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Introduction
Chubby and weight problems are threat components for noncommunicable illnesses, similar to kind 2 diabetes, heart problems, and a few cancers.1–4 Globally, the prevalence of weight problems and chubby has considerably risen over the previous three many years,5 and the projected weight problems developments are anticipated to reinforce its financial burden.6 In Taiwan, the prevalence of weight problems in adults has additionally elevated over the previous twenty years, and roughly half of adults in Taiwan have develop into chubby or overweight.7,8 Weight reduction by means of way of life modification can considerably produce well being advantages.9–12 Nonetheless, solely a small proportion of sufferers with weight problems present process way of life modification obtain clinically important weight reduction and weight reduction upkeep.13,14 Up to now, no nation has succeeded in reversing the present weight problems pandemic.15
Since coronavirus illness 2019 (COVID-19) was declared a world pandemic,16 a number of research performed in numerous nations have proven decrease weight loss program high quality, increased overeating frequency, much less bodily exercise, and weight acquire through the COVID-19 pandemic in comparison with earlier than the COVID-19 pandemic.17–20 Moreover, weight problems will increase the chance of extreme COVID-19 sickness, hospitalization, and mortality.21–24 Nonetheless, weight administration applications for weight problems have been diminished through the COVID-19 pandemic to make sure the protection of sufferers and healthcare professionals.25 Thus, distant approaches as a substitute of face-to-face interactions for weight administration are required.
Previous to the COVID-19 pandemic, many research demonstrated that telehealth and cellular well being (mHealth) applied sciences are efficient instruments for weight reduction therapy.26 Weight reduction therapy delivered by smartphone purposes (apps) could result in increased adherence and higher weight reduction in comparison with that delivered by web sites or paper diaries.27 Within the Asian inhabitants, the usage of a cellular app utilized to weight reduction might also have advantages for bettering weight loss program high quality and weight reduction self-efficacy.28,29 Through the COVID-19 pandemic, the usage of telehealth elevated by nearly 200% within the US.30 Just lately, a randomized scientific trial, utilizing the mHealth app to advertise ketogenic weight loss program through the COVID-19 pandemic, discovered that self-reported dietary adherence is a vital predictor of weight-loss success.31 Thus, telehealth applied sciences could also be a possible selection for weight administration through the COVID-19 pandemic.
Though a nation-wide lockdown was not applied till Could 18, 2021, a social distancing coverage was applied after a locally-transmitted COVID-19 an infection was reported on January 21, 2020 in Taiwan.32 Meeting and gathering had been restricted in response to public meeting pointers revealed by the Taiwan Facilities for Illness Management. Since September 1, 2020, the Taichung Veteran Basic Hospital (VGH) supplied a weight administration program, which mixed self-monitoring of meal monitoring and weight monitoring in addition to person-to-person individualized suggestions, through a cellular app throughout follow-up within the Weight Management Outpatient Division within the Taichung VGH.
The current research retrospectively assessed knowledge from real-life follow to look at the diploma of weight reduction throughout a cellular weight administration program within the Taichung VGH through the COVID-19 pandemic and explored impartial components related to profitable weight reduction.
Supplies and Strategies
Sufferers
We retrospectively collected the medical info of topics who had undergone weight reduction therapy on the Weight Management Outpatient Division within the Taichung VGH between September 2020 and Could 2021. The inclusion standards had been: (1) age between 20 and 64 years; (2) preliminary physique mass index (BMI) ≥ 24 kg/m2; (3) sufferers registering the homecare app between September 2020 and Could 2021. The exclusion standards had been: (1) altering any drugs inside 3 months earlier than the primary go to; (2) the usage of anti-obesity medication inside 3 months earlier than the primary go to; (3) the usage of glucagon-like peptide 1 agonists; (4) a historical past of bariatric surgical procedure; (5) weight reduction by > 5% in 6 months previous to baseline measurements; (6) a historical past of endocrine problems; (7) a historical past of drug dependancy or psychological problems; (8) the usage of systemic steroids; (9) being pregnant; and (10) no any meal photograph uploaded onto the homecare app. Lastly, we enrolled individuals in our analyses provided that they’d at the least two anthropometric measurements at totally different visits throughout this system (Determine 1).
Determine 1 Circulate diagram of the enrollment of research topics. Abbreviation: VGH, Veteran Basic Hospital. |
Taichung VGH Homecare App
The Taichung VGH homecare app is a non-commercial app consisting of a affected person interface and an expert interface. The affected person interface permits topics to report their blood stress, blood glucose, physique weight, and meal contents through a smartphone. Notably, meal contents could be uploaded as pictures with textual content annotations and affected person customers can receive suggestions messages from skilled customers. The skilled interface is the backstage administration system, accessible by skilled customers. Skilled customers monitor the information of blood stress, blood glucose, physique weight, and meal contents uploaded by individuals. Notably, skilled customers can ship person-to-person messages in response to meal pictures by means of the skilled interface.
Cellular Weight Administration Program
The cellular weight administration program was supplied, starting September 1, 2020. Sufferers within the first go to to the Weight Management Outpatient Division registered within the Taichung VGH homecare app. Sufferers had been assigned to a customized meal plan with a particular calorie and macronutrient aim primarily based on their preliminary weight. This program used each day weight monitoring, meal monitoring, and customized suggestions for meal monitoring on the homecare app. Sufferers had been inspired to take part in weight monitoring on daily basis and add all meals and drinks consumed all through this system and not using a restrict on the variety of meals logs entered each day. Sufferers logged meals, snacks, treats, and drinks, together with their photograph, description, and amount. Every photograph of a person meal, snack, deal with, or beverage was thought-about a single meals log entry.
Skilled customers, 4 physicians and one dietitian, checked the burden and meal monitoring information on the skilled interface and despatched customized suggestions messages, together with psychological well being help and weight loss program schooling primarily based on every meal photograph, to the patient-user interface. Weight-reduction plan schooling included estimation of calorie, information and estimation of macronutrients, and ideas for dietary changes. Affected person customers obtained messages on the homecare app from skilled customers, and had been inspired to regulate their weight loss program content material primarily based on suggestions to fulfill their customized meal targets (Determine 2).
Determine 2 Circuit of cellular weight administration program on the app. |
Outpatient follow-up visits had been requested in an interval of lower than 3 months, and anthropometric measures (physique weight, waist circumference, hip circumference, physique fats mass, skeletal muscle mass, physique fats mass proportion, and fat-free mass) had been evaluated on each follow-up go to. Sufferers who didn’t attend the subsequent outpatient follow-up visits inside 3 months had been outlined as being at finish of weight reduction therapy.
Evaluation
Baseline knowledge obtained from the medical information of the preliminary face-to-face interview included age, intercourse, and anthropometric measures (physique top, physique weight, waist circumference, hip circumference, physique fats mass, skeletal muscle mass, physique fats mass proportion, and fat-free mass). Physique weight, physique fats mass, physique fats mass proportion, skeletal muscle mass, and fat-free mass had been measured at each follow-up go to with a calibrated bioelectrical impedance scale (InBody 230 multifrequency analyzer, Biospace Corp., Seoul, Korea). BMI was calculated by means of the next equation: weight (kg)/(top [m])2. Waist circumference was measured to the midpoint between the decrease border of the rib cage and the iliac crest. Hip circumference was measured on the degree of the best protrusion of the buttocks when the topic was standing erect with ft collectively.
Kind 2 diabetes was outlined in response to a recorded analysis of kind 2 diabetes or use of antidiabetic medication, an HbA1c degree ≥ 6.5%, or a fasting glucose degree ≥ 126 mg/dL earlier than the date of the primary go to. Prediabetes was outlined in response to a recorded analysis of prediabetes, an HbA1c between 5.7 and 6.4% or glucose between 100 and 125 mg/dL earlier than the date of the primary go to in topics who didn’t meet the standards for diabetes. Hypertension was outlined in response to a recorded analysis of hypertension or use of anti-hypertensive medication.
Academic standing, marital standing, fertility standing, historical past of weight reduction, train habits, snacking habits, and instances of consuming out per week had been all categorized and obtained on the first weight management outpatient go to.
Consequence Measures
The first final result was a profitable weight reduction, outlined as a remaining weight discount by ≥ 5% of the preliminary physique weight.33 Adjustments in different anthropometric measures had been outlined as follows: (the final noticed anthropometric measurements) – (the primary noticed anthropometric measurements). Length of therapy was outlined because the interval between the date of the primary and final noticed in-person exams. The variety of dietary information was outlined because the variety of meal pictures tracked over the period of therapy. The variety of weight loss program information per week was outlined as follows: (the variety of dietary information)/(period of therapy). The variety of days of weight recording was outlined because the variety of days of weight monitoring over the period of therapy. The completion ratio of each day weight recording was outlined as follows: (days of weight recording/days of the period of therapy) ×100%. The variety of outpatient visits was outlined because the variety of outpatient visits over the period of therapy. The interval of outpatient visits was outlined as follows: (weeks of therapy period)/(variety of outpatient visits).
Statistical Analyses
All steady knowledge are offered because the imply ± customary deviation (SD). Categorical knowledge are offered as numbers and percentages. A Mann–Whitney U-test was performed to detect important variations in steady variables between teams. A Wilcoxon Signed Rank take a look at was performed to detect important variations in steady variables earlier than and after therapy. Chi-square exams had been performed to detect variations in categorical variables. Backward-stepwise logistic regression was used to establish the components related to profitable weight reduction (weight reduction by ≥ 5%). Statistical analyses had been carried out utilizing SPSS model 22.0 software program (IBM Corp., Armonk, NY, USA).
Outcomes
In a complete of 45 topics enrolled within the research, a imply weight discount of 4.1 ± 4.4 kg (P < 0.001) was noticed over a imply period of 11.0 ± 7.3 weeks. There have been 24 (53.3%) topics within the unsuccessful weight reduction group with weight reduction < 5%, and 21 (46.7%) topics within the profitable weight reduction group, together with: 14 topics (31.1%) with weight reduction between 5% and 9.9%, 5 (11.1%) topics with weight reduction between 10% and 14.9%, and a couple of (4.4%) topics with weight reduction ≥ 15% (Determine 3).
Determine 3 Proportions of sufferers categorized by weight lack of their baseline physique weight. |
The traits of enrolled topics are proven in Desk 1. Topics within the profitable weight reduction group had decrease baseline physique fats percentages in comparison with these within the unsuccessful weight reduction group (37.5 ± 6.9% vs 41.6 ± 6.3%, P = 0.032). There have been no important variations in age (37.4 ± 11.2 years vs 43.1 ± 12.3 years, P = 0.108) and intercourse (47.6% feminine vs 75% feminine, P = 0.114) between the profitable weight reduction and the unsuccessful weight reduction teams, respectively. There have been no important variations in baseline physique weight, BMI, waist circumference, hip circumference, physique fats mass, skeletal muscle mass, physique fats mass proportion, fat-free mass, variety of topics with kind 2 diabetes, prediabetes, hypertension, antidiabetic drug historical past, academic standing, marital standing, fertility standing, historical past of weight reduction, train habits, snacking habits, and instances of consuming out per week between these two teams.
Desk 1 Baseline Traits of the Enrolled Sufferers |
The usage of the cellular app and different points of the interventions are proven in Desk 2.
Desk 2 The Medical Follow within the Weight Loss Program |
Topics within the profitable weight reduction group had longer period of therapy (14.6 ± 6.5 weeks vs 6.9 ± 6.0 weeks, P < 0.001), increased variety of dietary information (109.2 ± 84.7 vs 54.7 ± 58.8, P = 0.002), increased variety of outpatient visits (6.1 ± 2.7 vs 3.7 ± 2.3, P < 0.001), and better interval of outpatient visits (2.5 ± 1.1 weeks vs 1.8 ± 0.9 weeks, P = 0.003) than these within the unsuccessful weight reduction group. There have been no important variations within the variety of dietary information per week, days of weight recording, and completion ratio of each day weight recording between these two teams.
Desk 3 exhibits the adjustments within the anthropometric measurements. Topics within the profitable weight reduction group had increased weight reduction in proportion (8.6 ± 3.4% vs 1.3 ± 2.4%, P < 0.001), increased weight reduction (7.6 ± 3.4 kg vs 1.1 ± 2.4 kg, P < 0.001), increased BMI discount (2.7 ± 1.1 kg/m2 vs 0.4 ± 0.8 kg/m2, P < 0.001), increased waist circumference discount (7.0 ± 3.7 cm vs 1.9 ± 3.2 cm, P < 0.001), increased hip circumference discount (5.4 ± 3.4 cm vs 0.7 ± 3.3 cm, P < 0.001), increased physique fats mass discount (6.2 ± 3.0 kg vs 1.0 ± 1.1 kg, P < 0.001), increased skeletal muscle mass discount (0.9 ± 1.1 kg vs 0 ± 1.1 kg, P = 0.018), increased physique fats proportion discount (4.4 ± 3.0% vs 0.7 ± 1.1%, P < 0.001), and better fat-free mass discount (1.5 ± 1.9 kg vs 0.1 ± 1.9 kg, P = 0.021) than these within the unsuccessful weight reduction group.
Desk 3 Adjustments in Anthropometric Consequence Measures |
Multivariate logistic regression analyses demonstrated that period of therapy was an impartial issue related to profitable weight reduction (odds ratio = 1.23, 95% confidence interval: 1.08–1.41, P = 0.003). The affiliation was important in each the crude and adjusted fashions (Desk 4).
Desk 4 Univariate and Backward Multivariate Logistic Evaluation Exhibiting Odds Ratios for Profitable Weight Loss |
Dialogue
The current research confirmed a imply weight lack of 4.7% of baseline physique weight throughout a mean 11 weeks of therapy utilizing a cellular app. There have been 46.7% of sufferers who had profitable weight reduction ≥ 5% of baseline weight. The period of therapy was an impartial issue related to profitable weight reduction. Setting a weight reduction aim is vital for weight problems administration.34 In response to the Report of the American School of Cardiology/American Coronary heart Affiliation Job Power on Follow Pointers and The Weight problems Society in 2013, a lack of ≥ 5% of the preliminary physique weight generally is a goal for profitable weight reduction.33 Consistent with our findings, the period of therapy was reported as the one impartial issue of profitable weight reduction outlined by ≥ 5% baseline weight, and all different assessed variables had been now not considerably related to profitable weight reduction after adjustment for period of therapy primarily based on the information retrospectively extracted from digital medical information in The Wharton Weight Administration Clinic.35 Hu et al demonstrated that enrollment size within the digital Foodsmart platform was considerably related to profitable weight lack of 5% in a retrospective cohort.36 Equally, 52-week weight reduction applications confirmed considerably higher weight losses than 12-week applications primarily based on a randomized managed trial utilizing life-style modification.37 Notably, early attrition and drop out, outlined as a participant not attending a scheduled go to, had been adverse predictors of profitable weight reduction throughout scientific trials.38
It was beforehand reported {that a} increased frequency of face-to-face attendance is a big predictor of higher weight reduction in typical weight reduction applications.39–42 In distinction to the standard weight reduction applications, we noticed an extended interval of outpatient visits and extra outpatient visits within the profitable weight reduction group than within the unsuccessful weight reduction group. None of above outpatient go to profile was impartial issue after adjustment at some stage in therapy within the current research. Since self-monitoring and weight loss program schooling are performed through the cellular app, the aim of weight reduction could be achieved with out frequent face-to-face visits through the COVID-19 pandemic.
Dietary self-monitoring is a vital element of weight reduction applications.43–45 This relationship between a dietary diary and weight reduction has been revealed through use of on-line help.46 Within the Livongo Diabetes Prevention Program, meals logging had a very powerful affect on weight reduction.47 Falkenhain et al additionally reported that self-reported dietary adherence was a very powerful metric to foretell weight reduction through the COVID-19 pandemic, primarily based on a secondary evaluation of a randomized scientific trial utilizing a mHealth ketogenic weight loss program app intervention.31 Though the variety of dietary information within the ≥ 5% weight reduction group was considerably higher than that within the < 5% weight reduction group within the current research, the distinction grew to become nonsignificant after standardizing the variety of dietary information by therapy time, ie the variety of dietary information per week. Carter et al reported {that a} lengthy period was considerably related to enchancment of weight reduction through digital dietary self-monitoring utilizing a cellular app.48 Consistent with our findings, weight reduction through an app utilizing a photograph function as a dietary report technique confirmed {that a} higher weight reduction is mediated by elevated period and logged days.49 Notably, a number of dietary-based applications for weight reduction demonstrated that higher preliminary weight reduction is related to a decrease research dropout price.50–54 Preliminary weight reduction is a recognized predictor of profitable weight reduction and higher preliminary weight reduction could be the motivating issue resulting in longer therapy size and fewer attrition.55
Excessive schooling is useful in adopting a nutritious diet and related to an excellent repose to weight reduction program.56 Regardless of excessive schooling was related to profitable weight reduction underneath univariable evaluation, the affiliation grew to become nonsignificant after adjustment at some stage in therapy utilizing cellular app within the current research. It has been reported that self-reporting weight has a possible social desirability bias.57 The power of our research was that the measurements of weight was carried out utilizing the identical InBody machine for body-component analyses. Nonetheless, the current research had a number of limitations: First, to advertise adherence to this system, topics weren’t adopted by a hard and fast time schedule, and weight loss program schooling through the app didn’t use a hard and fast formulation on this research program. Due to this fact, our outcomes can’t be utilized to the weight-reduction applications with fixed-visit schedules. Second, the case quantity was comparatively small within the current research. Third, adjustments in adherence-related profiles are vital for profitable weight reduction. The self-weighing trajectories are reported to be considerably related to weight-loss upkeep.58 Nonetheless, we didn’t carry out these analyses on account of restricted case numbers and totally different go to intervals in every participant. Fourth, the current research had an observational design, which didn’t enable the willpower of a causal impact. A randomized managed trial is warranted to assist decide causal route.
Conclusion
We current a retrospective evaluation of a weight administration program utilizing an app with self-monitoring dietary information, weight monitoring, and person-to-person individualized suggestions in real-world follow through the COVID-19 pandemic. The period of therapy was an impartial issue related to profitable weight reduction. The numbers of dietary information and outpatient visits weren’t considerably related to profitable weight reduction in multivariate logistic evaluation.
Moral Approval and Knowledgeable Consent
The research complied with the Declaration of Helsinki. The Institutional Overview Board of the Taichung Veterans Basic Hospital permitted the protocol (moral approval code: CE21241B) and waived the necessity for knowledgeable consent because of the retrospective assortment of information. Nameless medical report knowledge had been obtained from the Medical Informatics Analysis & Growth Heart of Taichung Veterans Basic Hospital after delinking the identification code.
Acknowledgments
This work was supported by grants from the Taichung Veterans Basic Hospital, Taichung, Taiwan (grant quantity TCVGH-1103503C) and the Ministry of Science and Know-how, Taiwan (grant quantity MOST 110-2314-B-075A-004-MY3). The funders had no position within the determination to submit the manuscript for publication.
Disclosure
The authors report no conflicts of curiosity on this work.
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