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Use of the internet in the treatment of obesity and prevention of type 2 diabetes in primary care

Published online by Cambridge University Press:  26 October 2012

Kathleen M. McTigue  and
Molly B. Conroy
Kathleen M. McTigue*
Affiliation:
Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA 15208, USA
Molly B. Conroy
Affiliation:
Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA 15208, USA
*
*Corresponding author: Dr Kathleen M. McTigue, fax +1 412-692-4838, email [email protected]
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Abstract

Cardiovascular prevention, including emphasising healthy diet and physical activity patterns for weight loss and diabetes prevention, is an important focus of primary care medicine, yet provision of intensive lifestyle counselling in the primary care setting remains uncommon. Online approaches for providing lifestyle counselling are emerging as a new avenue for bringing support to outpatient patient populations. Features of successful programmes include the use of a structured behavioural programme, electronic counselling support and feedback, and uncomplicated user interfaces. Online tools may be used independently or to complement in-person approaches. Limited data also suggest that the internet can be used to support the maintenance of weight loss. In addition, the internet may help overcome various clinical barriers to lifestyle support, including significant time limitations, a need to prioritise acute care and maintain clinical workflow, and the high cost of counselling. Furthermore, the continuity of the primary care patient–provider(s) relationship provides an established source of long-term support which has been difficult to create in other community settings. As the field of online lifestyle counselling matures, nutrition and physical activity experts will face new challenges in providing asynchronous counselling without the assistance of traditional non-verbal communication cues. However, the potential for reaching a wider population in a convenient and accessible manner also creates unique opportunities for providing lifestyle support.

Keywords

ObesityInternetPrimary healthcarePreventionWeight loss
Type
Conference on ‘Translating nutrition: integrating research, practice and policy’
Information
Proceedings of the Nutrition Society , Volume 72 , Issue 1 , February 2013 , pp. 98 - 108
Copyright
Copyright © The Authors 2012

Abbreviation:
PCP

primary care provider

Although cardiovascular prevention is an important focus of primary care medicine, the translation of intensive lifestyle counselling into the primary care setting remains uncommon. International obesity and diabetes trends have concerning implications for future population health, given the strong links between obesity and chronic disease or impaired physical function( Reference Wild, Roglic and Green 1 – Reference Messier, Loeser and Miller 7 ). In US adults, obesity prevalence has increased from 13% (1960–1962) to 35% (2003–2006)( 8 ), while recent estimates of obesity prevalence in European countries range from 4 to 28% in men and from 6 to 37% in women( Reference Berghofer, Pischon and Reinhold 9 ). Intensive lifestyle intervention promoting modest, sustained, weight loss has been shown to prevent or delay diabetes onset( Reference Tuomilehto, Lindstrom and Eriksson 10 , Reference Knowler, Barrett-Connor and Fowler 11 ). Yet, commercial and other community-based programmes are clearly not meeting the population's need for weight management assistance. Commercial weight-loss programmes often lack evidence of effectiveness and are prohibitively expensive for many patients( Reference Anhoj and Jensen 12 , Reference Tsai and Wadden 13 ). Other popular weight-loss strategies may have only marginal effectiveness( Reference Heshka, Anderson and Atkinson 14 , Reference Gardner, Kiazand and Alhassan 15 ) or have raised safety concerns( 16 ). In addition, community-based programmes are not privy to relevant health information from clinicians (e.g., dietary constraints or conditions impacting physical activity safety), and lack avenues to provide feedback to an individual's healthcare team.

Health care providers may play an important role in helping to manage body weight in the interest of long-term health. Primary care providers (PCP) are more likely than specialists to counsel on weight and exercise( Reference Frank and Kunovich-Frieze 17 , Reference Livaudais, Kaplan and Haas 18 ) and many PCP consider cardiovascular prevention counselling( Reference Tsui, Dodson and Jacobson 19 ), and specifically dietary counselling( Reference Kushner 20 ), to be important. Involving an individual's physician in lifestyle change helps ensure that people with health concerns will not initiate physical activity in an unsafe manner. Furthermore, theoretical models in primary care medicine are consistent with the support of lifestyle change. For example, the Chronic Care Model, one of the most accepted approaches for delivering high-quality primary care, embraces a model of well-coordinated team-delivered care which would naturally extend to including lifestyle counsellors( Reference Hung, Rundall and Tallia 21 – Reference Wagner 24 ). Likewise, clinical initiatives emphasising chronic care self-management and patient-centred care aim to empower patients to be active participants in their health, consistent with taking control of their lifestyle decisions( Reference Wagner, Bennett and Austin 25 , Reference Toop 26 ).

Although various evidence-based guidelines have recommended clinical attention for obesity( 27 – Reference Manson, Skerrett and Greenland 29 ), and obesity treatment is an important complement to pharmacotherapy in cardiovascular prevention( Reference Libby 30 ), interventions to treat obesity in primary care settings are lacking( Reference Scott, Cohen and DiCicco-Bloom 31 – Reference Wee, McCarthy and Davis 34 ). Unfortunately, even those who receive some advice may not receive comprehensive information; in one study, while 48% of obese patients reported that their physicians had advised them to lose weight, only 30% reported receiving exercise advice and 27% reported specific dietary advice( Reference Potter, Vu and Croughan-Minihane 35 ).

Online approaches for promoting healthy lifestyles are emerging as a potentially important new avenue for providing evidence-based lifestyle support

Approach to the literature evaluating online lifestyle interventions

To date, weight loss data from internet-based efficacy studies are limited, often relatively short-term( Reference White, Martin and Newton 36 – Reference Harvey-Berino, West and Krukowski 38 ), and sometimes negative( Reference Tsai and Wadden 13 ). Publicly available programmes are often not based on rigorous scientific principles( Reference Miles, Petrie and Steel 39 ). While the field is new, promising data for altering obesity-related health behaviours( Reference Winett, Tate and Anderson 40 ), and promoting weight loss( Reference Tate, Wing and Winett 37 , Reference Winett, Tate and Anderson 40 , Reference Tate, Jackvony and Wing 41 ) or weight-loss maintenance( Reference Harvey-Berino, Pintauro and Buzzell 42 , Reference Wing, Tate and Gorin 43 ) in adults suggest that further attention is warranted. To this end, we examined weight-change data from randomised controlled trials in adults, published between 2000 and 2012, in which at least one of the evaluated interventions included an online component to promote weight loss. Because weight loss is often transient, we only considered studies with a minimum of 12 months follow-up.

Summary of the interventions

We identified ten studies meeting these criteria, most reporting their outcomes in terms of kilogram change (Table 1), with the exception of one using body weight percentage( Reference Womble, Wadden and McGuckin 51 ) and another reporting kg/m2( Reference Turnin, Bourgeois and Cathelineau 50 ). The interventions varied considerably in design, with the internet used in some to deliver an automated intervention while in others it enabled remote communication with lifestyle experts or supplemented in-person counselling or community-based support. The most commonly reported online programme elements include self-monitoring of weight, dietary intake and/or physical activity( Reference Tate, Jackvony and Wing 41 , Reference Appel, Clark and Yeh 44 – Reference Winett, Anderson and Wojcik 46 , Reference Micco, Gold and Buzzell 48 – Reference Wylie-Rosett, Swencionis and Ginsberg 52 ), automated advice( Reference Appel, Clark and Yeh 44 , Reference Winett, Anderson and Wojcik 46 – Reference Micco, Gold and Buzzell 48 , Reference Turnin, Bourgeois and Cathelineau 50 – Reference Wylie-Rosett, Swencionis and Ginsberg 52 ), structured education( Reference Tate, Jackvony and Wing 41 , Reference Appel, Clark and Yeh 44 , Reference Winett, Anderson and Wojcik 46 , Reference Micco, Gold and Buzzell 48 , Reference Morgan, Lubans and Collins 49 , Reference Wylie-Rosett, Swencionis and Ginsberg 52 ), problem-solving support( Reference Bennett, Warner and Glasgow 45 , Reference Winett, Anderson and Wojcik 46 , Reference Micco, Gold and Buzzell 48 – Reference Turnin, Bourgeois and Cathelineau 50 ), online lifestyle coaching( Reference Tate, Jackvony and Wing 41 , Reference Appel, Clark and Yeh 44 , Reference Micco, Gold and Buzzell 48 , Reference Womble, Wadden and McGuckin 51 ) and reminder emails( Reference Tate, Jackvony and Wing 41 , Reference Appel, Clark and Yeh 44 , Reference McConnon, Kirk and Cockroft 47 , Reference Womble, Wadden and McGuckin 51 ). A few programmes reported additional features such as links to community or internet resources( Reference Tate, Jackvony and Wing 41 , Reference Bennett, Warner and Glasgow 45 , Reference Winett, Anderson and Wojcik 46 ), online peer-to-peer support( Reference Micco, Gold and Buzzell 48 , Reference Womble, Wadden and McGuckin 51 ), participant contests( Reference Micco, Gold and Buzzell 48 ), physician feedback( Reference Bennett, Warner and Glasgow 45 ) or counselling by telephone( Reference Appel, Clark and Yeh 44 , Reference Bennett, Warner and Glasgow 45 ).

Table 1. Summary of randomised trial data with at least 12 months of follow-up, published 2000–2012

Weight loss data over at least 1 year of follow-up

Among the ten weight-loss studies we examined, the weight change in each arm varied between a 5·3 kg loss (an online intervention)( Reference Morgan, Lubans and Collins 49 ) to a 0·1 kg gain (a waitlist control arm; see Fig. 1)( Reference Winett, Anderson and Wojcik 46 ). When the difference between study arms for each study was calculated (by designating as referent the study arm most similar to usual care or to a non-internet approach, and subtracting its outcome from that of the other study arm(s)), variability persisted but point estimates most often favoured online intervention. Although only about half of the studies showed a significant difference in weight loss between study arms, the non-significant findings are partially mitigated by the fact that some studies compared more than one active study arm( Reference Tate, Jackvony and Wing 41 , Reference Micco, Gold and Buzzell 48 , Reference Turnin, Bourgeois and Cathelineau 50 ).

Fig. 1. Summary of weight change from baseline to follow-up for the ten randomised trials examining online approaches for promoting weight loss and healthy lifestyles. The weight change for each study arm is graphed separately, and studies are differentiated by bar colour. Most studies show weight loss at 12 months, but one indicates results at 16 months( Reference Winett, Anderson and Wojcik 46 ) and two show 24-month data( Reference Appel, Clark and Yeh 44 , Reference Bennett, Warner and Glasgow 45 ). All results are displayed as change in kilograms with the exception of one using body weight percentage (Womble( Reference Womble, Wadden and McGuckin 51 )) and another reporting kg/m2 (Turnin( Reference Turnin, Bourgeois and Cathelineau 50 )).

Studies examining combinations of in-person and online support

Four studies examined different combinations of in-person and online support( Reference Appel, Clark and Yeh 44 , Reference Micco, Gold and Buzzell 48 , Reference Turnin, Bourgeois and Cathelineau 50 , Reference Wylie-Rosett, Swencionis and Ginsberg 52 ). One examined the effect of adding online tools to the standard schedule of seven medical and dietetic visits employed by a group of European diabetes and nutrition centres. It found that adding self-monitoring and automated problem-solving support and dietary advice to this in-person approach led to no improvement in 1-year weight loss( Reference Turnin, Bourgeois and Cathelineau 50 ). Similar findings were also reported for a subset of participants at 5 years follow-up. Two of the studies we examined found clinically significant weight loss with online interventions, which was similar regardless of whether an in-person component was present or not( Reference Appel, Clark and Yeh 44 , Reference Micco, Gold and Buzzell 48 ). One of these studies employed online group meetings, in contrast to most of the interventions we reviewed which typically utilised individualised asynchronous counselling. The researchers compared the use of a website plus internet-based chat sessions with the use of the same website plus monthly in-person meetings in place of the online chats( Reference Micco, Gold and Buzzell 48 ). Although session attendance was initially better in the fully online programme, there was no significant group effect on weight loss at either 6 or 12 months, with mean weight loss of 5·1 kg in the internet-alone arm and 3·5 kg in the internet plus in-person treatment arm at 12 months. The second study compared usual care with (a) remote support via website, telephone and email; and (b) a combination of remote and in-person support. It showed that each remote intervention led to more weight loss at the end of a year that this benefit persisted at 2 years follow-up with a mean weight change from baseline of −0·8 kg in the control group, −4·6 kg in the remote-support-only arm and −5·1 kg in the group receiving in-person support. Each intervention arm led to significantly more weight loss than the control( Reference Appel, Clark and Yeh 44 ). Last, one study examined three levels of support: workbook-based education alone, the same workbook plus tailored automated advice from a computer kiosk, or both those supports plus in-person counselling. The researchers found a significant group effect at 12 months, with a dose response across the levels of support (−1·0, −2·1 and −3·4 kg, respectively)( Reference Wylie-Rosett, Swencionis and Ginsberg 52 ).

Studies examining online support alone

Among studies that did not include any in-person support, three incorporated online counselling from lifestyle experts. In one, significant weight loss was found in both arms receiving access to an online tutorial on weight loss, weekly tips and links, and a directory of selected internet weight-loss resources. However, individuals receiving e-counselling in addition to this automated programme lost an additional 2·4 kg at the end of one year( Reference Tate, Jackvony and Wing 41 ). In a small study that enrolled staff and faculty at an Australian university, an online behavioural curriculum led to a 5·3 kg loss, which was not significantly different than the 3·1 kg lost among control participants( Reference Morgan, Lubans and Collins 49 ). In another study, a commercial weight loss programme led to less weight loss than dissemination of a weight-control manual( Reference Womble, Wadden and McGuckin 51 ). One study combined an automated website and telephone counselling with PCP feedback, and links to community resources. It found a small but clinically significant weight loss at the end of 1 year that could still be detected at 2 years follow-up (−1·03 kg more than usual care at 24 months)( Reference Bennett, Warner and Glasgow 45 ).

Two studies employed neither an in-person component nor online counselling; neither showed a significant weight-loss effect. One compared automated online advice and education delivered with or without church-based supports (e.g., prompts and reminders from the pulpit and in church bulletins) to a control arm, finding minimal weight change in any arm at the end of 16 months follow-up( Reference Winett, Anderson and Wojcik 46 ). The other study found that automated tailored advice and email reminders showed no difference in weight change from usual care over one year( Reference McConnon, Kirk and Cockroft 47 ).

Data specific to the primary care setting

Owing to the limited amount of published data on online weight-loss interventions specific to the primary care setting, we examined all identified articles for this population, regardless of follow-up duration or study design. In two short-term studies, internet intervention led to significantly more weight loss than did control arms. For example, in one, completers among 101 obese adults with hypertension lost 2·71 kg over 12 weeks (3·05 kg more than usual care; 95% CI −4·24, −1·85)( Reference Bennett, Herring and Puleo 53 ). Likewise, among 2862 clients of a large integrated managed care consortium, online programme participants lost 3·0% (v. 1·2% in information-only group) over 6 months (P < 0·001)( Reference Rothert, Strecher and Doyle 54 ). Two year-long studies showed mixed results. In one, an online version of a behavioural lifestyle intervention including lessons, self-monitoring and lifestyle coaching led to 4·9 kg (95% CI 2·22, 7·36) weight loss among obese primary care patients with weight-related cardiovascular risk factors. However, among general practice patients in the UK, a website providing automated lifestyle advice and email reminders led to similar weight change as did usual care (−1·3 v. −1·9 kg; P = 0·56)( Reference McConnon, Kirk and Cockroft 47 ). Two 24-month studies, as described earlier, also focused on primary care patients. One found that disadvantaged, largely ethnic minority, urban patients using an online behavioural intervention lost 1·05 kg more than those with usual care over 1 year and maintained this effect over a second year of follow-up( Reference Bennett, Warner and Glasgow 45 ). In the other, remote support or a combination of remote and in-person support both led to more weight loss at 2 years than did usual care( Reference Appel, Clark and Yeh 44 ).

Application to the maintenance of weight loss

While diverse intervention strategies can promote short-term weight loss, the maintenance of weight loss is a key challenge if lifestyle intervention is to promote long-term health. The behavioural principles involved in successful weight maintenance have been examined in few randomised clinical trials examining online intervention approaches, mostly with promising results. One study found that there was no difference in weight maintenance effectiveness, whether participants were provided with frequent in-person support, minimal in-person support, or internet support( Reference Harvey-Berino, Pintauro and Buzzell 42 ). In it, the frequency of losing and maintaining 5% of initial body weight at 18 months in the three groups was 62, 46, and 49%, respectively. A second randomised controlled trial, evaluating face-to-face v. internet weight maintenance (with a newsletter control group), focused on promoting daily self-weighing with weekly reporting (self-regulation) in a group of individuals who had lost 10% of their body weight( Reference Wing, Tate and Gorin 43 ). Individuals in all three arms regained weight but those in the self-regulation arms had better weight maintenance, particularly in the face-to-face group( Reference Wing, Tate and Gorin 43 ). A third study examined personal contact v. interactive technology weight maintenance strategies (comparing these strategies with a self-directed control) and found that monthly personal contact provided a modest benefit for weight maintenance. The interactive technology strategy provided early, but transient benefit( Reference Svetkey, Stevens and Brantley 55 ). Additional analyses showed that participants with consistent website use were more successful at maintaining long-term weight loss( Reference Funk, Stevens and Appel 56 ). A fourth study found that a web-based programme initiated after an initial 4-month weight-loss programme was no more effective than was self-directed weight maintenance( Reference Cussler, Teixeira and Going 57 ).

Features of successful online lifestyle change programmes

With such heterogeneity in both the online interventions themselves, and their associated effectiveness, it is essential to understand which programme features are associated with successful lifestyle change and weight loss. A number of studies have begun to provide insight into this question. For example, one 6-month intervention found that access to structured behavioural treatment programme (i.e., links to web-based resources, electronic lessons and online counselling) was more effective at promoting weight loss than provision of links to educational websites( Reference Tate, Wing and Winett 37 ). The inclusion of electronic counselling and feedback,( Reference Tate, Jackvony and Wing 41 ) and behavioural lessons( Reference Gold, Burke and Pintauro 58 ) also promote weight-loss success. As described earlier, the data are inconsistent regarding the value of combining online and in-person counselling. Complicated programme structure is a barrier to use( Reference Anhoj and Jensen 12 ) and in-person sessions may be preferred to internet-based ones by some patients( Reference Harvey-Berino, Pintauro and Gold 59 ). Among users of one multi-component web interface, an evaluation using factor analysis revealed that ‘feedback features’ (e.g., progress charts, physiologic calculators and tools for journaling) most strongly predicted weight loss over 6 months, while ‘social support features’ (e.g., web chats, biographical information and email addresses of participants) best predicted success during the lifestyle maintenance phase( Reference Krukowski, Harvey-Berino and Ashikaga 60 ).

Any primary care weight-loss initiative faces diverse clinical barriers

The movement towards the use of online counselling in the primary care setting is largely in response to the considerable barriers to traditional obesity treatment approaches that exist in clinical practice (Table 2). Indeed, among some general practitioners and practice nurses, such barriers are cited in justification of an opinion that the detection and management of risk for type 2 diabetes is inappropriate for the primary care setting( Reference Williams, Rapport and Elwyn 65 ). Clearly, they must be understood and addressed if lifestyle support is to be integrated into a primary care practice.

Table 2. Barriers to counselling* for obesity treatment in clinical settings

* One source refers to counselling for CVD prevention, rather than obesity alone( Reference Tsui, Dodson and Jacobson 19 ).

Physician-related barriers

Physicians often perceive obesity treatment as lacking effectiveness( Reference Foster, Wadden and Makris 61 ) and they may lack the skills or knowledge to counsel effectively( Reference Tsui, Dodson and Jacobson 19 , Reference Kushner 20 , Reference Melin, Karlstrom and Berglund 63 ). They may also hold negative attitudes towards obese patients( Reference Melin, Karlstrom and Berglund 63 ).

Patient-related barriers

Although published patient-related barriers include a perceived lack of patient compliance or interest( Reference Tsui, Dodson and Jacobson 19 , Reference Kushner 20 ), other data indicate considerable patient interest in lifestyle change( Reference Wee, Hamel and Davis 66 ). In fact, patients generally report they would be comfortable discussing weight with their physician and would particularly like assistance with specific dietary and exercise recommendations as well as help setting realistic weight goals( Reference Potter, Vu and Croughan-Minihane 35 ). Yet many patients are less satisfied with their physicians’ expertise regarding weight control than they are with their general health care( Reference Wadden, Anderson and Foster 67 ), and look to their doctor for help with weight control ‘not at all’ (46%) or only ‘a slight amount’ (30%)( Reference Foster, Wadden and Makris 61 ). In addition, many patients lack knowledge of weight-related health risk. For example, many patients with diabetes overestimate the healthiest weight for their height( Reference McTigue, Hess and Bryce 68 ), which is important since perceiving weight as a health risk is associated with readiness for lifestyle change( Reference Wee, Hamel and Davis 66 ). On the other hand, patients can also overestimate the amount of weight loss needed for health benefit; in one study, 42% of participants believed this figure to be >10%( Reference Katz, Feigenbaum and Pasternak 69 ). Furthermore, travel and scheduling constraints can make adherence to intensive in-person counselling difficult for patients.

System-related barriers and potential solutions

Systemic factors such as a lack of reimbursement or time are the most-frequently cited( Reference Tsui, Dodson and Jacobson 19 , Reference Kushner 20 , Reference Foster, Wadden and Makris 61 , Reference Melin, Karlstrom and Berglund 63 ), and among the most daunting, barriers to clinical obesity treatment. The available time for preventive services is often inadequate. For example, fulfilling all the US Preventive Service Task Force's recommendations alone is estimated to take 7·4 h/d( Reference Yarnall, Pollak and Ostbye 70 ). In fact, prevention is often delivered during acute care visits, at which the acute issue must be prioritised( Reference Melin, Karlstrom and Berglund 63 , Reference Getz, Sigurdsson and Hetlevik 71 ) and primary care visits already address multiple problems( Reference Flocke, Frank and Wenger 72 ). Adding intensive obesity counselling to the physician's docket may thus not be realistic. Furthermore, depending on the health-care system, counselling costs (which can be substantial for an intensive behavioural intervention) may be difficult to cover. For example, in the US, health insurance coverage for lifestyle counselling for obesity is very limited( Reference Tsai, Asch and Wadden 73 ).

The internet may help overcome diverse clinical barriers to implementing lifestyle support into primary care medicine

Internet delivery may decrease cost and increase convenience of lifestyle interventions, particularly for people with time or travel constraints( Reference Ahern, Phalen and Mockenhaupt 74 ). Patients can access programmes online at times which fit into their busy schedules. Furthermore, the ability to access the programme from different sites frees patients from the need to travel to a fixed counselling site. They may log on to the programme from a variety of locations; from home, at the library, or even while travelling. By using online tools to supplement brief PCP advice or adding an online counsellor to the healthcare team, physicians’ inadequate training in lifestyle counselling can be mitigated as can the time limitations of the typical physician–patient visit. Furthermore, internet delivery of counselling may be compelling for its potential to (a) reduce staffing needs by enabling electronic transmission of standardised educational materials, including some automated counselling; (b) facilitate communication between patients and health providers; (c) provide a forum for collection, management and presentation of data, such as self-monitoring information; and (d) facilitate individualised tailoring of advice, either automatically, or via electronic communication with experts.

Limited data examine PCP perspectives on the use of online behavioural interventions in primary care. One qualitative study addressing this issue emphasises the importance of using an evidence-based approach and that of educating PCP of its content and effectiveness( Reference Hwang, Stuckey and Chen 75 ). Many providers had not utilised online weight-loss programmes because they were not familiar with them and/or raised concerns of efficacy. They also were wary that programmes would attempt to sell unsafe or untested weight-loss medications. The ‘ideal’ programme that emerged from their perspectives was a free resource using a structured, behavioural curriculum with assistance with goal setting, self-monitoring tools, motivational and peer support. Reception to the concept of PCP feedback was mixed and emphasised the need for a streamlined approach.

A referral model is one approach that has allowed smooth integration of evidence-based lifestyle counselling into primary care practice( Reference McTigue, Conroy and Bigi 76 , Reference McTigue, Conroy and Hess 77 ). To ensure minimal impact on patient flow or costs, and maximise the likelihood of staff and administrative support, it utilises existing clinical processes and resources. Likewise, existing infrastructure of the clinical setting (e.g., scheduling, communication and record-keeping practices) can be adapted for the provision of lifestyle support( Reference McTigue, Conroy and Bigi 76 ). In this model, the clinician initiates a referral for weight-loss treatment, akin to ordering a mammogram or a dermatology consultation. Routine referral processing mechanisms are then used to connect the patient with the online intervention staff, who provide occasional provider feedback. One study found that among patients who had completed an online 1-year weight loss intervention, accessed via referral from their PCP, physician feedback was reported by 89%, and 80% stated that the programme helped them to follow their physician's advice( Reference McTigue, Bhargava and Bryce 78 ).

Internet access is an important consideration for determining the reach of an online approach

Online interventions are not appropriate for patients who lack access to the internet at home or in public locations. However, internet access has expanded rapidly, with 68% of households in the European Union having broadband internet access in 2011 compared with 30% in 2006( 79 ). In the US, approximately 74% of adults were using the internet at the end of 2009 and 60% reporting broadband connections at home( 80 ). Furthermore, the greatest growth in broadband adoption in 2009 occurred in population sub-groups that have historically shown below-average internet use, including senior citizens, low-income Americans and rural adults( Reference Horrigan 81 ). Web use in minority groups in the US has also considerably expanded( Reference Horrigan 81 – Reference Nielsen 85 ). The internet is already often used to find health information, particularly to augment limited health resources. For example, fairly high health-related internet use (often from non-home access sites) has been found in samples with a high proportion of poor, urban, minority individuals( Reference Bleakley, Merzel and VanDevanter 86 – Reference Mandl, Feit and Pena 88 ). Clearly, there is interest in and increasing access to the internet. In addition, primary care patients find computer-based preventive medicine tools to be usable and acceptable in routine medical care( Reference Hess, Santucci and McTigue 89 ). Such momentum should be parlayed into better population health.

As the field of interactive behaviour change technology matures, nutrition and physical activity experts will face new challenges

One major challenge in online counselling is that we do not fully understand how best to create a therapeutic alliance in an online counselling context( Reference Barnett 90 ). It is clear that textual communication lacks non-verbal cues, so may lead to a higher rate of misinterpretation or miscommunications than does in-person conversation( Reference Ensher, Heun and Blanchard 91 , Reference Rochlen, Zack and Speyer 92 ). In particular, the communication of empathy may be particularly difficult via text( Reference Mallen, Vogel and Rochlen 93 ). Some options for promoting empathetic communication include the counsellor openly stating their emotional reactions to participant statements or describing their non-verbal reactions (e.g., ‘I have been smiling for the last few minutes because it seems like you are really making progress with problem-solving for healthier eating’)( Reference Mallen, Vogel and Rochlen 93 ). The use of emoticons has also been suggested, but raises concerns that such simplistic symbols may be insufficient for conveying the level of empathy needed for a true therapeutic relationship( Reference Mallen, Vogel and Rochlen 93 ). Asynchronous online communication also introduces the problem of time delay into the counselling process; unexplained delays in a lifestyle expert's response can lead to participant anxiety( Reference Rochlen, Zack and Speyer 92 ). In addition, the option of counselling participants who are geographically dispersed adds the challenge of coaches understanding and appropriately responding to local variations of word usage and colloquial expressions( Reference Barnett 90 ).

Another consequence of remote communication is that in the online counselling setting, it may be more difficult to assess and intervene in an emergency( Reference Rochlen, Zack and Speyer 92 – Reference Simkin-Silverman, Conroy and Bhargava 94 ). Therefore, patients who pose a danger to themselves or others may not be good candidates for online counselling (e.g., substance abusers, the severely depressed( Reference Mallen, Vogel and Rochlen 93 )) while those with serious physical health problems should be medically evaluated regarding their ability to safely undertake unsupervised physical activity and dietary change prior to enrolment. Because of the potential for health emergencies, online counsellors should be trained in how to respond to potential safety concerns, should know the identity of any client that they work with and should be aware of emergency services in that person's area. In addition, emergency procedures should be discussed before intervention begins and patient consent obtained at that time( Reference Mallen, Vogel and Rochlen 93 ).

For effective online communication, both the counsellor and the patient need strong writing skills, as well as skills in the use of computers and the internet( Reference Ensher, Heun and Blanchard 91 – Reference Mallen, Vogel and Rochlen 93 ). In addition, measures should be taken to verify the identity of online participants (e.g., password-protected websites)( Reference Rochlen, Zack and Speyer 92 ), to ensure safe data transfer (e.g., data encryption)( Reference Mallen, Vogel and Rochlen 93 ) and to inform patients of any limitations for protecting confidential information( Reference Mallen, Vogel and Rochlen 93 ). Furthermore, training is needed for the development of online counselling skills, and supervision (including the review of online counselling transcripts) is helpful to ensure the maintenance of such skills( Reference Mallen, Vogel and Rochlen 93 ). While a limited literature is beginning to emerge for the training and oversight of online lifestyle counsellors( Reference Simkin-Silverman, Conroy and Bhargava 94 ), further work is needed in this area.

The potential for reaching a wider population in a convenient and accessible manner will also create unique opportunities for providing lifestyle support

Accessing care via the internet can substantially increase convenience for those with transportation or scheduling barriers. In addition, online counselling may be a more acceptable approach than in-person counselling for those who feel stigmatised by the counselling process( Reference Rochlen, Zack and Speyer 92 ). Likewise, a disinhibiting effect of online communication or the act of writing itself may promote self-reflection( Reference Rochlen, Zack and Speyer 92 ). Furthermore, while changing the BMI of an individual whose friends/family are obese is difficult because neighbours pull the individual back to their original weight( Reference Bahr, Browning and Wyatt 95 ), the internet can help with the formation of new networks that are supportive of healthy lifestyles. Indeed, users of one large internet weight-loss community report that the forum provides them with encouragement and motivation, information and shared experiences( Reference Hwang, Ottenbacher and Green 96 ). Finally, online counselling may open new opportunities for lifestyle experts, such as increased flexibility of work hours or locations.

Conclusions

Internet delivery has the potential for overcoming long-standing clinical barriers to lifestyle counselling, so may represent an innovative approach for diabetes prevention and obesity treatment, as well as new opportunities and challenges for those with expertise in nutrition and physical activity counselling. To date, interventions that have been studied vary considerably in design (e.g., fully automated interventions, online asynchronous counselling, or web-based tools supplementing in-person counselling or community-based support). Studies show considerable heterogeneity in the effectiveness of online interventions to promote behaviour change and weight loss or the maintenance of weight loss. This was true for wholly online approaches as well as for interventions that combined in-person and online approaches. This finding contrasts with a recent review including shorter-duration studies which concluded that adults receiving computer-based care in addition to standard treatment lost, on average, 1·5 kg more than those receiving a more standard (typically in-person) treatment approach( Reference Reed, Schifferdecker and Rezaee 97 ). This discrepancy with our findings may reflect the small number of longer-duration studies or the fact that short-term effectiveness may be transient. Among the studies we reviewed, interventions without personalised in-person or online counselling were not effective. With so much variability in intervention effectiveness, it is essential to gain a better understanding of which programme components are linked with lifestyle success. A structured behavioural curriculum, electronic counselling and feedback mechanisms have been identified as useful features for weight loss, while social support features may be particularly important for supporting the maintenance of weight loss. The fact that internet-based care can provide effective online support in the primary care setting is encouraging, as studies engaging patients typically enrolled less selected samples than is typical in efficacy studies. In addition, clinical data indicate that there may be value of using an online approach among ethnic minority( Reference Rothert, Strecher and Doyle 54 ) and under-served populations( Reference Bennett, Warner and Glasgow 45 ).

Acknowledgements

The authors declare no conflict of interest. This review was completed without grant funding. Both authors abstracted key data from each reviewed article; K. M. primarily drafted the manuscript and M. C. critically revised the manuscript for important intellectual content.

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Figure 0

Table 1. Summary of randomised trial data with at least 12 months of follow-up, published 2000–2012

Figure 1

Fig. 1. Summary of weight change from baseline to follow-up for the ten randomised trials examining online approaches for promoting weight loss and healthy lifestyles. The weight change for each study arm is graphed separately, and studies are differentiated by bar colour. Most studies show weight loss at 12 months, but one indicates results at 16 months(46) and two show 24-month data(44,45). All results are displayed as change in kilograms with the exception of one using body weight percentage (Womble(51)) and another reporting kg/m2 (Turnin(50)).

Figure 2

Table 2. Barriers to counselling* for obesity treatment in clinical settings