Adherence and weight loss outcomes associated with food-exercise diary preference in a military weight management program

Abstract

The more consistently someone records their food intake the more likely they are to lose weight. We hypothesized that subjects who kept track via their preferred method would demonstrate higher adherence and therefore improved outcomes compared to those who used a non-preferred method. Participants were randomly assigned to use a paper, PDA, or Web-based diary and classified as “Preferred” if they used their preferred method and “Non-Preferred” if they did not. Days adherent to diary use were collected for 12 weeks. Weight, % body fat, waist circumference, and self-efficacy scores were measured at baseline, 6 and 12 weeks. Thirty nine participants completed the 12 week study. Fifty nine percent were male. The mean age was 35 and mean baseline BMI was 33 kg/m² (± 3.5). Forty four % (n = 17) used their “Preferred” diary method and 56% (n = 22) did not. Participants who used their preferred diary were more adherent to recording both food intake (64.2% vs. 43.4%, p = .015) and exercise (60.6% vs. 31.2%, p = .001). Though no difference was seen between groups on weight management outcomes, these results suggest that diary preference affects adherence to diary use.

Introduction

Poor clinical and behavioral outcomes are often the result of poor adherence to therapeutic and behavioral regimens. Research suggests that treatment outcomes may be improved if patients perceive greater control over their treatment choice (Legg England & Evans, 1992). It is well described in education literature that providing choice can be a powerful instructional strategy (Seibert, 2008). According to the self-determination theory (Deci & Ryan, 2000), choice should be relevant to the students' interest and goals (autonomy support), not be too numerous or complex (competence support), and be congruent with their cultural values (relatedness support) (Katz & Assor, 2007). A meta-analysis of 41 studies that tested the effect of providing choice on intrinsic motivation found when individuals are allowed to affirm their sense of autonomy through choice they experience enhanced motivation, persistence, performance and production (Patall, Cooper, & Robinson, 2008). Therefore providing choices may be an important tool to promote adherence. Providing patients with a choice of medication (Montgomery et al., 2001, Protheroe et al., 2000, Qaseem et al., 2008, Reginster et al., 2006, Rennie et al., 2007), diet (Burke et al., 2006, Lutes et al., 2008), and treatment modalities for cervical neoplasia (Hartz & Fenaughty, 2001), insomnia (Vincent & Lionberg, 2001), and depression (Dwight-Johnson, Unutzer, Sherbourne, Tang, & Wells, 2001) have resulted in mixed outcomes. However most of the findings suggest the need for further research is needed in this area. To date, no research has been published exploring the effect of food/exercise diary choice on weight management adherence patterns and outcomes.

Currently the three most common ways to self-monitor energy intake and expenditure are: Paper diary, hand-held electronic diary (PDA) and Web-based diary. Maintaining detailed records on specific behaviors, is considered one of the most essential features of behavior therapy (Baker and Kirschenbaum, 1993, Berkel et al., 2005, Fabricatore, 2007, Shay, 2008) and consistent self-monitoring has been associated with improved adherence to dietary measures,(Schnoll and Zimmerman, 2001, Yancy and Boan, 2006) although accuracy is generally poor (Goris et al., 2000, Livingstone and Black, 2003, Schaefer et al., 2000, Stone et al., 2003). Because a positive effect is also seen without accurate recording (Blundell and Gillett, 2001, Boutelle and Kirschenbaum, 1998, Boutelle et al., 1999, Goris et al., 2000, Guare et al., 1989, Hollis et al., 2008, Kruger et al., 2006, Rosenthal and Marx, 1983, Sandifer and Buchanan, 1983, Sperduto et al., 1986, Stalonas and Kirschenbaum, 1985), it is likely that accuracy is not as important as consistently focusing attention on the behavior (Helsel, Jakicic, & Otto, 2007). The more consistently individuals self-monitor their daily energy balance the more weight they lose(Baker and Kirschenbaum, 1993, Boutelle and Kirschenbaum, 1998, Burke et al., 2008, Helsel et al., 2007, Hollis et al., 2008, Wadden et al., 2005). Unfortunately low adherence rates due to the tedious nature of keeping a detailed food diary is well known (Baker and Kirschenbaum, 1993, Burke et al., 2006). One contributing factor to low adherence rates may be the lack of choice in the type of food/exercise diary used. Weight management programs generally instruct all attendees to use the same type of diary. Because individuals often have different learning styles they may have different diary preferences. For example, some individuals prefer to use a Web-based diary while others prefer a paper diary or a portable electronic device such as a personal digital assistant (PDA). Of the three methods, the PDA diary provides both portable access to nutrition and exercise information and rapid computerized data entry. The paper diary is portable but not automated and the Web-based diaries provide rapid computerized data entry but are not particularly portable. The purpose of this article is to report the findings on food/exercise diary preference in relation to adherence patterns, self-efficacy and change in body composition. We hypothesized that subjects who kept records via a preferred method would demonstrate higher adherence and therefore improved outcomes compared to those who used a non-preferred method.