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Cell Phone Text Messages – the Panacea for Obesity?

Friday, October 09, 2009 Posted by Peter Janiszewski, PhD

For once there may actually be a grain of truth to my usually sarcastic title.

We are well aware that regular physical activity and proper nutrition are key to reducing risk of many diseases and associated mortality. These same bahaviors are also the cornerstone of weight management. Unfortunately, we are much less sure how to get the public to adopt these healthy behaviors. For example, we know that while physicians may counsel their patients about the benefits of a healthy lifestyle, seldomly do the patients change their behavior.

In other words, we are in desperate need to find new and innovative ways to make healthy lifestyle changes EASY for the majority of people.
What is absolutely not a viable strategy: physicians telling their patients to “eat less and move more.”

So what are the alternatives?

A very interesting study just published in the Journal of Medical Internet Research suggests that an intervention using personalized cell-phone text messages may be one novel way to make a healthy lifestyle change more probable.

In the study, Patrick and colleagues from the University of California, San Diego, randomized 75 overweight men and women for 4 months into one of two interventions: 1) receipt of monthly printed materials about weight control; (2) an intervention that included personalized text or multi-media (picture) messages sent two to five times daily to the participants phones, along with the same printed materials received by the previous group.

The time the text messages were received was dictated by each participant, as were the number of messages per day. Approximately half of the messages requested a reply, with the remainder providing tips, suggestions, and encouragement for improved behaviors.

The topics of the text messages included the following: “goal setting and self-monitoring, understanding calories, portion control, pedometers and physical activity, personal strategies for weight loss and overcoming barriers, volumetrics (consuming foods that are healthy and make one feel “full”), replacement and substitution, routine physical activity, organization and meal planning, strategies for eating out, strategies for creating healthy food and exercise environments, strength training, emotion eating, managing tough social situations, body image, and sticking with it.”

The messages went something like this:

“Control your portions by setting aside a large snack package into smaller bags or buy 100 calorie snack packs!”

“In a rush? Buy pre-cut vegetables like carrots, celery, and mushrooms for a quick, easy, and low calorie snack!”

And what were the results?

At the end of the 4 month intervention, those receiving regular messages to their phones lost about 4.5 kg (or about 10 lbs) in contrast to no change in the other group.

And all it took were regular text messages provided by a more or less automated system.

Finally, 92% of the participants in the texting group stated they would recommend the intervention to their friends and family – suggesting a very high overall satisfaction with the program.

While this study is the first to evaluate the effectiveness of tailored text messages for weight loss, the same technology is being used in Africa to increase AIDS awareness and education.

A key component to such an intervention is that it is EASY for the participant – they just receive small “nudges” towards healthy behaviors, and slowly but surely they begin to adopt them.

Secondly, such an approach in today’s fact paced world may be more feasible in contrast to forcing people to exercise a la boot camp style for hours each day and go on very-low calorie diets, as popularized on misguided TV shows.

And lastly, getting informative and helpful “nudges” may simply be more fun than reading diet books and being yelled at by a personal trainer.

If you have any doubt as to the veracity of the fun factor in helping people adopt healthy behaviours – look no further than the video below which showcases the most innovative method for getting people to adopt a simple behavior like taking the stairs. (Note to our email subscribers, you must log onto Obesity Panacea to view the video).



Have a great (Canadian) Thanksgiving weekend.

Peter

Credit to BJ Fogg for the fun video, via Twitter.


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Patrick, K., Raab, F., Adams, M., Dillon, L., Zabinski, M., Rock, C., Griswold, W., & Norman, G. (2009). A Text Message–Based Intervention for Weight Loss: Randomized Controlled Trial Journal of Medical Internet Research, 11 (1) DOI: 10.2196/jmir.1100


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11 Response to "Cell Phone Text Messages – the Panacea for Obesity?"

  1. Anonymous Said,

    Cell phone text messages sounds like a great idea. Ten pounds in four months is quite effective compared to many other interventions. Enjoyed the You Tube video as well!

    Posted on October 9, 2009 at 2:45 PM

     
  2. GnomeX Said,

    I see some nutritionists using Twitter to send simple nutrition tips and motivation messages throughout the day. I thought this was pretty ridiculous but it seems the same principles would apply and maybe they are onto something.

    Posted on October 10, 2009 at 1:03 AM

     
  3. Sue Said,

    It would be neat if there was a Tamagotchi-like keychain device that reminded you every 30 minutes or so to get up and walk around or do a set of pushups or something, as well as random motivational tips. When you're sitting in front of a computer, hours and hours can go by without you knowing it.

    Posted on October 10, 2009 at 9:56 AM

     
  4. uncdiss Said,

    I like the txt idea and how easy it is to reach the patients. Another idea which I implemented at my old job was a break for everyone. I found out that smokers took on average 3 breaks a day at 10 minutes. So I suggested (repeatedly) to management that we allow everyone 3 10-minute breaks a day but they had to be taken outside. At first participation was low but grew over time as everyone saw it as an opportunity to socialize. Eventually a walking tour was organized and had about 65% participation. This turned into a rather competitive weight-loss bet between many of the excessively obese employees that was rather successful, mean weight loss of 28 pounds in 2 months.

    The funny thing is productivity actually went up and after hours billing went down (I'd assume due to less mental fatigue). Everyone seemed to be happy with it and talking to former coworkers 4 years after I have moved on the policy is still in place.

    This is probably not feasible everywhere, but in the south where the weather is pleasant year round this was a great program to implement.

    Posted on October 11, 2009 at 1:09 PM

     
  5. Jan Said,

    Ok, I must be the only guy not enthusiastic about this study. I find it hard to believe that somebody actually signed of on it!

    It doesn't seem to proof anything, we didn't already know. The controlgroup receives a monthly weightcontrol leaflet versus a very expensive personalized program? Besides the sms, the interventiongroup also received a phonecall from a healthcounseler.

    What we already know is that in short term (< 1 year), weightloss with help works better than without. This is exactly what has been tested.

    This study shows, because of it's flawed (that's put nicely) design, absolute no academic or clinical relevance. We know nothing more. If you would come with this studydesign, I would flunk you immediately without any hesitation (I'm a teacher also).

    Oh, 92 percent was very satisfied and would recommend the program. That 92 percent is 22 out of 24. What happened to the rest, were they not satisfied? I know they did not respond, but if they did, the staggering 92 percent could drop to 66 percent. This percentage has no real value here.

    They proved that attention, reminders and empathy helps in weightloss. Wow, they actually proved that alternative medicine does get results ;-).

    Grtz Jan
    A guy who wants to help not hype!

    Posted on October 12, 2009 at 9:28 AM

     
  6. Peter Janiszewski, PhD (Cand.), MSc Said,

    @Sue - I think that is an excellent idea, and I have a feeling a few are currently working on making such a thing a reality. Not sure about a keychain based device, but other mobile methods for sure - iPod for example.

    @uncdiss - That is excellent - great work! But 28lbs in 2 months - that is some seriously fast weight-loss - I'd worry it would be very difficult to maintain such a drop. Also, I'm not surprised about the work efficiency - even from personal experience I know that the days I miss my regular workout, I will usually not be nearly as productive at work.

    @Jan I am unclear as to why you found this study to be so flawed in design – every study has limitations and no single study is perfect.

    The provision of a monthly handout on general weight loss topics to the control group is a norm in weight loss studies, as in reality this is the type of "treatment" they would receive from their physician, thus this forms a real "control" as opposed to giving these participants absolutely nothing - which has ethical implications in addition to being unrealistic. These researchers tested whether adding the additional component of regular and personalized sms and mms messages and a monthly phone chat would augment the effectiveness of regular advice to lose weight (as showed again in this study to be largely ineffective on its own).

    While you are right that short-term weight loss studies (<6 months) tend to be more effective than long-term studies, this is largely irrelevant to this study. Their purpose was not to assess whether their intervention permitted weight-loss maintenance – this is a matter of ongoing research. What has been tested and what is very novel about this study is the MODE of providing a weight-loss intervention.

    In stark contrast to your suggestion that the intervention was expensive - in fact, computers are much cheaper than are people, and thus an intervention run largely automatically is much cheaper than one run by nutritionists, personal trainers, counselors, etc. As an obesity researcher, I have been involved in numerous such studies over the past 6 years, and believe me they are immensely expensive to conduct. This is partly why I was so intrigued by the findings of the current study; they provide a program that could be implemented on a larger scale with minimal costs.

    Thus the assertion that the study has “absolutely no academic or clinical relevance” could not be more wrong. Also, your comments suggest why it is probably a good thing that scientific relevance is decided by no one else other scientists in the area of study through scientific peer-review.

    Posted on October 12, 2009 at 2:18 PM

     
  7. Jan Said,

    @ Peter,

    Thank you for your comment.

    The reason I think it is flawed is because of the confounding variable. If you want to test the SMS component of an intervention, it must be the only difference. If I state that the reason for success is the monthly call by a health professional (not in the controlgroup), it would be as valid as the statement that it is because of the daily textmessages. It breaks the basic rules of research. No conclusion can be drawn from this study. That's why it lacks any relevance. Nice idea, bad execution.

    The fact that it is peerreviewed does not prove relevance. I can flood you with peerreviewed, but recognised flawed studies, that could be a PhD project by itself. Peerreviewing does not excuse us from reviewing it critically oursselves.

    In 2006 I had a smallscale pilot project. Both groups (randomized) had a weekly session (weightwatcher like), but the ONLY difference was that the interventiongroup had daily textmessages (2, but not automated). After 12 weeks, the interventiongroup (n=6) was much more satisfied, but there was no difference in weightloss. I dropped the project.

    I don't say that textmessages wouldn't work or could be of added value. I say, that this design did not proof it.

    Grtz,


    Jan

    Posted on October 12, 2009 at 2:52 PM

     
  8. Darya Said,

    Rad video! Thanks so much for sharing!

    Posted on October 12, 2009 at 2:59 PM

     
  9. Travis Saunders Said,

    For the record, I don't believe that attention, reminders, and empathy are considered "alternative" medicine - they are just good medicine (and evidence-based medicine at that).

    :)

    Posted on October 13, 2009 at 9:44 AM

     
  10. Shannon Lacy Said,

    Could daily text messages potentially be a cure-all for obesity? Ten minutes ago I would have laughed at this proposition, but after having read your post, Cell Phone Text Messages- The Panacea for Obesity, I just might hold my tongue as the concept behind the idea is worth exploring. According to you, the study mentioned in your post yielded results that show that daily diet and health tips sent via text messages will help facilitate and execute the process of losing weight. Is this too good to be true? I mean, think about it, cell phones are virtually glued to the hands of the population. Already, cell phones have surpassed all expectations and can serve as alarm clocks, watches, day-planners, iPods, cameras, calculators, and, now, cell phones could have the potential to help people lose weight. Not quite. However reliable technology is these days, ‘too good to be true’ is most likely the case with this proposed elucidation as to how to shed the pounds. If so promising a program, there must be a reason why this prospective billion-dollar enterprise has not yet been launched to the masses.

    The fact is, that while the thought of feeling popular by receiving daily text messages and losing weight simultaneously is a tempting weight loss solution, it is not a means to a cure for obesity. In your post, you refer to the health tips as “small nudges towards healthy behaviors”, and, in putting the study to the test, that is ONLY what they are. The little “nudges” seemed to have facilitated a sort of zone of proximal development (ZPD) for those in the intervention. Though ZPD is generally used to describe child development, it is merely the effect that highlights what one can achieve with a little guidance, than just on their own. ZPD is supposed to serve as a means to achieving higher levels of results, but if results are not seen, frustration is bound to occur. Yes, the experiment yielded results, but is four months intervention really enough evidence to deem text messages a cure for obesity? When will the results start to plateau? When will the subjects begin to lose faith in the system and treat the texts as junk mail? I believe it is just a matter of time. Popular within the psychological world is the belief that self-control, the main cognitive factor in losing weight, is a limited resource easily drained when temptation is high and motivation is low. Without lasting and noticeable results, what makes this system anything different than a fad diet?

    On a side note, I think you are on to something with the Fun Theory. Great video!

    Posted on October 19, 2009 at 8:22 PM

     
  11. Peter Janiszewski, PhD (Cand.), MSc Said,

    @ Shannon Lacy

    Thanks very much for the thorough comment. Just to be clear, whenever we use words like "cure" or "panacea" on this site, we almost always use in in a tongue-in-cheek fashion. Of course I don't believe that SMS messages will cure obesity - currently there is NO cure for obesity. Available are only treatments, and these are only modestly effective.

    But I do like the idea of nudging people towards healthy behaviours - regardless of the effect on their weight. In fact, if I were to perform a similar study to this one, I would be less concerned with weight and more interested in cardiometabolic risk factors, quality of life, mental health, and even body composition - as all these critical factors can be altered in response to healthy behaviours when body weight refuses to budge.

    In a way, I see a parallel between the "fun stairs" video and this idea of texting for health improvement. The messages provided can be fun, and can highlight that being healthy does not require hours at the gym in intense exercise, or extreme hypocaloric dieting - what most overweight/obese people tend to believe thanks to shows like The Biggest Loser, etc.

    Posted on October 19, 2009 at 9:11 PM

     

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We are PhD students in the School of Kinesiology and Health Studies at Queen's University in Kingston, Ontario. Our research focuses on the relationships between obesity, physical activity, and health risk. This blog is our attempt to consider the many "cures" for obesity that we read about on a daily basis. Enjoy.

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The opinions expressed here belong only to Peter and Travis and do not reflect the views of any organization. Any medical discussion on this page is intended to be of a general nature only. This page is not designed to give specific medical advice. If you have a medical problem you should consult your own physician for advice specific to your own situation.

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