articles nature publishing group

Behavior and Psychology

The Effect of Electronic Self-Monitoring

on Weight Loss and Dietary Intake:
A Randomized Behavioral Weight Loss Trial
Lora E. Burke1,2, Molly B. Conroy2,3, Susan M. Sereika1,4, Okan U. Elci1,4, Mindi A. Styn1,2,
Sushama D. Acharya1,2, Mary A. Sevick3–5, Linda J. Ewing6,7 and Karen Glanz8,9

Technology may improve self-monitoring adherence and dietary changes in weight loss treatment. Our study aimed
to investigate whether using a personal digital assistant (PDA) with dietary and exercise software, with and without
a feedback message, compared to using a paper diary/record (PR), results in greater weight loss and improved
self-monitoring adherence. Healthy adults (N = 210) with a mean BMI of 34.01 kg/m2 were randomized to one of three
self-monitoring approaches: PR (n = 72), PDA with self-monitoring software (n = 68), or PDA with self-monitoring
software and daily feedback messages (PDA+FB, n = 70). All participants received standard behavioral treatment.
Self-monitoring adherence and change in body weight, waist circumference, and diet were assessed at 6 months;
retention was 91%. All participants had a significant weight loss (P < 0.01) but weight loss did not differ among
groups. A higher proportion of PDA+FB participants (63%) achieved ≥5% weight loss in comparison to the PR group
(46%) (P < 0.05) and PDA group (49%) (P = 0.09). Median percent self-monitoring adherence over the 6 months was
higher in the PDA groups (PDA 80%; PDA+FB 90%) than in the PR group (55%) (P < 0.01). Waist circumference
decreased more in the PDA groups than the PR group (P = 0.02). Similarly, the PDA groups reduced energy and
saturated fat intake more than the PR group (P < 0.05). Self-monitoring adherence was greater in the PDA groups with
the greatest weight change observed in the PDA+FB group.

Obesity (2011) 19, 338–344. doi:10.1038/oby.2010.208

Introduction continues to be the paper record (PR), which is time consuming

Research has demonstrated a consistent relationship between
dietary self-monitoring and success in losing weight and main-
taining weight loss (1–4). Estimates from the 2008 National
Health Interview Survey show that the prevalence of over-
weight/obesity has plateaued; however, it is still at the level of
an epidemic (5). The extremely high rate of relapse following
weight loss treatment magnifies the seriousness of this public
health problem (5–7). An important challenge is to identify
practical strategies that individuals can use to increase aware-
ness of their energy intake and expenditure, which can help
them with long-term weight management.
Self-monitoring increases individuals’ awareness of their behav-
ior and the circumstances that precipitate or surround the behav-
ior (8). However, the most often-used method of ­self-monitoring
and tedious to complete. Moreover, the feedback that is received
from a PR is only present to the degree that the person records
and calculates subtotals. Furthermore, PRs do not permit imme-
diate, real-time external feedback to support and motivate the
individual. The addition of the tailored feedback message is a
logical next step and is based on evidence supporting the role
of feedback in reinforcing motivation for behavior change when
delivered in relation to goal achievement (9,10). Emerging tech-
nologies may improve self-monitoring and the success of weight-
loss treatment through the feedback mechanism.
Several recent studies have focused on the use of the Internet
for weight loss (4,11–13). In a study that tested the use of an
Internet-delivered behavioral weight loss program, Tate and
colleagues showed that the number of weekly diaries submitted

1
University of Pittsburgh School of Nursing, Department of Health and Community Systems, Pittsburgh, Pennsylvania, USA; 2University of Pittsburgh Graduate School
of Public Health, Department of Epidemiology, Pittsburgh, Pennsylvania, USA; 3University of Pittsburgh School of Medicine, Department of Medicine, Pittsburgh,
Pennsylvania, USA; 4University of Pittsburgh Graduate School of Public Health, Department of Biostatistics, Pittsburgh, Pennsylvania, USA; 5Veterans Affairs
Pittsburgh Healthcare System, Center for Health and Equity Research and Promotion, Pittsburgh, Pennsylvania, USA; 6University of Pittsburgh School of Medicine,
Department of Psychology, Pittsburgh, Pennsylvania, USA; 7University of Pittsburgh School of Medicine, Department of Psychiatry, Pittsburgh, Pennsylvania, USA;
8
University of Pennsylvania School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia, Pennsylvania, USA; 9University of Pennsylvania School of
Nursing, Family and Community Health Division, Philadelphia, Pennsylvania, USA. Correspondence: Lora E. Burke (lbu100@pitt.edu)
Received 24 March 2010; accepted 19 July 2010; published online 16 September 2010. doi:10.1038/oby.2010.208

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 articles
Behavior and Psychology

online was significantly related to weight loss (4). A later study
by this same group examined E-mail feedback for weight loss
(12). Individuals in two intervention groups received weekly
reminders to complete the online diary. One group received a
preprogrammed computer message on a webpage and the other
group received an E-mail message from a weight loss coun-
selor; diary submission was significantly related to weight loss
in both groups. Weight loss between the groups was comparable
at 3 months; however, the group that received the E-mail mes-
sage lost significantly more weight at 6 months. These studies
laid the foundation for technologically supported behavioral
weight loss programs that have the potential to reach a large
portion of the population. However, for many individuals, use
of an online diary may limit accessibility and does not permit
one to check the nutrient content of foods before eating. In a
pilot study, where women in a diet modification trial were given
personal digital assistants (PDAs) for self-monitoring with feed-
back, participants significantly increased their self-monitoring
and more often achieved dietary goals (14). In a 4-week, diet-
focused weight loss trial that compared PDA for self-monitoring
to PR, dietary adherence was significantly higher in the PDA
group (43%) compared to the PR group (28%) (15); adherence
to the self-monitoring method was not reported. Despite the
proliferation of hand-held devices, no one has examined the use
of PDAs with dietary and exercise software for self-monitoring
in behavioral weight loss treatment. Moreover, no clinical trials
have examined the use of a PDA to deliver a tailored feedback
message in response to the recorded behavior.
The aim of this study was to determine whether self-mon-
itoring diet and exercise using a PDA, with or without tai-
lored feedback (PDA or PDA+FB), was superior to using a PR
for promoting and maintaining weight loss. We conducted a
three-group randomized clinical trial to examine the efficacy
of using a PDA as a means to improve adherence to self-mon-
itoring as part of a standard, 24-month behavioral interven-
tion for weight loss. This article presents the initial results of
the study at 6 months. We hypothesized that the groups using
the PDA would achieve greater weight loss for the short-term
(6 months) than those who use the PR. We also hypothesized
that those assigned to the PDA+FB group would show better
self-monitoring adherence than either of the other two treat-
ment groups, and that the PDA groups would show better self-
monitoring adherence than the PR group.
Methods and Procedures
Study design
The methods of the Self-Monitoring and Recording using Technology
(SMART) have been detailed elsewhere (16). Briefly, SMART was a
single-center, randomized clinical trial of behavioral treatment for
weight loss. All participants received a 24-month standard behavioral
weight loss treatment and were randomly assigned to use one of three
self-monitoring tools: (i) PR, (ii) PDA, or (iii) PDA+FB (Figure 1).
Outcome data were collected at semiannual assessments. This report
focuses on the results from the 6-month assessment.
Participants and randomization
Participants were recruited from the community in three cohorts from
2006 to 2008. Eligible individuals were between 18 and 59 years of age
Assessed for eligibility by phone (n = 704)
Excluded (n = 494)
• Did not meet eligibility criteria (n = 263)
• Declined to participate ( n = 198)
• Other reasons (n = 33)
Randomly assigned (n = 210)
Assigned to PR group Assigned to PDA group Assigned to PDA+FB
(n = 72) (n = 68) group (n = 70)
Discontinued study
participation (n = 9)
Discontinued study
participation (n = 4)
Discontinued study
participation (n = 5)
• Lost to follow-up (n = 7) • Lost to follow-up (n = 3) • Lost to follow-up (n = 3)
• Pregnancy (n = 1) • Pregnancy (n = 1) • Pregnancy (n = 1)
• Withdrawal (n = 1) • Withdrawal (n = 1)
Analyzed (n = 72) Analyzed (n = 68) Analyzed (n = 70)
Excluded from Excluded from Excluded from
analysis (n = 0) analysis (n = 0) analysis (n = 0)
Figure 1  CONSORT diagram. PDA, personal digital assistant; PDA+FB,
personal digital assistant plus feedback; PR, paper record.
and had a BMI between 27 and 43 kg/m2. We excluded individuals with
conditions that required medical supervision of diet or exercise and
those who participated in a weight-loss program in the 6 months before
recruitment or planned an extended vacation or relocation during the
24-month study period (16).
Of the 704 individuals screened for eligibility, 210 were enrolled in
the trial. The participants were randomly assigned, stratified by gender
and ethnicity, to one of the three different modes of self-monitoring. All
participants provided written informed consent. The study protocol was
approved by the University of Pittsburgh Institutional Review Board.
Participants were compensated only for their time in completing the
6-month assessment.
Intervention
All three treatment groups received the same standard behavioral
intervention, which has been successfully used in multiple studies
(8,17,18). The intervention included: (i) daily self-monitoring of eating
and ­exercise behaviors, (ii) group sessions, (iii) daily dietary goals, and
(iv) weekly exercise goals.
Self-monitoring. Participants in the PR group were given standard
paper diaries and instructed to record all foods eaten, the calories,
and fat grams, as well as minutes of exercise. At the first group session,
they were given a reference book that contained nutrition informa-
tion and were trained in how to determine the calorie and fat gram
content of their foods. Participants in the PDA and PDA+FB groups
were provided with Palm Tungsten E2 PDAs with self-monitoring soft-
ware that tracked energy and fat consumption and displayed current
intake related to daily goals and also provided easily accessed nutrition
information (Dietmate Pro) (15,19) and CalculFit (PICS, Reston, VA).
Participants in the PDA+FB group had a custom software program on
their PDAs with a feedback algorithm that provided daily messages tai-
lored to their entries and provided positive reinforcement and guidance
for goal attainment. Participants in the PDA and PDA+FB groups were
trained in how to use the PDA and self-monitoring software in the first
two group sessions.
The feedback messages varied by the time of day and conditions of
reported intake, e.g., if between 10:00 am and noon, a participant had
reported consuming >40% of the calorie allowance but only 20–40%
of the fat goal, a sample message could be “Good job making choices
low in fat. Watch portion sizes to control calories.” The feedback mes-
sages focused on diet could be delivered between 10:00 am and 9:00 pm.
The details of the feedback messages and algorithm are published else­
where (16).

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At each session, PR participants submitted their diaries and received
new ones to use until the next session. The interventionist reviewed those
diaries, provided written feedback, and returned the diaries at the next
session. The PDA and PDA+FB participants turned in their PDAs at
the beginning of the session, the self-monitoring data were uploaded
into the study database and the PDAs were returned to participants at
the end of the session. The interventionists received printed reports that
appeared similar to the standard paper diaries for their review and wrote
comments, which were returned to the participants at the next group
session.
Group sessions. There were 16 weekly and 4 biweekly group sessions
during the first 6 months. Sessions focused on nutritional and behav-
ioral counseling and practical hands-on experiences to develop skills to
implement a healthy lifestyle.
Dietary and exercise goals. Each participant received a daily energy
and fat gram goal based on their gender and baseline weight consis-
tent with standard behavioral weight loss treatment (18). The daily
energy intake goal was between 1,200 and 1,500 calories for females
and between 1,500 and 1,800 for males; the fat allowance was 25% or
less for all. They were counseled to reach a weekly goal of 150 min of
moderate intensity exercise by the 6th week.
Outcome measures
Our primary outcome was change in weight at 6 months. We measured
weight on a digital scale with the participant in light clothing and not
wearing shoes. Secondary outcomes included adherence to self-mon-
itoring, waist circumference, and diet. Adherence to self-monitoring
diet was measured on a weekly basis and analyzed as a binary variable
based on whether a participant completed daily recordings of food,
energy intake, and fat grams (adherent: self-monitored, nonadher-
ent: did not self-monitor). If the weekly record indicated that a par-
ticipant consumed ≥50% of the weekly calorie goal, the participant was
defined as adherent to self-monitoring for that week. For example, a
participant with a daily calorie goal of 1,200 (weekly goal = 8,400 kcal)
would be adherent to self-monitoring if the person recorded consum-
ing ≥4,200 calories for that week. If a diary was not returned, adherence
to self-monitoring was coded as nonadherent for that week. However,
if a PR participant missed a group session, the completed diary could
be mailed or brought it in at the next session to be counted for self-
monitoring. Since all the recordings on the PDA were stored, the days/
weeks of previous recordings were included in the adherence measure.
Adherence to self-monitoring physical activity was determined by the
number of entries reporting physical activity. Waist circumference was
measured at 1 inch above the umbilicus with a Gulick II measuring
tape at baseline and 6-month assessments. Dietary intake was assessed
through two unannounced 24-h dietary recalls (1 weekday and 1 week-
end day) at baseline and 6 months and the data were analyzed using the
Nutrition Data System for Research software (Nutrition Coordinating
Center, University of Minnesota).
Statistical analysis
Statistical analyses were conducted using SAS version 9.1.3 (SAS
Institute, Cary, NC). The significance level was set as P ≤ 0.05. Analyses
were performed using the intention-to-treat principle regardless of
the participant’s adherence and retention. Missing data were handled
by a baseline value carried forward imputation approach. Summary
statistics were reported as mean (s.d.) and frequency count (%). For
those continuous variables having outliers, the median (interquartile
range) was also reported. Changes from baseline to 6 months were

Table 1  Baseline characteristics by treatment groupsa

Variable PR (n = 72) PDA (n = 68) PDA+FB (n = 70) Total (N = 210)
Demographics
  Age (years)  47.4 (8.5) 46.7 (9.2) 46.4 (9.5) 46.8 (9.0)
  Women, n (%) 61 (84.7) 58 (85.3) 59 (84.3) 178 (84.8)
  White, n (%) 55 (76.4) 55 (80.9) 55 (78.6) 165 (78.6)
  Married, n (%) 55 (76.4) 42 (61.8) 47 (67.1) 144 (68.6)
  Employed full time, n (%) 62 (86.1) 58 (85.3) 54 (77.1) 174 (82.9)
  Education (years) 15.9 (3.1) 15.5 (2.9) 15.5 (3.0) 15.7 (3.0)
Anthropometry
  BMI (kg/m2)
   Women 33.9 (4.6) 33.5 (3.8) 34.2 (4.8) 33.9 (4.4)
   Men 32.9 (4.4) 36.3 (5.4) 35.5 (4.4) 34.9 (4.8)
  Waist circumference (cm)
   Women 104.3 (11.4) 102.4 (10.1) 103.4 (13.2) 103.4 (11.6)
   Men 114.7 (11.7) 120.2 (12.0) 118.9 (10.3) 117.9 (11.2)
Dietary intake
  Energy intake (kcal/day)b 1,970 (1,533, 2,483) 1,931 (1,705, 2,579) 1,990 (1,688, 2,362) 1,970 (1,608, 2,458)
  % kcal total fat 33.2 (7.3) 34.3 (6.9) 33.9 (7.4) 33.8 (7.2)
  % kcal SFA b
11.3 12 11.1 11.4
(8.9, 13.4) (9.0, 14.2) (9.9, 13.8) (9.2, 13.8)
  % kcal MUFA 12.1 (2.8) 12.7 (2.9) 12.6 (3.3) 12.5 (3.0)
  % kcal PUFA 7.1 (2.6) 7.2 (2.5) 6.8 (2.4) 7.0 (2.5)
MUFA, monounsaturated fatty acids; PDA, personal digital assistant; PDA+FB, personal digital assistant with the added customized feedback program; PR, paper record;
PUFA, polyunsaturated fatty acids; SFA, saturated fatty acids.
a
Data are presented as mean (s.d.) unless otherwise indicated. bValues are reported as median (interquartile range).

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used in the analyses. Successful (clinically meaningful) weight change
was defined as ≥5% weight loss. The F-test from a one-way ANOVA
or the Kruskal–Wallis test for continuous variables and χ2-test of inde-
pendence for categorical variables were used to compare the baseline
characteristics, anthropometric, and dietary variables as well as the
change scores for dietary intake and waist circumference and average
adherence to self-monitoring diet and physical activity over 6 months.
A dependent t-test was used to examine the changes from baseline to
6 months within each treatment group. Hypotheses regarding changes
from baseline to 6 months across the treatment groups were tested using
planned comparison via specified linear contrasts: (i) PDA, PDA+FB
vs. PR and (ii) PDA vs. PDA+FB for weight loss and adherence to self-
monitoring.
Mixed-effect logistic regression modeling was applied to assess the
effect of treatment groups and time on self-monitoring adherence. Both
linear and nonlinear functions of time (e.g., square root and squared
function of time) were considered. We used the likelihood ratio test
to assess treatment group and time effects to achieve more parsimoni-
ous models. Sensitivity analyses were conducted for outliers identified
through graphical methods. When outliers were omitted via sensitivity
analysis, the results did not change, supporting the robustness of our
findings.
Results
The sample was predominantly female (85%) and white (79%).
We found no significant differences in baseline demographic
and anthropometric characteristics among the three treatment
groups (Table 1). We also did not find statistically significant
differential attrition/retention among the three treatment
groups. Ninety-one percentage (n = 192) completed the
6-month assessment with no differences in race, gender, age,
weight, or BMI between completers and noncompleters.
At 6 months, the percent mean (s.d.) weight loss was statisti-
cally significant (P < 0.01) for all treatment groups (PR 5.3%
(5.9)%; PDA 5.5% (7.0)%; and PDA+FB 7.3% (6.6)%), with no
significant differences among the groups. However, a higher
proportion of participants in the PDA+FB group (63%)
achieved ≥5% weight loss in comparison to the PR (46%)
(P = 0.04) and PDA (49%) (P = 0.09) groups whereas there
was no significant difference in the proportion between the
combined PDA groups and the PR group (P = 0.17). Post hoc
analyses revealed a significant difference in the proportion that
achieved a ≥5% weight loss between the PDA+FB group and
the combined PDA and PR groups (P = 0.03).
The overall median adherence to self-monitoring for the
entire study period of 6 months was better in the PDA groups
than in the PR group; the proportion of sample adherent was
90, 80, and 55% in the PDA+FB, PDA, and PR groups, respec-
tively (P < 0.01). The pattern of adherence to self-monitoring
over time among the treatment groups is displayed in Figure 2.
Adherence was highest in the second week (PDA 97%; PDA+FB
96%, and PR 85%); however, self-monitoring began to decline
by the 3rd week. At 6 months, 53% of the PDA and 60% of the
PDA+FB groups were adherent to self-monitoring whereas
only 31% of the PR group was. There was no significant dif-
ference between the PDA and PDA+FB groups in adherence
to self-monitoring over time (P = 0.11); however, adherence to

Group: PD PDA PDA+FB

1.0

0.9

0.8

0.7
Proportion

0.6

0.5

0.4

0.3

0.2

0.1

0.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time (weeks)

Figure 2  Proportion of participants adherent to self-monitoring over time (N = 210). Based on the nonlinear mixed effects modeling, adherence to
self-monitoring decreased over time in all treatment groups (P < 0.001). The PDA+FB group was more adherent than the PR group (P = 0.003) and
the PDA group was more adherent than the PR group (P < 0.001). There was no significant difference between the PDA and the PDA+FB groups
(P = 0.11). PR, paper record; PDA, personal digital assistant; PDA+FB, personal digital assistant with the added customized feedback program.

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self-monitoring over time was significantly higher in the PDA
(P < 0.01) and PDA+FB (P < 0.01) groups compared to the PR
group.
Adherence to self-monitoring physical activity followed a
pattern similar to adherence to self-monitoring dietary intake.
On average, the PR group recorded 2.2 (1.8) entries per week
over the 6-month period compared to the PDA group record-
ing 2.7 (1.8) and the PDA+FB group recording 3.2 (1.8) entries
per week (P = 0.006). Post hoc analyses revealed that the PR
group was significantly less adherent than the combined PDA
and PDA+FB groups (P = 0.007).
Table 2 shows changes within and between groups. Percent
median (interquartile range) waist circumference also
decreased significantly (P < 0.01) within each group (PR −4.0%
(−8.4, 0.0)%; PDA −5.0% (−8.5, −1.7)%; and PDA+FB −6.4%
(−11.5, −1.8)%) and was significantly different among groups
(P = 0.03). Post hoc analyses revealed a significant difference in
percent waist circumference change between the PDA groups
and the PR group (P = 0.02).
Total energy intake (median (interquartile range)) decreased
significantly among the three groups (PR −12.5 (−34.7, 0.0)%;
PDA −19.9 (−39.2, −1.6)%; and PDA+FB −23.3 (−40.6, −8.3)%
(P = 0.05). The combined PDA group reduced total energy
(P = 0.03) and saturated fat (P = 0.03) intake more than the
PR group.
Discussion
This study demonstrated that participants who used a PR, a
PDA with dietary and exercise software or a PDA with the
same software and a daily, tailored feedback message achieved
significant weight loss at 6 months. A higher proportion of
the PDA+FB group achieved a ≥5% weight loss than the PR
and PDA groups, suggesting that the daily tailored feedback
messages may have enhanced the effect of standard behavioral

Table 2  Percent changes in weight, waist circumference, and dietary intake by groups at 6 months
Variable PR (n = 72) PDA (n = 68) PDA+FB (n = 70) P valuea
Weight b

  Median (IQR) −4.6 (−8.6, −0.5) −4.8 (−9.3, −0.5) −6.5 (−10.4, −2.7) 0.12
  Mean (s.d.) −5.3 (5.9) −5.5 (7.0) −7.3 (6.6)
Waist circumference b,c

  Median (IQR) −4.0 (−8.4, 0.0) −5.0 (−8.5, −1.7) −6.4 (11.5, −1.8) 0.03
  Mean (s.d.) −4.6 (6.0) −5.5 (5.4) −6.9 (5.8)
Energy intakeb,c
  Median (IQR) −12.5 (−34.7, 0.0) −19.9 (−39.2, −1.6) −23.3 (−40.6, −8.3) 0.05
  Mean (s.d.) −11.9 (31.9) −16.7 (31.7) −24.0 (22.4)
  Trimmed mean (s.d.) −17.4 (22.7) −20.8 (25.3) −26.6 (19.1)
% kcal total fat b

  Median (IQR) 0.0 (−21.3, 8.7) −9.2 (25.4, −0.1) −12.6 (−32.8, 0.0) 0.12
  Mean (s.d.) −5.5 (27.0) −9.2 (20.7) −14.0 (25.0)
  Trimmed mean (s.d.) −7.7 (23.9) −10.2 (19.0) −14.0 (25.0)
% kcal SFA b,c

  Median (IQR) 0.0 (−31.5, 17.7) −11.3 (−31.9, 4.5) −17.5 (−36.1, 0.0) 0.08
  Mean (s.d.) −1.9 (36.3) −7.8 (36.4) −14.4 (32.0)
  Trimmed mean (s.d.) −6.7 (28.4) −15.5 (22.3) −15.9 (29.5)
% kcal MUFAb
  Median (IQR) −5.4 (−23.4, 15.2) −8.9 (−26.8, 4.2) −11.5 (−31.6, 8.2) 0.37
  Mean (s.d.) −2.9 (33.5) −8.8 (25.6) −11.6 (30.5)
  Trimmed mean (s.d.) −8.0 (26.0) −11.2 (21.9) −13.0 (28.6)
% kcal PUFAb
  Median (IQR) −4.3 (−33.1, 11.0) −3.3 (−29.9, 9.5) −15.4 (−40.9, 15.4) 0.42
  Mean (s.d.) −4.6 (41.3) −2.8 (35.3) −8.6 (43.4)
  Trimmed mean (s.d.) −9.5 (34.3) −9.5 (26.9) −13.8 (35.1)
Trimmed mean (s.d.) is calculated by excluding outliers.
IQR, interquartile range; MUFA, monounsaturated fatty acids; PDA, personal digital assistant; PDA+FB, personal digital assistant with the added customized feedback
program; PR, paper record; PUFA, polyunsaturated fatty acids; SFA, saturated fatty acids.
a
P value calculated from Kruskal–Wallis test for the comparison of three groups. bP < 0.05 are for significant changes within treatment groups. cP < 0.05 are for significant
differences between the PR and the PDA (PDA and PDA+FB).

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weight loss treatment. Overall, the weight loss was good in all
three groups, which might be explained by the frequent group
sessions during the first 6 months. The attention and guidance
received through the standard behavioral intervention facili-
tated weight loss across all groups and thus the difference by
method of self-monitoring was less pronounced than what was
expected. We also demonstrated that those in the PDA and
the PDA+FB groups were significantly more adherent to self-
monitoring than those in the PR group. While the findings do
not support our hypothesis that the PDA+FB group would be
more adherent to self-monitoring than the PDA group, they do
support our hypothesis that the groups who used a PDA would
be more adherent than the PR group.
This was the first large randomized clinical trial to compare
different methods of self-monitoring in a behavioral weight loss
intervention and to compare the use of PDAs to conventional
paper diaries. Two previous studies addressed self-monitoring
methods and reported a significant association between the
number of diaries completed and weight loss; however, nei-
ther of them reported a group difference in weight loss (20,21).
Because of the methodological limitations in both studies, one
cannot definitively conclude that approaches to self-monitor-
ing other than the use of paper diaries result in better adher-
ence or weight loss outcomes. However, our findings from this
randomized trial with excellent retention do provide prelimi-
nary data to suggest that there is improved adherence to self-
monitoring with the use of a PDA.
Tate and colleagues reported previously on a weight loss
study that used a feedback system (12). While the group receiv-
ing the automatic computer feedback messages was compara-
ble in weight loss to the human E-mail counseling group at
3 months; at 6 months, the E-mail counseling group had sig-
nificantly greater weight loss than the computer-automated
feedback group or no counseling group. The main difference
between that study and our trial is that the computer feedback
message in their study was delivered on a weekly basis and
our PDA-delivered feedback message occurred daily (16). The
significantly greater weight loss in our PDA+FB group sug-
gests that the combined self-monitoring and feedback message
delivered in real-time and on a daily basis might have provided
the reinforcement and sustained motivation that was needed
to improve weight loss.
The findings supported the difference in adherence to self-
monitoring between the combined PDA groups and the PR
group but the adherence in the two PDA groups was similar.
As can be seen in Figure 2, the slope of the adherence curve
began to decline at 3 weeks and steadily declined thereafter
with only 30% of the PR group self-monitoring at 6 months.
However, adherence for the two PDA groups was sustained
by over 70% of the participants in these groups until the 12th
week. At 6 months, it was still above 50%. This decline in self-
monitoring over time has been a consistent finding in several
studies (12,22). The decline that we observed in this study is
slightly less than what we observed in a previous trial (23) and
most important, the decline in the PDA groups was signifi-
cantly less than what was observed in the PR group.
obesity | VOLUME 19 NUMBER 2 | February 2011
articles
Behavior and Psychology
While the study demonstrated that the use of the PDA
improved adherence to self-monitoring in both groups (90% in
PDA+FB and 80% in PDA), it was unclear why the improved
adherence in the PDA without feedback group did not lead to
a greater weight loss than what we observed. This may suggest
a more central role for individualized feedback to goal attain-
ment. This finding is consistent with the behavioral princi-
ples that document that feedback, both reinforcing feedback
and corrective or redirective feedback, enhances motivation
toward goal attainment. The feedback message functioned as a
compass that enabled the individual to stay on course toward
the goal; it also functioned as a source of more frequent atten-
tion that “someone” was noticing what the participant was
doing, which was another powerful reinforcer, regardless of
the nature of the feedback.
The goal of teaching an individual to self-monitor is that
the person will learn to use the tool to provide information
(feedback), and will use the information to self-correct behav-
iors (e.g., eating or food intake). However, many individuals
do not make that connection easily, which probably contrib-
utes to their stopping self-monitoring, since they never used
the strategy in a way that made a difference or sense to them.
The addition of a programmed, tailored feedback message may
have helped them make that connection (24).
Our findings showed that the participants in the PR group
were consistently less adherent to self-monitoring over the 6
months. This might have been explained by the disadvantages
to using a PR (25). Individuals who use a PR are faced with
the labor of maintaining handwritten records, searching for
the nutrient composition of foods in a pocket manual, and cal-
culating subtotals for nutritional intake. In a previous study
of participants who used PR, participants reported that self-
monitoring was often time-consuming and burdensome (26),
which often led them to record at the end of the day or days
later (27). This practice eliminated the opportunity to take cor-
rective action if one was close to the daily energy or fat goal.
In contrast, benefits of using the PDA included its portability
and immediate access to a US Department of Agriculture data-
base containing 5,000–6,000 food items including brand and
restaurant foods, real-time calculation and display of dietary
subtotals in relation to daily goals, and saving commonly eaten
meals. Participants reported that its use was socially accept-
able and thus reduced the uneasiness that might have accom-
panied self-monitoring in social settings. Finally, advances
in wireless technology now permit transmittal of monitoring
and feedback, which provide opportunities for intervention
­delivery (28).
There could be limitations to using a PDA. Use of techno-
logical devices might have been a barrier for some individu-
als; however, participants who were technologically naive were
able to learn how to use the device. It is still unclear if a person
saves time with a PDA (19), as this may vary depending on the
software being used and the screen design.
The major strengths of our study included the randomized
trial design with objective measures of the anthropometric
measures and its innovative approach to examining the use of
343
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Behavior and Psychology
a technology that is becoming ubiquitous. It was the first large
trial to compare the efficacy of PDAs with combined diet and
exercise software to the traditional PR in improving weight loss
and adherence to self-monitoring. An additional strength was
our 91% retention rate at 6 months and the 21.4% minority rep-
resentation. An important limitation was that we achieved only
15.2% male representation despite extra efforts that were made to
recruit men. Additionally, the study design was for a 24-month
final testing of the hypothesis; the results presented here were for
6 months and thus only revealed the short-term outcomes.
In summary, in our study that used three different approaches
to self-monitoring diet and exercise, each group achieved a
significant weight loss. Moreover, a higher proportion of the
PDA+FB group achieved a clinically significant weight loss
(5%) than the PDA and PR groups. The daily tailored feed-
back appears to have enhanced the effect of the behavioral
treatment. Our study revealed that a significantly greater pro-
portion of participants in the PDA and the PDA+FB groups
self-monitored compared to those in the PR group. Also, there
were significant within and between group differences in waist
circumference and energy intake at 6 months. These findings
suggest that use of an electronic diary facilitates improved
self-monitoring; however, the use of an electronic diary plus
a daily feedback message that was tailored to what had been
entered in the diary was related to the best weight loss.
Acknowledgments
We gratefully acknowledge the participants in this study who so willingly
gave of their time to complete the assessments. This study was supported
by National Institutes of Health grants #RO1-DK71817 and partial support
for L.E.B. by NIH K24 Award, NR010742. The conduct of the study was
also supported by the Data Management Core of the Center for Research
in Chronic Disorders NIH-NINR #P30-NR03924 and the General Clinical
Research Center, NIH-NCRR-GCRC #5MO1-RR00056 and the Clinical
Translational Research Center, NIH/NCRR/CTSA Grant UL1 RR024153 at
the University of Pittsburgh.
Disclosure
The authors declared no conflict of interest.
© 2010 The Obesity Society
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