Internet behavioral counseling - Diet Patterns and Programs

Nutrition Research Newsletter, May, 2003

Behavioral weight loss interventions markedly reduce the risk of diabetes, and recent studies suggest that new approaches to prevention are needed. In the Diabetes Prevention Program (DPP), a behavioral weight loss program produced a 58% reduction in diabetes incidence after 2.8 years. The DPP involved substantial individual face-to-face counseling; such an intensive intervention may be impractical to treat the large number of at-risk individuals. Consumers also desire alternatives to face-to-face treatment. The Internet offers opportunities to develop behavioral change interventions minimizing face-to-face interaction. It has been used for diabetes education and self-management, however, the efficacy of Internet-based weight loss programs, and specifically e-mail counseling, has not been used in a population at risk for diabetes, nor evaluated for a year-long weight loss intervention.

The current study recruited 92 overweight participants, with one or more risk factors for type 2 diabetes, who had access to a computer. Participants attended face-to-face orientation and completed baseline measurements including fasting plasma glucose to screen for diabetes. One subject was eliminated because of high fasting plasma glucose. Participants were randomly assigned following simple randomization procedures to one of two treatment groups: 46 to the basic Internet weight loss program (basic Internet) and 46 to the Internet weight loss program plus behavioral e-counseling (behavioral e-counseling). Participants were seen at baseline and at months 3, 6. and 12 for measurement of weight, waist circumference, and fasting blood glucose and were paid $10 to $25 for attending the respective assessments. All participants attended a 1 hr introductory group weight loss session, which covered topics such as diet instruction, exercise, and behavior change. Recommendations included a calorie restricted diet of between 1200 to 1500 calories, fat intake of 20% or fewer calories, and a minimal of 1000 kcal/wk of physical activity (equivalent to walking 10 miles/wk). All participants were encouraged to self monitor their daily diet and exercise using diaries and calorie books provided.

The study Website provided a tutorial on weight loss, a new tip and link each week, and a directory of selected Internet weight loss resources. Each group had a separate message board. Each week all participants received an email reminder to submit his/her weight and received weight loss information. Participants in the behavioral e-counseling underwent the same procedures as the basic Internet group plus they communicated through e-mail with their assigned weight loss counselor. Counselors had masters or doctoral degrees in health education, nutrition, or psychology. Participants were instructed to report calorie and fat intake, exercise energy expenditure, and any comments or questions for the therapist through a Web-based diary. Counselor e-mails provided feedback on the self-monitoring record, reinforcement, recommendations for change, answers to questions, and general support. Participants who did not report were sent a personal follow-up e-mail.

The intent-to-treat analysis at 12 months showed that the behavioral e-counseling group had greater reductions in weight (-4.4 vs -2.0 kg), body mass index (-1.6 vs -0.8), and waist circumference (-7.2 vs -4.4) compared with the basic Internet group. Weight change for the 77 participants who completed the 12-month follow-up followed a similar pattern with larger mean weight losses in the behavioral e-counseling group at 3 months, 6 months, and 12 months. The analysis of fasting plasma glucose showed no differences between groups at 12 months; however, reduction in glucose was significantly greater in behavioral e-counseling after 3 months corresponding with the initial weight loss period. Both groups reported significant reductions in caloric intake between 0 and 12 months. Logins to the Web site were significantly greater in the behavioral e-counseling group at all times. Logins were significantly correlated with weight change between 0 and 12 months in both groups.

In summary, the results of the current study showed that an Internet weight loss program with weekly e-mail counseling produced an average weight loss of 4.4 kg after 1 year among adults at risk for type 2 diabetes. The addition of e-mail behavioral counseling doubled the percentage of initial body weight lost compared with an Internet intervention without individualized therapist guidance. Thus, internet interventions involving weekly behavioral e-counseling have the potential for producing behavioral changes and weight loss, which may help reduce the risk for type 2 diabetes.

D Tate, E Jackvony, R Wing. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes. JAMA 289(14):1833-1836 (April 2003) [Correspondence: Deborah F. Tate, PhD, Brown University School of Medicine/Mikriam Hospital, Weight Control and Diabetes Research Center, 14 Third St, RISE Bldg, Providence, RI 02906. email: dtate@lifespan.org]