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Defeat Diabetes
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Suite 300

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Electronic Daily Diaries Boost Adherence to Diet, Exercise Goals

Posted: Saturday, April 21, 2012

In a prospective, randomized trial, people who used a personal digital assistant (PDA) to itemize their food intake were significantly more likely than those using old-school handwritten diet diaries to meet the program's goals for calorie and fat intake, exercise, and group meeting attendance.

There were signs, as well, that those PDA benefits may have been enhanced by periodic reminders and other kinds of device feedback that were personalized based on the diet-diary entries.

Dr. Lora E Burke from the University of Pittsburgh, PA, stated that, "The group that received the feedback did a little bit better than the group that did not receive the feedback." And with or without the feedback messages, those using the PDAs were significantly more likely than those writing out their diet entries to adhere to the trial's self-monitoring goals, she said.

"However, when you look at how that translated to weight loss, the PDA group that didn't get the feedback was similar to the paper-diary group. It was the [PDA] feedback method that really helped with the weight loss."

Although using the PDA boosted adherence to the program, "and that should translate to better weight loss and behavior change, it didn't quite as much as we thought it would."

In the trial, 210 adults (mostly female and white, with a mean body-mass index of about 34 kg/m2) were randomized to use of one of three self-monitoring methods -- handwritten diaries or PDA with or without feedback -- while attending meetings for cognitive-behavioral intervention. The meetings were held weekly for 16 weeks and then at increasingly longer intervals, concluding with one session at 21 months.

The study's signature intervention feature, PDA feedback, was controlled using software that read the participant's diet and exercise entries and regularly generated the messages.

"So, for example, at 10 am they could get a message related to how well they did at breakfast, reinforcing that," Burke said. "Then maybe at 4 pm a message might commend them on how well they're doing with the calories, but cautioning them that they're getting close to their fat-gram goal." Messages about exercise went out every other day.

"These were not generic messages. They were tailored based upon what the person entered into the PDA," according to Burke.

In the beginning, everyone attended the meetings (attendance) and used the electronic or paper diaries (self-monitoring), although somewhat fewer initially met the exercise and two dietary goals (calories and fat intake). Adherence to all five of those program components declined steadily in all three groups, but significantly more so in the handwritten-diary group.

Still, adherence to those components by week 60 to 70 was comparable in the three groups. And weight loss followed the same pattern, although those getting PDA feedback fared best throughout much of the study. On average, they lost >5% of their weight by six months, significantly more than the other groups, but they lost part of that advantage by study's end.

Burke et al saw a significant interaction (p<0.0001) between weight loss and each of the adherence components. For example, every 20% decrease in adherence to the exercise goals was associated with a 1 kg rise in weight. The change was 0.74 kg and 0.60 kg per 20% drop in adherence to fat-intake goals and meeting attendance, respectively.

At 24 months, there were few significant differences between the three groups, "which has been shown in studies over and over again," Burke observed: program participants may adhere to the goals and lose weight initially but generally backslide over time.

"We thought that maybe the PDA would be able to keep them [on the program], but we found that they would just use it less and less over time" as the opportunity for personal support at meetings diminished, she said.

"We wanted [the PDA] to be integrated into their lives, but not everybody did this. They might forget to charge it; maybe they would leave it at home some days. And when we weren't around, that kind of behavior started increasing."

Part of the problem, she said, was that some participants "weren't really into the PDA." Some used the handheld computer only for the study, "even though we encouraged them [also] to use it for their calendar, their schedule, to play games -- to just use it." Also, she said, the 2005-era software wasn't nearly as user-friendly as current versions.

The hardware has also evolved with the times. "We're doing a study right now that uses a smartphone, so the person has [only] one device, they charge it regularly, and they keep it with them all the time -- so that overcomes some of the barriers. And today we can communicate with the person in real time and change feedback messages more frequently."

Source:, Burke LE, Styn MA, Conroy MB, et al. Adherence to weight loss treatment across three self-monitoring approaches and the association with weight change. EPI|NPAM 2012; March 15, 2012; San Diego, CA.

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