Staff Update
Fall 2006
Self-Monitoring in Lifestyle Change Programs
Self-Monitoring in Lifestyle Change Programs: A Closer Look
By: Linda Gonder-Frederick, PhD
Behavioral interventions play a central role in treatment programs designed to promote lifestyle changes leading to weight loss, weight gain prevention, and improved physical fitness. Behavioral therapy is an umbrella term that actually describes a number of different specific strategies that have been shown to help people change their diet and activity habits. Some of these strategies include self-monitoring, stimulus control, goal setting, problem solving, stress management, contingency management, and social support. Of all these different types of behavioral strategies, many psychologists believe that self-monitoring is the most important. Unfortunately, adherence to self-monitoring techniques is often very poor. Because self-monitoring may be critical for successful lifestyle change, and adherence to self-monitoring can be so difficult to achieve, it might be helpful to take a closer look at this particular behavioral strategy.
Self-Monitoring Techniques: A Description
The most common type of self-monitoring in weight loss programs is keeping a food record or diary, in which the individual writes down everything they eat or drink throughout the day. Other helpful nutritional information can include time of day of eating, caloric content, fat content, and carbohydrate grams. In addition, some food diaries include more "psychological" variables, such as the situation, environmental or emotional "triggers" to eating, mood state at the time, or stress level. It is almost impossible, however, for most people to keep highly detailed daily food records over the long-term. For this reason, it is not uncommon to ask people to keep a detailed food record for a few days each week, perhaps on two weekdays and one weekend day. Even this type of self-monitoring regimen is difficult for most people over the long haul.
Self-monitoring of physical activity can be as important as self-monitoring of food intake. These diaries typically include recording the number of minutes of daily exercise and the intensity, but it can be helpful to record additional information, such as environmental barriers to planned activities, such as bad weather interfering with plans to walk or run outside. Emotional or social barriers can also be recorded, such as feeling too depressed to engage in activity, or exercise "buddies" being unavailable that day. The most important recent development in the ability to self-monitor physical activity is the pedometer, which can provide objective data on number of daily steps (1). In addition to serving as a tracking device and feedback tool, the pedometer can be a useful environmental cue and act as a "reminder" to be more active.
Because extensive, detailed diaries present adherence problems, practitioners often utilize more focused self-monitoring techniques that reflect the specific goals of the program. For example, if reducing fat intake is a primary goal, then daily fat grams would be recorded. If increasing vegetable and fruit intake is the goal, daily intake of these foods would be recorded. This type of highly specific self-monitoring can also be individually tailored to match individual patient's concrete goals. For example, the person who is trying to reduce meals per week at fast-food restaurants, or trying to increase weekly trips to the gym can monitor these specific events. The more relevant the behavior is for the individual, the more likely they will be to make the needed effort to self-monitor.
Another form of self-monitoring that has received more attention by researchers in recent years is self-weighing. The role of self-weighing in healthy weight loss and weight gain prevention has been somewhat controversial in the past. In part, this was due to the relationship between self-weighing behavior and eating disorders. Frequent and obsessive self-weighing is common in patients with anorexia, bulimia, and body-dysmorphic disorders, therefore it was often seen as pathological. However, this viewpoint ignores the fact that failure to self-weigh is often associated with rapid weight gain and obesity, and can serve to reinforce a state of "denial" about body weight.
Current research, described in more detail below, supports the idea that self-weighing can serve as an important type of self-monitoring to alert individuals to the early stages of weight gain. For example, surveys of people who have been highly successful at weight loss maintenance, such as the National Weight Control Registry studies, indicate that frequent self-weighing is a critical strategy (2). It appears to provide an early warning that weight regain is occurring, which allows people to make behavioral adjustments in a timely manner to reverse or stabilize the weight gain. For individuals who are losing weight, or maintaining weight loss, self-weighing can also serve as a form of reward for continuing healthy eating and exercise habits.
Some other techniques that fall under self-monitoring interventions include self-ratings of success (0 - 100%) at reaching behavioral goals, noting the fit of clothing, and recording comments by others. The precise technique used can be matched not only to the individual's priorities, but also to the goal of self-monitoring and the phase of treatment. For example, in the early stages of intervention, self-monitoring techniques such as detailed food diaries can help to 1) identifying problematic eating behaviors and 2) increasing individual awareness and understanding of eating habits. During active treatment, self-monitoring of specific targeted behavior changes can be helpful, as well as self-weighing to reinforce these behaviors. To avoid regaining lost weight, techniques such as self-weighing may be very useful, along with a return to self-monitoring of target behaviors if weight begins to increase.
Over recent years, there have been significant advances in the technology of self-monitoring, and this exciting trend is likely to continue. Currently, the primary example of technological devices for self-monitoring is the pedometer, which provides objective data for tracking physical activity (1). Pedometers now enjoy widespread use, both as a tool for motivating increased activity in lifestyle change programs, and as a means of objectively measuring physical activity in research. In addition, the development of PDA technology has produced several software programs for electronic self-monitoring, which offer the benefit of reducing work burden on the individual. Electronic diaries are essential to Internet-delivered weight loss programs, which are attempting to develop more sophisticated and user-friendly, methods of self-monitoring. There are also electronically instrumented paper-and-pencil diaries, which have been used to compare self-reports of self-monitoring to actual recordings (3).
Self-Monitoring Research: An Overview
By the early eighties, there was emerging evidence that failure to self-monitor was a major contributor to the failure to reach behavioral goals leading to weight loss and control (4). In the nineties, the literature on self-monitoring as a predictor of attrition and weight loss continued to grow (5 - 7). One of the major researchers and proponents of self-monitoring techniques is Daniel Kirschenbaum, a psychologist who directs the Center for Behavioral Medicine and Sports Psychology in Chicago. His studies have repeatedly shown that consistent self-monitors are more successful in behavioral weight loss programs than those who are not consistent (6,7). In addition, regardless of overall consistency, everyone loses more weight during those weeks when they are consistently using self-monitoring. However, only the most consistent self-monitors are able to lose substantial amounts of weight during behavioral programs.
Kirschenbaum estimates that about 25% of weight control success is due to consistent self-monitoring (8). According to his research, people need to self-monitor at least 75% of the time to be successful. Importantly, people who self-monitor fewer than half of the days they are in a program are highly unlikely to succeed at losing weight. Because of the need for consistency, Kirschenbaum recommends using highly targeted self-monitoring techniques. For example, his program emphasizes reducing fat intake and increasing physical activity, so participants are asked to record daily fat grams eaten and number of steps per day. Kirschenbaum calls this type of self-monitoring a "healthy obsession," and says that, in order to successfully control weight, people need to act in some ways like athletes, who have to stay focused and aware of their eating and exercise.
A more recent study investigated the role of exercise self-monitoring in a group of obese, sedentary men and women without diabetes participating in a six-month weight loss program (9). A comparison of consistent self-monitors to inconsistent self-monitors showed that those participants who were consistent exercised twice as much and lost twice as much weight (23 vs. 12 lbs). In addition, people who consistently self-monitored reported fewer difficulties meeting weekly exercise goals. The effect of self-monitoring was very specific in this study and recording daily exercise was not associated with caloric intake. This study also highlighted the difficulty of achieving adherence with self-monitoring. Only 43% of participants were able to achieve consistent self-monitoring, even with weekly meetings where diaries were reviewed.
Another recent study looked at self-weighing, and whether or not it has a positive or negative influence on weight loss or weight maintenance (10). As noted above, surveys of people who have been highly successful at weight loss and avoiding weight gain report frequent self-weighing as a form of self-monitoring. However, behavioral programs often do not emphasize self-weighing; for example, the CDC recommendations for weight loss do not mention self-weighing at all. The study included a large number (> 2000) of people who were trying to lose weight or maintain previous weight loss. In this study, only weekly self-weighing was recommended. The results showed that more consistent self-weighing was associated with greater weight loss in people trying to lose weight, and with lower BMI in people attempting to prevent weight gain. The effect of self-monitoring also appeared to be independent of other factors promoting weight loss, such as exercise and fat intake. Again, however, adherence was an issue, and consistent self-weighing was easier to achieve during the weight loss period compared to the weight maintenance period.
Although there is solid scientific evidence for the importance of self-monitoring, much more research is needed to help understand its role in lifestyle change. For example, the mechanisms by which self-monitoring contributes to successful behavior change remain unclear. We assume that it 1) increases self-awareness of target behaviors and/or outcomes, 2) provides a way to track success, 3) helps people grow in their knowledge and understanding of the impact of dietary and exercise behaviors and, 4) serves as an early warning system when problems arise. However, research has not systematically explored these different effects of self-monitoring on behavior change, or which effects have the most positive impact. Another important area that needs to be addressed by research is adherence to self-monitoring. For example, it would be extremely helpful to have a better understanding of the most common barriers, and what strategies are most effective in promoting good self-monitoring habits.
Enhancing Self-Monitoring Adherence: A Significant Challenge
The first step to approaching the problem of self-monitoring adherence is to recognize what you are up against. Achieving consistent self-monitoring has proven to be a significant challenge, even in programs that are highly structured, supportive and behaviorally-oriented. Furthermore, achieving consistent self-monitoring appears to be difficult, even for highly motivated and committed individuals, who are willing to attend weekly sessions for six months or longer. The research indicates that, at best, less than half of participants are likely to achieve and maintain adequate self-monitoring. Professionals working with individuals in lifestyle change programs need to take these numbers into consideration when forming expectations or evaluating the success of an intervention.
These scientific "facts" about the role of self-monitoring in meeting weight goals should also be an integral part of patient education and counseling. The research pretty clearly suggests that, without adequate self-monitoring, defined as close to 75% of the time, a participant's likelihood of achieving weight goals is very low. In fact, the research shows that only people who are willing to self-monitor consistently should expect to achieve substantial weight loss. This information should be communicated directly. By helping participants to understand the value of this technique, this education can be the first step in motivating the participant to self-monitor.
The next step is developing an individually-tailored plan for self-monitoring, based on the participant's personal goals, targeted behaviors, and willingness to invest time and energy. Approximately 25% to 40% or so of participants are likely to be able to follow such self-monitoring plans, with relatively few difficulties. The remaining participants will need more support to overcome barriers, as well as more time and effort to design a self-monitoring plan that they will be able to follow. Perhaps more patient education is needed to alter an individual's beliefs about the potential importance/usefulness of self-monitoring. One analogy that is often used when counseling individuals who are highly resistant to self-monitoring is that of balancing a budget. Ask how they would approach a friend or relative who needed and wanted to balance their budget, but did not want to keep a record of income or expenditures. Explore how likely this friend or relative would be to achieve the goal of a balanced budget if they continued to refuse to self-monitor financial behaviors.
Creating an individually-tailored self-monitoring plan, that can be followed, is essential. The word "creating" here is appropriate since this task can require much creativity on both the part of the counselor and the counseled. Techniques from motivational interviewing can be extremely helpful to identify what the individual is willing and/or not willing to do. Participants who are willing to keep more detailed records of food intake and physical activity should certainly be encouraged to do so, but signs of potential "burn-out" also need to be monitored. For those who are willing only to engage in minimal self-monitoring, the most important behaviors to track need to be identified and focused upon. Combining a non-judgmental stance and a sense of humor with creativity can serve as an invaluable resource throughout this process. If an individual is only willing or able to track number of fast food meals per week, then this should be the initial plan. The goal is to find some relevant behavior or outcome that the individual will self-monitor.
Psychological, environmental and social barriers to self-monitoring usually need to be addressed at some point. For example, an individual's beliefs concerning the cost-benefit ratio of self-monitoring (or any other behavioral change) is an important mediator of motivation. The perceived costs, including inconvenience and shortage of time, need to be normalized and explored from a problem-solving perspective. Another important issue that often arises is the perception that feedback obtained through self-monitoring can "feel" like punishment to participants, especially if the feedback is interpreted in a self-judgmental way. This is true not only in lifestyle change programs, but in any medical regimen that includes self-monitoring. People with diabetes, for example, often dread or avoid self-monitoring of blood glucose levels, especially if their readings are typically much higher than target ranges. When self-monitoring evokes a sense of guilt, shame, frustration or anger, the individual may need more intensive counseling or therapy to help them interpret feedback in a more constructive manner.
Finally, it is important to remember that only a small minority of individuals will be able to sustain a high level of consistency in self-monitoring over very long periods of time. Planned "vacations" from self-monitoring can be a reward and a relief for individuals who have shown sustained consistency and are meeting their goals. Reducing the degree and/or frequency of self-monitoring over time as goals are met is also appropriate. Individuals who are successful at long-term weight control appear to "intuitively" vary their self-monitoring behavior regimen according to personal need. During periods of stability, self-monitoring may include only weekly self-weighing to keep track of weight. But, if self-weighing indicates an increase in body weight, there may be a return to more intensive self-monitoring to promote behavior change. This type of interactive process, between self-awareness and adaptive behavioral changes, is the ultimate goal of self-monitoring.
References
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2. Hill J and Wing R. The National Weight Control Registry. The Permanente Journal, 2003, 7, 34 - 37.
3. Burke LE, Serika S, Choo J, Warziski M, Music E, Styn M, Novak J, Stone A. Ancillary Study to the PREFER Trial: a Descriptive Study of Participants Patterns of Self-Monitoring-Rational, Design and Preliminary Experiences. Contemporary Clinical Trials, 2006, 1, 23-33.
4. Dubbert PM and Wilson GT. Treatment Failure in Behavior Therapy for Obesity. Treatment Failure in Behavior Therapy, 1998, 17, 367-370.
5. Wadden T and Letizia K. Predictor of Attrition and Weight Loss in Patients Treated by Moderate and Severe Caloric Restriction. Treatment of the Seriously Obese, 1992, 338-410.
6. Baker R and Kirschenbaum D. Self-monitoring may be necessary for successful weight control. Behavior Therapy, 1993, 24, 377 - 394.
7. Boutelle K and Kirschenbaum D. Further support for consistent self-monitoring as a vital component of successful weight control. Obesity Research, 1998, 6, 219-224.
8. Bringing RL. More Effective Tools to the Weight-Loss Table. APA Onlie: Monitor on Psychology, 2004, 35, 1-5.
9. Carels RA, Darby LA, Rydin S, Douglas OM, Cacciapaglia HM, O'Brien WH. The Relationship Between Self-Monitoring, Outcome Expectancies, Difficulties With Eating and Exercise, and Physical Activity and Weight Loss Treatment Outcomes. Annals of Behavioral Medicine, 2005, 30, 182-190.
10. Linde JA, Jeffery RW, French SA, Pronk NP, Boyle RG. Self-Weighing in Weight Gain Prevention and Weight Loss Trials. Annals of Behavioral Medicine, 2005, 30, 210-216.
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