Supplemental Tables and Appendices

Technology-assisted weight loss interventions in primary care: A systematic review

David Levine, Stella Savarimuthu, Allison Squires, Joseph Nicholson, Melanie Jay

Supplemental Table 1: Delphi and EPOC scores

Delphi Criteria
Source / Randomization adequate? / Tx allocation concealed? / Groups similar at baseline? / Eligibility criteria specified? / Outcome assessor blinded? / Care provider blinded? / Patient blinded? / Point estimates and measures of variability presented? / Included intention-to-treat analysis? / Criteria met (#) / Criteria met (%)
Appel58 / 1 / 1 / 1 / 1 / 1 / 0 / 0 / 1 / 1 / 7 / 78
Bennett59 (2010) / 1 / 1 / 2 / 1 / 1 / 0 / 2 / 1 / 1 / 6 / 67
Bennett60
(2012) / 1 / 1 / 0 / 1 / 2 / 0 / 0 / 1 / 1 / 5 / 56
Christian61 (2008) / 1 / 1 / 1 / 1 / 2 / 0 / 0 / 1 / 1 / 6 / 67
Christian62 (2011) / 1 / 1 / 1 / 1 / 2 / 0 / 2 / 1 / 1 / 6 / 67
Ma63/Xiao / 1 / 1 / 1 / 1 / 2 / 0 / 2 / 1 / 1 / 6 / 67
McConnon64 / 1 / 1 / 1 / 1 / 1 / 0 / 0 / 1 / 1 / 7 / 78
McDoniel65 / 1 / 1 / 1 / 1 / 1 / 0 / 0 / 1 / 1 / 7 / 78
Mehring66 / 1 / 1 / 1 / 1 / 0 / 0 / 0 / 1 / 1 / 6 / 67
Nanchahal (2009)67 / 1 / 1 / 1 / 1 / 2 / 2 / 1 / 1 / 1 / 7 / 78
Nanchahal (2012)68 / 0 / 1 / 0 / 1 / 0 / 0 / 1 / 1 / 1 / 5 / 56
Rothert69 / 1 / 1 / 1 / 1 / 2 / 1 / 1 / 1 / 0 / 7 / 78
Spring70 / 1 / 1 / 1 / 1 / 2 / 2 / 0 / 1 / 1 / 6 / 67
ter Bogt71 / 1 / 2 / 1 / 1 / 2 / 2 / 2 / 1 / 1 / 5 / 56
Verheijden72 / 1 / 1 / 1 / 1 / 1 / 0 / 1 / 1 / 1 / 8 / 89
Wylie-Rosett73 / 1 / 2 / 1 / 1 / 2 / 0 / 2 / 1 / 0 / 4 / 44
Mean / 0.9 / 1.1 / 0.9 / 1 / 1.4 / 0.4 / 0.9 / 1 / 0.9 / 6.1 / 68.1

0 = No; 1 = Yes; 2 = Don't Know

Cochrane Effective Practice and Organisation of Care (EPOC)
Source / Allocation sequence adequately generated? / Allocation adequately concealed? / Baseline outcome measurements? / Baseline characteristics similar? / Incomplete data addressed? / Blinding? / Protected against contamination? / Selective outcome reporting? / Free from other risks of bias? / Criteria met (#) / Criteria met (%)
Appel58 / 0 / 0 / 0 / 0 / 0 / 1 / 0 / 0 / 0 / 8 / 89
Bennett59 (2010) / 0 / 0 / 0 / 2 / 0 / 2 / 2 / 0 / 0 / 6 / 67
Bennett60
(2012) / 0 / 0 / 0 / 2 / 0 / 1 / 0 / 0 / 0 / 7 / 78
Christian61 (2008) / 0 / 1 / 0 / 0 / 0 / 1 / 1 / 0 / 0 / 6 / 67
Christian62 (2011) / 0 / 0 / 0 / 0 / 0 / 1 / 0 / 0 / 1 / 7 / 78
Ma63/Xiao / 0 / 0 / 0 / 0 / 0 / 1 / 0 / 0 / 0 / 8 / 89
McConnon64 / 0 / 0 / 0 / 0 / 1 / 1 / 0 / 1 / 1 / 5 / 56
McDoniel65 / 0 / 0 / 0 / 0 / 0 / 2 / 0 / 0 / 1 / 7 / 78
Mehring66 / 1 / 0 / 0 / 1 / 0 / 1 / 0 / 0 / 1 / 5 / 56
Nanchahal (2009)67 / 0 / 0 / 0 / 0 / 0 / 1 / 0 / 0 / 1 / 7 / 78
Nanchahal (2012)68 / 0 / 0 / 0 / 0 / 0 / 2 / 0 / 0 / 0 / 8 / 89
Rothert69 / 0 / 0 / 0 / 0 / 1 / 0 / 0 / 1 / 1 / 6 / 67
Spring70 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 0 / 1 / 6 / 67
ter Bogt71 / 0 / 1 / 0 / 0 / 0 / 2 / 1 / 0 / 1 / 5 / 56
Verheijden72 / 0 / 0 / 0 / 0 / 1 / 0 / 0 / 0 / 1 / 7 / 78
Wylie-Rosett73 / 0 / 1 / 0 / 0 / 1 / 2 / 1 / 1 / 0 / 4 / 44
Mean / 0.06 / 0.2 / 0 / 0.3 / 0.3 / 1.2 / 0.4 / 0.2 / 0.6 / 6.4 / 70.8

0 = Low Risk; 1 = High Risk; 2 = Unclear

Supplemental Table 2: Technology-Assisted Weight Loss Interventions in Primary Care

Please note: due to space constraints, some fields were removed from the print Table that are included below

Participants / Intervention / Outcomes
Study / n / Age (x) / %F / Ethnicity (%) / BMI (x) / Practice Type / Intervention (n) / Tech Modality / Personnel / Behavior Change Elements / Duration (mos) / Attrition (%) / Weight Δ (kg) / ≥5% weight loss (%)
Appel58 / 415 / 54 / 64 / 56W, 41B / 37 / Mix / All: PCP visit at 6/12/24mos for encouragement
IG1 (138): in-person support, website: self-monitoring, auto feedback, & email reminder to login
IG2 (139): remote support via telephone, same website & emails as IG1
CG (138): 1 weight loss coach meeting, brochures, weight loss websites / Int / MD, O / AF, IPF, LC, MDF, Rem, SM / 24 / 16 / IG1: -5.1*
IG2: -4.6*
CG: -0.8 / IG1: 41*
IG2: 38*
CG: 19
Bennett (2010)59 / 101 / 54 / 47 / 50W, 31B, 5H / 35 / IM / IG (51): self-monitoring website, 4 RD visits via phone and in-person
CG (50): usual care & basic materials / Int / RD / AF, IPF, LC, SM / 3 / 16 / IG: -2.3*
CG: +0.3 / IG: 26NR
CG: 0
Bennett
(2012)60 / 365 / 55 / 69 / 71B, 13H / 37 / NR / IG (180): web-based tailored behavior change goals, skills training via website or interactive voice response, telephone counseling w trained community health educator, primary care provider endorsement, 12 optional in-person group support sessions, walking kit w pedometer
CG (185): usual care & self-help booklet / CS, Int, O / MD, O / AF, Con, IPF, LC, MDF, O, P2P, SM / 24 / 14 / IG: -1.5*
CG: -0.5 / IG: 20
CG: 20
Christian (2008)61 / 310 / 53 / 66 / 100H / 35 / FM/GP / IG (155): goal-setting computer program, then regular MD clinic visits w 3/6/9mos goals reassessment
CG (155): usual care & info packet / CS, K / MD / AF, MDF / 12 / 12 / IG: -0.08
CG: +0.6 / IG: 21*
CG: 11
Christian (2011)62 / 279 / 50 / 68 / 51W, 44H / 34 / FM/GP / IG (140): goal-setting computer program, then MD clinic visits to reinforce goals, 6mos goals reassessment w computer
CG (139): usual care & info packet / CS, K / MD / AF, MDF / 12 / 6 / IG: -1.5*
CG: +0.1 / IG: 26*
CG: 8
Ma63 / Xiao†79 / 171 / 53 / 46 / 79W, 4H / 32 / Mix / All: Heart360 website, standardized monthly emails, ability to submit questions online
IG1 (79): 3mo intensive in-person weekly DPP w physical activity food tastings, personalized monthly emails on Heart360 progress
IG2 (81): 3mo intensive at-home DPP DVD, standardized weekly emails
CG (81): usual care / Int, O / O, RD / AF, IPF, LC, Rem, SM / 24 / 29 / IG1: -5.4*
IG2: -4.5*
CG: -2.4 / IG1: 45*
IG2: 30
CG: 17
McConnon64 / 221 / 46 / 77 / 95W / 34 / FM/GP / IG (111): website: tailored advice, tools information to support behavior change in terms of dietary physical activity patterns, reminder emails
CG (110): usual care, small info booklet / Int / None / AF, Rem, SM / 12 / 41 / IG: -1.3
CG: -1.9 / IG: 22NR
CG: 18
McDoniel65 / 111 / 46 / 61 / 78W, 20H / 37 / FM/GP / All: MI counseling at wk4 & wk8; core topic email newsletters weekly
IG (55): MedGem Analyzer for nutrition program & Balance-Log for SM
CG (56): Usual care: 3-day food menu, paper journal) / HC, Int / EP / IPF, LC, SM / 3 / 28 / IG: -3.5
CG: -3.7 / IG: 31
CG: 42
Mehring66 / 186 / 48 / 69 / NR / 34 / FM/GP / IG (109): HausMed eHealth web-based coaching program w MD input and 3 phone calls from MD or MA at wks 1,5,12 for motivation
CG (77): usual care / CS, Int, Txt / MD, O / AF, IPF, LC, MDF, P2P, Rem, SM / 3 / 20 / IG: -2.9*
CG: -1.6 / IG: 26
CG: 16
Nanchahal (2009)67 / 123 / 47 / 80 / 96W / 36 / FM/GP / IG (61): ProHealthClinical structured lifestyle support w tailored diet, self-monitoring w diary, coping skills, & RN feedback
CG (62): usual care / CS / RN / AF, IPF, LC, SM / 3 / 15 / IG: -4.0*
CG: +1.2 / IG: 17NR
CG: 10
Nanchahal (2012)68 / 381 / 49 / 72 / 73W / 33 / FM/GP / IG (191): structured one-on-one in-person sessions (6 in 1st 12wks, 4 in 2nd 12wks, 3 in 3rd 12wks), perfect-diet-tracker.com for SM; adamsportionpot.com, pedometers
CG (190): usual care & asked to seek weight loss from PCP / HC, Int / O / IPF, LC, O, Rem, SM / 12 / 43 / IG: -2.4
CG: -1.3 / IG: 34*
CG: 19
Rothert‡69 / 2862 / 45 / 83 / 56W, 36B / 32 / Mix / All: 20min computer assessment
IG (1475): Web-tailored weight management program x 6wks w 1/3/6wk email asking participants to enter weight
CG (1387): Web-info-only materials on Kaiser's website / Int / None / AF, P2P, Rem, SM / 6 / 80 / IG: -2.8*
CG: -1.1 / NR
Spring70 / 70 / 58 / 14 / 75W, 25B, 6H / 36 / IM / All: 2wk run-in baseline
IG (35): Weight Loss Phase (mos0-6): twice weekly MOVE sessions, PDA for self-monitoring w automated feedback, coach-derived feedback; Maintenance Phase (mos7-12): monthly MOVE sessions, telephone coach conversation if no data transmitted
CG (34): All MOVE sessions as IG, but no PDA, no coach calls / App / MD, O, RD / AF, IPF, LC, P2P, Rem, SM / 12 / 23 / IG: -2.9*
CG: +0.02 / IG: 30*
CG: 15
ter Bogt71 / 457 / 56 / 52 / NR / 30 / FM/GP / All: baseline online or paper questionnaire
IG (225): 4 visits w NP using software, 1 telephone f/u in yr1, then 1 visit & 2 telephone f/u’s in yr2 & yr3
CG (232): MD usual care / CS / MD, NP / IPF, LC, O, SM / 36 / 22 / IG: -1.1
CG: -0.5 / IG: 5
CG: 5
Verheijden72 / 146 / 63 / 45 / NR / 29 / FM/GP / IG (73): Heartweb online program: monthly stage-of-change questionnaire w subsequent tailored nutrition suggestions, bulletin board, dietary fat tracker, low fat recipes
CG (73): usual care / Int / None / AF, P2P, SM / 8 / 9 / NR / NR
Wylie-Rosett‡73 / 588 / 52 / 82 / 83W / 36 / Mix / All: computer assessment
IG1 (236): 6 group workshops, RD/MSW consult (telephone or face-to-face) up to 18times + IG2 + CG
IG2 (236): kiosks weekly (20-30mins) x 3mos, then monthly + CG
CG (116): workbook / K / MSW, RD / LC / 12 / 21 / IG1: -3.4*
IG2: -2.1*
CG: -1.0 / IG1: 31*
IG2: 23*
CG: 15

B-Black; BMI-Body Mass Index (kg/m2); CG-Control Group; Δ-Change; DPP-Diabetes Prevention Program; FM/GP-Family Medicine/General Practitioner; H-Hispanic; IG-Intervention Group; IM-Internal Medicine; NR-Not Reported; PCP-Primary Care Provider; PDA-Personal Digital Assistant; W-White; x-Mean

Technology Modality: App-Mobile App; CS-Clinician Software; HC-Home Computer (No Internet); Int-Internet; K-Kiosk; O-Other

Personnel: EP-Exercise Physiologist; MSW-Master of Social Work; MD-Medical Doctor; None-No Personnel; NP-Nurse Practitioner; O-Other; RD-Registered Dietician; RN-Registered Nurse

Elements: AF-Automated Feedback; Con-Contests; IPF-In-person Feedback; LC-Lifestyle Coaching; MDF-MD Feedback; O-Other; P2P-Peer-To-Peer Support; Rem-Reminders; SM-Self Monitoring

*: p < 0.05

†: Xiao et al re-consented the patients from Ma et al and followed them for 9 additional months; we report their data with this extension period. Also, their data is for ≥7% weight loss, not ≥5%.

‡: Completers-only analysis (i.e., not intention to treat)

Supplemental Table 3: PRECIS Scores

PRagmatic Explanatory Continuum Indicator Summary (PRECIS)
Source / Participant eligibility / Flexibility (Experimental) / Practitioner expertise (Experimental) / Flexibility (Comparison) / Practitioner expertise (Comparison) / Follow-up intensity / Primary trial outcome / Participant compliance w prescribed intervention / Practitioner adherence to study protocol / Analysis of primary outcome / Average
Appel58 / 3 / 2 / 1 / 4 / 4 / 0 / 4 / 1 / 1 / 4 / 2.4
Bennett59 (2010) / 2 / 3 / 1 / 4 / 4 / 1 / 4 / 2 / 2 / 4 / 2.7
Bennett60
(2012) / 3 / 2 / 1 / 4 / 4 / 0 / 4 / 2 / 1 / 4 / 2.5
Christian61 (2008) / 0 / 3 / 3 / 4 / 4 / 2 / 4 / 2 / 3 / 4 / 2.9
Christian62 (2011) / 2 / 3 / 3 / 4 / 4 / 3 / 4 / 3 / 3 / 4 / 3.3
Ma63/Xiao / 3 / 3 / 3 / 4 / 4 / 3 / 4 / 2 / 3 / 4 / 3.3
McConnon64 / 3 / 4 / 4 / 4 / 4 / 3 / 4 / 3 / 4 / 3 / 3.6
McDoniel65 / 3 / 2 / 1 / 1 / 1 / 2 / 4 / 2 / 2 / 4 / 2.2
Mehring66 / 2 / 2 / 4 / 4 / 4 / 3 / 4 / 1 / 1 / 4 / 2.9
Nanchahal (2009)67 / 3 / 2 / 2 / 4 / 4 / 3 / 4 / 3 / 3 / 4 / 3.2
Nanchahal (2012)68 / 3 / 1 / 2 / 4 / 3 / 1 / 4 / 2 / 2 / 4 / 2.6
Rothert69 / 3 / 0 / 4 / 0 / 3 / 2 / 4 / 3 / 4 / 1 / 2.4
Spring70 / 3 / 0 / 3 / 1 / 3 / 0 / 4 / 1 / 3 / 4 / 2.2
ter Bogt71 / 3 / 2 / 1 / 4 / 4 / 1 / 4 / 2 / 2 / 4 / 2.7
Verheijden72 / 3 / 1 / 4 / 4 / 4 / 3 / 4 / 3 / 3 / 3 / 3.2
Wylie-Rosett73 / 3 / 2 / 1 / 3 / 4 / 0 / 4 / 2 / 1 / 0 / 2
Average / 2.6 / 2 / 2.4 / 3.3 / 3.6 / 1.8 / 4 / 2.2 / 2.4 / 3.4 / 2.8

0-Completely Explanatory (ideal circumstances) → 4-Completely Pragmatic (real-world circumstances).

Appendix 1: Search Strategy

Search strategies and searched the following databases to identify citations and trials from 2000 to February 28, 2013: PubMed/MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL. Our PubMed search strategy was: ((("behavior therapy" OR "cognitive therapy" OR counseling OR counselling OR diet OR diet, reducing OR health behavior [mh] OR health promotion [mh] OR self care [mh] OR health education [mh] OR "nutrition therapy") AND (computer-assisted instruction OR computers, handheld OR internet OR therapy, computer-assisted OR web-based OR Internet-based OR mobile app* OR computer* OR software OR website OR web site OR technology [tiab] OR mobile [tiab])) AND (body mass index OR body weight OR obesity/pc OR obesity/th OR overweight/pc OR overweight/th OR weight loss OR weight gain OR "weight management" OR "weight control")) AND (randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized[tiab] OR randomised[tiab] OR randomization[tiab] OR randomisation[tiab] OR placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab]) NOT (animals[mh] NOT humans[mh]). The authors are happy to discuss search strategies for the other databases upon request. Please also refer to our PROPSERO (CRD42013003998) entry: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013003998.

Appendix 2: Narrative Summation

Appel: The Hopkins POWER trial[i] compared in-person, remote, and self-directed (control) health coach support. Both intervention groups had access to a website for self-monitoring, learning modules, and automated feedback. They also both had 3 PCP visits for encouragement and reflection. In-person support participated in multiple group (9x90mins) and individual (3x20mins) sessions, with tapering frequency after 3 months. Remote support engaged in 1 weekly call for 3 months, then 1 monthly call. Over 24 months (16% attrition), in-person, remote, and self-directed participants lost 5.1kg, 4.5kg, and 0.8kg, corresponding to 41.4%, 38.2%, and 18.8% with >5% weight loss, respectively. While both intervention groups demonstrated significantly more weight loss than control (p<0.001), there was no difference between intervention groups.