key: cord-0797889-i4kl5wq7
authors: Krukowski, Rebecca A.; Ross, Kathryn M.
title: Measuring weight with e‐scales in clinical and research settings during the COVID‐19 pandemic
date: 2020-04-27
journal: Obesity (Silver Spring)
DOI: 10.1002/oby.22851
sha: cbf686c48607f85abe7285556bb8387fbe4e6546
doc_id: 797889
cord_uid: i4kl5wq7

With the COVID‐19 pandemic, clinicians and researchers have been suddenly confronted with the difficulty of treatment provision and continuation of clinical trials without face‐to‐face contact. This predicament has resulted in the rapid adoption of telehealth methodologies.(1) Clinicians and researchers focused on obesity management have an additional need‐‐ a remote way to measure weight. In this piece, we will describe electronic scales (e‐scales) and provide guidance on how clinicians/researchers might best implement e‐scales in their clinical practice or research studies to remotely measure weight.

With the COVID-19 pandemic, clinicians and researchers have been suddenly confronted with the difficulty of treatment provision and continuation of clinical trials without face-to-face contact. This predicament has resulted in the rapid adoption of telehealth methodologies. 1 Clinicians and researchers focused on obesity management have an additional need--a remote way to measure weight. In this piece, we will describe electronic scales (e-scales) and provide guidance on how clinicians/researchers might best implement e-scales in their clinical practice or research studies to remotely measure weight.

Although appearing no different from a traditional digital bathroom scale, e-scales transfer weight data directly to research/clinical centers through the cellular network, wireless internet, or pairing with a Bluetooth device that has internet access. E-scales can be mailed directly to individuals; beyond this, cellular models require no setup aside from placing scales on a hard, flat surface. Wireless internet e-scales need to be set up through a website or smartphone app connected to local wireless internet, while Bluetooth e-scales require pairing with the Bluetooth device. While e-scales cost more than traditional digital scales, costs have decreased enough to make these tools feasible for most clinical and research applications. Commercial scales cost approximately $30-$150 per unit, with research-grade scales costing $80-130. Examples of e-scales previously used in research include BodyTrace, Fitbit Aria, and Withings scales.

Two studies have shown measurement concordance between e-scales and calibrated clinic scales, with correlations of 0.99. 2,3 Both studies found a 1.0 kg difference between e-scale and clinic scale weights; this consistent difference is likely due to e-scale weights being generally captured earlier in the day than clinic weights, which were measured during clinic hours after likely least one meal with individuals who were wearing more clothing. Importantly, correlations were strong between the measurements regardless of gender, body mass index, race, and age categories. 3

General guidelines. To obtain the most valid and reliable measurement, individuals are encouraged to weigh first thing in the morning, without wearing clothing, before eating/drinking and after voiding their bladder/bowels.

As calibration may be affected by shipment, individuals should weigh themselves (i.e., stepping on the scale, waiting for a weight to appear, stepping off the scale, allowing for the weight to transmit) at least 3 times. If weights do not appear stable, individuals should repeat this protocol and contact the clinicians/researchers for troubleshooting if the technical problems cannot be resolved.

Clinicians/researchers can contact the scale manufacturer on the behalf of the individual for further troubleshooting as a final option.

Addressing common challenges. Individuals are encouraged to refrain from moving the scale or storing it on its side, as this may require scale re-calibration before each use. Participants should also discourage other family members from using the scale, unless the scale allows for separate profiles for multiple individuals; while some scale models "filter" out unlikely weights (as may be created by pets or other users), these extra measurements can cause challenges (procedures for "cleaning" e-scale data have been described elsewhere. 4, 5 ) Finally, e-scales may have transmission difficulties with weak cellular or wireless internet connections. Concrete walls can block cellular signals, so cellular scales should be placed near windows for optimal signal. Wireless internet scales should be placed near routers to improve signal strength. Moreover, many scales can retain weights for at least a week; thus, individuals who experience weak connections can weigh themselves and then move the scale to another location to transmit weights weekly.

Comparisons with self-reported weight. When e-scales cannot be used, self-report may serve as an alternative method for assessing weight. There is generally strong agreement between selfreported weight and e-scale weights 6 and between self-reported weight and clinic weights; 7 however, relying upon self-reported weights requires individuals to have a digital scale and for them to actively and accurately enter each weight. One method of ensuring accuracy of self-reported weight is to have individuals photograph the weight on the scale as it is being measured, 8 although this methodology necessitates human processing of resulting images.

This article is protected by copyright. All rights reserved Specific populations and considerations. An important consideration when choosing an e-scale is how data will be accessed. Some e-scales are primarily for consumer use and have limited functionality for clinicians/researchers. Others allow data to be pulled via Application Program Interface (API) tools (which allow the e-scale system to securely communicate with the clinician's/researcher's data management system, in order to transfer the requested weight data with date/time stamps), although this method often requires assistance from software developers. Finally, some scales have website portals allowing direct access to data from registered scales. Before selecting an e-scale, clinicians/researchers need to determine: 1) In what format do you want to view data? 2) Do you need data immediately after transmission, or is it sufficient to receive "batches" of data at specified time points? 3) Is data transmission/storage compliant with the Health Insurance Portability and Accountability Act Privacy Rule 9 ? Using third-party platforms to collect, transmit, or store data has important security and confidentiality implications; thus, clinicians/researchers interested in implementing these tools should consult with their local privacy office/institutional review board staff. In general, using identifiable personal health information should be limited, and individuals should be informed if their data may be accessed or transmitted by third-party sources.

Clinicians/researchers should also assess which e-scale type (e.g., cellular, wireless internet, or Bluetooth models) would be feasible to implement with the target population. Limited set-up required for cellular scales use can be helpful for users with low technology literacy; however, access to cellular signals may be limited in some areas (e.g., in low-resource rural communities). Moreover, use may be limited for individuals with higher weights; existing scales typically have maximum weights between 150 and 180kg.

The COVID-19 pandemic requires particular consideration of disease transmission with e-scales.

Since the virus survives on cardboard for about 24 hours, it is recommended that individuals do not handle the box for 24 hours after delivery and that they wash their hands after opening the box to take out the scale. Considering that individuals may be averse to reuse of e-scales that have been repeatedly used with bare feet/stored in the bathroom by others, e-scales are often used by just one individual when provided in an intervention context. For one-time assessments, scales can be mailed and cleaned (with hospital-grade sanitizing/disinfecting wipes) between uses.

This article is protected by copyright. All rights reserved While e-scales can be particularly helpful for managing the move to telehealth services in response to COVID-19, there are also other potential benefits to research and clinical practice. E-scales allow for weight measurement without requiring individuals to attend frequent appointments, and thus may help to reduce burden and lower attrition rates. Outcomes collected via e-scales may also be more precise than clinic weights, because individuals can weigh in the same standard conditions (as described above) on specified days, rather than having data collection windows that may span particularly sensitive times like the holidays. E-scale use may also help to increase study sample sizes and clinical service reach, as fewer individuals will be deemed ineligible because they will have difficulty attending follow-up appointments (e.g., based on distance from the measurement site or relocation).Thus, e-scales offer promise for evidence-based treatment dissemination in rural populations, highly-mobile individuals (e.g., young adults or active duty military personnel), and in groups that have difficulty attending regularly-scheduled in-person appointments (e.g., shift workers, nurses and first responders, and new parents). However, it will likely be important to maintain usual screening and behavioral run-in procedures, for individuals to sample the intervention before committing and to gauge motivation, which could impact data completeness and retention.

By supporting remote assessment and intervention, e-scales offer promise for widespread benefit to

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Accepted Article

weight-related research and clinical practice. The COVID-19 pandemic is thrusting us into the future of healthcare and may represent a crucial moment for adopting innovations that can improve population health, through increased access to care and decreased burden.

This article is protected by copyright. All rights reserved