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Innovating against Obesity: Applying Social Networking
Services to Manage Body Mass Index Following the World
Innovation Summit for Health Policy
Hutan Ashrafian*, Tania Toma, Leanne Harling, Karen Kerr,
Thanos Athanasiou and Ara Darzi
Institution:
1The Department of Surgery and Cancer, Imperial College London,
10th Floor Queen Elizabeth the Queen Mother (QEQM) Building, St
Mary’s Hospital, Praed Street, London, W2 1NY, UK
*Correspondence to:
Dr Hutan Ashrafian
The Department of Surgery and Cancer,
Imperial College London,
10th Floor Queen Elizabeth the Queen Mother (QEQM) Building,
St Mary’s Hospital,
Praed Street, London, W2 1NY, UK
Tel: +44(0) 203 3127651; Fax: +44(0) 203 3126309
Word Count: 4066 (including title page, abstract, tables and
references)
Funding Statement: This research was funded by the Qatar
Foundation
Abstract
The global epidemic of obesity continues to escalate. It
represents an increasing proportion of the international
socio-economic burden of non-communicable disease (NCD) that
was addressed at the 2013 World Innovation Summit for Health
(WISH). Global online social networking services (SNS) provide
a prevailing communication medium through which information
may be exchanged between obese and overweight patients and
their healthcare providers, potentially contributing to
superior weight-loss outcomes. We performed a systematic
review and meta-analysis to appraise the role of SNS in the
global management of obesity through its effect on modifying
Body Mass Index (BMI). Our results demonstrate that SNS
interventions may produce a significant, but modest 0.64%
reduction in BMI. As a result, we offer specific
recommendations for the integration of this global
communicative technology into policy-driven public health
reforms in order to facilitate multi-stakeholder partnerships
and create a supportive environment to tackle obesity and its
associated NCDs.
Key Words: ‘Social Networking Services’; ‘Obesity’;
‘Innovation’; ‘Health Policy’
Abstract Word Count: 148
Introduction
The global epidemic of obesity continues to escalate and
represents an increasing proportion of the substantial
international socio-economic burden of non-communicable
disease (NCD). Decades of caloric overconsumption combined
with reduced energy expenditure has produced an ‘obesogenic’
environment, causing the global prevalence of obesity to
double since 1980.(1) Similarly, these environmental forces
are driving a concomitant rise in diabetes, cardiovascular
disease, mental health and cancer, placing additional strain
on global heath services particularly in already overburdened
low- and middle- income countries. Although increased
consumption may have a positive effect on global GDP,
increased disease related expenditure negates the benefit of
higher consumption and the associated loss of productivity
negatively impacts on economic growth. As such, obesity has
become a disease of poverty, exaggerated by the high costs of
fresh produce and plentiful access to cheap and unhealthy food
choices.
An obesity policy forum convened in conjunction with the 2013
World Innovation Summit for Health (WISH) in Doha presented an
agenda for strategic action on this global problem. This
highlighted the current and predicted future global status of
obesity to identify key recommendations for ministers for
health (Technical appendix - Table 1), policy makers and
health providers.(2) It is currently estimated that obesity
and associated NCDs consume approximately 6% of the global
healthcare budget, and that for every 1 point increase in BMI
above 30, individual healthcare expenditure increases by 8%.
(3) Worrying trends from the United States also highlight the
potential scale of this problem without intervention;
estimating the total economic cost of obesity to reach $957
billion by 2030, accounting for 18% of US health expenditure.
(4) Addressing the global obesity crisis requires a whole-
population approach if we are to achieve the World Health
Assembly target of 0% global growth in obesity by 2025.(5)
This will necessitate collaboration between policy-makers and
health systems, as well as multi-stakeholder partnerships with
industry, private and public sectors.
Tackling obesity also demands a coordinated timeline of
intervention, combining short-term treatments with long-term
re-education. Government initiatives such as fiscal and trade
policy supporting healthy imports and domestic food
production, alongside the implementation of food labeling
standards go some way to shift societal norms and promote
healthy food choices.(2) However, additional social support
will be required to achieve long-term weight reduction.(6, 7)
As such, primary care physicians are expected to play an
increasing role in future obesity management strategies
through lifestyle counseling and intervention. However,
primary care resources are already oversubscribed and
substantial manpower and funds would be required for this to
be implemented. Consequently, it is vital that community based
treatments are integrated into any sustainable long-term and
cost-effective strategy to combat obesity. Furthermore,
community action groups and local/work place support networks
may also provide obese patients with an individualized social
framework, subsequently improving weight loss outcomes by
setting personalized, locally appropriate targets.
Computer and web-based technologies may also offer innovative
approaches to deliver weight loss programmes, and allow us to
impact on healthcare at a population level. Furthermore, these
technologies also offer potential to engage support for
environmental and policy changes that are essential to obesity
prevention. Existing web-based interventions have generally
adopted behavioural and cognitive restructuring strategies
through education, self-monitoring and goal setting.(8) Whilst
this has been partially effective, social networking services
(SNS) now provide a more multi-faceted approach, allowing us
to integrate online community networks and access to
healthcare providers through instant messaging and secure chat
forums. This novel approach offers improved accessibility as
online services can be used at any time of day, with greater
anonymity when compared to face-to-face contact. It also
offers the opportunity to improve data collection, and provide
detailed analysis.
SNS may be defined as “web-based services that allow
individuals to (1) construct a public or semi-public profile
within a bounded system, (2) articulate a list of other users
with whom they share a connection, and (3) view and traverse
their list of connections and those made by others within the
system”.(9) Already utilised in a number of chronic diseases,
SNS have become increasingly popular given the rapid uptake of
mobile phones and tablet devices.(10, 11) Current examples
include the Nutri-Expert system(12) and the online
CalorieKing™ website (http://www.calorieking.com. au),(13)
however the exact nature of this intervention presently varies
according to the region or institution. By exploiting the
expanding technology of global online social networking, SNS
offers a potentially cost-effective population-based means by
which we may both treat and prevent obesity and its associated
NCDs. Furthermore, these novel services allow for additional
features such as personalized feedback, decision advice and
peer-support forums to be provided real-time, delivering a
uniquely contextual and individualized intervention.
SNS technologies have recently shown encouraging results in
patients with Diabetes Mellitus producing positive metabolic
outcomes and improvements in both blood pressure and glycaemic
control.(14) However, when orientated to achieve weight loss,
previous studies of web-based interventions demonstrate more
modest results.(15, 16) One fundamental limitation to current
reviews of this literature is the use of weight-loss as a
primary outcome rather than BMI, producing a high degree of
heterogeneity given the wide range of starting weights and
body morphologies of overweight and obese patients. As such,
an accurate appraisal of the role of SNS interventions in
tackling obesity remains lacking. Although we recognise that
BMI also has its limitations as an outcome measure in that it
does not take into account lean muscle mass or body fat
distribution, it remains to be a globally accepted measure of
obesity in view of its universality and practical
calculability. The objective of this study is therefore to
review the role of SNS interventions in the management of
obese and overweight patients. We will begin by assessing the
effect of online social networking services (SNS) in achieving
beneficial reductions in BMI through a comprehensive meta-
analysis of published randomised controlled studies. Based on
these findings, we will then discuss the application of SNS
and how it may influence global healthcare. Finally, we will
conclude by providing policy recommendations regarding the
incorporation of SNS into public health reforms that strive to
combat the global epidemic of obesity.
Methods
A systematic search of MEDLINE (1946 to present), EMBASE (from
1974 to present) and PSYCHINFO (from 1967 to present) was
performed using the MeSH terms: "social networking”, “BMI”,
“obesity”, “overweight”, “weight loss,” “weight change,” “body
mass index”, “mobile phone", "cellular phone", "text message",
"smart phone", “SMS”, “web”, “web-based”, “internet” and
“internet-based”. Meta-analysis was performed using a random
effects model. A summary of the search strategy is shown in
the Technical Appendix, Figure 1.
Exclusion Criteria
Studies were excluded if: (1) BMI was not used as an outcome
measure; (2) the intervention group was not compared with a
control; (3) they were non-randomised studies or reviews, case
reports, comments or editorials; (4) they involved the use of
non-wireless technology e.g. telephone lines, as the primary
method of communication and exchange of data and (5) they
included participants with a normal BMI.
This meta-analysis was conducted in accordance with PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-
Analyses) guidelines(17) and written in line with
recommendations from the Cochrane Collaboration. Statistical
analysis was carried out using Review Manager® Version 5.0 for
Windows (The Cochrane Collaboration, Software Update, Oxford,
UK) and STATA v.11 statistical analysis software.
Continuous outcome data from individual studies was analysed
using a random effects model. Weighted mean difference (WMD)
was used as the summary statistic for continuous variables and
reported with 95% confidence intervals (CI). Point estimates
with a p-value <0.05 were considered statistically significant
providing the 95% confidence interval did not include the
value zero. Odds ratio (OR) was used to analyse categorical
data. An OR of <1 favoured the intervention group and was
considered statistically significant at p<0.05 providing the
95 % confidence interval did not include the value 1.
Between-study heterogeneity was calculated using the I2
statistic. Significant statistical heterogeneity was regarded
as present where I2 was greater than 50%.
A full description of study selection criteria, assessment of
study quality and potential bias was performed as described in
Technical Appendix 1.
Limitations
It is important to also consider a number of limitations when
evaluating this data. Firstly, the studies included in our
analysis are of small size and provide limited long-term
follow-up. This is particularly notable in that only two
studies report data at 12-months(12, 18). Secondly, although
we believe BMI is a superior outcome measure to weight-loss,
it may be criticised for not taking into account lean muscle
mass or body fat distribution, which may vary particularly
across gender and ethnic groups. Third, all included studies
focus on primary health outcomes such as BMI, waist
circumference and blood pressure. At present there is little
evidence regarding the effect of SNS on intermediate outcome
measures such as caloric intake or time spent on exercising.
Further evaluation of these parameters may provide better
insight into whether SNS does indeed produce recordable
behavioural changes.
It is also notable that although previous research suggests
that computer-based support may incur considerably lower cost
than in-person alternatives,(19) there is a lack of robust
evidence assessing the cost-effectiveness of SNS and its
viability in obesity care. Thus, it is necessary for policy
makers to account for this inadequacy, along with
considerations over the safety, sustainability, and
scalability of SNS before confirming it as an effective
therapy for obesity and overweight.(20)
It is also important to consider the potential disadvantages
of SNS technologies. Compared to face-to-face contact with
healthcare providers or even real-life participation in group-
programs, SNS may provide a more abstract patient-provider
interaction and thus result in a less individualized and
detached treatment approach. Furthermore, the Internet, and
particularly groups of ‘lay experts’, can be important
mechanisms for disseminating misinformation. Mitigating this
risk would require active moderation by a health expert, which
may create some extra burden on healthcare providers.
Additionally, although peer-support groups can be hugely
motivating, the relative anonymity offered by online
technologies also creates a risk of cyber-bullying when
participants do not meet group goals. Such negative emotional
impacts can result in achieving the opposite effect of that
intended and deter people from future participation in weight
management programs.
Finally, where SNS strategies are implemented, it is important
to ensure equity of care amongst all socio-economic classes.
This is of particular importance in the lower socio-economic
classes, in whom levels of obesity are likely to have an
inverse correlation with level of education and likelihood of
computer literacy. Similarly, SNS technologies should ideally
also be made available to economically weaker strata of the
population, where computers and smartphones are less likely to
be affordable. It is therefore important to consider the risk
of increasing health inequities when implementing SNS on a
wider scale, and future policy decisions should include a
discussion as to potential strategies that may mitigate such
risks in the future.
Results
Twelve studies were assessed comprising a pooled data set of
1884 patients, 941 of whom received SNS intervention
predominantly through Internet platforms. Prior to SNS
intervention, baseline BMI was comparable between SNS and
control patients.
Characteristics of Interventions
The Internet, particularly through interactive websites, was
the predominant platform used. Nine trials solely used web-
based tools(12, 13, 18, 21-26), 1 study combined Internet and
mobile technology,(27) and 2 studies integrated the Internet
with telephone communication.(28, 29) Two studies adopted
supplementary armbands with real-time electronic displays of
results(28, 29), one provided a wristwatch with a similar type
of display,(29) and one study provided participants with
pedometers.(18)
Nine studies delivered personalised feedback to participants
based on their online data.(12, 13, 18, 23, 24, 26-29). This
feature was enhanced in 5 studies by direct messaging with
providers via secure SMS, email or online chat-rooms.(12, 18,
21, 23, 27) Another defining feature occurring in 4 studies
was the use of online peer support and group discussion forums
as a communal space for interaction between participants.(21-
23, 25) In an additional study, providers were present
alongside participants in the online forums.(12) Five studies
incorporated goal-setting modules to encourage anti-obesity
actions(18, 25, 26, 28) and 4 provided online journals where
participants regularly documented a range of personal data
including physical and nutritional activity, weight, energy
expenditure and calorie consumption.(13, 23-25) Three studies
had an online education element delivering non-personalised
advice on nutrition, exercise and healthy living.(18, 22, 25)
Effect of SNS Interventions
After completing the intervention period, SNS patients had a
significantly lower BMI than control patients (0.64% lower)
and experienced a significantly greater change in BMI from
baseline (-0.66%). SNS also lead to a 1.40% greater reduction
in body weight and 0.79% greater reduction in waist
circumference than control patients although this did not
reach statistical significance. SNS interventions did not
however result in any significant changes in metabolic markers
such as body fat percentage, blood pressure or lipid profiles.
When considering the duration of SNS interventions, the
optimal period of intervention was found to be between six and
twelve months. Where follow-up was less than 6 months or
greater than 12 months, no significant effect on BMI was
observed.
A complete report of the meta-analysis methodology and results
is described in detail in Technical Appendix 1.
Discussion
This study demonstrates that SNS technologies may facilitate a
modest yet significant reduction in BMI in obese and
overweight individuals. As expected, these effects are
gradual, reaching significance when SNS interventions are
continued for 6 months or more. However, the impact of SNS on
BMI reduction appears less significant after 12 months,
suggesting that compliance may be a factor in achieving a
long-term, sustainable reduction in BMI. In accordance with
previous findings,(15, 16) this study did not demonstrate any
commensurate significant reductions in weight, waist
circumference, adiposity, blood pressure or lipid profiles in
these patients. These findings were independent of the length
of SNS intervention program.
With 82% of the world’s online population over 15 years of age
engaging in social networking activities,(30) SNS offers a
means whereby we may impact on healthcare at a global level to
broadcast and disseminate medical information across vast
virtual audiences.(31) Fundamentally, SNS acts not only as a
passive tool whereby information may be disseminated, but also
provides an adjunctive real-time, participatory communication
medium through features such as instant messaging services and
online support forums.
SNS strategies largely focus on targeting lifestyle patterns
to mitigate obesogenic behavior and achieve favourable
improvements in BMI. Through the enforcement of online goal
setting, journals and self-monitoring tools, patients are
empowered to adopt a more independent approach to self-care.
(32) Crucially, SNS provides social support through digital
communities, offering group encouragement as well as an
individualized interaction between patients and providers, and
exchange of personal data and recommendations.
As with other dietary and lifestyle weight-loss interventions,
patients do however become less responsive to SNS in the long
term, with even smaller reductions in BMI after an
intervention period beyond 12-months. One of the challenges of
SNS is therefore to maintain participant engagement in order
to achieve long-term weight reduction(12). Over time, patients
may develop tolerance and even boredom towards the various
stimuli provided by SNS.(15) Furthermore, SNS systems are
often blamed for being overly complex and time-consuming,(22,
24) decreasing long-term compliance. As such, in order to
optimize SNS technologies in obesity healthcare it is
important to create a simple, user-friendly, system that is
accessible to all patient groups.
Mobile phone and tablet devices provide one means by which we
may augment Internet based programs and improve the
portability of existing SNS systems. In addition, despite
early concerns regarding the privacy and confidentiality of
data exchange, social networking giants such as Facebook® or
Twitter may provide a familiar and practical approach to
initiate online connections between communities of physicians
and patients. Indeed, through use of a private online
Facebook® group within which participants were given caloric
targets, goal setting advice and online ‘buddies’; Facebook
has been shown to offer the potential to augment conventional
SNS interventions (33).
The results presented here highlight the potential for SNS to
contribute to the global strategy on tacking obesity by
offering a cost-effective means to augment existing policies
that address overconsumption and promote physical activity.
Furthermore, SNS platforms may be utilized in a similar way to
tackle many obesity associated non-communicable diseases
including diabetes, hypertension, and heart disease. As such,
social media presents a novel, accessible and realistic tool
to monitor both individual and population health in homes,
workplaces, schools and colleges. The flexibility of SNS also
allows for individual customization, with the setting of
specific targets according to the local culture and
environment. However, despite the aforementioned benefits of
SNS technologies, these initiatives must be considered as
adjuncts to a much wider, multi-faceted strategy on obesity
that requires multi-stakeholder partnerships between
governments, industry, private and public sectors.
Recommendations
The recent report from the World Innovation Summit for Health
(WISH) held in Doha in December 2013 addresses the key drivers
of obesity and outlines recommendations to tackle this ever
increasing problem in both the short- and long- term
(Technical appendix - Table 4).(2)
The key recommendations from this summit aim to champion the
issue of obesity and for policy makers to become ambassadors
for change. Beyond this, they highlight the importance of
finding innovative and economically viable ways to address
obesity-promoting forces in the food environment, with an
emphasis placed on learning from successes in similar
countries. Finally, these recommendations advise settings-
based initiatives in at least one of three core societal
institutions (schools, worksites and healthcare), with the
other institutions to follow in future years.(2)
Based on the results of this study we suggest a number of
additional SNS specific proposals. Firstly, we recommend the
implementation of a series of large scale randomised
controlled clinical trials to evaluate the impact of SNS on
BMI reduction with follow-up extended into the long-term to
assess 5- and 10- year outcomes. Furthermore, such studies
should include an adjunctive full cost-effectiveness
evaluation to determine the economic viability of scaling up
SNS interventions.
We also recommend the early implementation of SNS as an
adjunctive tool for measuring and monitoring obesity and the
metabolic syndrome in obese and overweight patients.
Furthermore, we recommend that social media platforms be
applied to the coordination of obesity treatment and
prevention services at planning and operational levels. This
should include social networks, nutritional guidance, physical
activity and behavioural support.
Importantly, in order to advance social networking service
technologies, SNS should now be developed to allow the
integration of social media hubs as portals for the
dissemination of anti-obesity treatment supervision, support
and guidance. Furthermore, this should be made applicable to a
variety of platforms including mobile applications (mHealth
Technologies), with a subsequent assessment made of the
relative effectiveness of each SNS platform by means of
further large scale appropriately designed randomised clinical
trials. Finally, effective social media interventions should
be ‘scaled up’ and both healthcare and community support staff
trained to provide anti-obesity SNS interventions to their
patients.
Conclusions
In summary, online social networking services (SNS) may
provide an accessible, cost-effective means of achieving
beneficial reductions in BMI. As such, SNS may augment policy-
driven public health reforms to combat the global epidemic of
obesity within school, workplace and healthcare environments.
Beyond weight loss, by utilising SNS platforms in NCDs such as
diabetes, hypertension, and heart disease, online technologies
may support the development of individualized metabolic
syndrome management programs through the integration of multi-
disciplinary services. Furthermore, through data collection
and focused research, enhanced applications of social media
platforms may help coordinate government, private and public
sectors in planning strategies for obesity treatment and
prevention.
Further research and developments are now necessary for SNS to
be developed into a clinically viable option in obesity and
overweight care. One of the key challenges faced by developers
is in ‘scaling-up’ effective social media interventions to
deliver a more portable, user-friendly service that integrates
mobile phones, tablet devices and popular online social
networking sites whilst maintaining participant
confidentiality and security. At the same time, increases in
SNS delivery must be coupled with the provision of expertly
trained staff to provide these interventions and facilitate
public engagement.
Whilst these and other challenges undoubtedly lie ahead, this
global communicative technology provides a valuable
opportunity for action on obesity and its associated NCDs,
with the potential to facilitate multi-stakeholder
partnerships and create supportive environments to combat
obesity. In this way we believe SNS technologies may augment
the policy-driven public health reforms of the future, and
form a keystone in tomorrows checklist to tackle the global
epidemic of obesity.
Acknowledgments: We would like to thank the panel members of
the World Innovation Summit for Health (WISH) Obesity Forum
for their invaluable contribution to this work: Shiriki
Kumanyika – University of Pennsylvania & International Obesity
Task Force and Chair of the WISH Obesity Forum; Javaid Sheikh
– Dean, Weill Cornell Medical School; Maryah B. Al-Dafa –
Project Director in the Office of President of Qatar
Foundation.
Funding: This research was funded by the Qatar Foundation
Conflict of Interest: None
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