Effect of remote nursing monitoring on overweight in women: clinical trial

ABSTRACT Objective: to evaluate the effect of remote nursing monitoring on the improvement of anthropometric measurements of overweight women. Method: controlled, randomized clinical trial, carried out in a reference outpatient clinic for treatment of obesity. The baseline sample was composed of 101 women randomly assigned to two groups, 51 in the intervention group (IG) and 50 in the control group (CG). The IG received remote monitoring through telephone calls and conventional monitoring, and the CG received conventional monitoring. Women were assessed at the baseline and after three months of intervention. A paired t-test and analysis of covariance were used to evaluate intragroup differences in anthropometric measurements, and the statistical significance of 5% was adopted. Eighty one women completed the study. Results: in the intergroup comparison after the intervention, a reduction of 1.66 kg in the mean weight (p = 0.017) and of 0.66 kg/m2 in the mean BMI (p = 0.015) was found in the intervention group. There was a borderline statistically significant (p = 0.055) reduction of 2.5 cm in WC with in the intervention group. Conclusion: the remote monitoring was beneficial in reducing anthropometric measurements. RBR-3hzdgv.


Introduction
Obesity is a complex chronic disease that has become a public health problem in many countries due to its high prevalence, causal relationship with many serious chronic diseases, negative effects on quality of life, and relevant economic consequences related to increased health care costs (1)(2) . Overweight people are at higher risk of developing type 2 diabetes mellitus, cardiovascular disease, high blood pressure, certain types of cancer, osteoarthritis, and depression (3) .
Although there is a global obesity pandemic, the prevalence of overweight and obesity in men and women varies greatly within and between countries; there are more obese women than obese men, in general, especially in developing countries (4) . In Brazil, overweight has increased in all age groups, in both sexes, at all levels of income and schooling (5) .
The basic principle of fat accumulation that characterizes obesity and overweight is the energetic imbalance between calorie consumption and expenditure (4) . The causes of overweight are complex and multifactorial, including biological, environmental, social and psychological factors, making its control a challenge, especially the maintenance of long-term weight loss (6)(7) . Although lifestyle interventions for weight loss are successful in the short term, weight regain is common (8) . Besides the few treatment options with proven efficacy for weight control, there is a lack of reference services with trained staff and an apparent lack of time and motivation of the clients that contribute to the problem (9)(10) .
Although obesity is associated with genetic issues, the effect of genotype on its development is strongly influenced by other lifestyle factors. In modern societies, increased consumption of fat-rich and carbohydrate-rich foods with high energy density and low levels of physical activity has favored weight gain (3) .
Although there is no perfect evaluation for overweight and obesity, which may vary according to ethnic and genetic factors, the most commonly used body mass measurement has been height-adjusted weight (6) . A situation is classified as overweight when the body mass index (BMI) (weight in kg divided by the square of the height in meters) is above 24.9 kg/m 2 (11) .
As excess visceral adipose tissue has been associated with metabolic syndrome and other chronic diseases, the assessment of visceral fat is indicated as an important marker. Waist measurement associated with BMI has been recommended for this evaluation (6,12) .
Research indicates that, in overweight people, small weight reductions, about 5 to 10%, may lead to improved control of major cardiovascular risk factors and prevent metabolic diseases (13) . Interventions that include behavioral changes and mainly address changes in eating habits and physical activity seem to aid in weight loss and long-term weight control (6) .
It is, therefore, essential to propose care to help people cope with the difficulties of weight loss and weight control and the problems arising from obesity.
A study shows that nurses can implement programs for the evaluation and monitoring of chronic health problems and help people self-manage problems (14) .
Health care should encompass a practical attitude mediated by the interaction of different sets of knowledge and should be based on a humanized relationship between the actors involved in situations that demand an integral therapeutic action, aiming at the best possible outcome (15) .
Remote monitoring is an innovative technology that can help people who experience in chronic health conditions, resulting in a greater sense of empowerment, better management of disease, and adherence to treatment. However, little is known about its benefits in the management of weight control. Researches that used this technology were mostly performed with people with other chronic health problems such as chronic obstructive pulmonary disease, congestive heart failure and diabetes mellitus (16)(17)(18) .
In this context, the present study aimed to evaluate the effect of remote nursing monitoring on the improvement of anthropometric measurements of overweight women.

Method
This is a randomized controlled trial conducted at an outpatient reference service for obesity in the city of Salvador, Bahia, Brazil.  (19) for the randomization, follow-up and analysis of the data. All participants signed the Informed Consent Form.
Of the 317 women enrolled in the service, 117 met the inclusion criteria as they had BMI ≥ 25 kg/m 2 , were over 18 year old and younger than 60, and had attended at least one consultation in the last 12 months. We excluded women with cognitive difficulties and severe psychiatric disorders who were Palmeira CS, Mussi FC, Santos CAST, Lima ML, Ladeia AMT, Silva LCJ.
unable to respond to the questionnaires, women using weight loss drugs, who had undergone bariatric surgery, or who did not have a telephone device. The choice for carrying out the study with women was due to the fact that they represented 91% of the people enrolled in the service. After the initial data collection with the baseline group of 101 women, they were randomized in blocks.
The proposal established 51 women allocated to group A (intervention group) and 50 to group B (control group) according to the age group because age is a variable that can influence the response to treatment.
Thus, the randomization was organized according to the age, which consisted in two groups: group 1: < 50 years, and group 2: ≥ 50 years. The group 1 had 51 women; 26 were randomly assigned to the intervention group A and 25 to the control group B.
As for the second age group, the same procedure was applied. Figure 1 shows the research flowchart.
While the control group only attended routine follow-up consultations, the intervention group received remote monitoring consisting of telephone calls in addition to these consultations. As for the randomization process, the characteristics of the population were analyzed to ensure comparability between groups. The food intake was evaluated by an instrument adapted from Vigitel (21) , with closed questions about the daily consumption of beans, vegetables, legumes, fruits, meats, soft drinks, cakes, pies and sweets, as well as the food preparation. and obesity III (≥ 40 kg/m 2 ) (11) .
The waist circumference (WC) was measured at the midpoint between the last rib and the anterior superior iliac crest on the right axillary line, using a flexible and inelastic metric tape to an accuracy of 0.1 cm. The classification of WC in women followed the International Diabetes Federation (IDF) parameter: normal (< 80 cm) and increased (≥ 80 cm) (6) .
The remote monitoring lasted three months, included weekly telephone contact following a previously established weekly thematic protocol prepared with basis on the information from guides of scientific societies (6) and consultation to specialists.

Results
The sociodemographic characteristics of the participants of the intervention and control groups are shown in  Regarding the anthropometric data, the control group and intervention group were homogeneous.
A higher proportion of women were observed with obesity (84.5%) and all of them had increased WC (≥ 80 cm). The mean weight of the sample was 91.6 kg (SD = 15.5), the minimum was 61.6 kg and the maximum was 128.9 kg. The median was 90.7 kg. Data on the intragroup comparison of the anthropometric measurements before and after the remote monitoring is presented in Table 3. When comparing the intragroup variation of weight before and after the intervention, an increase was observed in the control group (p = 0.041) and a decrease in the intervention group, but without statistical significance (p = 0.146).
There was an increase in average BMI in the control group with borderline statistical significance        and alcohol consumption were not prevalent. The recommended frequency of consumption of legumes, vegetables, salads and fruits was not observed, the frequency was rather unsatisfactory, but higher than those found in women in Salvador (32.3%) (5) . A higher intake of these foods is recommended in view of their higher fiber, vitamins, antioxidants, minerals and unsaturated fats content, and lower glycemic load, salt and trans fat, which allows weight loss and weight maintenance (25) .
Regarding the number of meals per day, the frequency of women who did the fractionation of the diet, which helps in decreasing the desire to eat, was low. This type of strategy can also contribute to lower cholesterol levels, maintenance of blood glucose levels, control of appetite, and control of proper weight (26) .
The percentage of women with obesity was higher than that of overweight and all were with increased waist circumference, thus representing a population group with a high risk of morbidity and mortality.
These parameters are strongly associated with a higher prevalence of type 2 diabetes mellitus and cardiovascular diseases (27) . Increased visceral adipose tissue is associated with a number of metabolic abnormalities, including reduced glucose tolerance and insulin sensitivity and adverse lipid profiles (28) .
Data from the present study showed that remote nursing monitoring was effective because the anthropometric measurements of the women in the intervention group presented a statistically significant reduction compared to the control group. Even small reduction of weight, BMI and waist circumference resulting from educational approaches should be seen as a positive thing if compared to weight reduction programs using medications where a reduction of 1% or more of body weight per month, reaching at least 5% in three to six months, is considered effective (6) .
Although a growing number of studies has investigated the use of information and communication technology for weight loss, the technical approaches used and the time of intervention differ considerably between them making it difficult to compare their findings with the present study. However, it is noteworthy that the use of these technologies also achieved favorable results in terms of weight loss (29) . Only one educational intervention study used face-to-face meetings and telemonitoring technology. It was a clinical trial that assessed the adherence of 170 adults to the weight loss program and found that the group that received the intensive education intervention presented a reduction of BMI of 1.0 kg/m 2 on average compared to the less intensive intervention group (30) .

Discussion
This randomized controlled trial evaluated the effect of remote nursing monitoring of overweight women and confirmed the benefits in terms of improved anthropometric measurements. The study provides evidence for the use of this therapeutic tool in health and nursing care.
Women who were the target of the remote monitoring were characterized predominantly by the low level of schooling and low income, in line with the literature. This indicates that excess weight is greater among people with lower socioeconomic level (22) . The relationship between weight accumulation and social conditions is explained by the fact that low-income people face more barriers to accessing healthy foods and practicing physical activity necessary for weight control (9) . The conditions of social inequality require sensitive approaches of the health team, in order to understand the difficulties of each person and adapt the guidelines accordingly.
Women participating in this study were predominantly black and the productive age range, This situation is worrying because regular physical activity for at least 150 minutes per week is one of the pillars of weight reduction treatment (24) . Lack of time, poor access to affordable facilities, and limited space available for physical activity at home can explain the lack of physical activity during leisure time in people with more financial constraints (9) .
Still with respect to lifestyle, the major problems were related to the eating pattern, because smoking Rev. Latino-Am. Enfermagem 2019;27:e3129.
The management of overweight people should not be limited to the goal of great weight reduction and its maintenance over time, but should also contribute to the valorization of incorporation of healthy habits and improvement of clinical conditions. In this sense, remote monitoring represents an effective therapeutic tool for health education and self-care incentive. As for obesity, this strategy should be considered as an additional option to conventional treatment (31) .
The effect of the monitoring mediated through telephone, the strong point of the present study, confirms this method as effective to approach users in their homes, mainly as an educational strategy, due to flexibility of schedules, optimization of time and resources and capacity to reach large numbers of users who face difficulties involving geographic and financial barriers to access the health service (17,32) .
In chronic health conditions, such as heart failure, acute myocardial infarction, and chronic respiratory and renal diseases, telemonitoring has proved to have beneficial effects. These benefits

Conclusions
The results showed that the remote monitoring of weight had a beneficial effect of reducing the anthropometric measures of women in the intervention group when compared to the control group.