Effectiveness of text messaging interventions for weight loss in primary care

Weight Loss Through Text Messaging

Decreasing Obesity Through Text Messaging

The focus of this professional paper is one of health and wellness, with emphasis on obesity control. Obesity is the dominant, unmet global health issue, with Western countries topping the list (WHO Technical Report Series, 2000). The reasons for the surge in obesity in the United States cannot be easily ascertained, but relate to multiple factors. Environmental and behavioral issues seem to cause the majority of obesity cases, including family dysfunction, a stressful life, increased time in sedentary activities, and low overall energy expenditures (Epstein, 2006). Researchers have also speculated that the increased energy density of modern foods, as well as the lower physical demands of contemporary society and the workplace have combined to increase the incidence of excessive weight (Anderson, 2003). At any rate, no single cause is responsible for obesity, as it is clearly a multifaceted issue.

A large component of resultant obesity is poor nutrition. Poor nutrition is the second largest cause of death annually in the United States, resulting in approximately 400,000 deaths per year, following only tobacco (Dansicker, 2004). Many organizations combating obesity and malnutrition in our society, including the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Dietetic Association, have targeted the fast food industry as a major contributor to the obesity epidemic. They have linked the fast food industry to most major health problems, including overweight, diabetes, coronary heart disease, hypertension, and hypercholesterolemia. Still, Americans flock to these restaurants, eating portion sizes that are too large, too fatty, and too sugary to maintain a healthy body or a healthy weight.

Statement of the Problem

Nutrition and diet information is very widespread in our society; the overload of facts and figures may actually lead to confusion among the population. When information is promulgated by so many sources, people may not know what, how much, or even how often they should eat. Translating the information into strategies and policies that can help Americans make smarter food choices continues to challenge the health-care community (CDC.gov, 2012). While it is safe to say that confusion may exist, mass-marketing works to fill the gap and promote the products that seldom meet the guidelines of what constitutes a healthy diet.

Research Question

This begs the question: given that literature has shown the ability to alter behavior in various populations using mHealth technology, could patients of a suburban family practice office utilize the same mobile technology ( in the form of text messaging) to improve eating habits and lose weight?

Statement of the Purpose

As primary health care providers, advanced practice nurses are tasked on a daily basis to impress upon their patients the importance of healthful living. The very essence of the role is one that is characterized by the deliberate, purposeful, and integrated use of expanded nursing knowledge, research, and clinical practice expertise, grounded in the values of holistic, patient-centered care (Donnelly, 2006). The health community is failing in efforts to motivate patients to change behaviors and integrate healthy habits of diet and exercise into their daily lives. The conventional discussions, handouts, and admonishments are simply not effective to motivate patients to decrease their intake of fats, sugars, and starches, and increase fruit and vegetable consumption. Conversation alone is not enough to encourage patients to join a gym, sign up for exercise classes, or simply get out and walk. Given that obesity is linked to hypertension, adverse lipid concentrations, type 2 diabetes, various cancers, and innumerable additional maladies (Ogden, 2012), it follows that, as a group, advanced practice nurses should concentrate on developing novel approaches to combat obesity.

The purpose of this research is to determine, based on current studies, if patients who network with each other using mobile technology while supervised by a health care provider on a daily basis can lose more weight and be more physically active than those who are not part of the network.

The purpose of this research is to determine if patients who receive text messages from a health care provider on a daily basis can lose more weight than those who do not receive text messages.

Review of the Literature

Mobile health (mHealth) is defined as the use of mobile electronic devices, such as cell phones, PDAs, tablets, and laptops to support healthcare (Free, Phillips, & Felix, 2010). While medical professionals have long used mHealth in their daily practice routines, researchers have concluded that mHealth is also an excellent way to produce long lasting behavioral changes not only among health care providers, but also among their patients. By using software applications, known as "apps," users can download programs for symptom monitoring, treatment tracking progress, skills training, and two-way communication with providers (Introducing the "App," 2010). Behavioral health lends itself well to mobile technology, and recent examples include assessment of alcohol and substance abuse (Bernhardt, 2009), treatment of tobacco use (Obermayer, 2004), and support of patients with traumatic brain injury (DePompei, 2008).

Additionally, the National Center for Telehealth and Technology is currently conducting studies regarding usability for the military. This research is relevant to demonstrate not only the capability of the devices, but whether members of the military and providers will utilize them, especially in isolated areas, while on deployment, or overseas (Luxton, 2011).

Project Masiluleke

Project Masiluleke (Project M) is an example of how cell phone technology and text messaging are being employed in an attempt to quell the AIDS epidemic in South Africa. Project M. is based on joint efforts of mobile operator MRN, handset manufacturer Nokia, and the National Geographic Society. It is an ongoing large scale project designed to increase HIV / AIDS awareness and encourage and monitor treatment protocols. The partners originally utilized text messaging as a means to encourage men to be tested for HIV. Eventually the model developed to address HIV at every stage in its lifecycle from awareness to testing and follow-up (Project Masiluleke, 2011).

Making progress against AIDs has been particularly challenging in South Africa. The high infection rates had overwhelmed the medical system, regarding both medical facilities and personnel. The government attitude toward the diagnosis and treatment of HIV has remained hostile and has complicated all efforts to address the disease. Understandably, this made many individuals reluctant to submit to testing, given the stigma surrounding HIV / AIDS. Lack of privacy at clinics frequented by neighbors and staffed by relatives fails to promote trust, and does not encourage testing. Consequently, those who are infected may never know their status until very late in the disease process when it is too late to administer any type of treatment. Additionally, traditional healers frequented by those in the community supported a different treatment model and perpetuated confusion and incongruence.

Project M. centers on utilizing mobile technologies to increase access to information and services, creating a set of services to integrate with the existing health care system, and adopting a model from the community perspective, rather than from the perspective of the existing health care system. With this model in place, the goal was to harness mobile phones to deliver messages designed to raise awareness and connect users to existing information. When this was initiated, no one knew if a mass mailing of text messages on mobile telephones would reach the appropriate people, nor did they know if the messages would raise awareness to the point that the messages would affect behavior. Today, the project is reaching more than 350 million short message service (SMS) per year. The campaign resulted in an impressive 300% increase in calls to the helpline, from 1000 calls a day to 3000-4000 calls a day. Since the project launch, over 685 million PCM messages were sent to the helpline. Upon receiving the PCM message, staff at the helpline, who are HIV patients themselves, offer counseling and direct callers to HIV and TB testing centers. (Pop!Tech, 2010).

Methods

This professional paper based on the scholarship of teaching will examine ways to combine the technology of the smartphone with the education of primary care patients. Interaction in this way will help to form a virtual bond for patients trying to live more healthful lives and the healthcare providers who are helping them, especially where it concerns eating, exercise, and stress.

A Pew poll conducted in 2011 estimates that 35% of American adults own a smartphone device. The data is based on a survey conducted in May, which found that 83% of U.S. adults have a cell phone, and 42% of those people have a smartphone (MacManus, 2011). Smart phone technology allows for quick access to widely dispersed materials, such as text messages.

Patients of a family practice group who desire to participate in the project can begin by completing a brief questionnaire regarding diet and exercise habits. See Appendix a. This survey is designed to obtain basic information regarding diet habits, and is designed to be repeated at a later date to ascertain if habits have improved, deteriorated, or stayed the same. This survey is being tested in this study, since it has not been vetted in the past and must be examined for reliability and validity as a part of the study itself.

While the study is being conducted, the results of the survey will also help to indicate whether the survey is appropriate for the information desired to send valuable text messages to patients. If the survey is found to ask for too little or too much information, future studies will need to utilize other types or styles of surveys in order to collect adequate information for text messages as it relates to health care. To this end, the researcher may undertake the development of a survey instrument in the future if the current survey being used is unsuccessful.

After completing the survey, the patient's mobile phone number where they receive text messaging is entered into a data base. When the patient becomes a member of the group, he or she will receive daily messages via text messaging. The study will be completed within the setting of a primary care office in Lake County, Florida, and would be offered to all patients of the practice.

Limitations

Given that Lake County, Florida is one of the top five locations in the country for Medicare recipients, patients over 65 may not be as willing to participate in a study involving mHealth. While technologically savvy, they tend to use their desktop computers more than mobile devices for research and communication. As Smartphones gain popularity and text messaging gains more prevalence, this practice may change in the future.

While it is rare, some patients do not have cellular phones that can receive text messages. Further, some cellular phone plans do not have unlimited text messaging, and these factors may deter some patients who cannot, or do not wish to receive daily messages. In that case, these patients could still participate in the study by email if this was offered by the patient's care provider in lieu of text messaging.

Future Study and Application for Practice

This premise could be utilized by any family practice practitioner, as well as those practicing in specialties. For example, a nurse midwife could sent out texts with tips and frequently asked questions to follow patients through conception, pregnancy, delivery, and postpartum issues. A cardiology practitioner could include tips that remind patients to weigh themselves and be mindful of salt. In this way, smartphones could be used as an innovative method of health care teaching. Patients may appreciate the reminders, as well as be inspired to conduct further research on their own. Additionally, the tips may open up a dialogue between the practitioner and the patient to further discuss specific health care concerns and issues and promote a higher degree of wellness for the patient.

Summary

While mobile health is a relatively new technology, it is taking the world by storm. In reviewing the literature, it is apparent that we are on the verge of expanding our roles as health care providers into low income, underserved, isolated populations. In this, we can connect with patients on an individual basis where we can teach, provide ongoing care, and receive feedback as never before