DIAL now protocol: A randomized trial examining the provision of phone coaching to those with sub-optimal early weight loss during an Internet weight management program

An Adaptive Telephone Coaching Intervention for Patients in an Online Weight Loss Program: A Randomized Clinical Trial

Importance

Weight loss (WL) during the first month of a behavioral program is associated with longer-term WL. Testing of translatable and adaptive obesity programs is needed.

Objective

To compare brief, extended, and no telephone coaching for individuals with suboptimal response (ie, 1-month WL <4%) within an online WL program.

Design, Setting, and Participants

This randomized clinical trial with enrollment between March 2019 and April 2022 (data collection completed May 2023) was conducted at an academic research center in the US. Eligible participants included adults aged 18 to 70 years with daily access to internet and a body mass index between 25 and 45.

Interventions

All participants received an automated online WL program (4 months) and WL maintenance program (8 months), consisting of video lessons, self-monitoring, and personalized feedback. Participants were randomized, such that individuals with suboptimal response received either brief telephone coaching (3 calls during weeks 5-8), extended telephone coaching (12 calls during weeks 5-16), or no coaching (control). Coaching included education, problem solving, and goal setting, and promoted engagement with the online program.

Main Outcomes and Measures

The primary outcomes were percent weight change and proportion of participants achieving 5% or greater WL at 4 and 12 months. A priori hypotheses for WL were that WL for extended coaching would be greater than for brief coaching, and both extended and brief coaching would be greater than no coaching (control). A longitudinal mixed-effects model with participant-specific intercept was used to examine intervention effects on percent WL at 4 and 12 months. Secondary analyses focused on program engagement and cost/kilogram of WL.

Results

The study included a total of 437 participants who reported WL at 1 month (mean [SD] age, 50.8 [11.4] years; mean [SD] BMI, 34.6 [5.0]; 305 female [69.8%] and 132 male [30.2%]) with 148 randomized to extended coaching, 143 assigned to brief coaching, and 146 assigned to the control group. Of all participants, 346 (79.2%) were considered to have a suboptimal response. WL at 4 months was significantly greater in the extended coaching group (mean [SD] WL, -7.0% [5.1%]) and brief coaching group (mean [SD] WL, -6.2% [4.7%]) vs the control group (mean [SD] WL, -4.5% [4.7%]) (P < .001). Similarly, the proportion of participants achieving 5% or greater WL at 4 months was greater in the extended coaching group (89 participants [65.9%]) and brief coaching group (77 participants [58.5%]) vs control group (46 participants [36.5%]) (P < .001). At 12 months, a similar pattern was observed for achievement of 5% WL or greater (extended coaching, 63 participants [48.1%]; brief coaching, 58 participants [45.9%]; control, 38 participants [32.8%]; P = .03). Percent WL at 12 months was significantly higher in extended coaching vs control (mean [SD] WL for extended coaching, -5.5% [6.7%]; mean [SD] WL for control, -3.9% [7.4%]; P = .03) but not for brief coaching (mean [SD] WL, -4.9% [6.1%]).Both the brief and extended coaching groups watched more lessons and self-monitored on more days compared with the control group. The cost per additional kilogram of WL, beyond that of the control group, was $50.09 for brief coaching and $92.65 for extended coaching.

Conclusions and Relevance

In this randomized clinical trial testing an adaptive intervention, the provision of coaching for individuals with suboptimal response improved WL and was cost-effective; further testing in clinical settings (eg, health care systems) is warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT03867981.

Characterization of early non-responders within behavioral weight loss treatment

Objective

Given that low early (4 weeks) weight loss (WL) predicts longer-term WL, the purpose of this study was to identify factors associated with poor early WL.

Methods

438 adults with overweight/obesity participating in an Internet-delivered behavioral WL program provided weights at baseline and 4 weeks. Participants were stratified by percent WL at 4 weeks: LOW: <2% WL, MEDIUM: 2 to <4% WL, HIGH: ≥4% WL and groups were compared on baseline variables (demographics, physical activity, and psychosocial measures) and 4-week intervention adherence.

Results

37.4%, 40.9%, and 21.7% of participants had LOW, MEDIUM, and HIGH early WL respectively. LOW was more likely to be female compared to HIGH and less likely to be non-Hispanic White compared to MEDIUM and HIGH (p's<0.05). After controlling for demographic differences, LOW had lower baseline physical activity compared to HIGH and watched fewer video lessons, self-monitored calorie intake and weight on fewer days, and were less likely to achieve the exercise goal compared to MEDIUM and HIGH (p's<0.05).

Conclusion

Findings can inform future adaptive interventions which tailor treatment based upon early WL to improve WL outcomes for more individuals.

Bad situation, treat yourself: a qualitative exploration of the factors influencing healthy eating habits during the COVID-19 pandemic

Purpose

To explore barriers and facilitators to healthy eating during the COVID-19 pandemic among adults enrolled in an internet-based weight loss program.

Methods

Adults in an internet-delivered weight loss program were recruited to participate. Participants completed online study surveys and a semi-structured interview via telephone between June 1, 2020 and June 22, 2020. The interview included questions to explore how the COVID-19 pandemic has influenced dietary behaviors. Constant comparative analysis was used to identify key themes.

Results

Participants (n = 30) were primarily female (83%) and white (87%), 54.6 ± 10.0 years old, and had a mean body mass index of 31.1 ± 4.5 kg/m². Barriers included snacking/ease of access to food, eating as a coping mechanism, and lack of routine/planning. Facilitators included calorie control, regular routine/scheduling, and self-monitoring. General themes with eating were a change in eating out frequency or modality, cooking more, and changes in alcohol consumption.

Conclusion

Eating habits among adults enrolled in a weight loss program changed during the COVID-19 pandemic. Future weight loss programs and public health recommendations should consider modifying recommendations to place increased emphasis on strategies to overcome barriers to healthy eating and promote facilitators that may help with healthy eating, particularly during unexpected circumstances or events.

Relationship between stress and weight management behaviors during the COVID-19 pandemic among those enrolled in an internet program

BACKGROUND

The COVID-19 pandemic resulted in mandated stay-at-home orders, potentially resulting in changes in mental health (e.g., stress, anxiety) and challenges maintaining healthy dietary and physical activity behaviors.

OBJECTIVE

This study examined how stress was associated with mental well-being and weight loss behaviors during the COVID-19 pandemic among adults enrolled in an internet-based weight loss program.

METHODS

Participants enrolled in a weight-loss program residing in Rhode Island or Massachusetts, USA, completed a brief survey on their mental health and current weight-loss behaviors during the COVID-19 pandemic. Surveys were completed between 14 April 2020 and 21 April 2020, approximately one month after stay-at-home orders were mandated. Linear regression was used to examine associations between stress, mental health, and weight-loss behaviors.

RESULTS

A total of 99 participants completed the survey (79% female, 91% white, 52.2 ± 9.8 years, 34.0 ± 5.2 kg/m2, 77% reported moderate to extreme stress). Greater stress was associated with higher BMI (p = 0.04), higher education (p = 0.04), working more hours (p = 0.003), and having school-age children at home (p = 0.002). Greater stress was also associated with higher levels of anxiety, worry, and concern regarding COVID-19 (p's < 0.001) and having less time to spend on weight-loss efforts (p < 0.001), after controlling for BMI and education.

CONCLUSIONS

Many individuals enrolled in a weight-loss program experienced more stress during COVID-19 compared to before the pandemic. This stress was related to more mental health challenges as well as more difficulties finding time for weight management efforts.