Original ArticleHigh or low intensity text-messaging combined with group treatment equally promote weight loss maintenance in obese adults
Introduction
The high prevalence of obesity worldwide indicates a need for developing effective, accessible, and affordable treatments. Compounding this challenge is the chronic nature of obesity. Weight regain following all types of interventions remains a significant and unresolved problem. Well-executed, theoretically-informed, and empirically-driven efforts to improve weight loss maintenance have met with little success [1], [2], [3]. Interventions which do produce a modest degree of sustained weight loss tend to involve continuing contact with health care professionals throughout the duration of weight maintenance [4], [5]. It is therefore important to explore low-cost intervention formats that minimise the need for ongoing face-to-face contact and associated costs, whilst improving long-term weight outcomes [6], [7].
Technology-based interventions such as text-message and e-mail are increasingly being used in combination with standard treatment to improve outcomes in a range of health situations [8]. Text-messaging may provide a direct point of contact between health professionals and patients at any time and place, and a low-cost means of increasing the frequency of patient-to-therapist contact [9]. The portability and convenience of cellular telephones, and their high penetration across income and ethnic groups, and populations living in both urban and rural locations, allow for the easy integration of technological interventions into patients’ lives [10], [11], [12]. There is preliminary evidence suggesting that text-messaging may enhance treatment acceptability, and improve patient self-monitoring, engagement, and attendance [13]. Text-messaging exploits the use of ‘push’ technology, where information can be transmitted without the need for patient-initiated contact, in contrast to other technological mediums that require individuals to access a website or call a telephone number [14].
Text-message technology has been successfully implemented in a variety of therapeutic domains [8], [9]. For example, text-message interventions have been used to enhance self-management in those with diabetes and asthma [15], [16]; improve medication compliance in patients with hypertension [17]; and provide advice, support, and distraction to aid smoking cessation [18]. However, research assessing the benefits of technological interventions on weight loss and weight loss maintenance is in its infancy. Previous trials of text-message contact in obese adults have found this approach to be significantly better at aiding weight loss than no contact [8], but not significantly more effective when compared to monthly e-newsletters containing diet and physical activity information [19]. E-mail counselling has also shown promise as a form of technology that may assist obese adults. However, both e-mail and text-message interventions only result in modest weight loss when employed in isolation [20], [21]. It has been suggested that technological approaches may be more useful as adjunct interventions, especially when the aim is long-term weight loss maintenance [22]. This finding was reinforced in a recent meta-analysis of six studies, with a total of 1252 participants, that found patients in weight-loss programmes that included a text-messaging component lost on average seven times more weight than patients in conditions that did not include text-messaging (2.56 kg versus 0.37 kg, respectively) [23].
Despite the recommendation that technology be used in combination with standard face-to-face treatment to promote weight management, the optimal frequency and timing of text-message delivery is yet to be determined. A previous study has shown that overweight and obese adults who were provided with twice-weekly text-message support after 12 weeks of standard treatment achieved greater weight loss compared to controls who did not receive any text-message support and who gained weight [24]. In addition to uncertainty about the optimal frequency of text-message contact, few studies have permitted two-way communication, where patients submit self-monitoring data (e.g. food intake, physical activity, weight reporting) to the therapist via text-message and receive a tailored reply [26]. Two-way communication may be advantageous given poor participant retention and engagement rates in health behaviour change studies that have disallowed this form of interactivity. For example, in one study, text-messages delivered to patients’ mobile phones two days per week for four months failed to improve compliance with therapy compared to control, possibly because patients were not allowed to reply to these messages, reducing their level of engagement [17].
In order to clarify the determinants, including duration, frequency, and level of interactivity, that maximise the success and cost effectiveness of this novel delivery medium, this study compared a high- and low-intensity technological support programme for promoting weight outcomes in obese adults, when combined with a CBT programme. This is the first study to utilise text-message and e-mail mediums to prompt patients to practice cognitive and behavioural strategies necessary for weight control in their natural environment, and positively reinforce behaviour change.
Section snippets
Study design
This 15-month randomised controlled trial consisted of three months of weekly group CBT followed by nine months of intensive technological support (CBT + ITS) in the form of one- and two-way text-message and e-mail communication, compared to a group who received the same three months of weekly group CBT followed by six months of minimal technological support (CBT + MTS) in the form of one-way therapist-to-patient text-message contact with no avenue for two-way communication. Fig. 1 shows the study
Results
Sixty obese adults (women: n = 43, men: n = 17) with a mean age of 44.3 years (range = 19–64 years) and a mean BMI of 37.5 kg/m2 (range = 30.4–54.8 kg/m2) participated in the trial. Baseline characteristics did not differ significantly between the two conditions in terms of mean weight, BMI, waist circumference, age, gender, education level, or living arrangements.
Of the 60 obese adults who began treatment, 88% (n = 53) completed the CBT group programme. Of the seven participants who discontinued
Discussion
This study showed that a minimal technological support programme may be just as effective as a more intensive support programme in promoting weight loss and psychological and behavioural improvements, when it follows a group CBT programme for weight management in obese adults. This novel electronic intervention, involving text-messages containing CBT weight control strategies, extended the treatment, as participants continued to lose weight and maintain that weight loss in the absence of
Conflict of interest
IDC has given talks for NovoNordisk, Servier Laboratories, and Pfizer in the last 3 years. He serves on the steering committees of international trials (SCOUT and EXSCEL) and for the latter has received an honorarium. AS has received payment from Eli Lilly, the Pharmacy Guild of Australia, Novo Nordisk and the Dietitians Association of Australia for seminar presentation at conferences. She is also the author of The Don’t Go Hungry Diet (Bantam, Australia and New Zealand, 2007) and Don’t Go
Funding
This work was supported by the National Health and Medical Research Council (NHMRC) of Australia via a Senior Research Fellowship to AS and by a Program Grant of the NHMRC APP1037786. We are also grateful to the Australian Research Council for an Australian Postgraduate Award to AAG.
Author contributions
KZ, ER, JS, CM, CM, and IC designed the study. KZ developed the treatment manual and content of daily and weekly text-messages and ER, JS and CM provided input and feedback. KZ, CM, CM, and JS screened, assessed and recruited participants. CM and KZ managed the data file. KZ and JS facilitated group treatment sessions. AG developed and presented the nutrition session. AS conducted a seminar on barriers to weight loss maintenance. ER, JS, and CM provided clinical supervision. KZ conducted the
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