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CHAPTER 28
e-Health: Developing Personal Skills for Weight Management
K. Ashlee McGuire and Sasha Wiens

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LEARNING OBJECTIVES
After studying this chapter, you should be able to:

1. Describe the challenges and opportunities for the use of technology in client-centred care

2. Describe a process for client engagement and support by using e-health strategies

Introduction
The prevalence of obesity in Canada has increased substantially; individuals with a body mass index (BMI) ≥30 kg/m2 increased 200% between 1985 and 2011 (Twells et al., 2014). The most marked increase is seen in those individuals that are in the higher classes of obesity. Specifically, the number of adults presenting with class III obesity (severely obese) increased by almost 450% between 1985 and 2011 whereas the number of adults presenting with class I obesity (moderately obese) increased by approximately 150% (Twells et al., 2014). Adults with obesity, especially those in higher classes of obesity, are at an increased risk of numerous chronic conditions (e.g., type 2 diabetes / hypertension), poor quality of life, functional limitations, and mental health concerns (Luo et al., 2007) (see Table 28.1). Obesity is also associated with a substantial economic burden that is estimated to be between $4.6 and $7.1 billion annually (Anis et al., 2010; Hodgson, 2011). Annual health care costs associated with obesity are now estimated to be higher than those associated with smoking ($1,330 versus $1,022, respectively per person in 2011) (An, 2015).

Although intentional weight loss of 5%–10% of body weight is associated with a 15% reduction in all-cause mortality (Kritchevsky et al., 2015), adherence to weight-loss interventions is generally poor (Coons et al., 2012). Thus, encouraging and sustaining reductions in obesity and obesity-related health conditions remain challenging for both the health care providers who are expected to counsel and assist clients in this journey and for the clients themselves. Challenges may be due to the complexity of obesity as a condition; in addition, social, environmental, genetic, lifestyle, emotional, and cultural factors all contribute to obesity prevalence (Hodgson, 2011).

TABLE 28.1 Canadian Guidelines for Body Weight Classification in Adults

TECHNOLOGY AND HEALTH PROMOTION
In recent years, technological advances and increased reliance on automated, energy-saving devices have emerged as key contributors to the increased rates of obesity (Dunstan et al., 2010; Tremblay et al., 2010; Gilmore et al., 2014). Canadians in particular have demonstrated an affinity for the Internet and mobile device usage, which is often captured as “screen time” or “sedentary behaviour” in the literature and associated with negative health outcomes such as obesity (Tremblay et al., 2010). In Canada, 83% of households own a cell phone (Statistics Canada, 2014) of which 57% constitutes smartphone ownership (Canadians Connected, 2014). Canadians are world leaders in Internet usage; on average, Canadians visit 3,731 web pages, spend 41.3 hours surfing the web, and watch videos for 24.8 hours per month. On average, 87% of households connect to the Internet daily (Canadians Connected, 2014).

Despite the negativity surrounding the use of technology and its impact on health, technology in conjunction with the Internet may also present a promising opportunity to assist health care providers to deliver innovative, engaging, and effective care to Canadian adults seeking assistance with obesity management. Indeed, delivering interventions and care via the Internet holds considerable promise as it improves access for people with transportation and/or mobility limitations and for those who live in rural or remote locations, it is readily available at all times, and it can reach a large number of people at low cost. As well, statements such as, “the Internet is part of the day-to-day lives of Canadians” (Canadians Connected, 2014) and “we live in a world wirelessly with almost as many cellular phone subscriptions as there are people on the planet” (PwC, 2014, p. 3) speak to the social acceptability and ubiquity of technology in our current environment.

Internet-based and technology-enhanced interventions and strategies to support weight loss may include a variety of tools such as (but not limited to) text messaging, smartphone applications, internet-based education, peer or provider support, and self-monitoring options. Based on systematic reviews and meta-analyses, there is evidence to suggest that internet-based and technology-enhanced interventions may be effective in or offer promise in promoting significant weight loss (Coons et al., 2012; Kirk et al., 2012; Gilmore et al., 2014; Hutchesson et al., 2015), especially those incorporating a component to address behaviour change, a self-monitoring component using individual data, and a component focused on personalized feedback (Gilmore et al., 2014). However, the mean difference in weight loss demonstrated in a recent meta-analysis of internet-based or technology-enhanced interventions compared to no or minimal interventions, was less than traditional (e.g., face-to-face) behavioural weight-loss interventions (Hutchesson et al., 2015). Additionally, there is significant heterogeneity in program components, length, and specific mode of delivery. This variability makes it difficult to draw concrete conclusions regarding the use of specific tools (i.e., smartphone applications, text messaging), but it does suggest that the tools are simply the vehicle by which to deliver the intervention and their success is determined more by the components included in the intervention and strategies used to encourage both compliance and retention.

Patients in a global study of the use of mobile devices and health care (n = 1,027 from 10 countries; representing a variety of economic backgrounds, ages, levels of education, and states of health) report that they expect technology, most specifically mobile technology, to make health care more convenient, improve its quality, and reduce costs (PwC, 2014). Further, patients in the study anticipated using mobile technology to seek information pertaining to specific health conditions, self-manage their health, communicate with their health care providers, and allow their health care providers to monitor their condition and compliance with treatment (PwC, 2014). Interestingly, it is those patients with poorly managed conditions who were most likely to be engaged in and using technology to assist in their management (82% with a poorly managed condition versus 64% of those from the general population) (PwC, 2014). The clear expectations for the use of technology by patients and the promising evidence suggest that incorporating technology-enhanced and/or internet-based tools may prove beneficial for health management. This evidence prompted the Adult Bariatric Specialty Clinic (ABSC) in Calgary to explore the use of internet-based tools to meet increasing demands for their weight management service.

RESPONDING TO CLIENT NEED: CREATING A SUPPORTIVE ENVIRONMENT
Twells et al. (2014) reported that the prevalence of adults living in Alberta with class II obesity is 4.3% and with class III obesity is 1.4% (i.e., they would meet the criteria for entry into the ABSC). Assuming this prevalence in Calgary, approximately 45,000 adults aged 20–64 years (of a total population of 790,061 in this age range (City of Calgary, 2014)) would be eligible to receive weight management support from the ABSC. Presently, the ABSC receives approximately 100 referrals per month. To maintain access to their services and minimize wait lists, the ABSC team began an ongoing process of quality improvement. They chose to integrate key components from the Ottawa Charter (WHO, 1986) and the Knowledge-to-Action Cycle model (Straus et al., 2013) into their clinic process as they recognized the importance of empowering clients to self-manage, developing or adapting their services based on the examination of health needs, current knowledge, barriers and facilitators to treatment, engaging relevant partners, and tailoring of evidence-based practices for local implementation. The use of the Ottawa Charter and model has allowed the team to adapt their program and services as the environment demands and provide clients with individualized care.

Community Assessment
The first step in population health promotion is to understand the issue and the people it affects by conducting an assessment. To begin, the ABSC used postal codes to geo-map (i.e., create a visual representation on a map) where its clients were located. As seen in Figure 28.1, although ABSC clients lived throughout the city, there were distinct areas where there was a higher concentration of clients. Consistent with the literature describing the socioeconomic and social contributors to obesity (Hodgson, 2011), these neighbourhoods also had a high percentage (relative to the Alberta average) of families living below the low-income cut-off point, a high proportion of immigrants, and a high percentage of people without a high school diploma. Additionally, as seen in Figure 28.2, people living in this area of the city presented with a higher incidence of chronic conditions such as type 2 diabetes (Alberta Health, 2013);

Client Feedback
Following geo-mapping, clients were surveyed to determine their personal preferences about the location of service and timing of group classes and appointments. Not surprisingly, 75% of clients requested service delivery at a location in the area with the highest density of clients. Consequently, a variety of group classes were offered at the preferred location. Additionally, 50% of clients requested weekend services to accommodate personal schedules; in response, the timing of group meetings was changed from weekday-only to include meetings on evenings and weekends as well.

In alignment with the Canadian Community as Partner Model (see Chapter 15), regular client surveys and focus groups were incorporated into the ABSC evaluation process to allow for the ongoing evolution of services in offering ease of access and a supportive environment. This information helped to shape clinic processes and services. From client feedback, the ABSC also learned that it was difficult for clients to attend all the face-to-face workshops required for program completion. Clients indicated that it would be helpful for them to receive ongoing, regular contact via email or online support from the ABSC team. Based on these suggestions, and the potential to reach a larger proportion of the population at a low cost, the ABSC turned to the Internet as a platform for service delivery, piloting an online education program, and employing a drip marketing strategy.

Take Note
Drip marketing is a concept used commonly in the business world. It is the process of sending prewritten communications (e.g., emails) automatically at designated intervals with the intent of keeping your message at the forefront of the receiver’s mind.

Planning and Delivery
Information provided in face-to-face sessions was adapted to suit an online format; for example, the length of each face-to-face session and amount of content provided was dramatically reduced. Vignettes between a client and provider were included to demonstrate key concepts and interactive activities and encourage active learning and self-management skills. Using an automated online service, education sessions and reminders were sent weekly to clients that had subscribed to the service.

The initial pilot of this online education aimed to compare outcomes (weight loss, change in knowledge, and confidence of targeted skills) and demographics (age, rural versus urban) between a group using the online option (n = 10) and a group participating in the standard face-to-face education (n = 42) and also to assess satisfaction with the online platform. Clients taking the online education were older (49.8 years versus 46.9 years), more likely to live outside of Calgary (60% versus 20%), and lost more weight (7.13 kg versus 5.29 kg) than those in the standard program. After completing the online education they also indicated an increase in knowledge and confidence. Clients liked the convenience of the online option and the ability to start and stop presentations and repeat sessions as needed. These results demonstrated the important role of online education in services provided by the ABSC. Consequently, this education was made freely available on the Internet and to all clients involved with the ABSC in an attempt to increase access to weight management services and ensure consistent messaging across the health care continuum in Alberta.

To satisfy the clients’ interest for increased contact from the ABSC via email, the ABSC staff communicated with clients between clinic appointments through twice-weekly purposeful email messages labeled as News, Nuggets and Nudges. Development of these messages was a collaborative effort involving multiple teams and portfolios within Alberta Health Services. Once again this service was made widely available, and as of January 2015, over 800 individuals had signed up for this service. In a survey of those clients who received the News, Nuggets and Nudges, 96% indicated they were satisfied overall with this service and 87% found it useful. Specific comments included: “I find these emails help me to maintain focus on the days I receive the email” and “It is quick and easy to read, and has a single subject to focus on. One small step at a time, it doesn’t overwhelm me with new info.” These comments suggest that this low-cost initiative that uses limited resources (compared to face-to-face appointments) is a successful and useful way by which to maintain regular contact with clients involved in weight management programs.

Peer Support
Since clients of the ABSC felt they needed more frequent social contact than what was feasible for the clinic to provide, one of the participating clients fully embraced the concept of self-management and capitalized on the available online opportunities with the creation of FeelGood Calgary, a Facebook site. Participation in an online social media site helps people feel more connected to others, especially those experiencing a similar condition or situation (Magnezi et al., 2014) and may support behaviour change efforts (Greene et al., 2013) (see Chapter 14). This project draws upon the principles that health is created by caring for oneself and others, by being able to have control over one’s life circumstances, and by ensuring that the society in which one lives creates conditions that allow the attainment of health.

Take Note
In addition to being one of the world leaders in Internet usage and video viewing, Canadians also top the charts for use of Facebook (a free online social platform that allows people to connect with others)—14 million Canadians per day log on to Facebook (Canadians Connected, 2014).

Initially, FeelGood Calgary, which aimed to help individuals achieve their goals of becoming healthier and happier while supporting their local community, provided the opportunity for clients of the ABSC to support each other in an ongoing, high frequency, and non-judgemental environment. The Facebook site was a hit with the group because it not only offered increased social support, it also provided the opportunity to garner immediate assistance if needed and allowed those with time constraints, transportation, and mobility limitations the opportunity to experience the camaraderie that was otherwise not available to them. As the needs of this group expanded, the FeelGood Calgary website was launched as a multi-faceted site with a blog feature, a community newsletter, community events, and community professionals. This platform allowed for the delivery of more information and sharing of expertise in a well-organized format to a larger audience.

Reflection
Although this initiative is owned and operated by FeelGood Calgary ’s founder, the importance of sharing responsibility for population health with people and communities has been recognized. In fact, evidence suggests that patients or families working in collaboration with their health care teams have better outcomes and express greater satisfaction with their health care experiences (Hibbard & Greene, 2013). Thus, clients of the ABSC are encouraged to interact with the FeelGood Calgary Facebook page and website.1

Although the ABSC team is committed to tailoring services to address specific needs of their clients, it is important to consider that this team is part of a large (>100,000 employees) publicly funded health care organization. While the nature of this type of organization ensures that everyone has access to required health care services, it also operates within a restricted budget and lacks the ability to shift resources. Thus, ABSC is unable to fulfill their clients’ every request and must seek creative solutions to meet an ever-increasing demand. As well, consideration must be given to the unique needs of the population requesting service. These clients require specialized equipment that is not available throughout the city. Thus, service delivery is limited to specific locations.

Despite the promising potential of technology-enhanced and internet-based solutions to assist the population in weight management efforts (and health care in general), its widespread use will require significant disruption to how health care is currently delivered:

• In general, health care operates within a conservative culture that is highly regulated and fragmented.

• Technology would enable clients to experience greater opportunities for self-management and control of their health whereas health care providers would experience a decrease in control over a client’s health, a situation that causes concern among health care providers. Many clients admitted that access to information online had already replaced at least one visit to a health care provider (PwC, 2014).

• The use of technology and internet tools may compromise confidentiality and privacy of health information; many of the information technology systems used by health care organizations are not set up to accommodate the new technology or provide adequate security to comply with privacy laws and regulations.

• These tools may influence the therapeutic relationship between clients and health care providers. Consequently, the adoption of many available technologies and internet-based options will take considerable time or remain unavailable for health care services (PwC, 2014).

Summary
While it has been suggested that the advances in technology and constant availability of the Internet may be responsible in part for the increased prevalence of obesity, evidence indicates that technology-enhanced and internet-based solutions may also play important roles in obesity management. Further, when these tools are used in response to needs identified by clients, their potential impact increases as clients become engaged and empowered. Indeed, pilot projects conducted by the ABSC demonstrate that small changes to clinic processes increase access to services, improve patient outcomes, and lead to patient satisfaction. Importantly, these changes are not resource-intensive and thus may be quite favourable to large health care organizations that need to reach a large population at a low cost.

Although the use of technology-enhanced and internet-based solutions for weight management are currently not widely used in health care, they hold considerable promise; for example, applications for mobile devices may be used to track and transmit data wirelessly, allowing health care providers to monitor conditions remotely. Clients will not have to wait for face-to-face appointments but will have secure access to health care information on demand, and clients will have the tools and information available to self-manage their health.

REFERENCES
Alberta Health. (2013). Primary health care community profiles. Government of Alberta. URL=http://www.health.alberta.ca/services/PHC-community-profiles.html

An, R. (2015). Health care expenses in relation to obesity and smoking among U.S. adults by gender, race/ethnicity, and age group: 1998–2011. Public Health, 129(1), 29–36.

Anis, A. H., Zhang, W., Bansback, N., Guh, D. P., Amarsi, Z., & Birmingham, C. L. (2010). Obesity and overweight in Canada: An updated cost-of-illness study. Obesity Reviews, 11(1), 31–40.

Canadians Connected. (2014). The Canadian Internet CIRA factbook 2014. URL=http://cira.ca/factbook/2014/the-canadian-internet.html

City of Calgary. (2014). 2014 civic census results. Calgary: City Clerk’s Election & Information Services. URL=http://www.calgary.ca/CA/city-clerks/Pages/Election-and-information-services/Civic-Census/2014-Results.aspx

Coons, M. J., Demott, A., Buscemi, J., Duncan, J. M., Pellegrini, C. A., Steglitz, J., et al. (2012). Technology interventions to curb obesity: A systematic review of the current literature. Current Cardiovascular Risk Reports, 6(2), 120–134.

Dunstan, D. W., Healy, G. N., Sugiyama, T., & Owen, N. (2010). “Too much sitting” and metabolic risk – Has modern technology caught up with us?. European Endocrinology, 6(1), 19–23.

Gilmore, L. A., Duhe, A. F., Frost, E. A., & Redman, L. M. (2014). The technology boom: A new era in obesity management. Journal of Diabetes Science and Technology, 8(3), 596–608.

Greene, J., Sacks, R., Piniewski, B., Kil, D., & Hahn, J. S. (2013). The impact of an online social network with wireless monitoring devices on physical activity and weight loss. Journal of Primary Care & Community Health, 4(3), 189–194.

Health Canada. (2003). Canadian guidelines for body weight classification in adults – Quick Reference Tool for Professionals. Ottawa: Author. URL=http://www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/index-eng.php

Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Affairs, 32(2), 207–214.

Hodgson, C. (2011). Obesity in Canada: A joint report from the Public Health Agency of Canada and the Canadian Institute for Health Information. URL=http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/index-eng.php

Hutchesson, M. J., Rollo, M. E., Krukowski, R., Ells, L., Harvey, J., Morgan, P. J., et al. (2015). eHealth interventions for the prevention and treatment of overweight and obesity in adults: A systematic review with meta-analysis. Obesity Reviews, 16, 376–392.

Kirk, S. F., Penney, T. L., McHugh, T. L., & Sharma, A. M. (2012). Effective weight management practice: A review of the lifestyle intervention evidence. International Journal of Obesity, 36(2), 178–185.

Kritchevsky, S. B., Beavers, K. M., Miller, M. E., Shea, M. K., Houston, D. K., Kitzman, D. W., et al. (2015). Intentional weight loss and all-cause mortality: A meta-analysis of randomized clinical trials. PLoS One, 10(3), e0121993.

Luo, W., Morrison, H., de Groh, M., Waters, C., DesMeules, M., Jones-McLean, E., et al. (2007). The burden of adult obesity in Canada. Chronic Diseases in Canada, 27(4), 135–144.

Magnezi, R., Bergman, Y. S., & Grosberg, D. (2014). Online activity and participation in treatment affects the perceived efficacy of social health networks among patients with chronic illness. Journal of Medical Internet Research, 16(1), e12.

PwC. (2014). Emerging mHealth: Paths for growth. URL=http://www.pwc.com/en_GX/gx/healthcare/mhealth/assets/pwc-emerging-mhealth-full.pdf

Statistics Canada. (2014). Residential Telephone Service Survey, 2013. The Daily, June 23. URL=http://www.statcan.gc.ca/daily-quotidien/140623/dq140623a-eng.htm

Straus, S., Tetroe, J., & Graham, I. D. (Eds.). (2013). Knowledge translation in health care: Moving from evidence to practice (2nd ed.). Hoboken, NJ: Wiley Blackwell and BMJ Books. Also available from KT Clearinghouse, URL=httpy://ktclearinghouse.ca/knowledgebase/knowledgetoaction

Tremblay, M. S., Colley, R. C., Saunders, T. J., Healy, G. N., & Owen, N. (2010). Physiological and health implications of a sedentary lifestyle. Applied Physiology, Nutrition, and Metabolism, 35(6), 725–740.

Twells, L. K., Gregory, D. M., Reddigan, J., & Midodzi, W. K. (2014). Current and predicted prevalence of obesity in Canada: A trend analysis. CMAJ Open, 2(1), e18–26.

World Health Organization (WHO). (1986). The Ottawa Charter for Health Promotion. Geneva: Author.

ONLINE RESOURCES
Please visit at http://thepoint.lww.com/Vollman4e for up-to-date Internet resources and additional learning materials on this topic.

1Copyright © (2015) Ashton Michael. Please note that the FeelGood Calgary website and video links referenced by the authors in this chapter with permission from the website owners are maintained by third parties over whom Alberta Health Services (“AHS”) has no control. These links have been provided solely for informational purposes as a convenience for the reader and do not constitute an endorsement or approval by AHS of the content of such third party sites and materials. AHS does not make any representation or warranty, express, implied, or statutory, as to the accuracy, reliability, completeness, applicability, or fitness for a particular purpose of these sites or their content.