Web-based weight management programs

Nutrition Research Newsletter, April, 2006

The prevalence of obesity nationally, combined with the ever-increasing pressure to control health care use and costs, make it imperative for health care organizations to implement more effective, efficient, and proactive tools for health behavior change and decision-making. Web-based weight management programs have the potential to reach millions of individuals at a relatively low cost. Questions remain, however, about the efficacy of such programs in accurately informing the user and facilitating health-related behavior change through evidence-based methods. While a large number of weight management programs are now offered through the Web, most of these sites contain information of questionable value and generally fail to take advantage of existing research or established theoretical models. In one of the first randomized trials conducted in this area, the researcher recently found poor outcomes of a commercial Internet-based diet program (eDiets).

Web-based programs using trained on-line counselors, however, have shown successful weight-loss outcomes. These studies signify the Internet as a viable media channel for weight-loss programming. The reach of such programming, however, is limited to the number of available weight management counselors. One of the advantages of trained counselors is their ability to assess specific needs and interests of the client and tailor feedback in a manner that focuses content to these specific needs and interests, ideally providing just the right help at the right time, and removes extraneous content. The content and sequencing of the assessment and feedback by the human counselor are hopefully based on empirically- and theoretically-based understanding of the problem. Software programs attempting to replicate and standardize this interactive assessment and tailored feedback process are termed "expert systems". Digitally tailored print versions of expert systems have been found to be successful in reducing dietary fat intake and in increasing physical activity. While digitally tailored print materials can be distributed at a low-cost relative to most existing approaches to weight management, the Internet can distribute these materials at a far lower cost. Moreover, the Internet offers significant advantages over print-based tailored materials in the interactivity and vividness of data collection and feedback.

This study examines the outcomes of an Internet-based expert system compared against a user-navigated, information-only program for weight management. Both programs in this trial are completely automated, offering the ability to scale to millions of users at a relatively low cost. These programmatic attributes are critical to large health care organizations interested in population-based disease prevention and management.

Participants included 2862 eligible overweight and obese (BMI = 27 kg/[m.sup.2] to 40 kg/[m.sup.2]) members from four regions of Kaiser Permanente's integrated health care delivery system. Subjects were randomized to receive either a tailored expert system or information-only Web-based weight management materials. Weight change and program satisfaction were assessed by self-report through an Internet-based survey at three- and six-month follow-up periods. The tailored expert system (TES) condition used Balance, a six-week self-help weight management program developed by HealthMedia Inc. Using a software algorithm that uses the baseline assessment data and connections between data elements, Balance creates an individually tailored weight management plan. The Balance program does not use a specific diet per se, focusing instead on a healthy diet, behavioral and social cues to eating, physical activity, better understanding of the relationship between food consumption and energy expenditure, calorie and fat consumption, attributions for previous weight management efforts, body image, and social support. The information-only (IO) condition was part of the standard Kaiser Permanente member website available to all Kaiser Permanente members at the time of the study. The program included an overview and sections related to the importance of weight and weight management; definitions of a healthy weight; determinations of whether the participant is overweight; preparation for weight management; facts about weight loss diets and programs; and weight management strategies.

Significantly greater weight-loss at follow-up was found among participants assigned to the tailored expert system than among those assigned to the information-only condition. Subjects in the tailored expert system lost a mean of 3 [+ or -] 0.3% of their baseline weight, whereas subjects in the information-only condition lost a mean of 1.2 [+ or -] 0.4%. Participants were also more likely to report that the tailored expert system was personally relevant, helpful, and easy to understand. Notably, 36% of enrollees were African-American, with enrollment rates higher than the general proportion of African Americans in any of the study regions. Future research should further explore the active elements of Web-based weight management programs and their use in a variety of settings and populations. Methodological research should explore the validity and possible biases of Web-based surveys. Scholarly interactions between weight management and interactive health communications experts should yield important new approaches to more effective, higher reaching, and lower cost weight management programming.