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A Smart Approach to Weight Loss

There's an app for that


By Carole Bartoo
February 2013

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The fight against obesity may be shifting from the weight room to the chat room, as weaponry in the form of apps, gadgets and online tracking move to the front lines in the battle of the bulge.

The media has dubbed a new trend of self-tracking as the “quantified self” movement. On iTunes and at Google’s Play store there are more than 1,500 applications or “apps” to track diets and health habits, accompanied by an explosion of mobile monitoring devices that clip on a belt or slip on a wrist to calculate precise activity levels. Much of this technology also offers a social media element to inspire, motivate and encourage.

Weight management experts at Vanderbilt support the use of technology to lose weight, even recommending some of it to patients, but they caution that apps and gadgets may be a temporary fix that could go the way of home gyms and grapefruit diets: fading from the national spotlight without affecting real change.

That is, unless something more permanent can be achieved through use of this technology. Work is under way at Vanderbilt to use popular technologies as a tool and to find unique ways to turn the focus of mobile tracking devices to the environment around us, to create a culture of change that might finally turn the tide in the war against obesity.

Staying on Track
Vanderbilt nurse, Rachael Poff, R.N., is a weight loss success story. Two years ago she weighed 287 pounds at 5 feet, 3 inches and had uncontrolled diabetes, chronic pain issues and sleep apnea. She underwent bariatric surgery at Vanderbilt and turned her health around. Today, at 132 pounds, the diabetes, sleep apnea and aching joints are gone, but the fear remains.

“I’m afraid I’ll gain it back,” Poff said.

Rachael Poff, R.N. Photo by Daniel Dubois.

Rachael Poff, R.N. Photo by Daniel Dubois.

Poff, who once worked with the bariatric surgery team, knows the success of weight loss through surgery can be short-lived. In 10 percent to 20 percent of cases, people gain significant weight back after the first two years. Poff has avoided weight gain so far, but still struggles.

“I hadn’t really had sugar for almost two years, but then one weekend during the holidays I made sugar cookies with my daughter, and the cravings returned. It was tough,” she said.

Like so many, Poff has a smartphone she carries with her nearly every waking moment. The device has become a source of support to maintain her new, healthier lifestyle. She uses a tracking application called MyFitnessPal, a free download that tracks meals and automatically syncs with a website that monitors goals for calorie consumption and nutrition.

In addition, for her last birthday, Poff got a mobile activity-tracking device called a Fitbit. The device is like a supercharged pedometer, tracking not just steps but intensity levels, elevation and other digital data that downloads to a website. The Fitbit not only tracks weekly goals, but can also synchronize with MyFitnessPal.

“I am a creature of habit. Technology is a good tool for me to use when I go off the path, kind of like a safety harness,” Poff said. “I find when I am having a day when I struggle, am hungry or stressed, that’s when I track. When I need that mental extra input, to know where my diet is at.”

Accurate Assessment
John Cleek, M.D., director of Vanderbilt’s new Center for Medical Weight Loss, says applications and tracking devices like these are critical tools for his patients because they address a core problem among overweight Americans.

“Studies show we underestimate what we eat by 30 percent. I think it’s the same way with activity; we tend to overestimate by about the same percentage,” he said.

John Cleek, M.D., is the director of Vanderbilts new Center for Medical Weight Loss. Photo by John Russell.

John Cleek, M.D., is the director of Vanderbilts new Center for Medical Weight Loss. Photo by John Russell.

Research consistently shows self-tracking helps people lose weight and maintain weight loss. Now apps and devices are making tracking more convenient, and consumers are jumping at the opportunity to try it. A Pew Internet survey released in fall 2012 shows more than half of smartphone users have a health application on their phone or use their phones to look up health information. Of all smartphone users who have a health app, 38 percent have one that tracks exercise, 31 percent monitor diet, and 12 percent use an app to manage their weight.

Caroline Crow, M.S., R.D., the Medical Weight Loss Center’s licensed dietitian, says she has access to her patients’ MyFitnessPal data through the app’s website, and uses it to send notes of encouragement between clinic visits.

“When they are getting started, sometimes I don’t even think they are aware of the inconsistency between what they self report and their electronic food record. They might say ‘Oh, I don’t eat out more than one time a week,’ but when they are tracking they can see it’s more like four times a week,” she said.

And as patients get a dose of reality about what they eat, Mike Wigger, M.S., the certified exercise specialist at the Center, teaches them a new definition of activity. He says the focus is changing from an emphasis on individual workouts to finding ways to increase physical activity throughout the day.

“Instead of just adding a 45-minute workout to the day, it would help if we made changes throughout our 8-to-10- hour work day. Studies show that getting the recommended amount of physical activity might not be enough to undo the detrimental effects of long-term sedentary behavior, like sitting at a desk all day. Ideally, we should get some movement every hour, even if it’s just standing up and sitting down at your desk,” Wigger said.

Wigger provides patients with a list of some of the activity monitoring devices now on the market along with their cost (an average of $100) and features. He says the advantage of the newer devices over a simple pedometer is that they give a much clearer assessment of activity throughout the day. Some, like the Jawbone UP, can even be programmed to alert you with a buzz when you’ve been sitting for too long.

Cleek, who struggles with his own weight, uses a Fitbit to reach a weekly activity goal. He says his perception of his own fitness level is frequently adjusted with his tracking device.

“Like a lot of people, I can feel like I have been quite active when I am on my feet, seeing patients all day. But then I sync the Fitbit to my computer, it shows I often fall short of my goal. That motivates me to get up early for a morning walk to get more activity in my day,” he said.

And options for motivation are far easier to come by in today’s world of online social media groups. In addition to self-tracking, bariatric surgery patient Poff visits a website called Daily Strength where a chat room is set aside specifically for people who have had weight loss surgery. Vanderbilt experts are highly aware, and are watching this tech trend for virtual group therapy. Crow says one of her patients uses online support groups for a willpower boost just before placing an order at the drive-through. But she, like many of her colleagues, says she feels it is important that patients meet with her, or with real groups, face to face as well.

Technology as a Tool
Cyber support and mobile device tracking offer greater convenience for busy adults, but Colin Armstrong, Ph.D., assistant professor of Clinical Psychiatry and a certified wellness coach for the Vanderbilt Dayani Center’s Adult Weight Management Program, says it is not yet known if new technology is as effective as more traditional techniques.

Armstrong says his patients use technology, too, and that can be a good thing, but he wants to temper the excitement with another dose of reality.

“Once the novelty wears off, people may be disappointed. If technology were all we needed, we’d all be thin. Lots of folks purchase home exercise equipment that doesn’t mean they use it. By themselves, digital pedometers and apps don’t lead to weight loss, they’re just tools. It’s how you use them that counts,” he said.

“Even bariatric surgery is really just a tool,” Poff says. “It helps tremendously in those first 18 months because you have these rules you have to live by with this new stomach. But eventually it is no longer the strongest tool in the toolbox.”

Now Poff, who is still in the active phase of maintaining her recent weight loss, relies on her gadgets, apps and websites to stay on track. But Armstrong says it’s what comes next that is most critical in solving the obesity problem.

“Technology can help us raise our awareness of an issue and track our efforts to change it, but awareness by itself won’t necessarily lead to motivation. Knowledge is not sufficient to lead to behavior change,” he said.

Barriers to Better Behavior
Behavior change is both the key, and, up until now, the elusive Holy Grail in the war against obesity. What is missing, says Vanderbilt expert Joan Randall, MPH, administrative director of the Vanderbilt Institute for Obesity and Metabolism, is a culture change where the trend toward increasing convenience and comfort is replaced by lifestyle changes that favor activity and a healthy diet.

Some experts say the time is right to meet people halfway in this battle of the bulge. They argue the public interest and desire is there, and so policymakers at every level of society should begin to embrace efforts to remove barriers that can keep people from developing more permanent healthy behaviors.

“The default conditions within our communities often make the unhealthy choice the easy choice. It is time to change that,” said Randall.

Joan Randall, MPH, and David Schlundt, Ph.D., serve on the Tennessee Obesity Task Force and are studying barriers that keep people from walking or biking to work. Photo by John Russell.

Joan Randall, MPH, and David Schlundt, Ph.D., serve on the Tennessee Obesity Task Force and are studying barriers that keep people from walking or biking to work. Photo by John Russell.

Randall and David Schlundt, Ph.D., associate professor of Psychology, are helping communities find ways to reduce the physical barriers that prevent change. Each has a critical role with the Tennessee Obesity Task force (TOT), a five-year plan (2010-2015) funded by an agreement with the Tennessee’s Department of Health through a cooperative agreement with the Centers for Disease Control and Prevention (CDC). Randall serves as an executive director of TOT, and Schlundt chairs the evaluation efforts.

“People are being physically prevented from being more active,” says Schlundt. “I used to live in (Nashville’s) Germantown in the 1980s. That was only three miles from campus, but they had sewer grates with the drainage holes arranged so you could sink a tire in and flip the bike. The Complete Streets program is gradually replacing faulty grates, adding bike lanes, and designing more pedestrian and bicycle friendly streets, but there is much still to do,” he said.

Randall and Schlundt are working on a pilot program on the Vanderbilt campus through the Center for Nashville Studies using smartphone technology to understand non-car traffic coming and going from campus. The program tracks how many people use streets, sidewalks and parking areas to come and go from campus. The goal is to “qualify” the environment and collect evidence to discover barriers preventing people from walking or biking to work.

Schlundt designed a simple smartphone app to assess pedestrian/bike traffic. For one week in the fall of 2012, Randall and Schlundt each took their smartphones to street corners on the Vanderbilt campus from 7 to 9 a.m., then again from 4:30 to 6 p.m., an effort they will repeat this spring.

“GPS maps the location automatically,” Randall says, opening the application on her phone. “Then you’d put in biker or walker, male or female, the weather and temperature.”

An electronic survey will round out what employees report as barriers to walking or biking. At the end, it is hoped Vanderbilt administrators may consider solutions, like adding more bike racks around campus. But even more important, Randall says, the tools and techniques for Vanderbilt’s project will be shared with other large employers and campuses in town. Ultimately it is hoped the project will serve as a template for using everyday consumer devices like smartphones, to do ground-level research on barriers to healthy lifestyles in any community.

“We are doing the pilot survey first, and then we plan to scale it up to larger population levels. There is a national trend to do this. Investigators at Vanderbilt are on the cutting edge of developing and applying technology to create an environment which supports healthier choices,” Randall said.

Individuals like Rachael Poff are living proof that technology is a helpful weapon in the decades-long battle for a slimmer American waistline. The technology continues to reinforce the lessons learned, and to support work to maintain a new healthier lifestyle.

And on a larger scale it appears that something is working. Evidence now suggests obesity rates may be leveling off a bit in the United States. Tennessee is one of the few states on the CDC’s official obesity monitoring site that has even experienced a recent (and first-time) decline in the rate of obesity (see side bar).

Vanderbilt researchers involved in the war against obesity say it is time to strike while the iron is hot, to engage the public and policymakers in an effort to create a culture change that encourages greater health.

“The goal is to create population-based efforts rather than work on obesity at the individual level because one individual at a time won’t change the health of our population,” Randall said. “We need policies that support personal responsibility. We want to make it easier for those who want to make better choices.”

 



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