Successful Weight Loss: How Information Technology Is Used to Lose
Cheryl L. Shigaki, PhD, ABPP,1 Richelle J. Koopman, MD, MS,2 Allison Kabel, PhD,3 and Shannon Canfield, MPH4 Departments of 1Health Psychology and 3Health Sciences, School of Health Professions, University of Missouri, Columbia, Missouri. 2 Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri, Columbia, Missouri. 4 Center for Health Policy, University of Missouri, Columbia, Missouri.
Abstract Background: Commercial producers have outpaced traditional academic healthcare in terms of novel repackaging of traditional approaches to weight control for online delivery. Little is known, however, about consumers’ experiences with such products and services. We explored ways that people use information technology (IT) to facilitate health-related behavioral change. Materials and Methods: Qualitative methods and grounded theory methodology were used to analyze transcripts of audiotaped material from three focus groups, each with 12 participants. Participants were recruited from an ongoing, community-wide weight-loss event, who reported regular or frequent use of IT. Results: Participants frequently used IT applications for completing functional tasks associated with weight loss. In contrast, most participants preferred in-person social support. IT applications facilitated integration of behavior change tasks into everyday life. Despite easy access to a range of social networking Web sites and tools, however, having access to in-person social support was targeted as critical to successful weight loss and wellbeing. To this end, the role of work peers and work environments was emphasized by these participants. Conclusions: In terms of patient care, successful health portals may benefit from either developing or integrating existing IT applications that save time and/or provide users with visual feedback on progress toward goals. IT-delivered resources would likely optimize community-based behavioral health interventions that target naturally occurring social groups. Key words: e-health, commercial telemedicine, telehealth, obesity
Introduction
I
n 2010 over one-third of U.S. adults were obese (body mass index [BMI] ‡ 30 kg/m2).1 Prevalence of obesity is especially concerning because of its well-known association with increased risk for chronic health conditions such as diabetes mellitus, risk which can be mitigated with weight loss.2 Key elements for weight-loss programming include provision of education and support for improving dietary self-management, increasing partici-
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pants’ repertoire of general problem-solving and behavior change skills, and increasing social support.3–6 Several studies have successfully demonstrated information technology (IT)-based delivery of these elements.4,7 IT approaches have been successfully trialed in targeted populations, such as for preventing weight gain among firstyear college students and among pregnant women with gestational diabetes.8–10 Phone and tablet applications (‘‘apps’’) may be particularly helpful insofar as encouraging participant engagement.11 It has been argued that interventions targeting the individual alone will likely be less effective than approaches that treat weight loss and health behavior change from a relational perspective.12 To this end, commercial weight-loss and fitness Web sites have outpaced academic research in their development and integration of Internet-based social networking capability. Examples include Lose It! (www.loseit.com), LIVESTRONGSM (www.livestrong.com), and Spark People (www.sparkpeople.com). Endorsements integrated via blogs, forums, and product reviews also are prevalent. In the extant academic literature, IT supports for weight loss have focused primarily on integrating functional applications (e.g., food trackers, activity trackers, and calorie counters) and information resources (e.g., didactic materials and weight loss tips) with highquality counseling and participant monitoring. In some academic studies of health behavior change, resources for small-scale, restricted social interactions have been included, but this does not appear to be the norm.4,13–15 The omission of social networking capability in academic and private healthcare is likely due to several factors, including feasibility issues associated with recruiting and managing participants on a large scale, costs associated with developing and maintaining a high-quality Web site and patient portals, and the onus of maintaining participant data privacy and security in complying with the Health Insurance Portability and Accountability Act (HIPAA). For similar reasons, commercial services have greater flexibility in offering interesting and novel apps such as providing the user with a calorie estimate of photographed food items and barcode scanning capability to track nutrients in processed food items. Fitness apps can track distance walked or run, help the user locate walking and biking trails, and link exercise advice to anatomical maps. Some Web sites organize fitness challenges or provide services to match up exercise partners, while providing space for virtual fitness teams to blog and track progress. Overall, commercial producers have outpaced traditional academic healthcare in terms of novel repackaging of traditional approaches to weight control for online delivery. Despite their attractiveness and ubiquity, however, little is known about consumers’ experiences with such products and services. This gap presents a barrier to developing effective, patient-centered e-health applications for health-related behavior change. Our research
DOI: 10.1089/tmj.2013.0163
HOW INFORMATION TECHNOLOGY IS USED TO LOSE
addresses this gap by asking the question ‘‘What IT do people use to facilitate their weight-loss efforts and how do they use it?’’ Our study does not focus on new behavioral revelations, but rather on revelations about how IT allows users to integrate the essential elements of behavior change for weight loss into their daily lives and routines.
Materials and Methods We recruited study participants from a community-wide, 12-week ‘‘Slimdown Challenge’’ event that included 3,586 registered participants. The majority of Slimdown participants reside in an urban/rural county with approximately168,000 residents, where the prevalence of obesity is 28%.16,17 According to County Health Rankings, the county is ranked second among 115 counties in the state (where 1 is ‘‘healthiest’’) for health factors.18 The county also has been proactive in developing an environment conducive to healthy behaviors, for example, by passing legislation to make walking and biking easy and accessible and to prohibit smoking in public places. Participants formed teams of four to six people and designated a team captain. Weigh-in at baseline and 12 weeks was required. Online programming by the event sponsor included weekly e-mailed health tips, online graphical representation of participant weight, and a ranking of all participants with weight loss expressed as percentage of BMI lost. Small weekly prizes were offered for voluntary weighins, and large prizes were awarded to the top achievers based on percentage of BMI lost. One-third of participants (n = 1,170 [33%]) reportedly completed the challenge.19 We collaborated with the event sponsor to e-mail a focus group invitation to all registered participants during the course of the Slimdown Challenge. Participants who responded to the e-mail invitation were entered in a random drawing for several small prizes (e.g., a certificate for a free sandwich). The focus group invitation e-mail contained a link to SurveyMonkey (www.surveymonkey.com), where potential participants were presented with the informed consent, with a check box to indicate that they had reviewed it and wished to participate. Survey respondents who wished to participate then answered demographic questions, including their height, starting weight, current weight, and their availability for several days and times for focus groups. Initial BMI and BMI change were calculated using self-reported weights and height. Respondents also were asked if they were ‘‘staying with it,’’ ‘‘dropped out,’’ or ‘‘never really started,’’ if they considered themselves successful in their efforts to lose weight so far, and how frequently they used e-mail and the Internet. Respondents were invited to participate in a focus group if they reported using e-mail or the Internet at least a few times weekly. We also targeted individuals with a range of weights and amounts of weight lost, focusing primarily on those who were either overweight or obese at baseline by their calculated BMI. Among volunteers who indicated they were available at the times given, we invited a group of individuals who in toto reflected a wide range on the factors of age, gender, ethnic origin, and household income. Participants attending the focus group were reimbursed $40 for their time and effort. We conducted three 90-min focus groups, each with 12 participants. A semistructured focus group script (see Supplementary Data)
was used, and one focus group leader, one co-leader, and one observer/field note-taker were present. Focus group participants were asked about their method of weight loss, their team interaction, their motivations and perceived barriers, and how the online environment and online and mobile apps assisted them in their weightloss efforts. Participants were encouraged to discuss ways in which IT was not helpful as well as ways that it was helpful. Focus groups were audio-recorded, and these recordings were then transcribed by an experienced qualitative transcriptionist; the observer’s field notes were added to the transcripts. Transcripts were deidentified by replacing participant names with pseudonyms and then analyzed using grounded theory methodology, assisted by Dedoose qualitative software.20,21 Investigators were C.L.S., a health psychologist, R.J.K., a family physician and clinical researcher, A.K., a medical anthropologist, and S.C., an MPH well-acquainted with focus group methods. Investigators independently coded the transcripts and then met to agree on codes. Investigators also created memos with emerging ideas during the analysis. Major themes emerged, with organization and consensus among the investigators. This research was approved by and conducted under the auspices of our university’s Health Sciences Institutional Review Board.
Results PARTICIPANTS Our focus groups included 36 individuals with 12 per group, reflecting a 100% show rate. Table 1 gives descriptive information. As
Table 1. Focus Group Participant Characteristics (n = 36) CHARACTERISTIC
VALUE
Women
30 (83%)
Age (years) [mean (range)]
40 (23–61)
Married/partnered
24 (67%)
Race/ethnicity Non-white
6 (22%)
Hispanic/Latino
2 (6%)
At least some college education
32 (89%)
Employed
32 (89%) 2
Baseline BMI (kg/m ) [mean (range)] Feel successful in weight-loss efforts
33.2 (20.4–47.5) 27 (67%)
Household income < $15,000
0
$15,000–$29,999
7 (19%)
$30,000–$69,999
18 (50%)
$70,000 +
11 (31%)
BMI, body mass index.
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indicated previously, the purpose of this study was to explore the ways in which people use IT to facilitate their weight-loss efforts. Responses from our focus group participants suggest that many, if not most, used or had tried some type of weight-loss–related IT, and two prominent themes emerged in the data analysis: 1. Participants experimented with and were satisfied with a range of IT applications for weight loss and fitness. Many of the applications used were considered central and essential for completing discrete, functional tasks. 2. In meeting social support needs, however, most participants preferred more intimate, local resources and in-person contacts— if IT was used, this was mainly to support existing relationships.
USING IT TO FACILITATE FUNCTIONAL TASKS (SEE TABLE 2 FOR NARRATIVES) There’s an app for that. Use of IT Web site and smartphone apps to manage time-consuming, functional tasks associated with weight loss was highly prevalent. Most frequently, participants reported using apps for tracking nutrients (calories, fat grams, etc.) and exercise. There were numerous options, oftentimes free of charge. None of the focus group members reported using paper-and-pencil logs or calorie counter books, although some appeared to have had experience with manual logging in the past. Participants agreed that if it were not for electronic methods, they would not have been able or motivated to track these things. Specific features of food trackers apps favored by the group included barcode scanning capability and large databases that allowed for identifying and tracking the exact item consumed rather than a similar or generic item. Participants described being able to use these capabilities to plan ahead and make good choices. One participant used a ‘‘budget’’ analogy, describing how she used the data from her app to work within an energy budget. Feedback is rewarding and motivational. Numeric and especially graphic feedback from a range of apps and Web sites was perceived as entertaining and motivating. Specifically discussed were the online feedback features provided by the event organizer, as described above, that allowed participants to monitor both their own trends and compare themselves with other teams. More ideas needed. Participants in each focus group voiced appreciation for tips on diet, cooking, and lifestyle management. In fact, participants expressed disgruntlement with the event organizers for not providing more of this type of support. They felt that having access to more ‘‘tips’’ would prevent having to learn what others had already figured out. The groups also suggested that there was a wealth of information that could come from the participants themselves. Thus, a ‘‘share your ideas’’ section for the event Web site would have been welcome and also affirming for successful participants. A notable proportion of participants expressed dissatisfaction with their team captain and the lack of cohesiveness of their teams during
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the Slimdown Challenge. Dissatisfaction was especially apparent if the participant was able to observe well-functioning teams and captains. It appeared that a shortcoming of the event was that organizers did not provide team captains with tools or support for motivating players. In summary, focus group participants from the Slimdown Challenge experimented and were happy with a range of IT applications for discrete, functional tasks. In fact, logging and researching tasks (i.e., looking up nutritional content) may well have been barriers to successful weight loss, if it had not been for the availability of computer and phone apps. Graphic feedback on one’s progress and status were like ‘‘instant gratification’’ and, as such, were rewarding and motivating. Many participants wished for more informational offerings, delivered in small, digestible doses. An area of weakness appears to have been that very limited support was available for team captains. Team captains may well have benefited from additional ITbased tools and support, delivered across the event, so they could effectively encourage team members to stay motivated and keep their teams competitive.
IT AND SOCIAL SUPPORT (SEE TABLE 3 FOR NARRATIVES) Accountability. Consistent with the literature on weight loss and lifestyle change, our focus group participants identified social support as an important factor in their weight-loss endeavors. The role and perceived value of IT in garnering and maintaining social support were much less clear-cut, however, than for using IT for functional tasks. Maintaining ‘‘accountability’’ was one aspect of social support for which some participants did use IT, although perspectives on accountability varied widely. One participant took it upon herself to be accountable to family and friends, using a general social networking site. Additionally, several focus group participants reported using texting to maintain contact and accountability with their teams. These examples occurred primarily within relationships established prior to the Slimdown Challenge event. Participants described apps for weight loss that would ‘‘call out’’ individuals in a public forum. One of our participants felt personally benefitted from this approach, although others were doubtful. Another participant preferred a similar app, designed to encourage needed support rather than to ‘‘call out’’ or confront. The Slimdown Challenge added a competitive twist to typical individual weight-loss efforts. IT tools were described as useful in this context to communicate messages of encouragement and accountability in a more diffused and impersonal way than face-to-face. One participant recognized the intense emotional triggers that may be associated weight-loss efforts and noted that sending information by e-mail may diffuse or prevent unnecessary emotional reactivity. However, reactions to group motivational messages were variable. About equal numbers of participants felt annoyed or offended by such messages as those who felt more positively. Garnering social support. The importance of social support in weight-loss efforts was a recurring topic in each of the focus groups.
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Table 2. Focus Group Narratives for Theme 1: Using Information Technology to Facilitate Functional Tasks (n = 36) THEME, DESCRIPTION
EXAMPLES OF NARRATIVES
There’s an app for that . : use of IT Web site and smartphone apps to manage time-consuming, functional tasks Tracking
Carly: ‘‘I also use the My Fitness Pal, and I thought that was really helpful for me just because I had never had a food journal before and it was really easy for me to keep it. If it’s on my phone, I usually have it with me, I can just take it out, add something real fast, look it up, put it in there and.’’ Bonnie: ‘‘The ease of use? Yeah, wonderful!’’ Carly: ‘‘ . that was really nice because I thought about having a food journal before but I wasn’t gonna carry around a journal and then have to go look it up like later and do the math and all of that. The end of the day, like no, then it’s too late. So that was helpful.’’
Planning ahead
Catherine: ‘‘And what I liked about the My Fitness Pal was in the, initially, like I said, I’m not good at tracking, but what I could do was go through the foods that are really good for me, you know, like whether it was scanning or whether it was entering the information, figure what are the things that are healthy, and then those are the things that I know that I choose from. Just like with going out to eat, you know, at a restaurant, knowing what the menu items that are the best for me and then utilizing that as my menu, like pick through things as I go through the challenge.’’
‘‘Budgeting’’
Laura: ‘‘I’m into Sports Tracker . what I found myself doing is, you know, just thinking about the numbers just like you think about your financial budget. And so I would, you know, pick how intensely I needed to exercise because it tells you not only how many calories you’re eating but how many calories you’re burning based on those things. So I would plan what I was gonna eat and then how much I was gonna exercise . ’’
Feedback is rewarding and motivational: monitoring one’s own trends and comparing one’s progress to others Facilitator: ‘‘What are most helpful or the least helpful parts of the [organizer] Web site?’’ Jennifer: ‘‘The graphic is nice.’’ Seth: ‘‘Graphic and the weight loss.’’ Kate: ‘‘The stats, yeah.’’ Susan: ‘‘The weight-loss history.’’ Seth: ‘‘It gives you percent body mass.’’ Wayne: ‘‘It’s the closest thing to instant gratification that we have!’’ Seth: ‘‘It gives you a BMI. It calculates your BMI for you.’’ Jennifer: ‘‘And how much BMI you lost since the [beginning] . ’’ Bonnie: ‘‘And you see the lines either going down, or up . ’’ Jennifer: ‘‘I just like seeing where I’m at as far as, you know, my ranking.’’ Carly: ‘‘I admit, the ranking is helpful.’’ Seth: ‘‘I would say that the nice thing about that [organizer] Web site is, you know, any time you start one of these programs you need to set goals. That’s nice because it lets you track that goal.’’ Carly: ‘‘It tells you percentage-wise how close you are . ’’ Jennifer: ‘‘Yeah, that’s been helpful.’’ More ideas needed: tips on diet, cooking, and lifestyle management are desired Avoid having to learn what others have already figured out
Ian: ‘‘I thought all of the little weekly advice things from the [organizer] were very helpful as well, and so I used this as an opportunity for me to, to learn about how I can be healthier, and so it wasn’t a competition, it hasn’t been a competition for me.’’ Geraldine: ‘‘Recipes or . we could have done that . or just tips on what they’re doing, like what’s actually working for them, you know, even if it’s just exercising or, you know, eating healthier and I did this and this, you know.’’ Brad: ‘‘Or even just a poll, you know. You’ve got 300 people using My Fitness Pal and somebody else using a different app, or calorie counter. There’s so many out there. It just depends on, it’s hard to whittle it down to what you want to use.’’
Tools for team captains
Elizabeth: ‘‘Our team captain wasn’t that great, honestly. . She approached who she felt would be good on the team . and then that was it. That was basically all we heard from her throughout the 12 weeks.’’ Pansy: ‘‘I had a similar experience as far as a not so good team captain . this person just kind of approached me. . And it was just kind of like okay . but there really hasn’t been any communication. . So it’s just been kind of like a team solo within a team.’’
apps, applications; BMI, body mass index; IT, information technology.
And, although some participants discussed IT-based interactions, the importance of having supports ‘‘close to home’’ was a dominant theme across all groups. For many if not most, the availability of local supports translated into support at the worksite. Having tangible support from one’s work organization, per se, was viewed as
valuable and novel. It was notable that employer-based support appeared strong as almost 70 local employers agreed to partner with the event sponsor, and many of our participants indicated feeling supported in their work environment for participating in the Slimdown event.22
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Table 3. Focus Group Narratives for Theme 2: Information Technology and Social Support (n = 36) THEME, DESCRIPTION
EXAMPLES OF NARRATIVES
Accountability: using IT to make one’s self accountable to family, friends, and team Social networking
Catherine: ‘‘Well, what I did was I, every time I went and weighed in I put it on my Facebook page, so whether it was good or bad, you know. I had people cheering me on, positive, negative, you know, I don’t mean negative, but like I gained 10 pounds when I went on vacation . I was like ’I need something to motivate me!’. If I didn’t post it [people are going to ask] ’How are you doing on your weight thing?’’’
Texting
Susan: ‘‘We, we are big texters and so if we feel like a craving or something like that we’re like, we, we, we have everybody, we text them all at the same time like ’I really want to eat this whole pizza by myself,’ and they’re like ’No, no, no, no, no,’ and so (laughter), and they talk you through it or something . ’’
Apps for ‘‘calling out’’
Laura: ‘‘I really think a big part of being successful for me is accountability . In my little group on Lose It, you know, it even says like ’Oh, look, Laura ate 250 calories over her limit today.’’’ [Laughter] Rob: ‘‘I’m busted. I’m busted. I need to get on that!’’ [Group agrees] Rob: ‘‘That’s really getting personal.’’ Laura: ‘‘That’s really helpful to me to see that and, you know, you’re like ’Wow, look at that, you know, Laura isn’t losing her weight because every day she eats 250 calories more than she’s supposed to.’ So I wish it wasn’t true, but it is true [and it] really helped. . ’’ Carrie Ann: ‘‘I used the My Fitness Pal. I think the one thing, since the captain really wasn’t as vocal, the app itself will say to you, ’So and so hasn’t weighed in or entered their food in 3 days, so they might need some encouragement.’ . So it was . easier that way, to just send a nice little ’Hey, you haven’t logged in!’ And you can do that on your phone as well as on e-mail. I thought that was a good reminder ’cause before you know it it’s Sunday and you haven’t put your food in from like Thursday through Saturday.’’
Using e-mail to diffuse or prevent unnecessary emotional reactivity
Geraldine: ‘‘ . we all work within steps from each other and I think it’s hard to, to be the captain and come and tell somebody, you know, don’t eat that . because some people take it very, very, I mean, they’re very insecure and I learned from the very beginning, to let everybody do it at their own pace, you know, try to send them an e-mail or something like that but don’t, don’t, never go straight in. We did some things together, you know.but . if I go and ask somebody ’Hey, you want to go to the boot camp with me’ that was like ’What, are you telling me that I should be doing more?’ [Laughs] So I just send an e-mail. You know, it was a little bit more impersonal and I got better answers than just going straight to the person.’’
Reactions to group motivational messages
Theresa: ‘‘I used Fitday.com, which is a free app also. But it’s interesting to me that both of you said you like those reminders. I found them annoying when they came so often from [organizer] . My daughter is on a team also, a different team, and she found them annoying also, so. I mean, there were just so many of them.’’ Charlie: ‘‘Yeah. Some of my team didn’t like the e-mails I sent, but [I sent them] anyway.’’ Jennifer: ‘‘You’re the captain.’’ Charlie: ‘‘Yeah.’’
Garnering social support: local, in-person supports are essential Support from the work organization
Hattie: ‘‘There’s over 20 teams within my job and they have, our company Web site, they put tips on there every day of things to do and they put recipes on there, and all you gotta do is go on the company Web site. . I found it more helpful than the [organizer] Web site.’’ Facilitator: ‘‘The teams put them on?’’ Hattie: ‘‘No, the company does.’’ Facilitator: ‘‘Oh, the company?. Wow, very nice.’’
Regular contact viewed as essential
Seth: ‘‘ . the team is not all in the same building so they’re kind of scattered all over the place. There’s really only one that I interact with on a semi-regular basis, so for me it’s just having somebody that’s in the same boat you are, that’s trying to do the same thing, that you just touch base with and just talk a little bit about your challenges or a little bit about, you know, your frustrations: ’I did all this and I haven’t lost any weight this week.’ Or, you know, or, or, you know, and that just so some encouragement back and forth and so for me it’s, it’s that kind of thing. And, you know, they would send e-mails and stuff like that and that’s, that’s just sort of annoying to me. It’s the little bit of face-to-face that seems to be more helpful.’’
Teammates in the workplace Carly: ‘‘ . like the crap that everyone [typically] brings in the office . and so that’s just really been nice because it’s like this collective and environmental community and we’ve, like we, someone, it was their last day the other day and instead of having a big cake for her we had like a fruit salad improvements and I wanted to make brownies but I was like ’No, I got, my team is at the office,’ so I made some apple chips . those small things like that that I feel like when you’re in that collective community of people who care that has been really helpful, and I think that that will continue even if we’re not logging our weights.’’ Bonnie: ‘‘One of the coworkers and I run in the mornings. The other coworker and I did the trainer, and then the other one did the trainer and then stopped the trainer [laughs], but, so it was nice because we were all very in the same area so as you start to do that stuff together, you know, it’s just we’re gonna meet tonight, you have someone to meet with you. Having an accountability partner was a big thing cause 5:30 in the morning runs don’t really get me going, but I know she’s gonna be there! Other: ‘‘She’s waiting!’’ Bonnie: ‘‘So I’m not gonna be the person to sleep in! I’m gonna get up and get there . .’’ Bonnie: ‘‘We hired a trainer who watches our food journals and My Fitness Pal. . Five of us went in and it’s cheaper when you get five people to one trainer. It’s affordable at that point.’’ continued/
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Table 3. Focus Group Narratives for Theme 2: Information Technology and Social Support (n = 36) continued THEME, DESCRIPTION
EXAMPLES OF NARRATIVES
Workplace support supersedes team membership
Quinn: ‘‘What’s funny is we had several teams going on within my department . and we were actually encouraging each other even though we’re on separate teams, more so than my own team. . I helped one gal get on to My Fitness Pal and, you know, we helped count calories and everything and it was, we weren’t really competitive. I guess we should have been, but it was kind of like we’re, we’re working together so let’s, you know, let’s help each other. And so I got more support from other teams than I did from my own team.’’
Participants with limited local support felt isolated
Ann: ‘‘My team captain [and] the rest of the team were in her office, I didn’t even know them. I had met her and we’ve become kind of friends [but] when she invited me to be a part of the team I already felt a little disjointed. . I felt like I was an island of myself. I mean, I was already motivated and I’m doing it, she [the team captain] even sent an e-mail: ’Ann’s the one that’s . keeping us in the higher percentile.’ I’m like, well, I don’t even know what anybody else is doing. . It’s just our team was so disjointed, I felt like I was kind of over here and I don’t know what they were, if they were doing anything over here or not. If I weren’t already motivated I probably would have dropped the whole thing.’’
IT, information technology.
In contrast with the novelty of organizational support, having regular contact such as that which could be obtained from an office peer was viewed not only as helpful, but as essential. Participants with teammates in the workplace frequently reported environmental improvements whereby triggers for overeating or making poor food choices were reduced and opportunities for exercise were increased. In fact, workplace support had the potential to supersede team membership. Participants who had limited local support, in contrast, felt isolated and demoralized. In summary, participants sought out and valued social interactions, for both accountability and camaraderie. Regarding accountability, IT was felt to have the potential to facilitate discretion as well as the capability to broadcast. A few participants used commercial apps that provided prompts and reminders, although others found these to be aversive. In contrast to the variability of preferences for accountability, virtually all participants expressed clear preference for in-person camaraderie. It is important that the work environment had significant influence as a source of social support and could have either encouraging or demoralizing effects. When regular in-person contact was not available (such as when groups were not formed around one’s own work peers), participants felt isolated and unsupported.
Discussion Our study explored IT use among individuals as they were trying to lose weight. A locally sponsored, community-based weight-loss event provided us with an opportunity to query a broad mix of individuals regarding the ways they were using IT to help their weight-loss endeavors. As noted previously, key elements for weightloss programming include educational supports, focus on selfmanagement, increasing participants’ problem-solving and behavior change skills, and increasing social support.2–4 We found that participants frequently used IT to make clerical tasks more perfunctory, such as with tracking and recording tasks for self-management. Certain apps even enhanced capability for problem-solving incontext (for example, making food selections based on nutritional analysis and budgeting calories). Users especially appreciated
products and services with large and exacting databases. Apps with these capabilities clearly encouraged and facilitated integration of behavior change into everyday life. Additionally, a noticeable subgroup of participants were excited and reinforced by a combination of the competitive nature of the Slimdown Challenge and the availability of IT-based visual displays of progress. In other words, it appeared rewarding that individuals could see graphic or pictorial representations of their efforts and progress toward their goals, especially when results from other players were available for comparison. Given the level of IT savvy of our focus group members, our findings regarding social support were interesting and to some degree surprising. We observed that despite easy access to familiar and/or specialized (i.e., weight-loss and/or fitness-related) social networking Web sites, access to in-person social support appeared to be viewed as critical to successful weight loss and well-being. In this vein, the role of work peers and work environment in behavioral self-management emerged as an important subtheme. When weight-loss teams were built around the workplace, they had the potential to foster a healthy environment, providing participants with opportunities and support for making healthier food selections and engaging in exercise. Not all workplace-based teams were successful, however. Several focus group participants noted limited or ineffective involvement from their captains, even in workplace-based teams. Further, those in work environments that encouraged poor choices found their weight-loss efforts challenged. Areas for improvement that we suggest, given our findings, are for the event sponsors provide more tools and supports for team leaders, particularly those with workplace-based teams, to help them promote team cohesion, to provide a supportive environment, and to sustain member motivation. These could easily be provided through IT-based modalities. Strengths of our study include high motivation among focus group invitees to share their experiences. This was evidenced in an attendance rate of 100%, with virtually all participants contributing to discussion. Limitations of the study include our inability to quantify the degree to which participants actually used the IT they endorsed and the degree to which IT use correlated with
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outcomes. Additionally, it is unclear if the physical environment and culture of our community are unusually supportive of health and fitness. Despite these influences, we observed no evidence that our focus group participants viewed or used IT in an unusual way. Finally, given the relatively high educational and employment rates among our participants, we expect that our participants had greater than average access to IT, compared with the U.S. population at-large. However, frequent use of the Internet was a selection factor, and we expect that our sample is reasonably representative of the population of individuals willing to use IT for weight loss.
IMPLICATIONS AND RECOMMENDATIONS FOR PATIENT-CENTERED E-HEALTH Individuals who are generally comfortable using the Internet and other IT appear willing to explore and use a range of apps to help with their weight-loss endeavors. Furthermore, use of such apps may increase engagement and persistence while participating in a formal weight-loss program.11 Regarding e-health applications, successful patient health portals may benefit from capitalizing on these trends by either developing or integrating existing apps that save time or increase daily efficiency and/or provide users with visual feedback on progress toward goals. Although social support remains integral to weight-loss (and other lifestyle change) programs, developing social networking tools for patient health portals or other telemedicine services may not be the best investment of limited healthcare dollars if these do not integrate or facilitate in-person social interactions. Social networking tools are costly to develop, and our findings suggest that online groups may be more variably effective for promoting weight loss, particularly if there is no preexisting social relationship between participants in the network. For those who do derive benefit from online social supports, high-quality commercial products and services are readily available and may better accommodate existing social networks. Our results suggest that IT-delivered resources could be used to optimize community-based behavioral health interventions that target naturally occurring social groups, such as workplace wellness initiatives. Specifically, training and support resources for on-site leaders, tools for enhancing group cohesion and engagement, and ideas for creating healthier environments appear to be needed and would likely be valued.
Acknowledgments The investigators would like to acknowledge the University of Missouri Tiger Institute for Health Innovation for their assistance in recruiting participants for this study. This research was supported by the Small Grant Funding Program of the University of Missouri Department of Family & Community Medicine and the Research Facilitation Fund Program of the University of Missouri School of Health Professions.
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Disclosure Statement No competing financial interests exist. REFERENCES 1. Center for Disease Control and Prevention. Overweight and obesity. U.S. obesity trends: Trends by state. Updated August 20, 2012. Available at www.cdc.gov/ obesity/data/trends.html (last accessed April 17, 2013). 2. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403. 3. Baker RC, Kirschenbaum DS. Self-monitoring may be necessary for successful weight control. Behav Ther 1993;24:377–394. 4. Harvey-Berino J, Pintauro S, Buzzell P, Gold EC. Effect of Internet support on the long-term maintenance of weight loss. Obes Res 2004;12: 320–329. 5. Perri MG, Nezu AM, McKelvey WF, Shermer RL, Renjilian DA, Viegener BJ. Relapse prevention training and problem-solving therapy in the longterm management of obesity. J Consult Clin Psychol 2001;69:722–726. 6. Khaylis A, Yiaslas T, Bergstrom J, Gore-Felton C. A review of efficacious technology-based weight-loss interventions: Five key components. Telemed J E Health 2010;16:931–938. 7. Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: A randomized trial. JAMA 2003;289:1833–1836. 8. Homko CJ, Deeb LC, Rohrbacher K, et al. Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus. Diabetes Technol Ther 2012;14:624–629. 9. Soltani H, Furness PJ, Arden MA, et al. Women’s and midwives’ perspectives on the design of a text messaging support for maternal obesity services: An exploratory study. J Obes 2012;2012:835464. 10. Gow RW, Trace SE, Mazzeo SE. Preventing weight gain in first year college students: An online intervention to prevent the ‘‘freshman fifteen.’’ Eat Behav 2010;11:33–39. 11. Brindal E, Hendrie G, Freyne J, Coombe M, Berkovsky S, Noakes M. Design and pilot results of a mobile phone weight-loss application for women starting a meal replacement programme. J Telemed Telecare 23 May 2013 [Epub ahead of print]. doi: 10.1177/1357633X13479702. 12. Mulvaney-Day N, Womack CA. Obesity, identity and community: Leveraging social networks for behavior change in public health. Public Health Ethics 2009;2:250–260. 13. Lorig K, Ritter PL, Laurent DD, et al. Online diabetes self-management program: A randomized study. Diabetes Care 2010;33:1275–1281. 14. Shigaki C, Smarr KL, Siva C, Ge B, Musser D, Johnson R. RAHelp: An online intervention for individuals with rheumatoid arthritis. Arthritis Care Res (Hoboken) 2013;65:1573–1581. 15. Duffecy J, Sanford S, Wagner L, Begale M, Nawacki E, Mohr DC. Project Onward: An innovative e-health intervention for cancer survivors. Psychooncology 2013;22:947–951. 16. U.S. Census Bureau. State & county quickfacts (2012). Boone County, Missouri. Updated March 11, 2013. Available at http://quickfacts.census.gov /qfd/states/ 29/29019.html (last accessed April 25, 2013). 17. Centers for Disease Control and Prevention. Diabetes public health resources. Diabetes interactive atlases, obesity prevalence (Missouri, 2009). Updated February 20, 2013. Available at www.cdc.gov/diabetes/atlas/ countydata/(County_EXCELstatelistOBESITY.html (last accessed April 25, 2013. 18. County Health Rankings & Roadmaps. Health outcomes overall rank—Missouri. 2013. Available at www.countyhealthrankings.org/app/missouri/2013/ rankings/outcomes/overall/by-rank (last accessed April 25, 2013).
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Address correspondence to: Cheryl L. Shigaki, PhD, ABPP Department of Health Psychology School of Health Professions University of Missouri Dc116.88 One Hospital Drive Columbia, MO 65212
19. Dohack C. Slimdown challenge fosters new attitudes as well as weight loss. Columbia Daily Tribune. August 5, 2012. Updated January 29, 2013. Available at www.columbiatribune.com/arts_life/pulse/slimdown-challenge-fostersnew-attitudes-as-well-as-weight-loss/article_8ff40e14-ec8d-54b1-85c22f3a58e12b19.html (last accessed April 17, 2013). 20. Glazer B, Strauss AL. The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine, 1967. 21. Dedoose, Version 4.5.91, web application for managing, analyzing, and presenting qualitative and mixed method data. Los Angeles: SocioCultural Research Consultants, LLC, 2012. 22. Petenakis S. Columbia’s Slimdown Challenge. Updated April 23, 2012. Available at www.komu.com/news/columbia-s-slimdown-challenge/ (last accessed April 25, 2013).
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E-mail: [email protected] Received: May 3, 2013 Revised: June 17, 2013 Accepted: June 20, 2013
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Cheryl L. Shigaki, PhD, ABPP,1 Richelle J. Koopman, MD, MS,2 Allison Kabel, PhD,3 and Shannon Canfield, MPH4 Departments of 1Health Psychology and 3Health Sciences, School of Health Professions, University of Missouri, Columbia, Missouri. 2 Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri, Columbia, Missouri. 4 Center for Health Policy, University of Missouri, Columbia, Missouri.
Abstract Background: Commercial producers have outpaced traditional academic healthcare in terms of novel repackaging of traditional approaches to weight control for online delivery. Little is known, however, about consumers’ experiences with such products and services. We explored ways that people use information technology (IT) to facilitate health-related behavioral change. Materials and Methods: Qualitative methods and grounded theory methodology were used to analyze transcripts of audiotaped material from three focus groups, each with 12 participants. Participants were recruited from an ongoing, community-wide weight-loss event, who reported regular or frequent use of IT. Results: Participants frequently used IT applications for completing functional tasks associated with weight loss. In contrast, most participants preferred in-person social support. IT applications facilitated integration of behavior change tasks into everyday life. Despite easy access to a range of social networking Web sites and tools, however, having access to in-person social support was targeted as critical to successful weight loss and wellbeing. To this end, the role of work peers and work environments was emphasized by these participants. Conclusions: In terms of patient care, successful health portals may benefit from either developing or integrating existing IT applications that save time and/or provide users with visual feedback on progress toward goals. IT-delivered resources would likely optimize community-based behavioral health interventions that target naturally occurring social groups. Key words: e-health, commercial telemedicine, telehealth, obesity
Introduction
I
n 2010 over one-third of U.S. adults were obese (body mass index [BMI] ‡ 30 kg/m2).1 Prevalence of obesity is especially concerning because of its well-known association with increased risk for chronic health conditions such as diabetes mellitus, risk which can be mitigated with weight loss.2 Key elements for weight-loss programming include provision of education and support for improving dietary self-management, increasing partici-
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pants’ repertoire of general problem-solving and behavior change skills, and increasing social support.3–6 Several studies have successfully demonstrated information technology (IT)-based delivery of these elements.4,7 IT approaches have been successfully trialed in targeted populations, such as for preventing weight gain among firstyear college students and among pregnant women with gestational diabetes.8–10 Phone and tablet applications (‘‘apps’’) may be particularly helpful insofar as encouraging participant engagement.11 It has been argued that interventions targeting the individual alone will likely be less effective than approaches that treat weight loss and health behavior change from a relational perspective.12 To this end, commercial weight-loss and fitness Web sites have outpaced academic research in their development and integration of Internet-based social networking capability. Examples include Lose It! (www.loseit.com), LIVESTRONGSM (www.livestrong.com), and Spark People (www.sparkpeople.com). Endorsements integrated via blogs, forums, and product reviews also are prevalent. In the extant academic literature, IT supports for weight loss have focused primarily on integrating functional applications (e.g., food trackers, activity trackers, and calorie counters) and information resources (e.g., didactic materials and weight loss tips) with highquality counseling and participant monitoring. In some academic studies of health behavior change, resources for small-scale, restricted social interactions have been included, but this does not appear to be the norm.4,13–15 The omission of social networking capability in academic and private healthcare is likely due to several factors, including feasibility issues associated with recruiting and managing participants on a large scale, costs associated with developing and maintaining a high-quality Web site and patient portals, and the onus of maintaining participant data privacy and security in complying with the Health Insurance Portability and Accountability Act (HIPAA). For similar reasons, commercial services have greater flexibility in offering interesting and novel apps such as providing the user with a calorie estimate of photographed food items and barcode scanning capability to track nutrients in processed food items. Fitness apps can track distance walked or run, help the user locate walking and biking trails, and link exercise advice to anatomical maps. Some Web sites organize fitness challenges or provide services to match up exercise partners, while providing space for virtual fitness teams to blog and track progress. Overall, commercial producers have outpaced traditional academic healthcare in terms of novel repackaging of traditional approaches to weight control for online delivery. Despite their attractiveness and ubiquity, however, little is known about consumers’ experiences with such products and services. This gap presents a barrier to developing effective, patient-centered e-health applications for health-related behavior change. Our research
DOI: 10.1089/tmj.2013.0163
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addresses this gap by asking the question ‘‘What IT do people use to facilitate their weight-loss efforts and how do they use it?’’ Our study does not focus on new behavioral revelations, but rather on revelations about how IT allows users to integrate the essential elements of behavior change for weight loss into their daily lives and routines.
Materials and Methods We recruited study participants from a community-wide, 12-week ‘‘Slimdown Challenge’’ event that included 3,586 registered participants. The majority of Slimdown participants reside in an urban/rural county with approximately168,000 residents, where the prevalence of obesity is 28%.16,17 According to County Health Rankings, the county is ranked second among 115 counties in the state (where 1 is ‘‘healthiest’’) for health factors.18 The county also has been proactive in developing an environment conducive to healthy behaviors, for example, by passing legislation to make walking and biking easy and accessible and to prohibit smoking in public places. Participants formed teams of four to six people and designated a team captain. Weigh-in at baseline and 12 weeks was required. Online programming by the event sponsor included weekly e-mailed health tips, online graphical representation of participant weight, and a ranking of all participants with weight loss expressed as percentage of BMI lost. Small weekly prizes were offered for voluntary weighins, and large prizes were awarded to the top achievers based on percentage of BMI lost. One-third of participants (n = 1,170 [33%]) reportedly completed the challenge.19 We collaborated with the event sponsor to e-mail a focus group invitation to all registered participants during the course of the Slimdown Challenge. Participants who responded to the e-mail invitation were entered in a random drawing for several small prizes (e.g., a certificate for a free sandwich). The focus group invitation e-mail contained a link to SurveyMonkey (www.surveymonkey.com), where potential participants were presented with the informed consent, with a check box to indicate that they had reviewed it and wished to participate. Survey respondents who wished to participate then answered demographic questions, including their height, starting weight, current weight, and their availability for several days and times for focus groups. Initial BMI and BMI change were calculated using self-reported weights and height. Respondents also were asked if they were ‘‘staying with it,’’ ‘‘dropped out,’’ or ‘‘never really started,’’ if they considered themselves successful in their efforts to lose weight so far, and how frequently they used e-mail and the Internet. Respondents were invited to participate in a focus group if they reported using e-mail or the Internet at least a few times weekly. We also targeted individuals with a range of weights and amounts of weight lost, focusing primarily on those who were either overweight or obese at baseline by their calculated BMI. Among volunteers who indicated they were available at the times given, we invited a group of individuals who in toto reflected a wide range on the factors of age, gender, ethnic origin, and household income. Participants attending the focus group were reimbursed $40 for their time and effort. We conducted three 90-min focus groups, each with 12 participants. A semistructured focus group script (see Supplementary Data)
was used, and one focus group leader, one co-leader, and one observer/field note-taker were present. Focus group participants were asked about their method of weight loss, their team interaction, their motivations and perceived barriers, and how the online environment and online and mobile apps assisted them in their weightloss efforts. Participants were encouraged to discuss ways in which IT was not helpful as well as ways that it was helpful. Focus groups were audio-recorded, and these recordings were then transcribed by an experienced qualitative transcriptionist; the observer’s field notes were added to the transcripts. Transcripts were deidentified by replacing participant names with pseudonyms and then analyzed using grounded theory methodology, assisted by Dedoose qualitative software.20,21 Investigators were C.L.S., a health psychologist, R.J.K., a family physician and clinical researcher, A.K., a medical anthropologist, and S.C., an MPH well-acquainted with focus group methods. Investigators independently coded the transcripts and then met to agree on codes. Investigators also created memos with emerging ideas during the analysis. Major themes emerged, with organization and consensus among the investigators. This research was approved by and conducted under the auspices of our university’s Health Sciences Institutional Review Board.
Results PARTICIPANTS Our focus groups included 36 individuals with 12 per group, reflecting a 100% show rate. Table 1 gives descriptive information. As
Table 1. Focus Group Participant Characteristics (n = 36) CHARACTERISTIC
VALUE
Women
30 (83%)
Age (years) [mean (range)]
40 (23–61)
Married/partnered
24 (67%)
Race/ethnicity Non-white
6 (22%)
Hispanic/Latino
2 (6%)
At least some college education
32 (89%)
Employed
32 (89%) 2
Baseline BMI (kg/m ) [mean (range)] Feel successful in weight-loss efforts
33.2 (20.4–47.5) 27 (67%)
Household income < $15,000
0
$15,000–$29,999
7 (19%)
$30,000–$69,999
18 (50%)
$70,000 +
11 (31%)
BMI, body mass index.
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indicated previously, the purpose of this study was to explore the ways in which people use IT to facilitate their weight-loss efforts. Responses from our focus group participants suggest that many, if not most, used or had tried some type of weight-loss–related IT, and two prominent themes emerged in the data analysis: 1. Participants experimented with and were satisfied with a range of IT applications for weight loss and fitness. Many of the applications used were considered central and essential for completing discrete, functional tasks. 2. In meeting social support needs, however, most participants preferred more intimate, local resources and in-person contacts— if IT was used, this was mainly to support existing relationships.
USING IT TO FACILITATE FUNCTIONAL TASKS (SEE TABLE 2 FOR NARRATIVES) There’s an app for that. Use of IT Web site and smartphone apps to manage time-consuming, functional tasks associated with weight loss was highly prevalent. Most frequently, participants reported using apps for tracking nutrients (calories, fat grams, etc.) and exercise. There were numerous options, oftentimes free of charge. None of the focus group members reported using paper-and-pencil logs or calorie counter books, although some appeared to have had experience with manual logging in the past. Participants agreed that if it were not for electronic methods, they would not have been able or motivated to track these things. Specific features of food trackers apps favored by the group included barcode scanning capability and large databases that allowed for identifying and tracking the exact item consumed rather than a similar or generic item. Participants described being able to use these capabilities to plan ahead and make good choices. One participant used a ‘‘budget’’ analogy, describing how she used the data from her app to work within an energy budget. Feedback is rewarding and motivational. Numeric and especially graphic feedback from a range of apps and Web sites was perceived as entertaining and motivating. Specifically discussed were the online feedback features provided by the event organizer, as described above, that allowed participants to monitor both their own trends and compare themselves with other teams. More ideas needed. Participants in each focus group voiced appreciation for tips on diet, cooking, and lifestyle management. In fact, participants expressed disgruntlement with the event organizers for not providing more of this type of support. They felt that having access to more ‘‘tips’’ would prevent having to learn what others had already figured out. The groups also suggested that there was a wealth of information that could come from the participants themselves. Thus, a ‘‘share your ideas’’ section for the event Web site would have been welcome and also affirming for successful participants. A notable proportion of participants expressed dissatisfaction with their team captain and the lack of cohesiveness of their teams during
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the Slimdown Challenge. Dissatisfaction was especially apparent if the participant was able to observe well-functioning teams and captains. It appeared that a shortcoming of the event was that organizers did not provide team captains with tools or support for motivating players. In summary, focus group participants from the Slimdown Challenge experimented and were happy with a range of IT applications for discrete, functional tasks. In fact, logging and researching tasks (i.e., looking up nutritional content) may well have been barriers to successful weight loss, if it had not been for the availability of computer and phone apps. Graphic feedback on one’s progress and status were like ‘‘instant gratification’’ and, as such, were rewarding and motivating. Many participants wished for more informational offerings, delivered in small, digestible doses. An area of weakness appears to have been that very limited support was available for team captains. Team captains may well have benefited from additional ITbased tools and support, delivered across the event, so they could effectively encourage team members to stay motivated and keep their teams competitive.
IT AND SOCIAL SUPPORT (SEE TABLE 3 FOR NARRATIVES) Accountability. Consistent with the literature on weight loss and lifestyle change, our focus group participants identified social support as an important factor in their weight-loss endeavors. The role and perceived value of IT in garnering and maintaining social support were much less clear-cut, however, than for using IT for functional tasks. Maintaining ‘‘accountability’’ was one aspect of social support for which some participants did use IT, although perspectives on accountability varied widely. One participant took it upon herself to be accountable to family and friends, using a general social networking site. Additionally, several focus group participants reported using texting to maintain contact and accountability with their teams. These examples occurred primarily within relationships established prior to the Slimdown Challenge event. Participants described apps for weight loss that would ‘‘call out’’ individuals in a public forum. One of our participants felt personally benefitted from this approach, although others were doubtful. Another participant preferred a similar app, designed to encourage needed support rather than to ‘‘call out’’ or confront. The Slimdown Challenge added a competitive twist to typical individual weight-loss efforts. IT tools were described as useful in this context to communicate messages of encouragement and accountability in a more diffused and impersonal way than face-to-face. One participant recognized the intense emotional triggers that may be associated weight-loss efforts and noted that sending information by e-mail may diffuse or prevent unnecessary emotional reactivity. However, reactions to group motivational messages were variable. About equal numbers of participants felt annoyed or offended by such messages as those who felt more positively. Garnering social support. The importance of social support in weight-loss efforts was a recurring topic in each of the focus groups.
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Table 2. Focus Group Narratives for Theme 1: Using Information Technology to Facilitate Functional Tasks (n = 36) THEME, DESCRIPTION
EXAMPLES OF NARRATIVES
There’s an app for that . : use of IT Web site and smartphone apps to manage time-consuming, functional tasks Tracking
Carly: ‘‘I also use the My Fitness Pal, and I thought that was really helpful for me just because I had never had a food journal before and it was really easy for me to keep it. If it’s on my phone, I usually have it with me, I can just take it out, add something real fast, look it up, put it in there and.’’ Bonnie: ‘‘The ease of use? Yeah, wonderful!’’ Carly: ‘‘ . that was really nice because I thought about having a food journal before but I wasn’t gonna carry around a journal and then have to go look it up like later and do the math and all of that. The end of the day, like no, then it’s too late. So that was helpful.’’
Planning ahead
Catherine: ‘‘And what I liked about the My Fitness Pal was in the, initially, like I said, I’m not good at tracking, but what I could do was go through the foods that are really good for me, you know, like whether it was scanning or whether it was entering the information, figure what are the things that are healthy, and then those are the things that I know that I choose from. Just like with going out to eat, you know, at a restaurant, knowing what the menu items that are the best for me and then utilizing that as my menu, like pick through things as I go through the challenge.’’
‘‘Budgeting’’
Laura: ‘‘I’m into Sports Tracker . what I found myself doing is, you know, just thinking about the numbers just like you think about your financial budget. And so I would, you know, pick how intensely I needed to exercise because it tells you not only how many calories you’re eating but how many calories you’re burning based on those things. So I would plan what I was gonna eat and then how much I was gonna exercise . ’’
Feedback is rewarding and motivational: monitoring one’s own trends and comparing one’s progress to others Facilitator: ‘‘What are most helpful or the least helpful parts of the [organizer] Web site?’’ Jennifer: ‘‘The graphic is nice.’’ Seth: ‘‘Graphic and the weight loss.’’ Kate: ‘‘The stats, yeah.’’ Susan: ‘‘The weight-loss history.’’ Seth: ‘‘It gives you percent body mass.’’ Wayne: ‘‘It’s the closest thing to instant gratification that we have!’’ Seth: ‘‘It gives you a BMI. It calculates your BMI for you.’’ Jennifer: ‘‘And how much BMI you lost since the [beginning] . ’’ Bonnie: ‘‘And you see the lines either going down, or up . ’’ Jennifer: ‘‘I just like seeing where I’m at as far as, you know, my ranking.’’ Carly: ‘‘I admit, the ranking is helpful.’’ Seth: ‘‘I would say that the nice thing about that [organizer] Web site is, you know, any time you start one of these programs you need to set goals. That’s nice because it lets you track that goal.’’ Carly: ‘‘It tells you percentage-wise how close you are . ’’ Jennifer: ‘‘Yeah, that’s been helpful.’’ More ideas needed: tips on diet, cooking, and lifestyle management are desired Avoid having to learn what others have already figured out
Ian: ‘‘I thought all of the little weekly advice things from the [organizer] were very helpful as well, and so I used this as an opportunity for me to, to learn about how I can be healthier, and so it wasn’t a competition, it hasn’t been a competition for me.’’ Geraldine: ‘‘Recipes or . we could have done that . or just tips on what they’re doing, like what’s actually working for them, you know, even if it’s just exercising or, you know, eating healthier and I did this and this, you know.’’ Brad: ‘‘Or even just a poll, you know. You’ve got 300 people using My Fitness Pal and somebody else using a different app, or calorie counter. There’s so many out there. It just depends on, it’s hard to whittle it down to what you want to use.’’
Tools for team captains
Elizabeth: ‘‘Our team captain wasn’t that great, honestly. . She approached who she felt would be good on the team . and then that was it. That was basically all we heard from her throughout the 12 weeks.’’ Pansy: ‘‘I had a similar experience as far as a not so good team captain . this person just kind of approached me. . And it was just kind of like okay . but there really hasn’t been any communication. . So it’s just been kind of like a team solo within a team.’’
apps, applications; BMI, body mass index; IT, information technology.
And, although some participants discussed IT-based interactions, the importance of having supports ‘‘close to home’’ was a dominant theme across all groups. For many if not most, the availability of local supports translated into support at the worksite. Having tangible support from one’s work organization, per se, was viewed as
valuable and novel. It was notable that employer-based support appeared strong as almost 70 local employers agreed to partner with the event sponsor, and many of our participants indicated feeling supported in their work environment for participating in the Slimdown event.22
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Table 3. Focus Group Narratives for Theme 2: Information Technology and Social Support (n = 36) THEME, DESCRIPTION
EXAMPLES OF NARRATIVES
Accountability: using IT to make one’s self accountable to family, friends, and team Social networking
Catherine: ‘‘Well, what I did was I, every time I went and weighed in I put it on my Facebook page, so whether it was good or bad, you know. I had people cheering me on, positive, negative, you know, I don’t mean negative, but like I gained 10 pounds when I went on vacation . I was like ’I need something to motivate me!’. If I didn’t post it [people are going to ask] ’How are you doing on your weight thing?’’’
Texting
Susan: ‘‘We, we are big texters and so if we feel like a craving or something like that we’re like, we, we, we have everybody, we text them all at the same time like ’I really want to eat this whole pizza by myself,’ and they’re like ’No, no, no, no, no,’ and so (laughter), and they talk you through it or something . ’’
Apps for ‘‘calling out’’
Laura: ‘‘I really think a big part of being successful for me is accountability . In my little group on Lose It, you know, it even says like ’Oh, look, Laura ate 250 calories over her limit today.’’’ [Laughter] Rob: ‘‘I’m busted. I’m busted. I need to get on that!’’ [Group agrees] Rob: ‘‘That’s really getting personal.’’ Laura: ‘‘That’s really helpful to me to see that and, you know, you’re like ’Wow, look at that, you know, Laura isn’t losing her weight because every day she eats 250 calories more than she’s supposed to.’ So I wish it wasn’t true, but it is true [and it] really helped. . ’’ Carrie Ann: ‘‘I used the My Fitness Pal. I think the one thing, since the captain really wasn’t as vocal, the app itself will say to you, ’So and so hasn’t weighed in or entered their food in 3 days, so they might need some encouragement.’ . So it was . easier that way, to just send a nice little ’Hey, you haven’t logged in!’ And you can do that on your phone as well as on e-mail. I thought that was a good reminder ’cause before you know it it’s Sunday and you haven’t put your food in from like Thursday through Saturday.’’
Using e-mail to diffuse or prevent unnecessary emotional reactivity
Geraldine: ‘‘ . we all work within steps from each other and I think it’s hard to, to be the captain and come and tell somebody, you know, don’t eat that . because some people take it very, very, I mean, they’re very insecure and I learned from the very beginning, to let everybody do it at their own pace, you know, try to send them an e-mail or something like that but don’t, don’t, never go straight in. We did some things together, you know.but . if I go and ask somebody ’Hey, you want to go to the boot camp with me’ that was like ’What, are you telling me that I should be doing more?’ [Laughs] So I just send an e-mail. You know, it was a little bit more impersonal and I got better answers than just going straight to the person.’’
Reactions to group motivational messages
Theresa: ‘‘I used Fitday.com, which is a free app also. But it’s interesting to me that both of you said you like those reminders. I found them annoying when they came so often from [organizer] . My daughter is on a team also, a different team, and she found them annoying also, so. I mean, there were just so many of them.’’ Charlie: ‘‘Yeah. Some of my team didn’t like the e-mails I sent, but [I sent them] anyway.’’ Jennifer: ‘‘You’re the captain.’’ Charlie: ‘‘Yeah.’’
Garnering social support: local, in-person supports are essential Support from the work organization
Hattie: ‘‘There’s over 20 teams within my job and they have, our company Web site, they put tips on there every day of things to do and they put recipes on there, and all you gotta do is go on the company Web site. . I found it more helpful than the [organizer] Web site.’’ Facilitator: ‘‘The teams put them on?’’ Hattie: ‘‘No, the company does.’’ Facilitator: ‘‘Oh, the company?. Wow, very nice.’’
Regular contact viewed as essential
Seth: ‘‘ . the team is not all in the same building so they’re kind of scattered all over the place. There’s really only one that I interact with on a semi-regular basis, so for me it’s just having somebody that’s in the same boat you are, that’s trying to do the same thing, that you just touch base with and just talk a little bit about your challenges or a little bit about, you know, your frustrations: ’I did all this and I haven’t lost any weight this week.’ Or, you know, or, or, you know, and that just so some encouragement back and forth and so for me it’s, it’s that kind of thing. And, you know, they would send e-mails and stuff like that and that’s, that’s just sort of annoying to me. It’s the little bit of face-to-face that seems to be more helpful.’’
Teammates in the workplace Carly: ‘‘ . like the crap that everyone [typically] brings in the office . and so that’s just really been nice because it’s like this collective and environmental community and we’ve, like we, someone, it was their last day the other day and instead of having a big cake for her we had like a fruit salad improvements and I wanted to make brownies but I was like ’No, I got, my team is at the office,’ so I made some apple chips . those small things like that that I feel like when you’re in that collective community of people who care that has been really helpful, and I think that that will continue even if we’re not logging our weights.’’ Bonnie: ‘‘One of the coworkers and I run in the mornings. The other coworker and I did the trainer, and then the other one did the trainer and then stopped the trainer [laughs], but, so it was nice because we were all very in the same area so as you start to do that stuff together, you know, it’s just we’re gonna meet tonight, you have someone to meet with you. Having an accountability partner was a big thing cause 5:30 in the morning runs don’t really get me going, but I know she’s gonna be there! Other: ‘‘She’s waiting!’’ Bonnie: ‘‘So I’m not gonna be the person to sleep in! I’m gonna get up and get there . .’’ Bonnie: ‘‘We hired a trainer who watches our food journals and My Fitness Pal. . Five of us went in and it’s cheaper when you get five people to one trainer. It’s affordable at that point.’’ continued/
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Table 3. Focus Group Narratives for Theme 2: Information Technology and Social Support (n = 36) continued THEME, DESCRIPTION
EXAMPLES OF NARRATIVES
Workplace support supersedes team membership
Quinn: ‘‘What’s funny is we had several teams going on within my department . and we were actually encouraging each other even though we’re on separate teams, more so than my own team. . I helped one gal get on to My Fitness Pal and, you know, we helped count calories and everything and it was, we weren’t really competitive. I guess we should have been, but it was kind of like we’re, we’re working together so let’s, you know, let’s help each other. And so I got more support from other teams than I did from my own team.’’
Participants with limited local support felt isolated
Ann: ‘‘My team captain [and] the rest of the team were in her office, I didn’t even know them. I had met her and we’ve become kind of friends [but] when she invited me to be a part of the team I already felt a little disjointed. . I felt like I was an island of myself. I mean, I was already motivated and I’m doing it, she [the team captain] even sent an e-mail: ’Ann’s the one that’s . keeping us in the higher percentile.’ I’m like, well, I don’t even know what anybody else is doing. . It’s just our team was so disjointed, I felt like I was kind of over here and I don’t know what they were, if they were doing anything over here or not. If I weren’t already motivated I probably would have dropped the whole thing.’’
IT, information technology.
In contrast with the novelty of organizational support, having regular contact such as that which could be obtained from an office peer was viewed not only as helpful, but as essential. Participants with teammates in the workplace frequently reported environmental improvements whereby triggers for overeating or making poor food choices were reduced and opportunities for exercise were increased. In fact, workplace support had the potential to supersede team membership. Participants who had limited local support, in contrast, felt isolated and demoralized. In summary, participants sought out and valued social interactions, for both accountability and camaraderie. Regarding accountability, IT was felt to have the potential to facilitate discretion as well as the capability to broadcast. A few participants used commercial apps that provided prompts and reminders, although others found these to be aversive. In contrast to the variability of preferences for accountability, virtually all participants expressed clear preference for in-person camaraderie. It is important that the work environment had significant influence as a source of social support and could have either encouraging or demoralizing effects. When regular in-person contact was not available (such as when groups were not formed around one’s own work peers), participants felt isolated and unsupported.
Discussion Our study explored IT use among individuals as they were trying to lose weight. A locally sponsored, community-based weight-loss event provided us with an opportunity to query a broad mix of individuals regarding the ways they were using IT to help their weight-loss endeavors. As noted previously, key elements for weightloss programming include educational supports, focus on selfmanagement, increasing participants’ problem-solving and behavior change skills, and increasing social support.2–4 We found that participants frequently used IT to make clerical tasks more perfunctory, such as with tracking and recording tasks for self-management. Certain apps even enhanced capability for problem-solving incontext (for example, making food selections based on nutritional analysis and budgeting calories). Users especially appreciated
products and services with large and exacting databases. Apps with these capabilities clearly encouraged and facilitated integration of behavior change into everyday life. Additionally, a noticeable subgroup of participants were excited and reinforced by a combination of the competitive nature of the Slimdown Challenge and the availability of IT-based visual displays of progress. In other words, it appeared rewarding that individuals could see graphic or pictorial representations of their efforts and progress toward their goals, especially when results from other players were available for comparison. Given the level of IT savvy of our focus group members, our findings regarding social support were interesting and to some degree surprising. We observed that despite easy access to familiar and/or specialized (i.e., weight-loss and/or fitness-related) social networking Web sites, access to in-person social support appeared to be viewed as critical to successful weight loss and well-being. In this vein, the role of work peers and work environment in behavioral self-management emerged as an important subtheme. When weight-loss teams were built around the workplace, they had the potential to foster a healthy environment, providing participants with opportunities and support for making healthier food selections and engaging in exercise. Not all workplace-based teams were successful, however. Several focus group participants noted limited or ineffective involvement from their captains, even in workplace-based teams. Further, those in work environments that encouraged poor choices found their weight-loss efforts challenged. Areas for improvement that we suggest, given our findings, are for the event sponsors provide more tools and supports for team leaders, particularly those with workplace-based teams, to help them promote team cohesion, to provide a supportive environment, and to sustain member motivation. These could easily be provided through IT-based modalities. Strengths of our study include high motivation among focus group invitees to share their experiences. This was evidenced in an attendance rate of 100%, with virtually all participants contributing to discussion. Limitations of the study include our inability to quantify the degree to which participants actually used the IT they endorsed and the degree to which IT use correlated with
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outcomes. Additionally, it is unclear if the physical environment and culture of our community are unusually supportive of health and fitness. Despite these influences, we observed no evidence that our focus group participants viewed or used IT in an unusual way. Finally, given the relatively high educational and employment rates among our participants, we expect that our participants had greater than average access to IT, compared with the U.S. population at-large. However, frequent use of the Internet was a selection factor, and we expect that our sample is reasonably representative of the population of individuals willing to use IT for weight loss.
IMPLICATIONS AND RECOMMENDATIONS FOR PATIENT-CENTERED E-HEALTH Individuals who are generally comfortable using the Internet and other IT appear willing to explore and use a range of apps to help with their weight-loss endeavors. Furthermore, use of such apps may increase engagement and persistence while participating in a formal weight-loss program.11 Regarding e-health applications, successful patient health portals may benefit from capitalizing on these trends by either developing or integrating existing apps that save time or increase daily efficiency and/or provide users with visual feedback on progress toward goals. Although social support remains integral to weight-loss (and other lifestyle change) programs, developing social networking tools for patient health portals or other telemedicine services may not be the best investment of limited healthcare dollars if these do not integrate or facilitate in-person social interactions. Social networking tools are costly to develop, and our findings suggest that online groups may be more variably effective for promoting weight loss, particularly if there is no preexisting social relationship between participants in the network. For those who do derive benefit from online social supports, high-quality commercial products and services are readily available and may better accommodate existing social networks. Our results suggest that IT-delivered resources could be used to optimize community-based behavioral health interventions that target naturally occurring social groups, such as workplace wellness initiatives. Specifically, training and support resources for on-site leaders, tools for enhancing group cohesion and engagement, and ideas for creating healthier environments appear to be needed and would likely be valued.
Acknowledgments The investigators would like to acknowledge the University of Missouri Tiger Institute for Health Innovation for their assistance in recruiting participants for this study. This research was supported by the Small Grant Funding Program of the University of Missouri Department of Family & Community Medicine and the Research Facilitation Fund Program of the University of Missouri School of Health Professions.
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Disclosure Statement No competing financial interests exist. REFERENCES 1. Center for Disease Control and Prevention. Overweight and obesity. U.S. obesity trends: Trends by state. Updated August 20, 2012. Available at www.cdc.gov/ obesity/data/trends.html (last accessed April 17, 2013). 2. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403. 3. Baker RC, Kirschenbaum DS. Self-monitoring may be necessary for successful weight control. Behav Ther 1993;24:377–394. 4. Harvey-Berino J, Pintauro S, Buzzell P, Gold EC. Effect of Internet support on the long-term maintenance of weight loss. Obes Res 2004;12: 320–329. 5. Perri MG, Nezu AM, McKelvey WF, Shermer RL, Renjilian DA, Viegener BJ. Relapse prevention training and problem-solving therapy in the longterm management of obesity. J Consult Clin Psychol 2001;69:722–726. 6. Khaylis A, Yiaslas T, Bergstrom J, Gore-Felton C. A review of efficacious technology-based weight-loss interventions: Five key components. Telemed J E Health 2010;16:931–938. 7. Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: A randomized trial. JAMA 2003;289:1833–1836. 8. Homko CJ, Deeb LC, Rohrbacher K, et al. Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus. Diabetes Technol Ther 2012;14:624–629. 9. Soltani H, Furness PJ, Arden MA, et al. Women’s and midwives’ perspectives on the design of a text messaging support for maternal obesity services: An exploratory study. J Obes 2012;2012:835464. 10. Gow RW, Trace SE, Mazzeo SE. Preventing weight gain in first year college students: An online intervention to prevent the ‘‘freshman fifteen.’’ Eat Behav 2010;11:33–39. 11. Brindal E, Hendrie G, Freyne J, Coombe M, Berkovsky S, Noakes M. Design and pilot results of a mobile phone weight-loss application for women starting a meal replacement programme. J Telemed Telecare 23 May 2013 [Epub ahead of print]. doi: 10.1177/1357633X13479702. 12. Mulvaney-Day N, Womack CA. Obesity, identity and community: Leveraging social networks for behavior change in public health. Public Health Ethics 2009;2:250–260. 13. Lorig K, Ritter PL, Laurent DD, et al. Online diabetes self-management program: A randomized study. Diabetes Care 2010;33:1275–1281. 14. Shigaki C, Smarr KL, Siva C, Ge B, Musser D, Johnson R. RAHelp: An online intervention for individuals with rheumatoid arthritis. Arthritis Care Res (Hoboken) 2013;65:1573–1581. 15. Duffecy J, Sanford S, Wagner L, Begale M, Nawacki E, Mohr DC. Project Onward: An innovative e-health intervention for cancer survivors. Psychooncology 2013;22:947–951. 16. U.S. Census Bureau. State & county quickfacts (2012). Boone County, Missouri. Updated March 11, 2013. Available at http://quickfacts.census.gov /qfd/states/ 29/29019.html (last accessed April 25, 2013). 17. Centers for Disease Control and Prevention. Diabetes public health resources. Diabetes interactive atlases, obesity prevalence (Missouri, 2009). Updated February 20, 2013. Available at www.cdc.gov/diabetes/atlas/ countydata/(County_EXCELstatelistOBESITY.html (last accessed April 25, 2013. 18. County Health Rankings & Roadmaps. Health outcomes overall rank—Missouri. 2013. Available at www.countyhealthrankings.org/app/missouri/2013/ rankings/outcomes/overall/by-rank (last accessed April 25, 2013).
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Address correspondence to: Cheryl L. Shigaki, PhD, ABPP Department of Health Psychology School of Health Professions University of Missouri Dc116.88 One Hospital Drive Columbia, MO 65212
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E-mail: [email protected] Received: May 3, 2013 Revised: June 17, 2013 Accepted: June 20, 2013
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