self-monitoring: review of the literature lora e. burke, phd, mph, faha, faan obesity researchers...

Self-Monitoring: Review of Self-Monitoring: Review of the Literaturethe Literature

Lora E. Burke, PhD, MPH, FAHA, FAANLora E. Burke, PhD, MPH, FAHA, FAAN

Obesity Researchers Journal ClubObesity Researchers Journal Club

University of PittsburghUniversity of Pittsburgh

October 21, 2008October 21, 2008

Overview of ReviewOverview of Review

Self-monitoring – whySelf-monitoring – why Historical review of studies, 1980s – Historical review of studies, 1980s –

present using paper diariespresent using paper diaries Internet and electronic diary studiesInternet and electronic diary studies What have we learned, where do we What have we learned, where do we

need to goneed to go

Self-Monitoring in Weight LossSelf-Monitoring in Weight Loss

Is the systematic recording of one’s Is the systematic recording of one’s eating or physical activity behaviorseating or physical activity behaviors

Purpose is to increase one’s awareness Purpose is to increase one’s awareness of eating behaviorsof eating behaviors

Should occur in real time, throughout Should occur in real time, throughout dayday

AbbreviationsAbbreviations

Behavioral weight loss program = Behavioral weight loss program = BWLPBWLP

Physical activity = PAPhysical activity = PA Self-monitoring = SMSelf-monitoring = SM Intervention = TxIntervention = Tx

““First” study of Self-Monitoring in First” study of Self-Monitoring in Wt Loss (1)Wt Loss (1)

Study involved 16 groups of 11 adults in a Study involved 16 groups of 11 adults in a BWLP at a fee-for-service clinic for obesity; BWLP at a fee-for-service clinic for obesity; 15 weekly 1-hr meetings15 weekly 1-hr meetings

1/2 of groups given target behavior 1/2 of groups given target behavior monitoring forms – 9 behaviors related to monitoring forms – 9 behaviors related to eating & PA, frequency counteating & PA, frequency count

# of times/day behavior was engaged in # of times/day behavior was engaged in compared to total # of eating episodes = % compared to total # of eating episodes = % compliance; graphed behavior; rec’d compliance; graphed behavior; rec’d feedbackfeedback

Sperduto et al., 1986Sperduto et al., 1986

““First” study of Self-Monitoring in First” study of Self-Monitoring in Wt Loss (2)Wt Loss (2)

Combining the 8 groups that used SM forms, Combining the 8 groups that used SM forms, mean wt loss = 15.9 mean wt loss = 15.9 ± 3.9 ± 3.9 lbs vs. 9.7 lbs vs. 9.7 ± 1.9 lbs ± 1.9 lbs for comparison group at end of Tx (15 wks), p for comparison group at end of Tx (15 wks), p <.005<.005

At 3-mos f/u difference was 6.4 lbs, p <.005At 3-mos f/u difference was 6.4 lbs, p <.005 Completion rate was higher among SM Completion rate was higher among SM

group, 74.4% vs. 56.8%, p <.05group, 74.4% vs. 56.8%, p <.05 Implications: Need to begin to focus on eating Implications: Need to begin to focus on eating

behaviors, not outcome of wt lossbehaviors, not outcome of wt loss

Sperduto et al., 1986Sperduto et al., 1986

Self-Monitoring and Weight Self-Monitoring and Weight Change: Cross-sectional StudyChange: Cross-sectional Study

N = 56 obese adults previously Tx; agreed to N = 56 obese adults previously Tx; agreed to participate in SM studyparticipate in SM study

Given new booklet each week to record all Given new booklet each week to record all foods, caloriesfoods, calories

Focus: examine relationship between SM and Focus: examine relationship between SM and weight changeweight change

Result: Great diversity in percentage of Ss Result: Great diversity in percentage of Ss who SM and in type & frequency of variables who SM and in type & frequency of variables monitoredmonitored

Baker & Kirschenbaum, 1993Baker & Kirschenbaum, 1993

Percentage of Days All Foods Percentage of Days All Foods Were MonitoredWere Monitored


Conclusions and RecommendationsConclusions and Recommendations

6 variables correlated significantly with wt change 6 variables correlated significantly with wt change after 12 wks, e.g., SM any or all foods eaten, time after 12 wks, e.g., SM any or all foods eaten, time eaten, quantity, gms. of fateaten, quantity, gms. of fat

Ss in the highest level of SM lost sig more wt than Ss in the highest level of SM lost sig more wt than those at the lower levelsthose at the lower levels

Consistency/quality of SM in initial wks of Tx Consistency/quality of SM in initial wks of Tx predicted wt loss over 6-mos periodpredicted wt loss over 6-mos period

Important to view SM not only as a process that Important to view SM not only as a process that mediates wt control but also an important outcome; mediates wt control but also an important outcome; focus more on behaviors that produce wt loss than on focus more on behaviors that produce wt loss than on the wt lossthe wt loss

Need to develop means of sustaining SMNeed to develop means of sustaining SM


Further Support for Consistent SMFurther Support for Consistent SM

Study replicated Baker & Kirschenbaum’s Study replicated Baker & Kirschenbaum’s 1993 study re: relationship between SM and 1993 study re: relationship between SM and wt control; N = 59 women in long-term BWLP; wt control; N = 59 women in long-term BWLP; asked to participate in SM study for 8 wksasked to participate in SM study for 8 wks

26.3% SM all foods eaten on <50% of days26.3% SM all foods eaten on <50% of days Most consistent SMs lost more wt, Ss lost Most consistent SMs lost more wt, Ss lost

more wt during time of consistent SMmore wt during time of consistent SM Conclusion: Ss should SM at least 75% of the Conclusion: Ss should SM at least 75% of the

days; if SM <50% of days unlikely to succeeddays; if SM <50% of days unlikely to succeed

Boutelle and Kirschenbaum, 1998Boutelle and Kirschenbaum, 1998

Self-Monitoring and the HolidaysSelf-Monitoring and the Holidays

2 studies (N = 32 & 57) examined effect of SM on 2 studies (N = 32 & 57) examined effect of SM on weight gain among adults who had been in weight gain among adults who had been in long-termlong-term Tx for weight lossTx for weight loss

Findings:Findings: Holidays were high risk periodHolidays were high risk period Only the highly consistent SM quartile averaged any Only the highly consistent SM quartile averaged any

wt loss over 10-wk holiday period; least consistent wt loss over 10-wk holiday period; least consistent SM gained wtSM gained wt

22ndnd study showed that Ss SM more consistently study showed that Ss SM more consistently during the pre-holiday period than during the holidays during the pre-holiday period than during the holidays or post-holiday period; consistency was correlated or post-holiday period; consistency was correlated with wt change (r = -.35, p = .007)with wt change (r = -.35, p = .007)

Baker & Kirschenbaum, 1998;Boutelle et al., Baker & Kirschenbaum, 1998;Boutelle et al., 1999 1999

Comparison of 2 SM ApproachesComparison of 2 SM Approaches

16-wk correspondence BWLP compared 2 16-wk correspondence BWLP compared 2 methods of SM: traditional paper diary (n = methods of SM: traditional paper diary (n = 21, 45% retention) vs. traditional paper diary 21, 45% retention) vs. traditional paper diary with transition to abbreviated diary with with transition to abbreviated diary with checklists at 8 wks (n = 21, 57% retention) checklists at 8 wks (n = 21, 57% retention)

Results: Sig diff in # of diaries ret’d among Results: Sig diff in # of diaries ret’d among completers (14.0 completers (14.0 ± 2.0 detailed vs. 15.2 ± 1.4 ± 2.0 detailed vs. 15.2 ± 1.4 transition group, p =.04)transition group, p =.04)

No sig diff between groups in wt lossNo sig diff between groups in wt loss

Helsel, Jakicic, & Otto, 2007Helsel, Jakicic, & Otto, 2007

Number of Diaries by GroupsNumber of Diaries by Groups

Helsel, Jakicic, & Otto, 2007Helsel, Jakicic, & Otto, 2007

Wt Loss in Two SM GroupsWt Loss in Two SM Groups

Helsel, Jakicic, & Otto, 2007Helsel, Jakicic, & Otto, 2007TSM = transitioned to abbreviated SM, DSM = detailed SM

Self-Monitoring Physical ActivitySelf-Monitoring Physical Activity 6-mon BWLP, N = 40 obese, sedentary 6-mon BWLP, N = 40 obese, sedentary

adults, 85% retention at 6 mosadults, 85% retention at 6 mos Instructed to complete daily PA diary Instructed to complete daily PA diary

describing exercise type/duration; collected describing exercise type/duration; collected every 4-5 wks during 21-wk Txevery 4-5 wks during 21-wk Tx

Examined association between SM exercise Examined association between SM exercise and wt loss and PAand wt loss and PA

Results: 8 drop outs + 5 Ss did not complete Results: 8 drop outs + 5 Ss did not complete diaries; on average, 27 Ss completed 15.8 diaries; on average, 27 Ss completed 15.8 ± ± 6.2 wks of SM; greater SM assoc with wt loss 6.2 wks of SM; greater SM assoc with wt loss (r = .44, p <.05), weekly PA (r = .52, p <.01)(r = .44, p <.05), weekly PA (r = .52, p <.01)

Carels et al., 2005Carels et al., 2005

Differences Between Consistent & Differences Between Consistent & Inconsistent SM of ExerciseInconsistent SM of Exercise

Insert figure 1 from Carels et al articleInsert figure 1 from Carels et al article

Carels et al., 2005Carels et al., 2005

Phase I of Wt Loss Maintenance Phase I of Wt Loss Maintenance TrialTrial

4-center, one group BWLP lasting 6 mos.; N = 4-center, one group BWLP lasting 6 mos.; N = 1685, 44% minority; 92% retention at 6 mos.1685, 44% minority; 92% retention at 6 mos.

Results: Ss completed 3.7 daily food records Results: Ss completed 3.7 daily food records per wk.; men completed more diaries than per wk.; men completed more diaries than women (p <.004)women (p <.004)

After adjusting for race, gender & initial wt, After adjusting for race, gender & initial wt, greater wt loss with greater attendance, SM greater wt loss with greater attendance, SM records & min of PArecords & min of PA

Association between # FR kept per wk & wt Association between # FR kept per wk & wt loss greater for non-AA compared to AA loss greater for non-AA compared to AA regardless of genderregardless of gender

Hollis, Gullion, Stevens et al., 2008

Effect of No. of FRs/Wk on Wt ChangeEffect of No. of FRs/Wk on Wt Change

Hollis, Gullion, Stevens et al., 2008

Self-Monitoring in Internet Studies (1)Self-Monitoring in Internet Studies (1)

Study compared structured Internet BWLP to Study compared structured Internet BWLP to a weight loss education Web site; N = 91, a weight loss education Web site; N = 91, 71% retention at 6 mos. 71% retention at 6 mos.

SM diaries submitted online, individualized SM diaries submitted online, individualized feedback provided e-mailfeedback provided e-mail

Results: wt loss -4.1 Results: wt loss -4.1 ± 4.5± 4.5 vs. -1.6 vs. -1.6 ± 3.3± 3.3 kg kg Ss submitted 13.65 Ss submitted 13.65 ± 6.4 diaries during 24 ± 6.4 diaries during 24

wks, >50% of diaries submitted in 1wks, >50% of diaries submitted in 1stst 3 mos. 3 mos. Total # of diaries submitted related to wt loss, Total # of diaries submitted related to wt loss,

r = .50, p = .001r = .50, p = .001Tate, Wing & Winett, 2001Tate, Wing & Winett, 2001

Self-Monitoring in Internet Studies (2)Self-Monitoring in Internet Studies (2)

Study compared Internet wt loss program Study compared Internet wt loss program alone to Internet wt loss + behavioral alone to Internet wt loss + behavioral counseling via e-mail for 12 mos; N = 92, counseling via e-mail for 12 mos; N = 92, 84% retention at 12 mos. 84% retention at 12 mos.

Ss instructed to submit daily diaries for 1Ss instructed to submit daily diaries for 1stst month, thereafter option of daily or weekly month, thereafter option of daily or weekly diary, individualized feedback provided e-maildiary, individualized feedback provided e-mail

Results: wt loss -2.0 Results: wt loss -2.0 ± 5.7 vs.± 5.7 vs. -4.4 -4.4 ± 6.2± 6.2 kg kg Logins to Web site sig greater in behavioral Logins to Web site sig greater in behavioral

e-couns group (p <.05); logins correlated with e-couns group (p <.05); logins correlated with wt loss, r = -0.47, p =.003wt loss, r = -0.47, p =.003

Not clear if logins same as submitting diaryNot clear if logins same as submitting diaryTate, Jackvony & Wing, 2003Tate, Jackvony & Wing, 2003

Logins to Web SiteLogins to Web Site

Tate, Jackvony & Wing, 2003Tate, Jackvony & Wing, 2003

Improving SM Adherence with Improving SM Adherence with Hand-Held Computers: A Pilot StudyHand-Held Computers: A Pilot Study

Diet Modification arm of WHI, N = 33Diet Modification arm of WHI, N = 33 Personal digital assistant (PDA) system Personal digital assistant (PDA) system

used for 1 month; Ss received used for 1 month; Ss received immediate & weekly tailored feedbackimmediate & weekly tailored feedback

Results: Ss significantly increased SM, Results: Ss significantly increased SM, improved attitudes toward SM, met improved attitudes toward SM, met dietary goals more often, reduced fat dietary goals more often, reduced fat intakeintake

Glanz, Murphy, Moylan et al., 2005Glanz, Murphy, Moylan et al., 2005

Use of Technology in Self-MonitoringUse of Technology in Self-Monitoring

Quasi-exp design, 6-mos BWLP compared Quasi-exp design, 6-mos BWLP compared paper diary (n = 115, 81% retention in a paper diary (n = 115, 81% retention in a previous study) vs. PDA with Calorie King previous study) vs. PDA with Calorie King Diet software (n = 61, 93% retention) for SM Diet software (n = 61, 93% retention) for SM and effect on wt lossand effect on wt loss

Results: No sig difference between groups in Results: No sig difference between groups in wt loss, SM, adherence; 32% of wt loss was wt loss, SM, adherence; 32% of wt loss was explained by frequency of SM, p <.001explained by frequency of SM, p <.001

Yon, Johnson, Harvey-Berino et al., Yon, Johnson, Harvey-Berino et al., 20072007

Adherence to Tx by PDA vs. ControlAdherence to Tx by PDA vs. Control

Yon, Johnson, Harvey-Berino et al., 2007Yon, Johnson, Harvey-Berino et al., 2007

PDA-Based SM in ENHANCEPDA-Based SM in ENHANCE

2-group RCT testing 6-mon behavioral Tx for 2-group RCT testing 6-mon behavioral Tx for self-mgmt of type 2 diabetes vs. attention self-mgmt of type 2 diabetes vs. attention control; N = 151, 85% retention at 6 mos.control; N = 151, 85% retention at 6 mos.

Results: Adherence based on assumption of Results: Adherence based on assumption of 3 meals + snack/day – entered 43% of 3 meals + snack/day – entered 43% of expected meals; assuming 3 meals/day expected meals; assuming 3 meals/day entered 58% of mealsentered 58% of meals

End of study assessment revealed good End of study assessment revealed good acceptability of PDA: 88% understood acceptability of PDA: 88% understood usefulness of SM, 85% entering foods was usefulness of SM, 85% entering foods was easy, 70% could interpret graphseasy, 70% could interpret graphs

Sevick, Zickmund, Korytkowski et al., 2008Sevick, Zickmund, Korytkowski et al., 2008

BalanceLogBalanceLog®® on PDA on PDA

Nutrition Fact Sheet on PDANutrition Fact Sheet on PDA

Summary Feedback on PDASummary Feedback on PDA

Summary of PDA StudiesSummary of PDA Studies

Software variable Software variable Adherence defined and measured Adherence defined and measured

differentlydifferently SM occurred ~ 52-62% of daysSM occurred ~ 52-62% of days Yon et al. (2006) reported that validity of Yon et al. (2006) reported that validity of

energy intake did not improve with PDA; energy intake did not improve with PDA; 41% of Ss categorized as low energy 41% of Ss categorized as low energy reportersreporters

Software does not track date & time of Software does not track date & time of SMSM

Use of Instrumented Paper DiaryUse of Instrumented Paper Diary

Purpose of study: To examine and describe the Purpose of study: To examine and describe the actual patterns of self-monitoring among participants actual patterns of self-monitoring among participants in a weight loss intervention study, using an in a weight loss intervention study, using an instrumented paper diary* (IPD) instrumented paper diary* (IPD)

*Stone, A, et al. 2002*Stone, A, et al. 2002

Conducted as an ancillary study to PREFER trial – Conducted as an ancillary study to PREFER trial – 12-mon BWLP with 6-mon maintenance phase (n = 12-mon BWLP with 6-mon maintenance phase (n = 35, 13, 16 across 3 phases)35, 13, 16 across 3 phases)

Burke, Sereika, Choo et al., Burke, Sereika, Choo et al., 20062006

Method of Self-Monitoring UsedMethod of Self-Monitoring Used

Instrumented paper diary (IPD)Instrumented paper diary (IPD) Pages contained w/in a canvas binder Pages contained w/in a canvas binder Photosensors are unobtrusively Photosensors are unobtrusively

embedded in spine of binderembedded in spine of binder Circuit board is enclosed in back pocketCircuit board is enclosed in back pocket Photosensors detect when the binder is Photosensors detect when the binder is

opened and closed; date-and-time opened and closed; date-and-time stamped each actionstamped each action

Standard Paper DiaryStandard Paper Diary

Instrumented Paper DiaryInstrumented Paper Diary

Photosensor detects opening & closing of binder

Unobtrusive instrumentation records time/date -circuit board in right pocket

invivodata, inc., Pittsburgh, PA

Plastic ties lock rings closed

Card Reader to Upload IPD DataCard Reader to Upload IPD Data

invivodata, inc., Pittsburgh, PA

Adherence DefinitionsAdherence Definitions

ReportedReported adherenceadherence – – based on time Ss based on time Ss report recordingreport recording Conservative – Conservative – record w/in 2 hrs. of eatingrecord w/in 2 hrs. of eating LiberalLiberal – record w/in 6 hrs. of eating – record w/in 6 hrs. of eating

Actual adherenceActual adherence – – based on measure of based on measure of the IPD opening and closingthe IPD opening and closing

Faked adherenceFaked adherence – – difference between self-difference between self-reported time and IPD recordingreported time and IPD recording

HoardingHoarding – – no recording of IPD open/closing no recording of IPD open/closing yet there are diary pages that are completedyet there are diary pages that are completed

Adherent: IPD ReportAdherent: IPD Report

Time

Day of Monitoring Period

Adherent: IPD Report and Adherent: IPD Report and Self-Report of EatingSelf-Report of Eating

Time


Adherent: IPD Report and Self-Adherent: IPD Report and Self-Report of Eating and RecordingReport of Eating and Recording

Time


Sample Diary Page - AdherenceSample Diary Page - Adherence

Hoarding: IPD ReportHoarding: IPD Report

Time

Day of Recording

Hoarding: IPD Report and Hoarding: IPD Report and Self-Report of EatingSelf-Report of Eating

Time

Day of Recording

Hoarding: IPD Report and Self-Hoarding: IPD Report and Self-Report of Eating and RecordingReport of Eating and Recording

Day of Recording

Time

Sample Diary Page - HoardingSample Diary Page - Hoarding

Summary of Diary and IPD UseSummary of Diary and IPD Use

VariableVariable M M ± SD± SD

Mean # IPD openings/dayMean # IPD openings/day 2.7 2.7 ± 1.8± 1.8

Mean # of diary entries/dayMean # of diary entries/day 4.1 ± 2.24.1 ± 2.2

Mean time btw eating & recording (hrs)Mean time btw eating & recording (hrs) 6.4 ± 17.16.4 ± 17.1

% of days IPD was used% of days IPD was used 64.9 ± 27.464.9 ± 27.4

% eating entries w/in 2 hrs of recording% eating entries w/in 2 hrs of recording 51.5 ± 29.951.5 ± 29.9


% of recording w/in 15 min. IPD opening% of recording w/in 15 min. IPD opening 39.5 ± 34.039.5 ± 34.0

% of eating w/in 15 min. IPD opening% of eating w/in 15 min. IPD opening 20.5 ± 22.120.5 ± 22.1

Summary of Diary and IPD UseSummary of Diary and IPD Use

VariableVariable M M ± SD± SD

Mean # IPD openings/dayMean # IPD openings/day 2.7 2.7 ± 1.8± 1.8

Mean # of diary entries/dayMean # of diary entries/day 4.1 ± 2.24.1 ± 2.2

Mean time btw eating & recording (hrs)Mean time btw eating & recording (hrs) 6.4 ± 17.16.4 ± 17.1

% of days IPD was used% of days IPD was used 64.9 ± 27.464.9 ± 27.4



% of recording w/in 15 min. IPD opening% of recording w/in 15 min. IPD opening 39.5 ± 34.039.5 ± 34.0

% of % of eatingeating w/in 15 min. IPD opening w/in 15 min. IPD opening 20.5 ± 22.120.5 ± 22.1

Correlations of Recording and Correlations of Recording and Weight Change Baseline – 6 MonthsWeight Change Baseline – 6 Months

VariableVariable rr value value

% wt% wt 0-6 0-6 mos. mos.

pp value value

% days IPD used% days IPD used -0.52-0.52 .001.001

% recordings w/in 15 min % recordings w/in 15 min

IPD openingIPD opening

-0.36-0.36 .04.04

% diary recordings of % diary recordings of eating eating w/in 15 min IPD w/in 15 min IPD openingopening

-0.45-0.45 .007.007

Summary of Findings Summary of Findings

Majority of time little concordanceMajority of time little concordancebetween self-reported and electronicallybetween self-reported and electronicallydocumented datadocumented data

Data provide first evidence of actual Data provide first evidence of actual patterns of self-monitoring among patterns of self-monitoring among weight loss study subjectsweight loss study subjects

ConclusionConclusion

The IPD data document that:The IPD data document that: many subjects falsify the times of their self-many subjects falsify the times of their self-

reported self-monitoring reported self-monitoring subjects backfill their diariessubjects backfill their diaries recording within 15 min. of eating is recording within 15 min. of eating is

significantly correlated with weight losssignificantly correlated with weight loss confirms previous data that being adherent confirms previous data that being adherent

to the self-monitoring protocol results in to the self-monitoring protocol results in improved weight lossimproved weight loss

Qualitative Study of SM ExperiencesQualitative Study of SM Experiences

Post completion of PREFER trial Post completion of PREFER trial conducted in-depth interview of 15 Ss to conducted in-depth interview of 15 Ss to explore their reflections on feelings explore their reflections on feelings attitudes & behaviors while using PD to attitudes & behaviors while using PD to SMSM

Qualitative analysis procedures were Qualitative analysis procedures were followed to analyze the datafollowed to analyze the data

Qualitative Study ResultsQualitative Study Results

3 categories of SM experiences were identified:3 categories of SM experiences were identified: Well-Disciplined – had high adherence to SM, Well-Disciplined – had high adherence to SM,

high wt loss and a “can do” positive approach; high wt loss and a “can do” positive approach; 4 of 5 male, all 14 of 5 male, all 1stst time in BWLP time in BWLP

Missing the Connection – had mod adherence, Missing the Connection – had mod adherence, mod to low wt loss, & were unable to sustain mod to low wt loss, & were unable to sustain the connection between SM and wt lossthe connection between SM and wt loss

Diminished Support – had poor adherence, Diminished Support – had poor adherence, poor wt control, were adversely affected by co-poor wt control, were adversely affected by co-existing negative factorsexisting negative factors

Burke, Swigart, Warziski Turk et al., in Burke, Swigart, Warziski Turk et al., in presspress

Trajectory of Mean Adherence to Self-Monitoring (N = 15)

0

20

40

60

80

100

1-3 mo 4-6 mo 7-9 mo 10-12 mo

Time

% A

dh

ere

nce

Well-Disciplined

Missing the Connection

Diminished Support

Burke, Swigart, Warziski Turk et al., in pressBurke, Swigart, Warziski Turk et al., in press

Trajectory of Mean Percent Weight Loss (N = 15)

0

5

10

15

20

25

6 mo 12 mo 18 mo

Time

% W

eig

ht L

oss

Well-Disciplined

Missing the Connection

Diminished Support

Burke, Swigart, Warziski Turk et al., in pressBurke, Swigart, Warziski Turk et al., in press

Proportion of participants adherent to the five treatment components (N=176)

PREFER Trial Acharya, Elci, Sereika et al., under review

Studies with Results PendingStudies with Results Pending

SMART Study using PDAs with date- SMART Study using PDAs with date- and time stampand time stamp

Self-Efficacy in Weight Loss Treatment – Self-Efficacy in Weight Loss Treatment – 2-group RCT comparing standard group 2-group RCT comparing standard group BWLP to group BWLP + individual BWLP to group BWLP + individual intervention; adopting SM approach of intervention; adopting SM approach of DPP of decreasing frequency over time DPP of decreasing frequency over time in experimental group (weekly 1in experimental group (weekly 1stst 2 mos, 2 mos, 1 wk/mon for 10 mons, 1 wk/6wks)1 wk/mon for 10 mons, 1 wk/6wks)

Current SMART TrialCurrent SMART Trial

3-group RCT of 24-mon BWLP. Aim is to 3-group RCT of 24-mon BWLP. Aim is to compare 3 approaches to SM:1) paper diary compare 3 approaches to SM:1) paper diary (2) PDA with diet & PA software (3) PDA with (2) PDA with diet & PA software (3) PDA with tailored feedback message; N = 205, ~90% tailored feedback message; N = 205, ~90% retention of 1retention of 1stst cohort at 24 mos., 2 cohort at 24 mos., 2ndnd & 3 & 3rdrd cohort ongoingcohort ongoing

PDAs include date- and time-stamp so PDAs include date- and time-stamp so temporal patterns of adherence can be temporal patterns of adherence can be obtainedobtained

DietmateProDietmatePro® ® Software on PDASoftware on PDA

CalcuFitCalcuFit®® Software on PDA Software on PDA

Summary of Lit Review FindingsSummary of Lit Review Findings Many individuals find it difficult to sustain adherence Many individuals find it difficult to sustain adherence

to SM; studies show ~40-60% adherence during to SM; studies show ~40-60% adherence during intervention with continued decline over timeintervention with continued decline over time

Studies consistently show positive association Studies consistently show positive association between SM and wt lossbetween SM and wt loss

Due to study limitations, cannot draw conclusions Due to study limitations, cannot draw conclusions from studies comparing different methods of SM from studies comparing different methods of SM

Qualitative study revealed that there are variations in Qualitative study revealed that there are variations in how individuals integrated the process of SM; also how individuals integrated the process of SM; also that for some SM is burdensomethat for some SM is burdensome

IPD study revealed that self-reported times of SM IPD study revealed that self-reported times of SM may not be accurate may not be accurate

Future DirectionsFuture Directions

Need to consider approaches to reduce Need to consider approaches to reduce burden of SMburden of SM

Consider individualizing approachesConsider individualizing approaches Use of technology may reduce burden, Use of technology may reduce burden,

improve convenience and adherence; improve convenience and adherence; however, insufficient data at this time. however, insufficient data at this time.

Need to improve devices, software and Need to improve devices, software and accessibility to devicesaccessibility to devices

Funding sources: NIH, NIDDK RO1 Funding sources: NIH, NIDDK RO1 DK5863 and DK5863-04S1, R01 DK5863 and DK5863-04S1, R01 DK071817 and the Center for DK071817 and the Center for Research in Chronic Disorders, P30 Research in Chronic Disorders, P30 NR03924 NIH, School of Nursing at the NR03924 NIH, School of Nursing at the University of PittsburghUniversity of PittsburghK24NR010742K24NR010742

Acknowledgement

Slides and links to articles are Slides and links to articles are available at:available at:

prefer.pitt.eduprefer.pitt.edu

self-monitoring: review of the literature lora e. burke, phd, mph, faha, faan obesity researchers...

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