Adherence and weight loss outcomes associated with food-exercise diary preference in a military weight management program
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.
Section snippets
Methods
Prior to randomization, each participant was asked what diary they would prefer to use. Participants were then randomly assigned to use a paper and pencil, PDA, or Web-based diary for energy self-monitoring. After using their assigned diary for 12 weeks, participants were again asked which diary they preferred to use. For the purpose of this analysis, participants were classified as “Preferred” or “Non-Preferred” based on whether or not they used the diary they preferred for the 12 weeks of the
Sample
A total of 73 participants were enrolled into the study, with 39 finishing the study through 12 weeks, resulting in a completion rate of 53%. The primary reasons for participant dropout were inability to attend ShipShape as originally planned (n = 19), unanticipated deployments/transfers (n = 5), and pregnancy (n = 2). Completers (n = 39) were compared to dropouts (n = 34) on demographic variables to ascertain if there was differential attrition. The participant demographics and characteristics,
Discussion
The study did not find a difference in weight management outcomes, self-efficacy and adherence patterns between participants who used different diary methods to self-monitor energy intake and expenditure. However, this study provides data that suggests that diary preference has an affect on adherence to diary use. We hypothesized that subjects who kept records using a preferred diary method (Preferred-group) would demonstrate higher adherence and therefore improved outcomes compared to those
Conclusion
Though no difference was seen between groups on outcomes in this study, these results suggest that diary preference affects adherence to recording of entries with increased adherence patterns seen with participants who used the diary they preferred. Further study is suggested given that there are a number of diary options available; providing individuals with a choice may improve adherence which, in turn, may improve weight management outcomes.
Role of funding sources
This study was supported financially by a student research allotment from the National Naval Medical Center, Department of Graduate Research and Education (GEAR), Bethesda, Maryland.
Contributors
Dr. Shay designed the study and wrote the protocol. Dr. Seibert provided editorial and content support as well as summaries of previous research studies. Dr. Watts conducted the statistical analysis. Dr. Pagliara assisted in generating the data. All authors have approved the final manuscript.
Conflict of interest
The views expressed in this manuscript are those of the authors and do not necessarily reflect the official policy or position of Uniformed Services University of Health Sciences, the Department of Defense, nor the U.S. Government.
No relationship exists between any of the authors and any commercial entity or product mentioned in this article that might represent a conflict of interest. No inducements have been made by any commercial entity to submit the manuscript for publication.
Acknowledgements
We gratefully acknowledge Virginia Giroux, and Dianne Paraoan for their assistance on this project.
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