The use of handheld and computer-based technology has revolutionized many aspects of the clinical practice of medicine as well as patients’ experience of health care. The pace of development of this technology is extremely rapid, and busy clinicians often struggle with important questions about these innovations. How do I find and afford the best new devices and technologies? What are the best practices and rules for interacting with patients using these technologies? Are there security issues to consider? Will my patients like them or benefit from them? Despite these questions and concerns, there is evidence that clinicians and patients are adopting these technologies rapidly.1 The adoption of electronic health records, for example, was progressing slowly until 2011, when use began doubling for hospitals and clinician offices, due largely to incentives and legislation.2
Patients use Internet sources for medical information, especially about nutrition and weight management, at a high rate and often do not discuss this use with their clinicians.3,4 While increased use of computers and devices is thought to be associated with the sedentary activity that promotes obesity, both patients and clinicians are embracing the use of these methods.5 The proliferation of smartphones, with their always-on connection to the Internet, large data storage capacity, and camera and video capabilities, gives clinicians and patients enormous potential for using computing in daily clinical practice.
Clinicians have been grappling with the management of obesity for years, and obesity complicates many aspects of care for women, such as contraception, fertility, pregnancy, mental health, cancer, and cardiovascular disease.6,7 In addition to commonly holding negative attitudes toward obese patients, clinicians have lacked the appropriate tools and resources for referral to their patients for education, motivation, and support in achieving their weight management goals.8,9,10 The advent of these electronic tools—from industry, from entrepreneurs, and as part of national guideline efforts—has opened a new realm of possibility for clinicians to educate themselves and their patients about obesity, to help motivate these patients for change, and to support them in their journey.
We begin this chapter by discussing the categories and uses of electronic tools to manage obesity. In general, we focus on the issue of obesity in women’s health, but use more general sources when more specific data or recommendations were not available. Given the pace of change in this field, we do not attempt to create a list of the current or popular applications and sites but may use occasional specific examples. We discuss tools used by both patients and clinicians and make note of the theoretical basis of these technologies, where applicable. We then review the current “snapshot” of the evidence behind the use of these electronic tools to manage obesity to give the reader a sense of the empirical research behind their use. We discuss the use of electronic tools for obesity in the general population of adults and children or adolescents first, as women are well represented in these studies and there is a paucity of women-only studies. Finally, we close with some comments about the new directions in this field and “things to watch for.”
Terminology is an important concern in the world of technology. We adopt the following conventions for simplicity (Figure 15-1). Computers refers to desktop, laptop, or notebook computers. The term tablets is used to refer to portable devices that are larger than phones but operate on mobile software platforms rather than full operating systems. Smartphones are digital, handheld telephones with mobile operating systems that can run small applications (“apps”). We distinguish smartphones from more basic mobile phones—admittedly a technologically outdated term—which lack the major mobile operating systems and computing capacity and are used primarily for telephone calls and text messaging. Personal digital assistants (PDAs) are the predecessors of smartphones; they use mobile operating systems and applications but do not have cellular or Wi-Fi connectivity. Text messaging here includes both SMS (simple [or short] message service) and MMS (multimedia messaging service) applications, whether available over the telephone company networks or through Internet connections, and using open or closed messaging networks. The term telehealth refers to the use of (usually video teleconference) technology to conduct one-on-one or group education or treatment sessions. The newer terms mHealth and eHealth are meant to distinguish the use of electronic applications and devices in health care; the former is restricted to mobile applications and devices, the latter is more inclusive of all electronic tools in health care.
We have constructed four broad categories of electronic technology currently used or marketed for the management of obesity. First is “information management.” This category includes databases of guidelines and medical knowledge (including electronic textbooks), calorie information and diet plans, and exercise information. The second category is “social support.” With the varied modes of communication available with these technologies, a variety of new social support options exists, including online support communities and enhanced methods of synchronous and asynchronous communication between the patient and the patient’s doctor or office staff (e.g., nurse, care manager). The third category of use of these electronic tools is “support for behavior change.” From automated reminder systems, to online communities, to tracking of food and physical activity details, these tools can facilitate monitoring and habit formation, which are key to managing obesity. Finally, there are more specific “miscellaneous uses” of technology—applications that address an entire care episode—from information, to scheduling, to postoperative instructions.
As the computing power of handheld devices and prevalence of computers have increased over the last decade, clinicians are using the data storage power of electronic tools to replace the various paper-based textbooks, quick references, and handbooks. The promise of these tools is contained in the following characteristics: comprehensiveness, authoritativeness, currency, and ease of search. Computer tools’ ability to hold a large amount of data should enable quick access to comprehensive amounts of information with increasingly less regard for cost and technological limitation. Large databases of drug and clinical information can theoretically support practice by enabling better retrieval of diagnoses, pharmaceutical and other therapy options, and potential adverse effects. The use of search and cross-referencing functionality further leverages the comprehensiveness of these databases by allowing both directed inquiries about a given topic and drug interaction information or likelihood of disease given a certain combination of symptoms. This comprehensiveness can, of course, be a challenge if the information is not appropriately indexed and outlined.
Patients also have benefitted from this explosion of easily accessible information. Some of the most popular Internet sites and mobile apps feature dietary recommendations for weight loss as well as recommendations for physical activity (complete with video demonstrations). These sites are heavily advertised on the Internet and on mobile devices. An unfortunate downside to this information, however, has been the proliferation of misinformation: fad diets, ineffective weight loss plans, and, potentially even more harmful, availability of a relatively unregulated universe of sites offering weight loss “supplements” and “dietary aids.” Patients consult these information sources frequently, often without disclosing that information to their clinicians.3
Electronic tools can also help extend the reach of more traditional patient education methods. Both individual and group education can be enhanced by multimedia and distance education technologies (telehealth, webinars, etc.) available through both computers and mobile devices.11
From even the early days of the Internet, computers provided a way to seek community. From the pioneering “bulletin board services” to the enormous and varied social networking sites of today, people with similar interests and needs can gather to share information and provide social support and motivation for each other. In the realm of obesity and weight management, this has spurred the development of new weight loss sites (focusing on healthy eating, physical activity or both) as well as conversion of traditional face-to-face groups (like Weight Watchers®) to online communities. These sites at their basic, usually free, levels not only can offer community assistance from the other members, but also can offer enhanced resources (personal coaching, expert online classes, diets, etc.), often through a premium subscription service. As with other Internet sites, these groups may be moderated (with varying degrees of control), but the quality of information and advice found on these sites can vary considerably.
Engagement with online services and communities can vary considerably, with many demographic factors: age, race, or socioeconomic status. However the results of existing studies are not consistent, and there is considerable engagement among populations that are traditionally considered to have low engagement with technology.3,12,13,14 Some of the existing research has targeted traditionally difficult-to-reach or underserved populations. Use of mHealth technologies has been found, for example, to be a promising method for engaging in healthy behaviors patients with serious mental illness (e.g., schizophrenia, depression, bipolar disorder) and patients with developmental or acquired disabilities.15,16,17
The dramatic increase in the use of electronic health records by clinicians coupled with monetary incentives to drive specific communications uses (e.g., “meaningful use” payments from government insurers), as well as an emphasis on population health, have created new opportunities for clinicians’ offices to engage in multiple new communications strategies with patients. Health information messages and reminders from a clinician’s office can keep patients focused on their efforts to effect healthy change in their lives. The ability to ask questions and obtain minor services online from the clinician’s office can create more communication around the desired behavior change and can help keep patients on the path toward wellness. The advent of health care reform has ushered in a new focus on care management utilizing other-than-clinician health care professionals to track a group of patients carefully and ensure their ongoing engagement with the practice, compliance with medications and laboratory monitoring, and attendance at scheduled follow-ups. Each of these electronic tools extends the patients’ support systems beyond the traditional family and social circle to the clinicians’ office and to online communities—theoretically allowing access to a broader and more compatible and committed set of social supporters to help patients eat healthier, get more physical activity, and lose weight. These tools—often multidevice or multiplatform—can also support enhanced communications between patients and a number of different health professionals: clinicians, dieticians/nutritionists, and so on.18,19 For patients with a more defined significant psychological basis for their obesity, such as binge-eating disorder, telehealth (usually video communication with patients at a distance) can expand the access and reach of behavioral health providers to target populations.20,21
Supporting healthy behavior change is a key component of most clinician-patient relationships, yet many clinicians feel inadequately prepared and compensated for this work. A good deal of the support for behavior change can be found simply in the social support and communication interventions described previously. Online social support and enhanced contact with clinicians’ offices can help patients with goal setting, provide recommendations for reaching and maintaining goals, and support and motivate patients to enact and sustain their change. Electronic tools also provide easy-to-use automation for reminders and prompts and motivational messaging and monitoring that can help keep patients on track with their desired change.
Overall, behavioral change interventions for obesity, while only partially effective on their own, are an important set of tools in the clinician’s management of obesity. A comprehensive behavioral approach to weight loss can lead to as much as 10% weight loss, enough to effect positive clinical outcomes,22 and electronic tools can be important in supporting the length and frequency of engagement of this behavioral treatment and can automate some of it. Electronic tools, arising as they do from a variety of sources (companies, organizations, individual developers), have a wide array of theoretical bases for their construction. The more useful tools will use either accepted psychological theories or proven models of care in their design and application.
An important caveat to consider is that the use of these electronic tools most often does not result in behavior change on its own. The tools must be integrated into a thoughtful plan for patient engagement around the behavior change and used as facilitators for this engagement.23 Theories of behavioral change, such as the theory of self-efficacy, health belief model, the information-processing paradigm, social learning, theory of planned action, and motivational interviewing, are incorporated into the design of many apps and devices and the designs of studies evaluating them.24,25
Enhancing motivation for difficult personal behavioral change is an important part of this theoretical basis for the use of electronic tools, and many of the tools allow a significant amount of personalization and customization, from generating suggestions based on personal data and setting individual health goals to virtual environments and gaming.26 Wearable accelerometer bands engage the highly effective behavioral conditioning theory of “variable reinforcement” by rewarding the user with a “buzzing” on achievement of a step goal, usually without displaying the exact count of steps leading up to the goal. The result is users “chasing” this reward, often by engaging in simple physical activity at the end of a day to achieve the goal.27 The impact of these tools’ effect on behavior change, however, can be moderated by the user’s initial expectations for their success; it remains to be seen whether clinicians can affect these expectations by actively discussing these technologies with patients.28
A host of electronic tools have been created for monitoring food and calorie intake, exercise and physical activity, and other obesity-related behaviors, such as screen time, sedentary activity, and sleep. The accuracy of these electronic tools in measuring physical activity has improved significantly over the years—with even smartphone accelerometers achieving high levels of accuracy in detecting specific differences in exercise intensity.29,30 Further progress will be made as the requirements for manual data entry will be replaced with the increasing capability of sensors, for instance, replacing manual entry of foods in a diet log with automatic sensing of ingestion activity or with analysis of digital photographs of food consumed followed by immediate feedback.31,32 The US Food and Drug Administration (FDA) has determined that apps that can function as a medical device or that will integrate with medical devices fall under their purview for regulation.33 The full meaning and impact of this regulation is still evolving.
The potential for electronic tools goes beyond the single sensor to the emerging field of “wireless body-area networks” and “wireless personal-area networks”—a system of sensors simultaneously tracking different parameters to provide coordinated physiologic information to the patient and clinician to support weight loss. In the case of obesity management, a single network could simultaneously track movement, heart rate, blood pressure, weight, and calorie intake and perform continually updating calculations to provide the patient with choices for the patient to increase calorie expenditure or decrease intake. The technology for these networks is currently being refined and optimized to ensure proper operation and security.34,35,36
Patients—The tools used for monitoring frequently also contain motivational messages and feedback based on goals set by the app or by the patient. These goals are frequently configurable: weight loss, weight maintenance, increasing exercise, decreasing unhealthy eating, increasing healthy foods, and so on.37 Text messaging, either as a primary intervention or as an adjunct to other clinical or population health efforts, is a popular method that is assumed to be more universally available—relying only on an SMS-capable phone rather than requiring a smartphone for an app.38,39,40 Apps that support a specific weight loss plan (whether diet, physical activity, or both) are used by the promoters of these plans and by patients as value-added components of a subscription service or product.41 Interactive voice response technology can be a relatively low-technology solution that provides both monitoring and directed feedback for patients who only have access to telephones.42
Clinicians—A proven strategy for changing clinician behavior is the use of reminder systems in the patient chart. With the increased penetration and capabilities of electronic health records, along with the ubiquity of handheld devices used as clinical decision aids, these reminders can be more sophisticated, targeted, and powerful.43 Research into the acceptability of these reminders, however, has raised concerns about reminder “fatigue” (especially due to any logistical issues with the reminders themselves), as well as questions about the source and evidence base of recommendations. Greater attention needs to be paid to the refinement of these reminder systems and to thorough education on their use.44
A study reviewing smartphone apps related specifically to the broad application store search topic of “bariatric surgery” found a variety of apps—many in the categories discussed. A substantial number, however, were focused on bariatric surgery itself: knowledge about the procedure, online communities, postsurgery meal trackers, or gastric band volume trackers. The reviewers in this study bemoaned the lack of medical professional involvement and lack of consumer review of these apps.45,46
There are many potential barriers to using electronic tools to manage any health condition. The multiplicity of sources of apps and tools combined with the lack of a single, reliable source for critical consumer-oriented review results in a general knowledge gap about available, high-quality tools. Another barrier is the lack of available technology to employ electronic tools. The technology—whether it is sensor technology like wrist-worn monitoring devices or an app that requires a capable smartphone or computer—can be cost prohibitive, especially for those whose obesity is already due to difficult socioeconomic circumstances. In addition, problems with the interoperability of devices, apps, and computers can increase cost. Health or technology illiteracy and concerns about privacy of health information and personal details (age, location, etc.) are important issues that are not always well addressed. Unfortunately, the enthusiasm for the capability of this technology can often overwhelm caution about equal access and the privacy of personal data.47
Usability is a particular concern in technology adoption. Usability is a broad term comprising the quality of content and the ease of use of a technical device or application and is thought to play an important role in determining the adoption of technology by the end user. Several studies have looked at particular categories of technology in this field and found a variety of results. Factors affecting usability of technology in specific populations (e.g., pregnant women in the care of midwives) include an accurate appraisal of risks and benefits for specific populations as well as the accessibility and availability of the technology and influence over the content and frequency of messaging.48,49
Despite the relatively recent development of many of the tools described, a sizable existing body of literature examines the effectiveness of these tools in combating obesity. Often, the designs of these studies involve a combination of technological methods, so their evaluation and results will frequently not promote the use of a single technology in isolation, but a combination of electronic tools as well as combining these tools with more traditional aspects of care. During the 10-year period from 2005 to 2015, over 100 relevant studies were published, including several systematic reviews and at least 2 systematic reviews of reviews.50,51 As a group, these studies suggested that electronic tools can be valuable in helping people lose weight in the short term. However, the usefulness of the findings of these studies thus far has been somewhat limited by both methodological and reporting issues.
Because they involve comprehensive review of existing research as well as methodological assessment of individual studies, systematic reviews can provide valuable, high-level evidence to guide clinical practice. More than a dozen such reviews have been published on the use of electronic tools in the treatment and management of obesity. The relatively large number of available systematic reviews, and the breadth of their coverage, improves the chance that all available evidence about these tools has been found and that there has been some assessment of the included studies. We have therefore based much of our overview of the effectiveness of existing electronic tools on the findings of current systematic reviews.
The reviews summarized here have, as expected, varied in their scope and focus. Some have used broad selection criteria—such as all “technology-based,”52,53 “-assisted,”54,55 or “-supported”56 interventions—in selecting studies to include in their reviews, while others have restricted their focus to the use of specific types of tools, such as computers,57 mobile phones,58,59 or smartphones.60 Most of the studies included in these reviews have reported at least one physical measure of weight loss (e.g., change in weight, waist circumference, or body mass index [BMI]). Others have focused on change in related behaviors (e.g., physical activity, healthy eating), and a few have included measures of psychosocial variables. The majority of the studies lasted 3 to 12 months, with a few including follow-up data for longer periods. All reviews provided narrative summaries of results; 3 employed meta-analytic techniques to combine quantitative results of individual studies.57,61,62 Regardless of the specific focus, most systematic reviews have found mixed-quality studies, with weak-to-moderate evidence of short-term benefits of electronic tools in promoting weight loss.
We elected to present evidence from the use of electronic tools without regard to gender initially because women are overrepresented in most studies of weight loss interventions, and the number of female-only studies is still small. We examine systematic review data for adults first, then children and adolescents (because the data are difficult to parse into adolescent age groups only). We then look at the findings of recent studies that have focused on the effectiveness of these tools specifically for women.
Allen and colleagues54 reviewed clinical trials of technology-assisted weight management interventions in a variety of outpatient and population-based settings. The 39 trials selected for inclusion in their review employed a variety of electronic tools, including text or e-mail messaging, online chat rooms, or self-monitoring with smartphones or other mobile devices. Duration for most trials was 3, 6, or 12 months, with only 4 of the 39 studies reporting follow-up data greater than 12 months. Of the trials, 53% reported statistically significant weight loss for intervention groups as compared with control groups, but the magnitude of the weight loss seen ranged in the low single digits for both absolute loss (in kilograms) and percentage loss.
Levine et al.,55 also looking at technology-assisted weight loss interventions, limited their focus to interventions implemented in an ambulatory primary care setting. Sixteen studies qualified for inclusion in their review. Similar to the review by Allen et al., the duration of included studies ranged from 3 to 12 months, with only 4 lasting longer than 12 months. Twelve of the 16 studies that met the review’s inclusion criteria reported greater weight loss for intervention groups than for control groups, with weight loss in intervention groups ranging from 0.08 to 5.4 kg (0.8%–5.8% of initial body weight, respectively). Of note, there were 5 studies in common between the Allen and Levine reviews.
A Cochrane systematic review by Wieland et al. focused specifically on computer-based interventions for weight loss in obese adults.57 The reviewers included in their study only randomized controlled trials (RCTs) or quasi-RCTs, in which follow-up data were available for at least 80% of participants. Their literature search was unusually comprehensive, including searches of a federally funded biomedical research database, a registry of controlled trials, and reference lists of included studies and review articles, as well as consultation with study authors and experts in the field. Eighteen studies were included: 14 that focused on weight loss and 4 that focused on weight maintenance. Because of the great variability in study design across the included studies, reviewers grouped individual studies according to treatment type, control condition, outcomes, and time frames and performed several separate analyses using meta-analytic (quantitative) techniques. Overall, they found that interactive computer-based interventions led to greater short-term weight loss compared to minimal or no treatment (mean differences of 1–2 kg between groups). However, computer-based interventions were found to be less effective than in-person interventions.
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