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Using Synchronous Distance-Education Technology to Deliver a Weight Management Intervention
Research Brief Using Synchronous Distance-Education Technology to Deliver a Weight Management Intervention Carolyn Dunn, PhD, RD, LDN1; Lauren MacKenzie Whetstone, PhD2; Kathryn M. Kolasa, PhD, RD, LDN3; K. S. U. Jayaratne, PhD4; Cathy Thomas, MAEd5; Surabhi Aggarwal, MHSc, MPH, RD, LDN6; Kelly Nordby, MPH, RD, LDN6; Kenisha E. M. Riley, MPH, CHES, CWWPM7 ABSTRACT Objective: To compare the effectiveness of online delivery of a weight management program using synchronous (real-time), distance-education technology to in-person delivery. Methods: Synchronous, distance-education technology was used to conduct weekly sessions for participants with a live instructor. Program effectiveness was indicated by changes in weight, body mass index (BMI), waist circumference, and confidence in ability to eat healthy and be physically active. Results: Online class participants (n ¼ 398) had significantly greater reductions in BMI, weight, and waist circumference than in-person class participants (n ¼ 1,313). Physical activity confidence increased more for in-person than online class participants. There was no difference for healthy eating confidence. Conclusions and Implications: This project demonstrates the feasibility of using synchronous distanceeducation technology to deliver a weight management program. Synchronous online delivery could be employed with no loss to improvements in BMI, weight, and waist circumference. Key Words: adult, body mass index, Internet, obesity, overweight (J Nutr Educ Behav. 2014;46:602-609.) Accepted June 2, 2014. Published online July 19, 2014.
INTRODUCTION Overweight and obesity continue to be pressing public health problems.1,2 Eat Smart, Move More, Weigh Less (ESMMWL) is an evidence-based, 15week, adult weight management program.3 It has been delivered through the Cooperative Extension and the local public health department
1
network4 as well as in partnership between health insurers, academia, and public health.5 The program has been effective at helping participants achieve their weight management goals.4,5 However, even with a community delivery system using existing infrastructure, ESMMWL has a limited reach. Hence, a real-time, online delivery of the program using
Department of Youth, Family, and Community Sciences, North Carolina State University, Raleigh, NC 2 Public Health Institute, Research and Evaluation Section, Nutrition Education and Obesity Prevention Branch, California Department of Public Health, Sacramento, CA 3 Department of Family Medicine, and Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC 4 Department of Agricultural and Extension Education, North Carolina State University, Raleigh, NC 5 Community and Clinical Connections for Prevention and Health, North Carolina Division of Public Health, Department of Health and Human Services, Raleigh, NC 6 Eat Smart, Move More, Weigh Less Program, Department of Youth, Family, and Community Sciences, North Carolina State University, Raleigh, NC 7 Health Promotion and Wellness, North Carolina State Health Plan for Teachers and State Employees, Raleigh, NC Address for correspondence: Carolyn Dunn, PhD, RD, LDN, Department of Youth, Family, and Community Sciences, North Carolina State University, NCSU Campus Box 7606, Raleigh, NC 27695-7606; Phone: (919) 515-9142; Fax: (919) 515-3483; E-mail: [email protected] Ó2014 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR http://dx.doi.org/10.1016/j.jneb.2014.06.001
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synchronous distance-education technology was developed. Reviews of the effectiveness of Internet delivery for obesity treatments and related behavior change are mixed.6-15 Most published studies compared Web-based programs to inperson clinical treatment programs or usual clinical care. While the studies are difficult to compare because each intervention has different elements, most early reports have shown lower weight loss and poorer retention for the Internet-delivered interventions than one-on-one, face-to-face counseling. However, none of these used live instructors using synchronous distance-education technology in real time. In general, it appears that the more intense and interactive the Internet-delivered interventions are, the higher is the weight loss.11,14-16 The ESMMWL was built, in part, on the premise that the greater the engagement with the instructor, the greater the adherence to the program. Questions remain as to whether using the Internet as a delivery method is comparable to a face-to-face method.17 However, enthusiasm for the potential of technology-delivered weight management programs continues to
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014 grow.18 Studies that compared the delivery of a nonclinical weight management in-person class, similar to ESMMWL, to the same intervention delivered online in real time were not found in literature. Best practice distance-education tools were used to duplicate the ESMMWL in-person, on-site delivery by conducting online sessions in real time. The same curriculum, program materials, incentive ($25 refund out of the $30 registration fee for program completion), and protocols were employed as those used in in-person classes. This paper describes the performance of ESMMWL delivered using real-time, synchronous distance-education techniques as compared to results from in-person delivery that were previously published.5
METHODS Participants Participants in the study were members enrolled in the State Health Plan for Teachers and State Employees19 across the state. Information about the program was shared via regular email announcements to wellness committee leaders and key contacts at state worksites and public schools. Participants self selected to enroll in the program. An online registration system was made available for participants to sign up for an upcoming class. Prior to the first session, a welcome e-mail was sent to all participants by their assigned instructor. This e-mail contained login information for their particular class. An information packet was sent to each participant through regular mail. The packet included hard copies of the program magazine and journal, weekly report card, guidelines for measuring waist circumference and weight, and a participant waiver/contract with a self-addressed, stamped envelope. The results described in this study are from 399 participants who completed the online program, submitted an evaluation form, and had not participated in ESMMWL previously. Data from 1 participant with an outlying weight loss value (54 pounds) were deleted, yielding a final sample size of 398 participants. Results from online classes are compared to 1,314 participants who participated
in an in-person delivery of the program (methods and results reported previously5). One in-person class participant with an outlying weight loss of 55 pounds was deleted. Program completion was defined as attending at least 10 of the 15 weekly sessions for both online and in-person classes. The North Carolina State University Institutional Review Board approved the study.
Intervention A total of 48 ESMMWL online classes were offered by four trained instructors from January 2011 through August 2012. The same instructors also taught the majority of the in-person classes. Each class consisted of 15 weekly, 1-hour sessions delivered online. All sessions were conducted in real time by a live instructor using the online teaching software Elluminate Live! (Elluminate Live!, versions 9.5 and 10.0, Elluminate Inc, Calgary, Alberta, Canada, T2A1X5). Classes were offered at different times of the day; early morning (5 classes), lunch (18 classes), and early and late evening (25 classes) times. Each class had a unique login and password. Participants attended all weekly sessions at the same day and time for which they originally signed up during registration. This allowed participants to stay with the same instructor and same cohort to build group cohesiveness. Switching between different class times was not allowed during the course of the 15week online program. Additionally, weekly sessions were not recorded to view after the live class ended unless a session fell over a state holiday. These protocols allowed the online delivery to be as similar to the in-person classes as possible. The ESMMWL lessons were revised to be delivered via the online environment, maintaining lesson content. Program content, instructor training, number and length of sessions, and data collected were the same for both online and in-person classes. The ESMMWL team consulted with specialists in the Distance Education Learning Technology Applications (DELTA) office at North Carolina State University to identify and employ best practices for online instruction.20 Their experience and the distance education literature suggested features
Dunn et al 603 that could be added to enhance online learning. Interactive features such as polling, providing Web tours (a tool to introduce and walk participants through the content of a Web site), asking participants to respond to questions, and calling on participants to share were added to keep participants engaged during the online sessions. These techniques are similar to teaching strategies used during the in-person program. Participants met online each week for 15 weeks during a 50- to 60-minute educational/motivational session and completed a personal goal assessment with their class instructor. Participants were able to see and hear the instructor through their computers and were able to interact with the instructor as well as other participants via the chat box. Instructors monitored participants' attention by calling on them or asking questions several times during the entire session. Several other Elluminate Live! tools such as ‘‘raise hand,’’ ‘‘emoticons,’’ ‘‘green check’’ (symbol to indicate yes in response to a question), or ‘‘red cancel’’ (symbol to indicate no in response to a question) provided added interactivity during the sessions. As with the in-person classes, online class participants set a healthy weight goal for themselves at the beginning of the program, which could be a steady loss of weight or maintenance of current weight. Weight-loss goals were set within the safe recommended weight loss range of ½ to 2 pounds per week.21 They could also set goals to establish a regular physical activity routine or to make healthier food choices. Additionally, each participant was encouraged to pair with another participant in the class or someone outside the class to help develop a support system throughout the program. A Web portal with a unique login was provided to participants to allow for online reporting of their weekly weight, minutes of aerobic activity, and minutes of strength training with their class instructor. This information was also accessible by the assigned instructor for each class to allow them to provide individualized feedback and motivation to the participant on an ongoing basis in between the weekly sessions. A paper version of a weekly report card was used in the in-person classes to allow the
604 Dunn et al same exchange of information between participants and instructor. In both delivery formats, effort was made to answer questions from participants during the class; however, instructors were available via e-mail to clarify any unanswered questions or questions that came up after the class. Participants shared their successes with their instructors on an ongoing basis.
Measures Participants in online classes were provided with detailed instructions prior to the start of the class series for measuring their beginning and ending weight, and waist circumference. In addition, participants weighed themselves each week and were instructed to use the same scale and weigh-in at the same time of day throughout the program. Time was provided during the last session in both online and in-person classes for participants to complete a 33-item questionnaire documenting self-reported changes in mindfulness and the 12 eating and physical activity behaviors taught in ESMMWL. Online participants completed the questionnaire using a single anonymous evaluation form administered online via SurveyMonkey (Palo Alto, CA). Inperson participants completed the questionnaire in paper-and-pencil format. The questionnaire's development was previously described.3 Using a 5-point Likert scale (very low to very high), participants rated their confidence in engaging in each behavior before and after the program, and they reported whether behavior changes were a result of program participation.22 In addition, participants reported their demographic characteristics; whether they reached the goal(s) they set at the beginning of the program, past participation in weight management classes, satisfaction with the ESMMWL program and the online delivery system, and described their weight as either a lifelong struggle or a new concern. Two summary confidence scores were calculated as measures of program effectiveness. The score for confidence in participants' ability to engage in physical activity was based on being physically active at least 30 min per day, at least 60 min per day,
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014 at least 90 min per day, participating in strength training, and limiting daily screen time with a possible score ranging from 5 to 25. The score for confidence in participants' ability to follow healthful eating behaviors was based on responses for nine distinct healthful eating practices, with a possible score ranging from 9 to 45. The higher the value on these two scales, the greater the confidence of participants. Measures of internal consistency for these summary scores for in-person classes were reported previously.5 Internal consistency of the physical activity score, as measured by Cronbach a, was .82 for confidence before the program and .79 for confidence after the program; for the healthful eating score, internal consistency was .90 for confidence before the program and .87 for confidence after the program. For online classes, Cronbach a was .77 for physical activity score before and .78 for after. Internal consistency for the healthful eating score was .85 before and .83 after. Pre- to postprogram change was calculated for body mass index (BMI; kg/m2), weight (pounds), waist circumference (inches), and the confidence scores for physical activity and healthy eating. Measures of skewness and kurtosis on the change variables were calculated. For the online classes, with the exception of change in waist circumference (skewness ¼ 1.5, kurtosis ¼ 4.5), measures of skewness for change in weight, BMI, physical activity confidence, and healthy eating confidence were < .8 for skewness and # 1.2 for kurtosis. Results were similar for in-person classes: measures of skewness were < 1.0 for all change variables, and measures of kurtosis were between .92 and 2.4. All participant data were analyzed using SPSS (version 21, IBM Corp, Armonk, NY, 2011). Descriptive statistics were used to summarize the demographic characteristics of participants and their responses to questions about reasons for enrollment, goals for the program, and satisfaction with the online format. Crosstabulations and independent-samples t tests were used to compare demographic characteristics, baseline biometric measures, baseline confidence scores, and behavior changes attributable to program participation
of online and in-person participants. Participants who indicated they were already doing a behavior were not included in the comparisons of behavior changes. Separate repeated-measures analyses of variance were conducted to compare change in BMI, weight, waist circumference, physical activity confidence, and healthful eating confidence by method of delivery (online vs in person). One-way analyses of variance with change scores were conducted to examine outcomes by gender, age categories (< 40 years, 40–49 years, 50–59 years, 60 years and older), and whether the participant did or did not have a weight loss goal.
Real-time, online distance education delivery produced similar weight loss outcomes when compared to in-person delivery. RESULTS For online classes, 835 participants enrolled in 48 classes that were taught between January 2011 and August 2012. Of these participants, 67% completed the program, that is, attended 10 or more of the 15 weekly sessions. Evaluation forms were obtained from 480 (86%) of the completers. Over half of online participants (57.2%) reported they were very comfortable using the computer before they signed up for ESMMWL online; only 8.7% were not comfortable. For the in-person group, 2,574 participants enrolled in 141 in-person classes between August 2009 and December 2010; the completion rate was 71%. Evaluation forms were obtained from 1,542 (85%) of the completers. Analyses are for only those participants who had never before enrolled in ESMMWL online or in person (n ¼ 398 online; 1,314 in person). The majority of these participants was female, Caucasian, and reported to mostly sit or stand while at work (see Table 1 for demographic characteristics and a description of weight
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014 Table 1. Demographic Characteristics of Online and In-Person Program Participants
Characteristic Sex Female Male Race African American Caucasian Other Age, y Mean (SD) Range
Online (n ¼ 398)
In Person (n ¼ 1,313)
90.9% 9.1%
88.9% 11.1%
21.2% 74.8% 4.0%
25.8% 69.3% 4.9%
49.13 (10.50) 48.79 (9.69) 24–78 22–82
Employment* State agency Public college, university, or community college Public school Others
35.8% 27.2% 27.7% 9.3%
62.2% 14.3% 22.3% 1.2%
Attendance location Home Work Another location
64.7% 33.2% 2.1%
N/A
44.5%
39.3%
23.9%
25.7%
17.1%
18.9%
14.5%
16.1%
Weight history and participation in weight loss programs Struggled with their weight most of their lives and attended a class or been part of a group to lose weight Did not have a weight problem for most of their lives and this was the first time they had attended or been part of a group to lose weight Struggled with their weight most of their lives but this was the first time they had attended or been part of a group to lose weight Did not have a weight problem for most of their lives but had attended or been part of a group to lose weight *P < .001 (c2 test).
history and participation in weightloss programs for online and inperson class participants). There were no significant differences in gender, race, or age between online and inperson classes, with the exception of the distribution of place of employment; c2 ¼ 168.24, P < .001, Table 1. There was a higher percentage of public college, university, or community college in the online classes than the in-person classes. Most participants set a goal to lose weight; 42.0% of online and 46.5% of in-person participants set a goal to lose between 1 and 10 pounds, 36.7% of online and 35.3% of inperson to lose 11–20 pounds, and 9.0% of online and 9.1% of in-person
to lose 21–30 pounds. More than 79% of online and 70% of in-person participants set a goal to eat healthier, and 80% of online and 63.8% of in-person set a goal to be more physically active. Participants were able to set more than one goal for the program. At completion of the online program, 96.7% of online participants and 93.9% of in-person participants said they had either reached or progressed toward their goals. Weight loss was the predominant reason for enrolling (92.5% for online vs 83.4% for in-person); other reasons included to manage a health condition better (74.3% for online vs 44.4% for in-person), for social support (45.3% for online vs 36.1% for in-person),
Dunn et al 605 or to fulfill insurance requirements (6.8% for online vs 5% for in-person). Beginning weight (t1,166 ¼ .368) and BMI (t1,1674 ¼ .019) did not differ between in-person and online classes (Table 2). Beginning waist circumference was slightly larger for in-person class participants than for online class participants (t1,1570 ¼ 2.0, P ¼ .045). Beginning healthy eating confidence score and beginning physical activity confidence score were significantly higher among participants in the in-person classes than in the online classes (t1,1624 ¼ 3.41, P < .01; t1,1620 ¼ 4.32, P < .001, respectively; Table 2). Average weight loss at the end of the program for online participants was 8.0 pounds, ranging from 35 pounds to þ5 pounds, and for in-person participants 5.95 pounds, ranging from 41 to þ15.5 pounds. For both groups, BMI, weight, and waist circumference decreased significantly, while healthy eating confidence and physical activity confidence increased significantly from preprogram to postprogram (Table 2).
Real-time, online distance education is a promising approach to delivery of weight management programs. Online class participants had significantly greater reductions in BMI, weight, and waist circumference than in-person class participants. Physical activity confidence increased more for in-person than online class participants. There was no difference for healthy eating confidence (Table 2). Effect sizes for these differences were small, ranging from .001 to .02. Participants with a weight-loss goal lost more weight than those who identified a goal to eat healthier, be more physically active, or some other goal (F1,1685 ¼ 30.77, P < .001; online 8.4 vs 5.9 pounds, in-person 6.4 vs 2.6 pounds). They also had a larger reduction in BMI (F1,1665 ¼ 30.5, P < .001; online 1.39 v 1.00 kg/m2, in-person 1.06 v .41 kg/m2) and waist circumference (F1,1518 ¼ 7.16, P < .01; online 1.9 v 1.7 inches, in-person 1.7 v .9 inches),
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606 Dunn et al
Table 2. Comparison of Pre- and Postprogram Outcomes and Comparison of Baseline Outcomes for Online and In-Person Classes Online Classes
Characteristic Body mass index, kg/m2
Preprogram Meana n (SD) 384 32.65e (7.29)
In-Person Classes
Postprogram Preprogram Meana Meanb (SD) n (SD) 31.31 1,289 32.64e (7.05) (6.98)
Postprogram Meanb (SD) Fc 31.66 31.9** (6.83)
Effect sized .02
191.07 (43.99) 30.3**
.02
Weight, lbs
391
197.85e (45.13)
189.81 (43.51)
1,303
197.02e (45.01)
Waist circumference, inches
328
39.57f (5.81)
37.68 (5.51)
1,198
40.29f (5.92)
38.72 (5.78)
8.9*
.01
Physical activity confidenceg
391
10.05h (3.57)
14.13 (3.32)
1,176
10.89h (3.86)
16.04 (3.68)
26.3**
.02
Eating confidencei
395
25.46j (6.67)
35.92 (4.88)
1,173
26.71j (7.28)
36.57 (5.12)
2.3
.001
Comparison of preprogram and postprogram means for online classes, paired-samples t tests, all P < .001; bComparison of preprogram and postprogram means for in-person classes, paired-samples t tests, all P < .001; cRepeated-measures analysis of variance, time (preprogram v postprogram) method of delivery (online v in-person) interaction, *P < .01, **P < .001; dPartial h2; eComparison of preprogram (baseline) means by method of delivery (online v in-person), independent samples t-test, ns; f Comparison of preprogram (baseline) means by method of delivery (online v in-person), independent samples t-test, P < .05; gOverall confidence in being physically active ranges from 5 being very low to 25 being very high on this aggregated scale; h Comparison of preprogram (baseline) means by method of delivery (online v in-person), independent samples t test, P < .001; i Overall confidence in eating healthfully ranges from 9 being very low to 45 being very high on this aggregated scale; jComparison of preprogram (baseline) means by method of delivery (online v in-person), independent samples t test, P < .01. a
and a greater increase in healthy eating confidence score (F1,1561 ¼ 7.13, P < .01; online 4.2 v 3.6, in-person 5.3 v 4.1) and physical activity confidence score (F1,1563 ¼ 4.37, P < .05; online 10.6 v 9.8, in-person 10.0 v 8.4). Men lost more weight than women (F1,1660 ¼ 25.18, P < .001; online 11.1 v 7.76 pounds, in-person 8.7 v 5.6 pounds) and correspondingly had a greater reduction in BMI (F1,1641 ¼ 7.83, P < .01; online 1.6 v 1.3 kg/ m2, in-person 1.3 v .9 kg/m2 ), but there were no significant differences in waist circumference, healthy eating confidence, or physical activity confidence. Only for change in physical activity confidence score was there a significant difference by age group (F3,1511 ¼ 3.0, P < .05); post hoc analyses revealed greater change among those younger than 40 years than among those 60 years and older (online 4.4 v 3.9, in-person 5.6 v 4.6). For none of the preceding analyses was there a significant interaction with method of delivery. Participants indicated which specific health behaviors they adopted as a result of ESMMWL. More than 85% of online and in-person participants
reported being more mindful of what and how much they eat and more mindful of getting physical activity each day as a result of ESMMWL; < 6% reported that they were already mindful of these things before the class (Table 3). Among those who were not already including strength training in their physical activity routine at least two times per week, a larger percentage of online (72.2%) than in-person (58.7%) participants reported they now engage in that behavior as a result of ESMMWL (c2 ¼ 22.0, P < .001, Table 3). Comparisons for all other behaviors were nonsignificant. When online participants were asked about their level of satisfaction with the real-time, online delivery of the ESMMWL program, 94% reported that they were very satisfied or satisfied. Further, 98% indicated that they would recommend the real-time, online ESMMWL program to others. Again, for online participants only, the strategies that were presented in the weekly sessions, tracking food intake and physical activity, setting a SMART goal, and the convenient, online environment were all selected by over 50% of the participants as components
of ESMMWL. These data were not collected for in-person participants. Both online and in-person participants were asked about their satisfaction with the cost of the program (99% online, 97% in-person), instructor's knowledge (98% online, 96% inperson), quality of the instructor (96% online, 94% in-person), overall quality of the program (90% online, 92% in-person), and program materials (86% online, 89% in-person).
Real-time, online distance education supported with personalized e-mail support expands the reach of nonclinical weight management programs. DISCUSSION This study demonstrated the potential for using synchronous distanceeducation technology supported with personalized e-mail support to expand the reach of a nonclinical weight
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Dunn et al 607
Table 3. Behaviors Attributed to Program Participation by State Employees Who Completed Eat Smart, Move More, Weigh Less Program (Online vs In-Person) Online (n ¼ 398)
In-Person (n ¼ 1,314)
Yes % 94.7
No % 1.8
I Was Already Doing This % 3.5
Yes % 92.0
No % 1.6
I Was Already Doing This % 6.4
Am more mindful of getting physical activity each day
90.2
4.5
5.3
88.0
5.2
6.8
Eat fewer calories
89.1
4.3
6.6
87.3
6.0
6.7
Eat smaller portions
85.6
4.8
9.6
86.3
6.0
7.7
Eat 2–3 cups of vegetables most days
69.9
11.7
18.4
69.6
10.7
19.7
Eat 1½–2 cups of fruit most days
67.9
11.9
20.2
72.4
10.9
16.7
Eat less fast food
65.3
4.9
29.8
73.7
4.8
21.5
Include strength training in my physical activity routine at least 2 times per weeka
67.7
26.0
6.3
54.3
38.2
7.5
Am physically active at least 30 min most days
64.0
12.7
23.3
60.7
16.3
23.0
Pack healthy lunches for myself
63.1
8.4
28.5
68.8
10.8
20.4
Prepare and eat more meals at home
59.1
4.8
36.1
63.3
6.8
29.9
As a Result of This Program, I Now: Am more mindful of what and how much I eat
Limit screen time for myself
58.5
23.0
18.5
58.7
23.3
18.0
Limit screen time for my family
47.0
38.2
14.8
47.7
37.8
14.5
Pack healthy lunches for my family
45.9
37.6
16.5
49.1
37.2
13.7
Drink fewer calorie-containing beverages
42.8
1.3
55.9
51.0
3.7
45.3
Am physically active at least 60 min most days
37.0
56.2
6.8
31.9
61.4
6.7
Eat breakfast most days
35.1
2.8
62.1
49.0
5.1
45.9
Am physically active at least 90 min most days
12.7
85.8
1.5
11.6
85.9
2.5
c ¼ 22.0, P < .001; all other comparisons nonsignificant.
a 2
management program such as ESMMWL to a wider audience. More participants from public schools, community colleges, public colleges, and universities participated in the online model than in-person, most likely due to the flexibility that online scheduling provides. The online model allows for participation even when in-person classes are not available or where there would not be enough participation for an inperson class, including rural areas. Others are searching for methods of delivering nutrition information to audiences previously served primarily face to face.23,24 Neuenschwander and coworkers23 demonstrated that Webbased nutrition education can lead to favorable and equivalent nutritionrelated changes when compared with in-person delivery in low-income populations. Harvey-Berino and colleagues24 found that undergraduate students who volunteered or elected to enroll in a one-credit online behavioral weight management class had
higher than usually reported attendance and lower dropout rates than other behavioral weight loss programs targeting that age group. Participants attributed many positive behavior changes to the program, similar to what others have observed.15,23 Of note were the changes in mindfulness, a key component of ESMMWL. Participants indicated that the program helped them to be more mindful of both healthy eating and physical activity. Miller and coworkers25 had the opportunity to conduct a prospective randomized controlled trial, comparing a 3-month intervention of mindful eating with a diabetes self-management intervention among adults with type 2 diabetes. They found that training in mindful eating facilitates improvement in dietary intakes as well as modest weight loss. One of the seemingly positive advantages of Internet-based weight management programs is their 24/7 availability. However, researchers of Internet health interventions have
pointed out nonoptimal exposure as a major concern. Brouwer and coworkers26 found that only peer support, counselor support, e-mail/ phone contact with visitors, and updates of the intervention Web site were related to better exposure. A meta analysis of Web-based weight control programs found inconsistent effects, largely depending upon type of Internet usage or the duration of use.15 The ESMMWL attempts to address these adherence issues by providing real-time live rather than 24/7 access to the intervention. With the exception of strength training, changes in weight-related health behaviors were similar in online and in-person participants. Real-time, online delivery of ESMMWL continues and has also been expanded to private businesses, community organizations, and individuals interested in joining the program. Participants from states outside North Carolina have also joined the program; these include Colorado,
608 Dunn et al Texas, Massachusetts, Virginia, and Iowa (Eat Smart, Move More, Weigh Less, unpublished data, 2014). This study had limitations. The program was implemented without a control group and all data were selfreported by participants. The program was delivered using a set curriculum, thus, generalizability would be limited to programs using similar curricula and methods. All data on participant behavior change were collected at the end of the class, without a survey of healthy eating and physical activity attitudes and behaviors before the start of the class. The study did not include a longterm follow up of participants, nor did it include participants that did not complete the program.
IMPLICATIONS FOR RESEARCH AND PRACTICE Results obtained from online classes indicate positive changes for the participants in their BMI (kg/m2), waist circumference, and confidence in their ability to eat healthy and be more physically active. Changes in BMI, weight, and waist circumference were greater for online than the inperson classes, indicating that the online delivery could be employed with no loss of impact on these measures. Review of other studies did not provide a definitive answer to whether face-to-face instruction or distance education had more impact. There is a high level of variability in success of these two methods for outcomes that were measured. However, this study supports the premise that synchronous, distance-education technology may be of value for the delivery of a weight management program. Synchronous distance education is a promising approach to make weight management programs more accessible to interested individuals. This study does indicate that even if users are comfortable with computers and user-friendly software is employed, significant staff time is needed to help participants resolve technological issues, especially during the first few weekly sessions. Future research should include long-term follow up of participants and assessment of reasons for noncompletion of the program.
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014
ACKNOWLEDGMENTS Funding for the Eat Smart, Move More, Weigh Less project was provided by the State Health Plan for Teachers and State Employees (grant number 53179). Thanks to Dede Nelson and DELTA for technical assistance with the online delivery of the program. The authors have no conflict of interest to report.
REFERENCES 1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010;303:235-241. 2. Flegal M, Graubard I, Williamson F, Gail H. Excess deaths associated with underweight, overweight and obesity. JAMA. 2005;293:1861-1867. 3. Dunn C, Kolasa KM, Vodicka S, et al. Eat Smart, Move More, Weigh Less, a weight management program for adults – revision of curriculum based on first-year pilot. J Extension. 2011; 49:6TOT9. 4. Whetstone LM, Kolasa KM, Dunn C, et al. Effects of a behavior-based weight management program delivered through a state cooperative extension and local public health department network, North Carolina, 2008–2009. Prev Chronic Dis. 2011;8:A81. 5. Dunn C, Whetstone LM, Kolasa KM, et al. Delivering a behavior-change weight management program to teachers and state employees in North Carolina. Am J Health Promot. 2013;27: 378-383. 6. Weiland LS, Falzon L, Sciamanna CN, et al. Interactive computer-based interventions for weight loss or weight maintenance in overweight or obese people. Cochrane Database Syst Rev. 2012;8:CD007675. 7. Bennett GG, Herring SJ, Puleo E, Stein EK, Emmons KM, Gillman MW. Web-based weight loss in primary care: a randomized controlled trial. Obesity (Silver Spring). 2010;18:308-313. 8. Neve M, Morgan PJ, Jones PR, Collins CE. Effectiveness of web based interventions in achieving weight loss and weight loss maintenance in overweight and obese adults. Obes Rev. 2010;11:306-321. 9. Arem H, Irwin M. A review of web based weight loss interventions in adults. Obes Rev. 2011;12:e236-e243.
10. Reed VA, Schifferdecker KE, Rezaee ME, O’Connor S, Larson PJ. The effects of computers for weight loss: a systematic review and meta analysis of randomized trials. J Gen Intern Med. 2011;27:99-108. 11. Tate DF, Wing RR, Winett RA. Using Internet technology to deliver a behavioral weight loss program. JAMA. 2001;285:1172-1177. 12. Wantland DJ, Portillo CJ, Holzeman WL, Slaughter R, McGhee EM. The effectiveness of web based vs non-web based interventions: a meta analysis of behavioral change outcomes. J Med Internet Res. 2004;6:e40. 13. Harvey-Berino J, West D, Krukowski R, et al. Internet delivered behavioral obesity treatment. Prev Med. 2010;51:123-128. 14. Gold BC, Burke S, Pintauro S, Buzzell P, Harvey-Berino J. Weight loss on the Web: a pilot study comparing a structured behavioral intervention to a commercial program. Obesity (Silver Spring). 2007;15:155-164. 15. Kodama S, Saito K, Tanaka S, et al. Effect of web-based lifestyle modification on weight control: a meta-analysis. Int J Obes (Lond). 2012;36:675-685. 16. 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. 17. Rosser BA, Vowles KE, Keogh E, Eccleston C, Mountain GA. Technologically-assisted behaviour change: a systematic review of studies of novel technologies for the management of chronic disease. J Telemed Telecare. 2009;15:327-338. 18. Rao G, Burke LE, Spring BJ, et al. American Heart Association Obesity Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Clinical Cardiology, Council on Cardiovascular Nursing, Council on the Kidney in Cardiovascular Disease, and Stroke Council. New and emerging weight management strategies for busy ambulatory settings. A scientific statement from the American Heart Association. Circulation. 2011;124: 1182-1203. 19. North Carolina State Health Plan for Teachers and State Employees. Welcome to the North Carolina State Health Plan. http://www.shpnc.org. Accessed December 19, 2013. 20. Keengwe J, Kidd TT. Towards best practices in online learning and teaching in higher education. J Online Learn
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014 Teach. 2010;6. http://jolt.merlot.org/ vol6no2/keengwe_0610.htm. Accessed June 26, 2014. 21. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute. The Practical Guide – Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (NIH Publication No. 00–4084; October 2000). http://www.nhlbi.nih.gov/guidelines/ obesity/prctgd_c.pdf. Accessed June 26, 2014.
22. Rockwell SK, Kohn H. Post-thenpre evaluation. J Extension. 1989;27. www.joe.org/joe/1989summer/a5.php. Accessed May 8, 2014. 23. Neuenschwander LM, Abbott A, Mobley AR. Comparison of a webbased vs in-person nutrition education program for low-income adults. J Acad Nutr Diet. 2013;113:120-126. 24. Harvey-Berino J, Pope L, Gold BC, et al. Undergrad and overweight: an online behavioral weight management program for college students. J Nutr Educ Behav. 2012;44:604-608.
Dunn et al 609 25. Miller CK, Kristeller JL, Headings A, Nagaraja H, Miser WF. Comparative effectiveness of a mindful eating intervention to a diabetes self-management intervention among adults with type 2 diabetes: a pilot study. J Acad Nutr Diet. 2012;112:1835-1842. 26. Brouwer W, Kroeze W, Crutzen R, et al. Which intervention characteristics are related to more exposure to Internet-delivered healthy lifestyle promotion interventions? A systematic review. J Med Internet Res. 2011; 13:e2.
INTRODUCTION Overweight and obesity continue to be pressing public health problems.1,2 Eat Smart, Move More, Weigh Less (ESMMWL) is an evidence-based, 15week, adult weight management program.3 It has been delivered through the Cooperative Extension and the local public health department
1
network4 as well as in partnership between health insurers, academia, and public health.5 The program has been effective at helping participants achieve their weight management goals.4,5 However, even with a community delivery system using existing infrastructure, ESMMWL has a limited reach. Hence, a real-time, online delivery of the program using
Department of Youth, Family, and Community Sciences, North Carolina State University, Raleigh, NC 2 Public Health Institute, Research and Evaluation Section, Nutrition Education and Obesity Prevention Branch, California Department of Public Health, Sacramento, CA 3 Department of Family Medicine, and Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC 4 Department of Agricultural and Extension Education, North Carolina State University, Raleigh, NC 5 Community and Clinical Connections for Prevention and Health, North Carolina Division of Public Health, Department of Health and Human Services, Raleigh, NC 6 Eat Smart, Move More, Weigh Less Program, Department of Youth, Family, and Community Sciences, North Carolina State University, Raleigh, NC 7 Health Promotion and Wellness, North Carolina State Health Plan for Teachers and State Employees, Raleigh, NC Address for correspondence: Carolyn Dunn, PhD, RD, LDN, Department of Youth, Family, and Community Sciences, North Carolina State University, NCSU Campus Box 7606, Raleigh, NC 27695-7606; Phone: (919) 515-9142; Fax: (919) 515-3483; E-mail: [email protected] Ó2014 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR http://dx.doi.org/10.1016/j.jneb.2014.06.001
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synchronous distance-education technology was developed. Reviews of the effectiveness of Internet delivery for obesity treatments and related behavior change are mixed.6-15 Most published studies compared Web-based programs to inperson clinical treatment programs or usual clinical care. While the studies are difficult to compare because each intervention has different elements, most early reports have shown lower weight loss and poorer retention for the Internet-delivered interventions than one-on-one, face-to-face counseling. However, none of these used live instructors using synchronous distance-education technology in real time. In general, it appears that the more intense and interactive the Internet-delivered interventions are, the higher is the weight loss.11,14-16 The ESMMWL was built, in part, on the premise that the greater the engagement with the instructor, the greater the adherence to the program. Questions remain as to whether using the Internet as a delivery method is comparable to a face-to-face method.17 However, enthusiasm for the potential of technology-delivered weight management programs continues to
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014 grow.18 Studies that compared the delivery of a nonclinical weight management in-person class, similar to ESMMWL, to the same intervention delivered online in real time were not found in literature. Best practice distance-education tools were used to duplicate the ESMMWL in-person, on-site delivery by conducting online sessions in real time. The same curriculum, program materials, incentive ($25 refund out of the $30 registration fee for program completion), and protocols were employed as those used in in-person classes. This paper describes the performance of ESMMWL delivered using real-time, synchronous distance-education techniques as compared to results from in-person delivery that were previously published.5
METHODS Participants Participants in the study were members enrolled in the State Health Plan for Teachers and State Employees19 across the state. Information about the program was shared via regular email announcements to wellness committee leaders and key contacts at state worksites and public schools. Participants self selected to enroll in the program. An online registration system was made available for participants to sign up for an upcoming class. Prior to the first session, a welcome e-mail was sent to all participants by their assigned instructor. This e-mail contained login information for their particular class. An information packet was sent to each participant through regular mail. The packet included hard copies of the program magazine and journal, weekly report card, guidelines for measuring waist circumference and weight, and a participant waiver/contract with a self-addressed, stamped envelope. The results described in this study are from 399 participants who completed the online program, submitted an evaluation form, and had not participated in ESMMWL previously. Data from 1 participant with an outlying weight loss value (54 pounds) were deleted, yielding a final sample size of 398 participants. Results from online classes are compared to 1,314 participants who participated
in an in-person delivery of the program (methods and results reported previously5). One in-person class participant with an outlying weight loss of 55 pounds was deleted. Program completion was defined as attending at least 10 of the 15 weekly sessions for both online and in-person classes. The North Carolina State University Institutional Review Board approved the study.
Intervention A total of 48 ESMMWL online classes were offered by four trained instructors from January 2011 through August 2012. The same instructors also taught the majority of the in-person classes. Each class consisted of 15 weekly, 1-hour sessions delivered online. All sessions were conducted in real time by a live instructor using the online teaching software Elluminate Live! (Elluminate Live!, versions 9.5 and 10.0, Elluminate Inc, Calgary, Alberta, Canada, T2A1X5). Classes were offered at different times of the day; early morning (5 classes), lunch (18 classes), and early and late evening (25 classes) times. Each class had a unique login and password. Participants attended all weekly sessions at the same day and time for which they originally signed up during registration. This allowed participants to stay with the same instructor and same cohort to build group cohesiveness. Switching between different class times was not allowed during the course of the 15week online program. Additionally, weekly sessions were not recorded to view after the live class ended unless a session fell over a state holiday. These protocols allowed the online delivery to be as similar to the in-person classes as possible. The ESMMWL lessons were revised to be delivered via the online environment, maintaining lesson content. Program content, instructor training, number and length of sessions, and data collected were the same for both online and in-person classes. The ESMMWL team consulted with specialists in the Distance Education Learning Technology Applications (DELTA) office at North Carolina State University to identify and employ best practices for online instruction.20 Their experience and the distance education literature suggested features
Dunn et al 603 that could be added to enhance online learning. Interactive features such as polling, providing Web tours (a tool to introduce and walk participants through the content of a Web site), asking participants to respond to questions, and calling on participants to share were added to keep participants engaged during the online sessions. These techniques are similar to teaching strategies used during the in-person program. Participants met online each week for 15 weeks during a 50- to 60-minute educational/motivational session and completed a personal goal assessment with their class instructor. Participants were able to see and hear the instructor through their computers and were able to interact with the instructor as well as other participants via the chat box. Instructors monitored participants' attention by calling on them or asking questions several times during the entire session. Several other Elluminate Live! tools such as ‘‘raise hand,’’ ‘‘emoticons,’’ ‘‘green check’’ (symbol to indicate yes in response to a question), or ‘‘red cancel’’ (symbol to indicate no in response to a question) provided added interactivity during the sessions. As with the in-person classes, online class participants set a healthy weight goal for themselves at the beginning of the program, which could be a steady loss of weight or maintenance of current weight. Weight-loss goals were set within the safe recommended weight loss range of ½ to 2 pounds per week.21 They could also set goals to establish a regular physical activity routine or to make healthier food choices. Additionally, each participant was encouraged to pair with another participant in the class or someone outside the class to help develop a support system throughout the program. A Web portal with a unique login was provided to participants to allow for online reporting of their weekly weight, minutes of aerobic activity, and minutes of strength training with their class instructor. This information was also accessible by the assigned instructor for each class to allow them to provide individualized feedback and motivation to the participant on an ongoing basis in between the weekly sessions. A paper version of a weekly report card was used in the in-person classes to allow the
604 Dunn et al same exchange of information between participants and instructor. In both delivery formats, effort was made to answer questions from participants during the class; however, instructors were available via e-mail to clarify any unanswered questions or questions that came up after the class. Participants shared their successes with their instructors on an ongoing basis.
Measures Participants in online classes were provided with detailed instructions prior to the start of the class series for measuring their beginning and ending weight, and waist circumference. In addition, participants weighed themselves each week and were instructed to use the same scale and weigh-in at the same time of day throughout the program. Time was provided during the last session in both online and in-person classes for participants to complete a 33-item questionnaire documenting self-reported changes in mindfulness and the 12 eating and physical activity behaviors taught in ESMMWL. Online participants completed the questionnaire using a single anonymous evaluation form administered online via SurveyMonkey (Palo Alto, CA). Inperson participants completed the questionnaire in paper-and-pencil format. The questionnaire's development was previously described.3 Using a 5-point Likert scale (very low to very high), participants rated their confidence in engaging in each behavior before and after the program, and they reported whether behavior changes were a result of program participation.22 In addition, participants reported their demographic characteristics; whether they reached the goal(s) they set at the beginning of the program, past participation in weight management classes, satisfaction with the ESMMWL program and the online delivery system, and described their weight as either a lifelong struggle or a new concern. Two summary confidence scores were calculated as measures of program effectiveness. The score for confidence in participants' ability to engage in physical activity was based on being physically active at least 30 min per day, at least 60 min per day,
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014 at least 90 min per day, participating in strength training, and limiting daily screen time with a possible score ranging from 5 to 25. The score for confidence in participants' ability to follow healthful eating behaviors was based on responses for nine distinct healthful eating practices, with a possible score ranging from 9 to 45. The higher the value on these two scales, the greater the confidence of participants. Measures of internal consistency for these summary scores for in-person classes were reported previously.5 Internal consistency of the physical activity score, as measured by Cronbach a, was .82 for confidence before the program and .79 for confidence after the program; for the healthful eating score, internal consistency was .90 for confidence before the program and .87 for confidence after the program. For online classes, Cronbach a was .77 for physical activity score before and .78 for after. Internal consistency for the healthful eating score was .85 before and .83 after. Pre- to postprogram change was calculated for body mass index (BMI; kg/m2), weight (pounds), waist circumference (inches), and the confidence scores for physical activity and healthy eating. Measures of skewness and kurtosis on the change variables were calculated. For the online classes, with the exception of change in waist circumference (skewness ¼ 1.5, kurtosis ¼ 4.5), measures of skewness for change in weight, BMI, physical activity confidence, and healthy eating confidence were < .8 for skewness and # 1.2 for kurtosis. Results were similar for in-person classes: measures of skewness were < 1.0 for all change variables, and measures of kurtosis were between .92 and 2.4. All participant data were analyzed using SPSS (version 21, IBM Corp, Armonk, NY, 2011). Descriptive statistics were used to summarize the demographic characteristics of participants and their responses to questions about reasons for enrollment, goals for the program, and satisfaction with the online format. Crosstabulations and independent-samples t tests were used to compare demographic characteristics, baseline biometric measures, baseline confidence scores, and behavior changes attributable to program participation
of online and in-person participants. Participants who indicated they were already doing a behavior were not included in the comparisons of behavior changes. Separate repeated-measures analyses of variance were conducted to compare change in BMI, weight, waist circumference, physical activity confidence, and healthful eating confidence by method of delivery (online vs in person). One-way analyses of variance with change scores were conducted to examine outcomes by gender, age categories (< 40 years, 40–49 years, 50–59 years, 60 years and older), and whether the participant did or did not have a weight loss goal.
Real-time, online distance education delivery produced similar weight loss outcomes when compared to in-person delivery. RESULTS For online classes, 835 participants enrolled in 48 classes that were taught between January 2011 and August 2012. Of these participants, 67% completed the program, that is, attended 10 or more of the 15 weekly sessions. Evaluation forms were obtained from 480 (86%) of the completers. Over half of online participants (57.2%) reported they were very comfortable using the computer before they signed up for ESMMWL online; only 8.7% were not comfortable. For the in-person group, 2,574 participants enrolled in 141 in-person classes between August 2009 and December 2010; the completion rate was 71%. Evaluation forms were obtained from 1,542 (85%) of the completers. Analyses are for only those participants who had never before enrolled in ESMMWL online or in person (n ¼ 398 online; 1,314 in person). The majority of these participants was female, Caucasian, and reported to mostly sit or stand while at work (see Table 1 for demographic characteristics and a description of weight
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014 Table 1. Demographic Characteristics of Online and In-Person Program Participants
Characteristic Sex Female Male Race African American Caucasian Other Age, y Mean (SD) Range
Online (n ¼ 398)
In Person (n ¼ 1,313)
90.9% 9.1%
88.9% 11.1%
21.2% 74.8% 4.0%
25.8% 69.3% 4.9%
49.13 (10.50) 48.79 (9.69) 24–78 22–82
Employment* State agency Public college, university, or community college Public school Others
35.8% 27.2% 27.7% 9.3%
62.2% 14.3% 22.3% 1.2%
Attendance location Home Work Another location
64.7% 33.2% 2.1%
N/A
44.5%
39.3%
23.9%
25.7%
17.1%
18.9%
14.5%
16.1%
Weight history and participation in weight loss programs Struggled with their weight most of their lives and attended a class or been part of a group to lose weight Did not have a weight problem for most of their lives and this was the first time they had attended or been part of a group to lose weight Struggled with their weight most of their lives but this was the first time they had attended or been part of a group to lose weight Did not have a weight problem for most of their lives but had attended or been part of a group to lose weight *P < .001 (c2 test).
history and participation in weightloss programs for online and inperson class participants). There were no significant differences in gender, race, or age between online and inperson classes, with the exception of the distribution of place of employment; c2 ¼ 168.24, P < .001, Table 1. There was a higher percentage of public college, university, or community college in the online classes than the in-person classes. Most participants set a goal to lose weight; 42.0% of online and 46.5% of in-person participants set a goal to lose between 1 and 10 pounds, 36.7% of online and 35.3% of inperson to lose 11–20 pounds, and 9.0% of online and 9.1% of in-person
to lose 21–30 pounds. More than 79% of online and 70% of in-person participants set a goal to eat healthier, and 80% of online and 63.8% of in-person set a goal to be more physically active. Participants were able to set more than one goal for the program. At completion of the online program, 96.7% of online participants and 93.9% of in-person participants said they had either reached or progressed toward their goals. Weight loss was the predominant reason for enrolling (92.5% for online vs 83.4% for in-person); other reasons included to manage a health condition better (74.3% for online vs 44.4% for in-person), for social support (45.3% for online vs 36.1% for in-person),
Dunn et al 605 or to fulfill insurance requirements (6.8% for online vs 5% for in-person). Beginning weight (t1,166 ¼ .368) and BMI (t1,1674 ¼ .019) did not differ between in-person and online classes (Table 2). Beginning waist circumference was slightly larger for in-person class participants than for online class participants (t1,1570 ¼ 2.0, P ¼ .045). Beginning healthy eating confidence score and beginning physical activity confidence score were significantly higher among participants in the in-person classes than in the online classes (t1,1624 ¼ 3.41, P < .01; t1,1620 ¼ 4.32, P < .001, respectively; Table 2). Average weight loss at the end of the program for online participants was 8.0 pounds, ranging from 35 pounds to þ5 pounds, and for in-person participants 5.95 pounds, ranging from 41 to þ15.5 pounds. For both groups, BMI, weight, and waist circumference decreased significantly, while healthy eating confidence and physical activity confidence increased significantly from preprogram to postprogram (Table 2).
Real-time, online distance education is a promising approach to delivery of weight management programs. Online class participants had significantly greater reductions in BMI, weight, and waist circumference than in-person class participants. Physical activity confidence increased more for in-person than online class participants. There was no difference for healthy eating confidence (Table 2). Effect sizes for these differences were small, ranging from .001 to .02. Participants with a weight-loss goal lost more weight than those who identified a goal to eat healthier, be more physically active, or some other goal (F1,1685 ¼ 30.77, P < .001; online 8.4 vs 5.9 pounds, in-person 6.4 vs 2.6 pounds). They also had a larger reduction in BMI (F1,1665 ¼ 30.5, P < .001; online 1.39 v 1.00 kg/m2, in-person 1.06 v .41 kg/m2) and waist circumference (F1,1518 ¼ 7.16, P < .01; online 1.9 v 1.7 inches, in-person 1.7 v .9 inches),
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606 Dunn et al
Table 2. Comparison of Pre- and Postprogram Outcomes and Comparison of Baseline Outcomes for Online and In-Person Classes Online Classes
Characteristic Body mass index, kg/m2
Preprogram Meana n (SD) 384 32.65e (7.29)
In-Person Classes
Postprogram Preprogram Meana Meanb (SD) n (SD) 31.31 1,289 32.64e (7.05) (6.98)
Postprogram Meanb (SD) Fc 31.66 31.9** (6.83)
Effect sized .02
191.07 (43.99) 30.3**
.02
Weight, lbs
391
197.85e (45.13)
189.81 (43.51)
1,303
197.02e (45.01)
Waist circumference, inches
328
39.57f (5.81)
37.68 (5.51)
1,198
40.29f (5.92)
38.72 (5.78)
8.9*
.01
Physical activity confidenceg
391
10.05h (3.57)
14.13 (3.32)
1,176
10.89h (3.86)
16.04 (3.68)
26.3**
.02
Eating confidencei
395
25.46j (6.67)
35.92 (4.88)
1,173
26.71j (7.28)
36.57 (5.12)
2.3
.001
Comparison of preprogram and postprogram means for online classes, paired-samples t tests, all P < .001; bComparison of preprogram and postprogram means for in-person classes, paired-samples t tests, all P < .001; cRepeated-measures analysis of variance, time (preprogram v postprogram) method of delivery (online v in-person) interaction, *P < .01, **P < .001; dPartial h2; eComparison of preprogram (baseline) means by method of delivery (online v in-person), independent samples t-test, ns; f Comparison of preprogram (baseline) means by method of delivery (online v in-person), independent samples t-test, P < .05; gOverall confidence in being physically active ranges from 5 being very low to 25 being very high on this aggregated scale; h Comparison of preprogram (baseline) means by method of delivery (online v in-person), independent samples t test, P < .001; i Overall confidence in eating healthfully ranges from 9 being very low to 45 being very high on this aggregated scale; jComparison of preprogram (baseline) means by method of delivery (online v in-person), independent samples t test, P < .01. a
and a greater increase in healthy eating confidence score (F1,1561 ¼ 7.13, P < .01; online 4.2 v 3.6, in-person 5.3 v 4.1) and physical activity confidence score (F1,1563 ¼ 4.37, P < .05; online 10.6 v 9.8, in-person 10.0 v 8.4). Men lost more weight than women (F1,1660 ¼ 25.18, P < .001; online 11.1 v 7.76 pounds, in-person 8.7 v 5.6 pounds) and correspondingly had a greater reduction in BMI (F1,1641 ¼ 7.83, P < .01; online 1.6 v 1.3 kg/ m2, in-person 1.3 v .9 kg/m2 ), but there were no significant differences in waist circumference, healthy eating confidence, or physical activity confidence. Only for change in physical activity confidence score was there a significant difference by age group (F3,1511 ¼ 3.0, P < .05); post hoc analyses revealed greater change among those younger than 40 years than among those 60 years and older (online 4.4 v 3.9, in-person 5.6 v 4.6). For none of the preceding analyses was there a significant interaction with method of delivery. Participants indicated which specific health behaviors they adopted as a result of ESMMWL. More than 85% of online and in-person participants
reported being more mindful of what and how much they eat and more mindful of getting physical activity each day as a result of ESMMWL; < 6% reported that they were already mindful of these things before the class (Table 3). Among those who were not already including strength training in their physical activity routine at least two times per week, a larger percentage of online (72.2%) than in-person (58.7%) participants reported they now engage in that behavior as a result of ESMMWL (c2 ¼ 22.0, P < .001, Table 3). Comparisons for all other behaviors were nonsignificant. When online participants were asked about their level of satisfaction with the real-time, online delivery of the ESMMWL program, 94% reported that they were very satisfied or satisfied. Further, 98% indicated that they would recommend the real-time, online ESMMWL program to others. Again, for online participants only, the strategies that were presented in the weekly sessions, tracking food intake and physical activity, setting a SMART goal, and the convenient, online environment were all selected by over 50% of the participants as components
of ESMMWL. These data were not collected for in-person participants. Both online and in-person participants were asked about their satisfaction with the cost of the program (99% online, 97% in-person), instructor's knowledge (98% online, 96% inperson), quality of the instructor (96% online, 94% in-person), overall quality of the program (90% online, 92% in-person), and program materials (86% online, 89% in-person).
Real-time, online distance education supported with personalized e-mail support expands the reach of nonclinical weight management programs. DISCUSSION This study demonstrated the potential for using synchronous distanceeducation technology supported with personalized e-mail support to expand the reach of a nonclinical weight
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Dunn et al 607
Table 3. Behaviors Attributed to Program Participation by State Employees Who Completed Eat Smart, Move More, Weigh Less Program (Online vs In-Person) Online (n ¼ 398)
In-Person (n ¼ 1,314)
Yes % 94.7
No % 1.8
I Was Already Doing This % 3.5
Yes % 92.0
No % 1.6
I Was Already Doing This % 6.4
Am more mindful of getting physical activity each day
90.2
4.5
5.3
88.0
5.2
6.8
Eat fewer calories
89.1
4.3
6.6
87.3
6.0
6.7
Eat smaller portions
85.6
4.8
9.6
86.3
6.0
7.7
Eat 2–3 cups of vegetables most days
69.9
11.7
18.4
69.6
10.7
19.7
Eat 1½–2 cups of fruit most days
67.9
11.9
20.2
72.4
10.9
16.7
Eat less fast food
65.3
4.9
29.8
73.7
4.8
21.5
Include strength training in my physical activity routine at least 2 times per weeka
67.7
26.0
6.3
54.3
38.2
7.5
Am physically active at least 30 min most days
64.0
12.7
23.3
60.7
16.3
23.0
Pack healthy lunches for myself
63.1
8.4
28.5
68.8
10.8
20.4
Prepare and eat more meals at home
59.1
4.8
36.1
63.3
6.8
29.9
As a Result of This Program, I Now: Am more mindful of what and how much I eat
Limit screen time for myself
58.5
23.0
18.5
58.7
23.3
18.0
Limit screen time for my family
47.0
38.2
14.8
47.7
37.8
14.5
Pack healthy lunches for my family
45.9
37.6
16.5
49.1
37.2
13.7
Drink fewer calorie-containing beverages
42.8
1.3
55.9
51.0
3.7
45.3
Am physically active at least 60 min most days
37.0
56.2
6.8
31.9
61.4
6.7
Eat breakfast most days
35.1
2.8
62.1
49.0
5.1
45.9
Am physically active at least 90 min most days
12.7
85.8
1.5
11.6
85.9
2.5
c ¼ 22.0, P < .001; all other comparisons nonsignificant.
a 2
management program such as ESMMWL to a wider audience. More participants from public schools, community colleges, public colleges, and universities participated in the online model than in-person, most likely due to the flexibility that online scheduling provides. The online model allows for participation even when in-person classes are not available or where there would not be enough participation for an inperson class, including rural areas. Others are searching for methods of delivering nutrition information to audiences previously served primarily face to face.23,24 Neuenschwander and coworkers23 demonstrated that Webbased nutrition education can lead to favorable and equivalent nutritionrelated changes when compared with in-person delivery in low-income populations. Harvey-Berino and colleagues24 found that undergraduate students who volunteered or elected to enroll in a one-credit online behavioral weight management class had
higher than usually reported attendance and lower dropout rates than other behavioral weight loss programs targeting that age group. Participants attributed many positive behavior changes to the program, similar to what others have observed.15,23 Of note were the changes in mindfulness, a key component of ESMMWL. Participants indicated that the program helped them to be more mindful of both healthy eating and physical activity. Miller and coworkers25 had the opportunity to conduct a prospective randomized controlled trial, comparing a 3-month intervention of mindful eating with a diabetes self-management intervention among adults with type 2 diabetes. They found that training in mindful eating facilitates improvement in dietary intakes as well as modest weight loss. One of the seemingly positive advantages of Internet-based weight management programs is their 24/7 availability. However, researchers of Internet health interventions have
pointed out nonoptimal exposure as a major concern. Brouwer and coworkers26 found that only peer support, counselor support, e-mail/ phone contact with visitors, and updates of the intervention Web site were related to better exposure. A meta analysis of Web-based weight control programs found inconsistent effects, largely depending upon type of Internet usage or the duration of use.15 The ESMMWL attempts to address these adherence issues by providing real-time live rather than 24/7 access to the intervention. With the exception of strength training, changes in weight-related health behaviors were similar in online and in-person participants. Real-time, online delivery of ESMMWL continues and has also been expanded to private businesses, community organizations, and individuals interested in joining the program. Participants from states outside North Carolina have also joined the program; these include Colorado,
608 Dunn et al Texas, Massachusetts, Virginia, and Iowa (Eat Smart, Move More, Weigh Less, unpublished data, 2014). This study had limitations. The program was implemented without a control group and all data were selfreported by participants. The program was delivered using a set curriculum, thus, generalizability would be limited to programs using similar curricula and methods. All data on participant behavior change were collected at the end of the class, without a survey of healthy eating and physical activity attitudes and behaviors before the start of the class. The study did not include a longterm follow up of participants, nor did it include participants that did not complete the program.
IMPLICATIONS FOR RESEARCH AND PRACTICE Results obtained from online classes indicate positive changes for the participants in their BMI (kg/m2), waist circumference, and confidence in their ability to eat healthy and be more physically active. Changes in BMI, weight, and waist circumference were greater for online than the inperson classes, indicating that the online delivery could be employed with no loss of impact on these measures. Review of other studies did not provide a definitive answer to whether face-to-face instruction or distance education had more impact. There is a high level of variability in success of these two methods for outcomes that were measured. However, this study supports the premise that synchronous, distance-education technology may be of value for the delivery of a weight management program. Synchronous distance education is a promising approach to make weight management programs more accessible to interested individuals. This study does indicate that even if users are comfortable with computers and user-friendly software is employed, significant staff time is needed to help participants resolve technological issues, especially during the first few weekly sessions. Future research should include long-term follow up of participants and assessment of reasons for noncompletion of the program.
Journal of Nutrition Education and Behavior Volume 46, Number 6, 2014
ACKNOWLEDGMENTS Funding for the Eat Smart, Move More, Weigh Less project was provided by the State Health Plan for Teachers and State Employees (grant number 53179). Thanks to Dede Nelson and DELTA for technical assistance with the online delivery of the program. The authors have no conflict of interest to report.
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