Benefits of adding small financial incentives or optional group meetings to a web-based statewide obesity initiative

A randomized controlled trial testing an Internet delivered cost-benefit approach to weight loss maintenance

Weight loss maintenance is a significant challenge in obesity treatment. During maintenance the "costs" of adhering to weight management behaviors may outweigh the "benefits." This study examined the efficacy of a novel approach to weight loss maintenance based on modifying the cost-benefit ratio. Individuals who achieved a 5% weight loss (N=75) were randomized to one of three, 10-month maintenance interventions. All interventions were delivered primarily via the Internet. The Standard arm received traditional weight maintenance strategies. To increase benefits, or rewards, for maintenance behaviors, the two cost-benefit intervention conditions received weekly monetary rewards for self-monitoring and social reinforcement via e-coaching. To decrease behavioral costs (boredom) and increase novelty, participants in the cost-benefit conditions also monitored different evidence-based behaviors every two weeks (e.g., Weeks 1 & 2: steps; Week 3 & 4: red foods). The primary difference between the cost-benefit interventions was type of e-coach providing social reinforcement: Professional (CB Pro) or Peer (CB Peer). Study procedures took place in Providence, RI from 2013 to 2014. Retention was 99%. There were significant group differences in weight regain (p=.01). The Standard arm gained 3.5±5.7kg. In contrast, participants in CB Pro and CB Peer lost an additional 1.8±7.0kg and 0.5±6.4kg, respectively. These results suggest that an Internet delivered cost-benefit approach to weight loss maintenance may be effective for long-term weight control. In addition, using peer coaches to provide reinforcement may be a particularly economic alternative to professionals. These data are promising and provide support for a larger, longer trial.

Technology-based interventions for weight management: current randomized controlled trial evidence and future directions

Obesity is a prevalent health care issue associated with disability, premature morality, and high costs. Behavioral weight management interventions lead to clinically significant weight losses in overweight and obese individuals; however, many individuals are not able to participate in these face-to-face treatments due to limited access, cost, and/or time constraints. Technological advances such as widespread access to the Internet, increased use of smartphones, and newer behavioral self-monitoring tools have resulted in the development of a variety of eHealth weight management programs. In the present paper, a summary of the most current literature is provided along with potential solutions to methodological challenges (e.g., high attrition, minimal participant racial/ethnic diversity, heterogeneity of technology delivery modes). Dissemination and policy implications will be highlighted as future directions for the field of eHealth weight management.

A mixed methods approach to improving recruitment and engagement of emerging adults in behavioural weight loss programs

Objective

Emerging adults ages 18–25 are at high risk for obesity, but are markedly underrepresented in behavioural weight loss (BWL) programs and experience lower engagement and retention relative to older adults.

Purpose

To utilize a mixed methods approach to inform future efforts to effectively recruit and engage this high‐risk population in BWL programs.

Methods

We used a convergent parallel design in which quantitative and qualitative data were given equal priority. Study 1 (N = 137, age = 21.8 + 2.2, BMI = 30.1 + 4.7) was a quantitative survey, conducted online to reduce known barriers and minimize bias. Study 2 (N = 7 groups, age = 22.3 + 2.2, BMI = 31.5 + 4.6) was a qualitative study, consisting of in person focus groups to gain greater depth and identify contextual factors unable to be captured in Study 1.

Results

Weight loss was of interest, but weight itself was not a central motivation; an emphasis on overall lifestyle, self‐improvement and fitness emerged as driving factors. Key barriers were time, motivation and money. Recruitment processes should be primarily online with messages tailored specifically to motivations and preferences of this age group. Preferences for a program were reduced intensity and brief, hybrid format with some in‐person contact, individual level coaching, experiential learning and peer support. Key methods of promoting engagement and retention were autonomy and choice, money and creating an optimal default.

Conclusions

An individually tailored lifestyle intervention that addresses a spectrum of health behaviours, promotes autonomy and emphasizes activity and fitness may facilitate recruitment and engagement in this population better than traditional BWL protocols.

Effects of Charitable Versus Monetary Incentives on the Acceptance of and Adherence to a Pedometer-Based Health Intervention: Study Protocol and Baseline Characteristics of a Cluster-Randomized Controlled Trial

BACKGROUND

Research has so far benefited from the use of pedometers in physical activity interventions. However, when public health institutions (eg, insurance companies) implement pedometer-based interventions in practice, people may refrain from participating due to privacy concerns. This might greatly limit the applicability of such interventions. Financial incentives have been successfully used to influence both health behavior and privacy concerns, and may thus have a beneficial effect on the acceptance of pedometer-based interventions.

OBJECTIVE

This paper presents the design and baseline characteristics of a cluster-randomized controlled trial that seeks to examine the effect of financial incentives on the acceptance of and adherence to a pedometer-based physical activity intervention offered by a health insurance company.

METHODS

More than 18,000 customers of a large Swiss health insurance company were allocated to a financial incentive, a charitable incentive, or a control group and invited to participate in a health prevention program. Participants used a pedometer to track their daily physical activity over the course of 6 months. A Web-based questionnaire was administered at the beginning and at the end of the intervention and additional data was provided by the insurance company. The primary outcome of the study will be the participation rate, secondary outcomes will be adherence to the prevention program, physical activity, and health status of the participants among others.

RESULTS

Baseline characteristics indicate that residence of participants, baseline physical activity, and subjective health should be used as covariates in the statistical analysis of the secondary outcomes of the study.

CONCLUSIONS

This is the first study in western cultures testing the effectiveness of financial incentives with regard to a pedometer-based health intervention offered by a large health insurer to their customers. Given that the incentives prove to be effective, this study provides the basis for powerful health prevention programs of public health institutions that are easy to implement and can reach large numbers of people in need.

Self-Expansion is Associated with Better Adherence and Obesity Treatment Outcomes in Adults

BACKGROUND

Previous studies have shown that self-expansion (e.g., increasing positive self-content via engaging in novel, rewarding activities) is associated with smoking cessation and attenuated cigarette-cue reactivity.

PURPOSE

This study examined whether self-expansion is associated with better adherence, weight loss, and physical activity (PA) outcomes within a weight loss intervention.

METHODS

Participants from Shape Up Rhode Island 2012, a Web-based community wellness initiative, took part in a randomized controlled trial that involved a 12-week behavioral weight loss intervention [1]. At baseline and post-intervention, objective weights and self-reported self-expansion and PA were obtained from 239 participants. Treatment adherence was assessed objectively.

RESULTS

Self-expansion during treatment was significantly associated with percent weight loss including clinically significant weight loss (i.e., 5 %), minutes of PA, and treatment adherence. These results held after controlling for relevant covariates.

CONCLUSIONS

This is the first study to show that self-expansion is associated with better behavioral weight loss outcomes including weight loss, adherence, and PA. These results suggest that self-expansion is a promising novel target for future research which could inform health interventions.

A Review of the Literature on Remote Monitoring Technology in Incentive-Based Interventions for Health-Related Behavior Change

Use of technology (e.g., Internet, cell phones) to allow remote implementation of incentives interventions for health-related behavior change is growing. To our knowledge, there has yet to be a systematic review of this literature reported. The present report provides a systematic review of the controlled studies where technology was used to remotely implement financial incentive interventions targeting substance use and other health behaviors published between 2004 and 2015. For inclusion in the review, studies had to use technology to remotely accomplish one of the following two aims alone or in combination: (a) monitor the target behavior, or (b) deliver incentives for achieving the target goal. Studies also had to examine financial incentives (e.g., cash, vouchers) for health-related behavior change, be published in peer-reviewed journals, and include a research design that allowed evaluation of the efficacy of the incentive intervention relative to another condition (e.g., non-contingent incentives, treatment as usual). Of the 39 reports that met inclusion criteria, 18 targeted substance use, 10 targeted medication adherence or home-based health monitoring, and 11 targeted diet, exercise, or weight loss. All 39 (100%) studies used technology to facilitate remote monitoring of the target behavior, and 26 (66.7%) studies also incorporated technology in the remote delivery of incentives. Statistically significant intervention effects were reported in 71% of studies reviewed. Overall, the results offer substantial support for the efficacy of remotely implemented incentive interventions for health-related behavior change, which have the potential to increase the cost-effectiveness and reach of this treatment approach.

Implementation of an Internet Weight Loss Program in a Worksite Setting

BACKGROUND

Worksite wellness programs typically produce modest weight losses. We examined whether an efficacious Internet behavioral weight loss program could be successfully implemented in a worksite setting.

METHODS

Participants were 75 overweight or obese employees/dependents of a large healthcare system who were given access to a 12-week Internet-based, multicomponent behavioral weight loss program. Assessments occurred at baseline, Month 3 (end of intervention), and Month 6 (follow-up).

RESULTS

Retention was excellent (93% at Month 3 and 89% at Month 6). Intent-to-treat analyses demonstrated that participants lost an average (±SE) of -5.8 ± .60 kg from baseline to Month 3 and regained 1.1 ± .31 kg from Month 3 to Month 6; overall, weight loss from baseline to Month 6 was -4.7 ± .71 kg, p < .001. Men lost more weight than women, p = .022, and individuals who had a college degree or higher lost more weight than those with less education, p = .005. Adherence to viewing lessons (8 of 12) and self-monitoring (83% of days) was excellent and significantly associated with weight loss, ps < .05.

CONCLUSIONS

An Internet-based behavioral weight management intervention can be successfully implemented in a worksite setting and can lead to clinically significant weight losses. Given the low costs of offering this program, it could easily be widely disseminated.

The Challenges and Opportunities Associated with Reimbursement for Obesity Pharmacotherapy in the USA

Obesity has become a serious public health problem that has stimulated primordial and primary prevention efforts, and a triad of management options (lifestyle, pharmacotherapy, and surgical interventions). A growing body of evidence supports the need for a multi-pronged, clinic-based approach that leverages the synergy between pharmaceutical and lifestyle modification. Recent US policy changes-namely, the passage of the Patient Protection and Affordable Care Act coupled with recognition of obesity as a disease by the American Medical Association-suggest that financial incentives and attitudes towards obesity management are changing. This paradigm shift has implications for current and future obesity pharmacotherapy. However, barriers to pharmacotherapy utilization include patient and physician perceptions of modest efficacy, historical safety issues, regulatory obstacles, and lack of reimbursement. The shifting attitudes and challenges associated not only with a multi-payer system, but also the lack of clearly defined cross-payer reimbursement strategies, prompted a survey to determine coverage for obesity treatment. Participants indicated that federal/state mandates and growth of quality-driven healthcare initiatives will eventually drive wider pharmacotherapy reimbursement within 1-5 years. There are signs that federal/state programs are already moving towards reimbursement by improving quality measures to track obesity outcomes and reduce costs. Future research on clinical and economic outcomes of combination weight-management programs coupled with innovative approaches (e.g., eHealth) in the real-world setting that demonstrate value to patients, healthcare providers, payers, and employers will help reshape obesity management by reducing barriers and broadening reimbursement coverage for anti-obesity pharmacotherapy.

Examination of whether early weight loss predicts 1-year weight loss among those enrolled in an Internet-based weight loss program

One-month weight loss (WL) predicts post-treatment WL in face-to-face interventions; however whether this holds true within Internet programs is unknown. This study examined whether 4-week WL predicts WL following a 12-week Internet program and at 6 and 12 months follow-up. 181 participants (BMI=33.4±5.5kg/m²; 83.1% female) received a 12-week behaviorally-based Internet WL program consisting of weekly video lessons. Participants were given a daily WL, calorie, and physical activity goal and asked to enter these data on the study website weekly. Personalized feedback was provided. Using 4-week WL, individuals were categorized as ‘early non-responders’ (<2.0% WL) or ‘early responders’ (≥2.0% WL). Early non-responders had significantly lower WL than early responders at 3 (-1.3±3.8% vs. -6.3±4.3%), 6 (-1.7±5.1% vs. -5.8±5.2%), and 12 months (-0.05±6.8% vs. -2.7±6.3%, p's<0.05). The odds of achieving a ≥5% WL were 8.5 (95% CI:3.3–22.1), 3.4 (95% CI:1.4-8.3), and 2.6 (95% CI:0.93-7.4) times lower in early non-responders, compared to early responders at 3, 6, and 12 months respectively. Compared to early responders, early non-responders viewed fewer video lessons and self-monitored less often across the 12-week intervention (p's<0.05). This study provides initial evidence that a 4-week WL of <2.0% places an individual at an increased risk of failing to achieve clinically significant WL following an Internet program.