice-Based Opportunities for Weight Reduction (POWER) trial, a randomized trial examining the effectiveness of two lifestyle-based weight loss interventions compared to a control group among obese adult patients with at least one cardiovascular risk factor. One treatment group was offered telephonic coaching and the other group was offered in-person individual coaching and group sessions. All intervention participants (n=277) received a digital scale and were asked to track their weight weekly on a study website. Research staff used a standard protocol to measure weight in the clinic. Differences (self-reported weight – clinic weight) indicate if self-report under (-) or over (+) estimated clinic weight using the self-reported weight that was closest in time to the clinic weight and was within a window ranging from the day of the clinic visit to 7 days before the 6-month (n=225) and 24-month (n=191) clinic visits. The absolute value of the differences (absolute difference) describes the overall accuracy.

Results

Underestimation of self-reported weights increased significantly from 6 months (mean -0.5kg, SD 1.0kg) to 24 months (mean -1.1kg, SD 2.0kg; P=.002). The average absolute difference also increased from 6 months (mean 0.7kg, SD 0.8kg) to 24 months (mean 1.3, SD 1.8kg; P<.001). Participants who achieved the study weight loss goal at 24 months (based on clinic weights) had lower absolute differences (P=.01) compared to those who did not meet this goal. At 24 months, there was 9% misclassification of weight loss goal success when using self-reported weight compared to clinic weight as an outcome. At 24 months, those with self-reported weights (n=191) had three times the weight loss compared to those (n=73) without self-reported weights (P<.001).

Conclusions

Underestimation of weight increased over time and was associated with less weight loss. In addition to intervention adherence, weight loss programs should emphasize accuracy in self-reporting.

Trial Registration

ClinicalTrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT00783315","term_id":"NCT00783315"}}NCT00783315; http://clinicaltrials.gov/show/{"type":"clinical-trial","attrs":{"text":"NCT00783315","term_id":"NCT00783315"}}NCT00783315 (Archived by WebCite at http://www.webcitation.org/6R4gDAK5K).     

Web-based guide to health: relationship of theoretical variables to change in physical activity, nutrition and weight at 16-months

Background

Evaluation of online health interventions should investigate the function of theoretical mechanisms of behavior change in this new milieu.

Objectives

To expand our understanding of how Web-based interventions influence behavior, we examined how changes at 6 months in participants’ psychosocial characteristics contributed to improvements at 16 months in nutrition, physical activity (PA), and weight management as a result of the online, social cognitive theory (SCT)-based Guide to Health intervention (WB-GTH).

Methods

We conducted recruitment, enrollment, and assessments online with 272 of 655 (41.5%) participants enrolling in WB-GTH who also completed 6- and 16-month follow-up assessments. Participants’ mean age was 43.68 years, 86% were female, 92% were white, mean education was 17.45 years, median income was US $85,000, 84% were overweight or obese, and 73% were inactive. Participants received one of two equally effective versions of WB-GTH. Structural equation analysis of theoretical models evaluated whether psychosocial constructs targeted by WB-GTH contributed to observed health behavior changes.

Results

The longitudinal model provided good fit to the data (root mean square error of approximation <.05). Participants’ weight loss at 16 months was predicted by improvements in their PA (beta_total = -.34, P = .01), consumption of fruits and vegetables (F&V) (beta_total = -.20, P = .03) and calorie intake (beta_total = .15, P = .04). Improvements at 6 months in PA self-efficacy (beta_total = -.10, P = .03), PA self-regulation (beta_total = -.15, P = .01), nutrition social support (beta_total = -.08, P = .03), and nutrition outcome expectations (beta_total = .08, P = .03) also contributed to weight loss. WB-GTH users with increased social support (beta_total = .26, P = .04), self-efficacy (beta_total = .30, P = .01), and self-regulation (beta_total = .45, P = .004) also exhibited improved PA levels. Decreased fat and sugar consumption followed improved social support (beta_total = -.10, P = .02), outcome expectations (beta_total = .15, P = .007), and self-regulation (beta_total = -.14, P = .008). Decreased calorie intake followed increased social support (beta_total = -.30, P < .001). Increased F&V intake followed improved self-efficacy (beta_total = .20, P = .01), outcome expectations (beta_total = -.29, P = .002), and self-regulation (beta_total = .27, P = .009). Theorized indirect effects within SCT variables were also supported.

Conclusions

The WB-GTH influenced behavior and weight loss in a manner largely consistent with SCT. Improving social support, self-efficacy, outcome expectations, and self-regulation, in varying combinations, led to healthier diet and exercise habits and concomitant weight loss. High initial levels of self-efficacy may be characteristic of Web-health users interested in online interventions and may alter the function of SCT in these programs. Researchers may find that, although increased self-efficacy enhances program outcomes, participants whose self-efficacy is tempered by online interventions may still benefit.

Trial Registration

Clinicaltrials.gov NCT00128570; http://clinicaltrials.gov/ct2/show/NCT00128570 (Archived by WebCite at http://www.webcitation.org/5vgcygBII)     

Evaluation of a Web-based intervention providing tailored advice for self-management of minor respiratory symptoms: exploratory randomized controlled trial

Background

There has been relatively little research on the role of web-based support for self-care in the management of minor, acute symptoms, in contrast to the wealth of recent research into Internet interventions to support self-management of long-term conditions.

Objective

This study was designed as an evaluation of the usage and effects of the “Internet Doctor” website providing tailored advice on self-management of minor respiratory symptoms (eg, cough, sore throat, fever, runny nose), in preparation for a definitive trial of clinical effectiveness. The first aim was to evaluate the effects of using the Internet Doctor webpages on patient enablement and use of health services, to test whether the tailored, theory-based advice provided by the Internet Doctor was superior to providing a static webpage providing the best existing patient information (the control condition). The second aim was to gain an understanding of the processes that might mediate any change in intentions to consult the doctor, by comparing changes in relevant beliefs and illness perceptions in the intervention and control groups, and by analyzing usage of the Internet Doctor webpages and predictors of intention change.

Methods

Participants (N = 714) completed baseline measures of beliefs about their symptoms and self-care online, and were then automatically randomized to the Internet Doctor or control group. These measures were completed again by 332 participants after 48 hours. Four weeks later, 214 participants completed measures of enablement and health service use.

Results

The Internet Doctor resulted in higher levels of satisfaction than the control information (mean 6.58 and 5.86, respectively; P = .002) and resulted in higher levels of enablement a month later (median 3 and 2, respectively; P = .03). Understanding of illness improved in the 48 hours following use of the Internet Doctor webpages, whereas it did not improve in the control group (mean change from baseline 0.21 and -0.06, respectively, P = .05). Decline in intentions to consult the doctor between baseline and follow-up was predicted by age (beta = .10, P= .003), believing before accessing the website that consultation was necessary for recovery (beta = .19, P < .001), poor understanding of illness (beta = .11, P = .004), emotional reactions to illness (beta = .15, P <.001), and use of the Diagnostic section of the Internet Doctor website (beta = .09, P = .007).

Conclusions

Our findings provide initial evidence that tailored web-based advice could help patients self-manage minor symptoms to a greater extent. These findings constitute a sound foundation and rationale for future research. In particular, our study provides the evidence required to justify carrying out much larger trials in representative population samples comparing tailored web-based advice with routine care, to obtain a definitive evaluation of the impact on self-management and health service use.     

Custom-molded foot-orthosis intervention and multisegment medial foot kinematics during walking

Context:

Foot-orthosis (FO) intervention to prevent and treat numerous lower extremity injuries is widely accepted clinically. However, the results of quantitative gait analyses have been equivocal. The foot models used, participants receiving intervention, and orthoses used might contribute to the variability.

Objective:

To investigate the effect of a custom-molded FO intervention on multisegment medial foot kinematics during walking in participants with low-mobile foot posture.

Design:

Crossover study.

Setting:

University biomechanics and ergonomics laboratory.

Patients or Other Participants:

Sixteen participants with low-mobile foot posture (7 men, 9 women) were assigned randomly to 1 of 2 FO groups.

Interventions :

After a 2-week period to break in the FOs, individuals participated in a gait analysis that consisted of 5 successful walking trials (1.3 to 1.4 m/s) during no-FO and FO conditions.

Main Outcome Measure(s):

Three-dimensional displacements during 4 subphases of stance (loading response, mid-stance, terminal stance, preswing) were computed for each multisegment foot model articulation.

Results:

Repeated-measures analyses of variance (ANOVAs) revealed that rearfoot complex dorsiflexion displacement during midstance was greater in the FO than the no-FO condition (F_1,14 = 5.24, P = .04, partial η² = 0.27). Terminal stance repeated-measures ANOVA results revealed insert-by-insert condition interactions for the first metatarsophalangeal joint complex (F_1,14 = 7.87, P = .01, partial η² = 0.36). However, additional follow-up analysis did not reveal differences between the no-FO and FO conditions for the balanced traditional orthosis (F_1,14 = 4.32, P = .08, partial η² = 0.38) or full-contact orthosis (F_1,14 = 4.10, P = .08, partial η² = 0.37).

Conclusions:

Greater rearfoot complex dorsiflexion during midstance associated with FO intervention may represent improved foot kinematics in people with low-mobile foot postures. Furthermore, FO intervention might partially correct dys-functional kinematic patterns associated with low-mobile foot postures.     

Design and implementation of an interactive website to support long-term maintenance of weight loss

Background

For most individuals, long-term maintenance of weight loss requires long-term, supportive intervention. Internet-based weight loss maintenance programs offer considerable potential for meeting this need. Careful design processes are required to maximize adherence and minimize attrition.

Objective

This paper describes the development, implementation and use of a Web-based intervention program designed to help those who have recently lost weight sustain their weight loss over 1 year.

Methods

The weight loss maintenance website was developed over a 1-year period by an interdisciplinary team of public health researchers, behavior change intervention experts, applications developers, and interface designers. Key interactive features of the final site include social support, self-monitoring, written guidelines for diet and physical activity, links to appropriate websites, supportive tools for behavior change, check-in accountability, tailored reinforcement messages, and problem solving and relapse prevention training. The weight loss maintenance program included a reminder system (automated email and telephone messages) that prompted participants to return to the website if they missed their check-in date. If there was no log-in response to the email and telephone automated prompts, a staff member called the participant. We tracked the proportion of participants with at least one log-in per month, and analyzed log-ins as a result of automated prompts.

Results

The mean age of the 348 participants enrolled in an ongoing randomized trial and assigned to use the website was 56 years; 63% were female, and 38% were African American. While weight loss data will not be available until mid-2008, website use remained high during the first year with over 80% of the participants still using the website during month 12. During the first 52 weeks, participants averaged 35 weeks with at least one log-in. Email and telephone prompts appear to be very effective at helping participants sustain ongoing website use.

Conclusions

Developing interactive websites is expensive, complex, and time consuming. We found that extensive paper prototyping well in advance of programming and a versatile product manager who could work with project staff at all levels of detail were essential to keeping the development process efficient.

Trial Registration

clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00054925","term_id":"NCT00054925"}}NCT00054925     

Motivation and satisfaction in GP training: a UK cross-sectional survey

Background

Recruitment to general practice has had periods of difficulty, but is currently going through a phase of relative popularity in the UK.

Aim

To explore motivators for career choice and career satisfaction among UK GP trainees and newly qualified GPs.

Design and setting

Cross-sectional web-based questionnaire of GP trainees and GPs within the first 5 years of qualification in the UK.

Method

All 9557 UK GP trainees and 8013 GPs who were within the first 5 years of qualification were invited to participate by email. Further publicity was conducted via general practice publications and the internet.

Results

Overall, there were 2178 responses to the questionnaire (12.4% response rate, 61.5% women, 61.8% trainees). Levels of satisfaction were high, with 83% of responders stating that they would choose to be a doctor again; of these, 95% would choose to be a GP again. The most frequently cited reason for choosing general practice was ‘compatibility with family life’, which was chosen by 76.6% of women and 63.2% of men (P<0.001). Other reasons given were: ‘challenging medically diverse discipline’ (women 59.8%, men 61.8%, P = 0.350), ‘the one-to-one care general practice offers’ (women 40.0%, men 41.2%, P = 0.570), ‘holistic approach’ (women 41.4%, men 30.1%, P<0.001), ‘autonomy and independence’ (women 18.0%, men 34.8%, P<0.001), ‘communication’ (women 20.6%, men 12.2%, P<0.001), ‘negative experiences in hospital’ (women 12.8%, men 9.8%, P= 0.036), and ‘good salary’ (women 7.8%, men 14.9%, P<0.001).

Conclusion

The most important reason for both women and men choosing general practice as a career in the UK is its compatibility with family life. As such, changes to UK primary care that decrease family compatibility could negatively impact on recruitment.     

Half-marathon and full-marathon runners' hydration practices and perceptions

Context:

The behaviors and beliefs of recreational runners with regard to hydration maintenance are not well elucidated.

Objective:

To examine which beverages runners choose to drink and why, negative performance and health experiences related to dehydration, and methods used to assess hydration status.

Design:

Cross-sectional study.

Setting:

Marathon registration site.

Patients or Other Participants:

Men (n = 146) and women (n = 130) (age = 38.3 ± 11.3 years) registered for the 2010 Little Rock Half-Marathon or Full Marathon.

Intervention(s):

A 23-item questionnaire was administered to runners when they picked up their race timing chips.

Main Outcome Measure(s):

Runners were separated into tertiles (Low, Mod, High) based on z scores derived from training volume, expected performance, and running experience. We used a 100-mm visual analog scale with anchors of 0 (never) and 100 (always). Total sample responses and comparisons between tertile groups for questionnaire items are presented.

Results:

The High group (58±31) reported greater consumption of sport beverages in exercise environments than the Low (42 ± 35 mm) and Mod (39 ± 32 mm) groups (P < .05) and perceived sport beverages to be superior to water in meeting hydration needs (P < .05) and improving performance during runs greater than 1 hour (P < .05). Seventy percent of runners experienced 1 or more incidents in which they believed dehydration resulted in a major performance decrement, and 45% perceived dehydration to have resulted in adverse health effects. Twenty percent of runners reported monitoring their hydration status. Urine color was the method most often reported (7%), whereas only 2% reported measuring changes in body weight.

Conclusions:

Greater attention should be paid to informing runners of valid techniques to monitor hydration status and developing an appropriate individualized hydration strategy.     

Breathe Easier Online: evaluation of a randomized controlled pilot trial of an Internet-based intervention to improve well-being in children and adolescents with a chronic respiratory condition

Background

Chronic respiratory illnesses are the most common group of childhood chronic health conditions and are overrepresented in socially isolated groups.

Objective

To conduct a randomized controlled pilot trial to evaluate the efficacy of Breathe Easier Online (BEO), an Internet-based problem-solving program with minimal facilitator involvement to improve psychosocial well-being in children and adolescents with a chronic respiratory condition.

Methods

We randomly assigned 42 socially isolated children and adolescents (18 males), aged between 10 and 17 years to either a BEO (final n = 19) or a wait-list control (final n = 20) condition. In total, 3 participants (2 from BEO and 1 from control) did not complete the intervention. Psychosocial well-being was operationalized through self-reported scores on depression symptoms and social problem solving. Secondary outcome measures included self-reported attitudes toward their illness and spirometry results. Paper-and-pencil questionnaires were completed at the hospital when participants attended a briefing session at baseline (time 1) and in their homes after the intervention for the BEO group or a matched 9-week time period for the wait-list group (time 2).

Results

The two groups were comparable at baseline across all demographic measures (all F < 1). For the primary outcome measures, there were no significant group differences on depression (P = .17) or social problem solving (P = .61). However, following the online intervention, those in the BEO group reported significantly lower depression (P = .04), less impulsive/careless problem solving (P = .01), and an improvement in positive attitude toward their illness (P = .04) compared with baseline. The wait-list group did not show these differences. Children in the BEO group and their parents rated the online modules very favorably.

Conclusions

Although there were no significant group differences on primary outcome measures, our pilot data provide tentative support for the feasibility (acceptability and user satisfaction) and initial efficacy of an Internet-based intervention for improving well-being in children and adolescents with a chronic respiratory condition.

Trial registration

Australian New Zealand Clinical Trials Registry number: ACTRN12610000214033; http://www.anzctr.org.au/trial_view.aspx?ID=308074 (Archived by WebCite at http://www.webcitation.org/63BL55mXH)     

Results from an online computer-tailored weight management intervention for overweight adults: randomized controlled trial

Background

Prevention of weight gain has been suggested as an important strategy in the prevention of obesity and people who are overweight are a specifically important group to target. Currently there is a lack of weight gain prevention interventions that can reach large numbers of people. Therefore, we developed an Internet-delivered, computer-tailored weight management intervention for overweight adults. The focus of the intervention was on making small (100 kcal per day), but sustained changes in dietary intake (DI) or physical activity (PA) behaviors in order to maintain current weight or achieve modest weight loss. Self-regulation theory was used as the basis of the intervention.

Objective

This study aims to evaluate the efficacy of the computer-tailored intervention in weight-related anthropometric measures (Body Mass Index, skin folds and waist circumference) and energy balance-related behaviors (physical activity; intake of fat, snacks and sweetened drinks) in a randomized controlled trial.

Methods

The tailored intervention (TI) was compared to a generic information website (GI). Participants were 539 overweight adults (mean age 47.8 years, mean Body Mass Index (BMI) 28.04, 30.9% male, 10.7% low educated) who where recruited among the general population and among employees from large companies by means of advertisements and flyers. Anthropometric measurements were measured by trained research assistants at baseline and 6-months post-intervention. DI and PA behaviors were assessed at baseline, 1-month and 6-month post-intervention, using self-reported questionnaires.

Results

Repeated measurement analyses showed that BMI remained stable over time and that there were no statistically significant differences between the study groups (BMI: TI=28.09, GI=27.61, P=.09). Similar results were found for waist circumference and skin fold thickness. Amount of physical activity increased and intake of fat, snacks and sweetened drinks decreased during the course of the study, but there were no differences between the study groups (eg, fat intake: TI=15.4, GI=15.9, P=.74). The first module of the tailored intervention was visited by almost all participants, but only 15% completed all four modules of the tailored intervention, while 46% completed the three modules of the general information intervention. The tailored intervention was considered more personally relevant (TI=3.20, GI=2.83, P=.001), containing more new information (TI=3.11, GI=2.73, P=.003) and having longer texts (TI=3.20, GI=3.07, P=.01), while there were no group differences on other process measures such as attractiveness and comprehensibility of the information (eg, attractive design: TI=3.22, GI=3.16, P=.58).

Conclusions

The online, computer-tailored weight management intervention resulted in changes in the desired direction, such as stabilization of weight and improvements in dietary intake, but the intervention was not more effective in preventing weight gain or modifying dietary and physical activity behaviors than generic information. A possible reason for the absence of intervention effects is sub-optimal use of the intervention and the self-regulation components. Further research is therefore needed to gain more insight into how the intervention and exposure to its contents can be improved.

Trial Registration

NTR1862; http://apps.who.int/trialsearch/trial.aspx?trialid=NTR1862     

Supporting Informed Decision Making Online in 20 Minutes: An Observational Web-log Study of a PSA Test Decision Aid

Background

Web-based decision aids are known to have an effect on knowledge, attitude, and behavior; important components of informed decision making. We know what decision aids achieve in randomized controlled trials (RCTs), but we still know very little about how they are used and how this relates to the informed decision making outcome measures.

Objective

To examine men''s use of an online decision aid for prostate cancer screening using website transaction log files (web-logs), and to examine associations between usage and components of informed decision making.

Methods

We conducted an observational web-log analysis of users of an online decision aid, Prosdex. Men between 50 and 75 years of age were recruited for an associated RCT from 26 general practices across South Wales, United Kingdom. Men allocated to one arm of the RCT were included in the current study. Time and usage data were derived from website log files. Components of informed decision making were measured by an online questionnaire.

Results

Available for analysis were 82 web-logs. Overall, there was large variation in the use of Prosdex. The mean total time spent on the site was 20 minutes. The mean number of pages accessed was 32 (SD 21) out of a possible 60 pages. Significant associations were found between increased usage and increased knowledge (Spearman rank correlation [ρ] = 0.69, P < .01), between increased usage and less favorable attitude towards PSA testing (ρ = -0.52, P < .01), and between increased usage and reduced intention to undergo PSA testing (ρ = -0.44, P < .01). A bimodal distribution identified two types of user: low access and high access users.

Conclusions

Increased usage of Prosdex leads to more informed decision making, the key aim of the UK Prostate Cancer Risk Management Programme. However, developers realistically have roughly 20 minutes to provide useful information that will support informed decision making when the patient uses a web-based interface. Future decision aids need to be developed with this limitation in mind. We recommend that web-log analysis should be an integral part of online decision aid development and analysis.

Trial Registration

ISRCTN48473735; http://www.controlled-trials.com/ISRCTN48473735 (Archived by WebCite at http://www.webcitation.org/5pqeF89tS)     

Weight-management interventions in primary care: a pilot randomised controlled trial

Background

There is a paucity of randomised controlled trials of weight management in primary care.

Aim

To ascertain the feasibility of a full trial of a nurse-led weight-management programme in general practice.

Design of study

Factorial randomised control trial.

Setting

Primary care, UK.

Method

A total of 123 adults (80.3% women, mean age 47.2 years) with body mass index ≥27 kg/m², recruited from eight practices, were randomised to receive structured lifestyle support (n = 30), structured lifestyle support plus pedometer (n = 31), usual care (n = 31), or usual care plus pedometer (n = 31) for a 12-week period.

Results

A total of 103 participants were successfully followed up. The adjusted mean difference in weight in structured support compared to usual care groups was −2.63 kg (95% confidence interval [CI] = −4.06 to −1.20 kg), and for pedometer compared to no pedometer groups it was −0.11 kg (95% CI = −1.52 to 1.30 kg). One in three participants in the structured-support groups (17/50, 34.0%) lost 5% or more of their initial weight, compared to less than one in five (10/53, 18.9%) in usual-care groups; provision of a pedometer made little difference (14/48, 29.2% pedometer; 13/55, 23.6% no pedometer). Difference in waist circumference change between structured-support and usual-care groups was −1.80 cm (95% CI = −3.39 to −0.20 cm), and between the pedometer and no pedometer groups it was −0.84 cm (95% CI = −2.42 to 0.73 cm). When asked about their experience of study participation, most participants found structured support helpful.

Conclusion

The structured lifestyle support package could make substantial contributions to improving weight-management services. A trial of the intervention in general practice is feasible and practicable.