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

Testing motivational and self-regulatory mechanisms of action on device-measured physical activity in the context of a weight loss maintenance digital intervention: A secondary analysis of the NoHoW trial

BACKGROUND

To date, few digital behavior change interventions for weight loss maintenance focusing on long-term physical activity promotion have used a sound intervention design grounded on a logic model underpinned by behavior change theories. The current study is a secondary analysis of the weight loss maintenance NoHoW trial and investigated putative mediators of device-measured long-term physical activity levels (six to 12 months) in the context of a digital intervention.

METHODS

A subsample of 766 participants (Age = 46.2 ± 11.4 years; 69.1% female; original NoHoW sample: 1627 participants) completed all questionnaires on motivational and self-regulatory variables and had all device-measured physical activity data available for zero, six and 12 months. We examined the direct and indirect effects of Virtual Care Climate on post intervention changes in moderate-to-vigorous physical activity and number of steps (six to 12 months) through changes in the theory-driven motivational and self-regulatory mechanisms of action during the intervention period (zero to six months), as conceptualized in the logic model.

RESULTS

Model 1 tested the mediation processes on Steps and presented a poor fit to the data. Model 2 tested mediation processes on moderate-to-vigorous physical activity and presented poor fit to the data. Simplified models were also tested considering the autonomous motivation and the controlled motivation variables independently. These changes yielded good results and both models presented very good fit to the data for both outcome variables. Percentage of explained variance was negligible for all models. No direct or indirect effects were found from Virtual Care Climate to long term change in outcomes. Indirect effects occurred only between the sequential paths of the theory-driven mediators.

CONCLUSION

This was one of the first attempts to test a serial mediation model considering psychological mechanisms of change and device-measured physical activity in a 12-month longitudinal trial. The model explained a small proportion of variance in post intervention changes in physical activity. We found different pathways of influence on theory-driven motivational and self-regulatory mechanisms but limited evidence that these constructs impacted on actual behavior change. New approaches to test these relationships are needed. Challenges and several alternatives are discussed.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN88405328. Registered December 16, 2016, https://www.isrctn.com/ISRCTN88405328.

Behaviors and psychological states associated with transitions from regaining to losing weight

OBJECTIVE

Little is known about week-to-week recovery from regains following a behavioral weight loss intervention (BWLI). This study examined changes in behaviors, cognitions, and moods associated with transitioning from weight regain to weight loss during the nine-month weight loss maintenance period after a three-month Internet-based BWLI.

METHOD

Participants (n = 68) self-weighed daily via "smart" scales and answered 40 weekly questionnaires about their weight-related behaviors and psychological states. Mixed models were used to (a) determine whether weight gain in a given week predicted changes in weight, behaviors (e.g., self-monitoring), and psychological states (e.g., mood, temptation) the following week and to (b) compare back-to-back weeks when individuals recovered from weight gain (gained in the first week and lost in the second) versus those in which they gained both weeks.

RESULTS

Weight gain in a given week predicted greater weight gain and greater report of behaviors and psychological states associated with weight gain the following week. Back-to-back weeks when individuals switched from gaining to losing were few (5%) compared with weeks when individuals continued gaining (60%). Switching from gaining to losing was associated with greater physical activity during the initial weight gain week and greater self-reported behaviors/cognitions consistent with weight loss (e.g., greater calorie self-monitoring, greater importance of "staying on track") during the following week.

CONCLUSIONS

Engagement in more weight loss consistent behaviors and more favorable ratings of key psychological variables were associated with the rare shifts from gaining to losing. Future research should investigate interventions to help individuals quickly recover from weight regain. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Effectiveness of Incentives for Improving Diabetes-Related Health Indicators in Chronic Disease Lifestyle Modification Programs: a Systematic Review and Meta-Analysis

Introduction

We examined the effectiveness of providing incentives to participants in lifestyle modification programs to improve diabetes-related health indicators: body weight, body mass index (BMI), blood pressure, cholesterol, and hemoglobin A_1C (HbA_1C). We also examined the potential effect of 4 different incentive domains (ie, type, monetary value, attainment certainty, and schedule) on those indicators.

Methods

We searched Medline, Embase, PsycINFO, and Cochrane Library to identify relevant studies published from January 2008 through August 2021. We used a random-effects model to pool study results and examine between-study heterogeneity by using the I² statistic and the Cochran Q test. We also conducted moderator analyses by using a mixed-effects model to examine differences between subgroups of incentive domains (eg, incentive type [cash vs other types]).

Results

Our search yielded 10,965 articles, of which 19 randomized controlled trials met our selection criteria. The random-effects model revealed that, relative to the control group, the incentive group had significant reductions in weight (−1.85kg; 95% CI, −2.40 to −1.29; P < .001), BMI (−0.47kg/m²; 95% CI, −0.71 to −0.22; P < .001), and both systolic blood pressure (−2.59 mm HG; 95% CI, −4.98 to −0.20; P = .03) and diastolic blood pressure (−2.62 mm Hg; 95% CI, −4.61 to −0.64; P = .01). A reduction in cholesterol level was noted but was not significant (−2.81 mg/dL; 95% CI, −8.89 to −3.28; P = .37). One study found a significant reduction in hemoglobin A_1c (−0.17%; 95% CI, −0.30% to −0.05%; P < .05). The moderator analyses showed that the incentive effect did not vary significantly between the subgroups of the incentive domains, except on weight loss for the attainment certainty domain, suggesting that a variety of incentive subgroups could be equally useful.

Conclusion

Providing incentives in lifestyle modification programs is a promising strategy to decrease weight, BMI, and blood pressure.

A 2.5-Year Weight Management Program Using Noom Health: Protocol for a Randomized Controlled Trial

BACKGROUND

Overweight and obesity are serious public health concerns. As the prevalence of excess weight among individuals continues to increase, there is a parallel need for inexpensive, highly accessible, and evidence-based weight loss programs.

OBJECTIVE

This weight loss trial will aim to examine the efficacy of the Noom weight loss program in comparison to a digital control after a 6-month intervention phase and a 24-month maintenance phase, with assessments continuing for 2 years beyond the intervention (to 30 months-after the baseline). The secondary outcomes include quality of life, psychosocial functioning, sleep quality, physical activity, diet, and health status. This trial will also examine the severity of obesity-related functional impairment, weight loss history, and demographic moderators, along with adherence and self-efficacy as mediators of the outcome.

METHODS

A total of 600 participants were randomized in a parallel-group, controlled trial to either Noom Healthy Weight Program (intervention) or Noom Healthy Weight Control (control) for a 6-month intervention. Both intervention and control groups include diet and exercise recommendations, educational content, daily logging capabilities, and daily weigh-in entries. The Noom Healthy Weight Program also includes a coach support for weight loss. Remote follow-up assessments of eating, physical activity, psychosocial factors, app use data, and weight will be conducted at 1, 4, 6, 12, 18, 24, and 30 months after baseline. Weight is measured at each follow-up point during a Zoom call using the participants' scales.

RESULTS

Enrollment began in March 2021 and the 6-month intervention phase ended in March 2022. Data collection for the final assessment will be completed in March 2024.

CONCLUSIONS

This study tests commercially available digital lifestyle interventions for individuals with overweight and obesity seeking weight loss support. Data obtained from the study will evaluate whether the Noom Healthy Weight Control Program can help individuals overcome weight loss, achieve long-term maintenance, adhere to lifestyle changes, and feature use barriers that are present in other traditional weight loss treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04797169; https://clinicaltrials.gov/ct2/show/NCT04797169.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37541.

A pilot randomized trial of simplified versus standard calorie dietary self-monitoring in a mobile weight loss intervention

OBJECTIVE

This study tested the efficacy of a lower-burden, simplified dietary self-monitoring approach compared with a standard calorie monitoring approach for self-monitoring adherence and weight loss in a mobile-delivered behavioral weight loss intervention.

METHODS

Participants (n = 72) with overweight or obesity who had children 2 to 12 years of age living in the home were randomly assigned to a group that used simplified dietary self-monitoring of high-calorie foods (Simplified) or a group that tracked calories (Standard). Both groups received a wireless scale, Fitbit trackers, and a 6-month intervention delivered via a smartphone application with lessons, text messages, and weekly personalized feedback messages.

RESULTS

Percentage weight loss at 6 months was 5.7% (95% CI: -8.3% to -3.2%) in the Standard group and 4.0% (95% CI: -5.7% to -2.3%) in the Simplified group, which was not significantly different. Similar proportions reached 5% weight loss at 6 months (43.2% in Standard and 42.9% in Simplified). There were no differences in number of dietary tracking days or change in average daily caloric intake between groups.

CONCLUSIONS

Two mobile-delivered weight loss interventions produced clinically meaningful levels of weight loss at 6 months, with no differences in dietary tracking adherence or dietary intake. The results suggest that simplified monitoring of high-calorie foods could be a promising alternative to calorie monitoring.

Randomized controlled trial of financial incentives during weight-loss induction and maintenance in online group weight control

OBJECTIVE

This study examined the impact of a financial incentive scheme integrating process and outcome incentives across weight-loss induction and weight maintenance on 18-month weight outcomes.

METHODS

This was a randomized controlled trial. Participants with overweight or obesity (n = 418; 91% female; 28% racial/ethnic minority) were randomized to an 18-month, online, group-based behavioral weight-control program (Internet-Only) or the same program with financial incentives provided for 12 months, contingent on self-regulatory weight-control behaviors (self-weighing, dietary self-monitoring, and physical activity) and weight-outcome benchmarks (Internet+Incentives). No financial incentives were provided from Months 13 to 18 to examine the durability of weight-control behaviors and outcomes without incentives.

RESULTS

Weight-loss induction at Month 6 was significantly greater for Internet+Incentives than Internet-Only (6.8% vs. 4.9%, respectively, p = 0.01). Individuals receiving incentives were significantly more likely to maintain weight loss ≥ 5% at Month 12 (45% in Internet+Incentives vs. 32% in Internet-Only, p < 0.02) and remain weight stable (39% vs. 27%, respectively, p < 0.01). Internet+Incentives participants also reported significantly greater behavioral engagement through Month 12. However, once incentives ceased, there were no differences in sustained weight outcomes (Month 18), and engagement declined dramatically.

CONCLUSIONS

Despite promoting greater treatment engagement and initial weight loss, financial incentives as offered in this study did not promote better extended weight control.

What goes on in digital behaviour change interventions for weight loss maintenance targeting physical activity: A scoping review

OBJECTIVE

To identify the core components of digital behaviour change interventions for weight loss maintenance targeting physical activity, in terms of: (i) behaviour change techniques, (ii) mechanisms of action, (iii) modes of delivery, (iv) dose and (v) tailoring/personalization. In addition, the links between these components were investigated.

METHODS

A literature search was performed in five electronic databases: PubMed, Embase, CINHAL, PsycINFO and Web of Science. Two reviewers independently screened the identified articles and extracted data related with the study characteristics and behaviour change techniques, mechanism of action, mode of delivery, dose, and tailoring, using standardized classifications whenever available (e.g. behaviour change techniques taxonomy).

RESULTS

Seventeen articles reporting 11 original studies were selected. Two studies were protocols, 9 studies presented results for weight change and all but one showed no significant differences between the intervention and control groups. Eight studies (73%) provided adequate information on behaviour change techniques. Five studies (45%) provided partial information about how the behaviour change techniques were linked to mechanisms of action, and only one study (0.9%) described these links for all the techniques. Around half of the studies reported the modes through which behaviour change techniques were delivered. Descriptions of dose were present in most studies, but with minimal information. The use of tailoring or personalization approaches was mentioned in eight studies (73%), but descriptions of what was tailored and how were minimal.

CONCLUSIONS

The compilation of information regarding intervention components was difficult due to the lack of information and systematization in reporting across papers. This is particularly true for the reporting of the links between behaviour change techniques and the other core intervention components. This information is crucial to help us understand in the context of behaviour change interventions what works or does not work, how it works and why.

A Novel Virtual Coaching System Based on Personalized Clinical Pathways for Rehabilitation of Older Adults-Requirements and Implementation Plan of the vCare Project

Home-based rehabilitation after an acute episode or following an exacerbation of a chronic disease is often problematic with a clear lack of continuity of care between hospital and home care. Secondary prevention is an essential element of long-term rehabilitation where strategies oriented toward risk reduction, treatment adherence, and optimization of quality of life need to be applied. Frail and sometimes isolated, the patient fails to adhere to the proposed post-discharge clinical pathway due to lack of appropriate clinical, emotional, and informational support. Providing a suitable rehabilitation after an acute episode or a chronic disease is a major issue, as it helps people to live independently and enhance their quality of life. However, as the rehabilitation period usually lasts some months, the continuity of care is often interrupted in the transition from hospital to home. Virtual coaches could help these patients to engage in a personalized rehabilitation program that complies with age-related conditions. These coaches could be a key technology for empowering patients toward increasing their adherence to the care plan and to improve their secondary prevention measures. In this paper, we are presenting a novel virtual coaching system that will address these challenges by combining recent technological advances with clinical pathways, based on joint research and validation activities from researchers from the medical and information and communication technology (ICT) domains.

A randomized feasibility pilot trial of a financial incentives intervention for dietary self-monitoring and weight loss in adults with obesity

Financial incentives could be used to improve adherence to behavioral weight loss interventions, increasing their effectiveness. This Phase IIb randomized pilot study evaluated the feasibility and acceptability of a study protocol for providing financial incentives for dietary self-monitoring and/or weight loss. Community-dwelling adults with obesity were enrolled in a 24 week, group-based weight loss program. Participants were randomized in a 2 × 2 factorial design to receive financial incentives for both dietary self-monitoring and weekly weight loss, just one, or neither. Participants could earn up to $300, evolving from fixed weekly payments to intermittent, variable payments. The notice of reward was provided by text message. The study was conducted in three successive cohorts to evaluate study procedure changes, including dietary approach, recruitment and retention strategies, text messaging, and incentives. Descriptive statistics calculated separately for each cohort described study performance relative to predefined targets for recruitment, including minority representation; retention; adherence; and weight loss. Acceptability was assessed via postintervention qualitative interviews. In Cohort 1 (n = 34), a low-carbohydrate diet was used. Recruitment, retention, adherence, and weight loss were adequate, but minority representation was not. For Cohort 2 (n = 31), employing an additional recruitment method and switching to a reduced-calorie diet yielded adequate recruitment, minority representation, retention, and adherence but less weight loss. Returning to a low-carbohydrate diet in Cohort 3 (n = 28) yielded recruitment, minority representation, retention, adherence, and weight loss similar to Cohort 2. Participant feedback informed changes to text message timing and content and incentive amount. Through successive cohorts, we optimized recruitment and retention strategies and text messaging. An adequately powered trial is warranted to evaluate the efficacy of these incentive structures for reducing weight. The trial registration number is NCT02691260.

Novel behavioral interventions to improve long-term weight loss: A randomized trial of acceptance and commitment therapy or self-regulation for weight loss maintenance

Maintenance of weight loss is hard to achieve, and novel interventions are needed to improve long-term outcomes. In this pilot randomized controlled trial, N = 188 participants received an online, 12-week weight loss intervention and N = 102 who lost ≥ 5% were then randomly assigned to a 1-day, 5-h workshop based on Acceptance and Commitment Therapy (ACT), Self-Regulation (SR), or no workshop (Control) with 3 months of limited email follow-up. Assessments were conducted at baseline, 3, 6, 12, 18, and 24 months. The primary outcome was percent weight change; secondary outcomes were weight-related experiential avoidance and health values-consistent behavior. ACT had greater overall weight loss (-7.18%, SE = 1.33) when compared to Control (-1.15%, SE = 1.50; p = .03). Post hoc analyses showed that ACT had significantly greater weight losses than Control (6.11%, β = -2.03, p = .048) among those with lower initial weight loss (5-7%), and significantly greater weight loss than SR (6.19%, β = -1.77, p = .05) among those with the highest initial weight losses (10% +). There is potential for continuing to develop ACT in a limited interventionist-contact format with modifications. This pilot study represents an innovative model for behavioral weight loss by reversing the typical treatment intensity model with the aim of providing interventionist support during a critical period after initial weight loss. REGISTRATION: Clinicaltrials.org #NCT02156752 https://www.clinicaltrials.gov/ct2/show/NCT02156752 .

Two-year weight trajectories following completion of a behavioral weight loss maintenance intervention

Introduction

Long‐term effects of behavioral weight loss maintenance interventions need to be assessed in order to understand their durability of effects. This can be evaluated with the use of weights recorded in the electronic medical record. The goal of this study was to use electronic health record (EHR)‐recorded weight to examine outcomes 2 years beyond the completion of a trial in which participants were randomized to receive a weight maintenance intervention or usual care after required initial weight loss.

Methods

Weights collected in the Veteran's Affairs national EHR were obtained for 2 years following trial completion. Outliers and implausible weights were identified and removed prior to analysis. Mixed‐effects models with quadratic time were fit to estimate between‐arm differences in weight change.

Results

Model‐estimated weight at trial completion was 109.7 kg for usual care and 106.8 kg for intervention, estimated difference of −2.9 kg (95% confidence interval [CI]: −8.8, 3.0; p = 0.34). Two years later, estimated mean weight collected from (n = 211) participants with available EMR weights was 111.5 kg for usual care and 108.0 kg for intervention, estimated difference −3.4 kg (95% CI: −9.3, 2.4 kg; p = 0.35).

Conclusions

While not statistically significant, weights from the EHR suggest the possibility of a clinically meaningful difference that should be confirmed by future adequately powered studies.

Peer-Assisted Lifestyle (PAL) intervention: a protocol of a cluster-randomised controlled trial of a health-coaching intervention delivered by veteran peers to improve obesity treatment in primary care

INTRODUCTION

Among US veterans, more than 78% have a body mass index (BMI) in the overweight (≥25 kg/m²) or obese range (≥30 kg/m²). Clinical guidelines recommend multicomponent lifestyle programmes to promote modest, clinically significant body mass (BM) loss. Primary care providers (PCPs) often lack time to counsel and refer patients to intensive programmes (≥6 sessions over 3 months). Using peer coaches to deliver obesity counselling in primary care may increase patient motivation, promote behavioural change and address the specific needs of veterans. We describe the rationale and design of a cluster-randomised controlled trial to test the efficacy of the Peer-Assisted Lifestyle (PAL) intervention compared with enhanced usual care (EUC) to improve BM loss, clinical and behavioural outcomes (aim 1); identify BM-loss predictors (aim 2); and increase PCP counselling (aim 3).

METHODS AND ANALYSIS

We are recruiting 461 veterans aged 18-69 years with obesity or overweight with an obesity-associated condition under the care of a PCP at the Brooklyn campus of the Veterans Affairs NY Harbor Healthcare System. To deliver counselling, PAL uses in-person and telephone-based peer support, a tablet-delivered goal-setting tool and PCP training. Patients in the EUC arm receive non-tailored healthy living handouts. In-person data collection occurs at baseline, month 6 and month 12 for patients in both arms. Repeated measures modelling based on mixed models will compare mean BM loss (primary outcome) between study arms.

ETHICS AND DISSEMINATION

The protocol has been approved by the Institutional Review Board and the Research and Development Committee at the VA NY Harbor Health Systems (#01607). We will disseminate the results via peer-reviewed publications, conference presentations and meetings with stakeholders.

TRIAL REGISTRATION NUMBER

NCT03163264; Pre-results.

Weight Management Interventions for Adults With Overweight or Obesity: An Evidence Analysis Center Scoping Review

The objectives of this evidence scoping review were to identify and characterize studies investigating weight management interventions provided by a registered dietitian nutritionist or international equivalent (RDN) among adults with overweight or obesity. A medical librarian conducted an electronic literature search in 6 databases-MEDLINE (Ovid), Embase (Ovid), PyscINFO (Ovid), Cochrane CENTRAL (Ovid), Cochrane Database of Systematic Reviews (Ovid), and CINAHL (Ebsco). Except for narrative review, gray literature, and case study or report, all types of peer-reviewed articles published between January 2008 and April 26, 2019 were eligible. Two content advisors, who are experts in adult weight management, guided the process and reviewed the search plan and findings. The literature search resulted in 30,551 records with 16 additional records identified through other sources. A total of 29,756 records were excluded during the first round of screening due to duplication or irrelevancy. Of the 811 full-text articles that were screened, 139 met the criteria and were included. Approximately 51% and 43% of the studies were conducted in the community setting and in the United States or Canada, respectively. Over 97% of the studies were clinical or quasi-experimental trials. A total of 6 different intervention delivery modes were reported, which resulted in 22 combinations of the modes of delivery. RDNs delivered the weight management intervention (especially the nutrition component) in all studies, but some (61%) also involved an interdisciplinary team to deliver other components of the intervention. The average length of the intervention was about 10 months with a follow-up that ranged from 0 to 9 years. The commonly reported outcomes were anthropometrics, endocrine, and cardiovascular measures; dietary intake; and physical activity. Based on the scoping review, there were systematic reviews and evidence-based practice guidelines on weight management interventions but none of them met the a priori inclusion or exclusion criteria. Therefore, it would be beneficial to conduct a systematic review and develop an evidence-based practice guideline on adult weight management interventions provided by an RDN to guide practitioners and to evaluate their effects on health and nutrition-related outcomes.

Protocol for Partner2Lose: A randomized controlled trial to evaluate partner involvement on long-term weight loss

Background

Behavioral interventions produce clinically significant weight reduction, with many participants regaining weight subsequently. Most interventions focus on an individual, but dietary and physical activity behaviors occur with, or are influenced by, domestic partners. According to interdependence theory, couples who approach behavior change as a problem to be tackled together versus independently are more likely to utilize communal coping processes to promote behavior change. We utilized interdependence theory to develop a partner-assisted intervention to increase long-term weight loss.

Methods

Community-dwelling individuals (index participants) cohabitating with a partner with 1) overweight and at least one obesity-related comorbidity or 2) obesity are randomized to participate in a standard weight management program alone or with their partner. The weight management program involves biweekly, in-person, group sessions focusing on weight loss for six months, followed by three group sessions and nine telephone calls focusing on weight loss maintenance for twelve months. In the partner-assisted arm, partners participate in half of the group sessions and telephone calls. Couples receive training in principles of cognitive behavioral therapy for couples, including sharing thoughts and feelings and joint problem solving, to increase communal coping. The primary outcome is participant weight loss at 24 months, with caloric intake and moderate-intensity physical activity as secondary outcomes. Partner weight and caloric intake will also be analyzed. Mediation analyses will examine the role of interdependence variables and social support.

Discussion

This trial will provide knowledge about effective ways to promote long-term weight loss and the role of interdependence constructs in weight loss.

Clinical trials identifier: NCT 03801174.

Rehabilitation, the Great Absentee of Virtual Coaching in Medical Care: Scoping Review

BACKGROUND

In the last few years, several studies have focused on describing and understanding how virtual coaches (ie, coaching program or smart device aiming to provide coaching support through a variety of application contexts) could be key drivers for health promotion in home care settings. As there has been enormous technological progress in the field of artificial intelligence and data processing in the past decade, the use of virtual coaches gains an augmented attention in the considerations of medical innovations.

OBJECTIVE

This scoping review aimed at providing an overview of the applications of a virtual coach in the clinical field. In particular, the review focused on the papers that provide tangible information for coaching activities with an active implication for engaging and guiding patients who have an ongoing plan of care.

METHODS

We aimed to investigate the use of the term virtual coach in the clinical field performing a methodical review of the relevant literature indexed on PubMed, Scopus, and Embase databases to find virtual coach papers focused on specific activities dealing with clinical or medical contexts, excluding those aimed at surgical settings or electronic learning purposes.

RESULTS

After a careful revision of the inclusion and exclusion criteria, 46 records were selected for the full-text review. Most of the identified articles directly or indirectly addressed the topic of physical activity. Some papers were focused on the use of virtual coaching (VC) to manage overweight or nutritional issues. Other papers dealt with technological interfaces to facilitate interactions with patients suffering from different chronic clinical conditions such as heart failure, chronic obstructive pulmonary disease, depression, and chronic pain.

CONCLUSIONS

Although physical activity is a healthy practice that is most encouraged by a virtual coach system, in the current scenario, rehabilitation is the great absentee. This paper gives an overview of the tangible applications of this tool in the medical field and may inspire new ideas for future research on VC.

Week-to-week predictors of weight loss and regain

OBJECTIVES

Despite increased interest in the development of individually tailored weight management programs, little is known about what factors proximally predict weight change.

METHOD

The current study investigated proximal (week-to-week) predictors of weight loss and regain in 74 adults during a 3-month, Internet-based behavioral weight loss program followed by a 9-month "maintenance" period (during which no additional intervention was provided). Participants were asked to self-weigh daily using scales that transmitted weight via the cellular network and to answer a brief questionnaire each week querying mood, behaviors, and cognitions hypothesized to be associated with weight loss and regain.

RESULTS

Longitudinal multilevel models demonstrated that weight loss during initial intervention was proximally predicted by (a) greater frequency of self-monitoring weight and caloric intake, consistency between eating choices and weight loss goals, and importance of "staying on track" with these goals and (b) less negative mood, boredom with weight control efforts, hunger, and temptation to eat foods "not on plan" (ps < .05). Greater weight regain after intervention was also proximally predicted by these factors (with effects in the opposite direction) and additionally by less physical activity, less positive mood, more stress, greater temptation to skip planned physical activity, and higher ratings of the amount of effort required to stay on track (ps < .05).

CONCLUSIONS

Results confirmed the importance of self-monitoring for weight loss and maintenance and identified other key week-to-week predictors of weight change. Results also supported efforts to develop intervention approaches specifically focused on weight loss maintenance. Future research should investigate whether using identified predictors to tailor intervention content and timing can improve weight outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Factors associated with early non-response within an Internet-based behavioural weight loss program

OBJECTIVE

While behavioural weight loss interventions are effective overall, many individuals fail to achieve a clinically significant weight loss. Given that 4-week weight loss has been shown to predict longer term outcomes, one potential strategy for improving rates of success is to provide additional support to early non-responders. To inform these early rescue efforts, it is important to first identify how they may differ from their more successful peers.

METHODS

At week 4 of a 12-week Internet-delivered weight loss program, 130 adults (age: 49.8 ± 9.8 years, body mass index: 31.2 ± 4.6 kg m-2) were asked to complete an 11-item survey assessing mood and weight-related cognitions and behaviours. Participants were then categorized as early non-responders (4-week weight loss <2%) or initial responders (4-week weight loss ≥2%), and groups were compared on intervention adherence during weeks 1-4 and week 4 survey question responses.

RESULTS

Early non-responders and initial responders did not differ on any intervention adherence variables (ps > 0.05). Compared to initial responders, early non-responders reported less positive mood (p = 0.011), greater boredom with weight loss efforts (p = 0.036), greater temptation to eat foods not consistent with their goals (p = 0.023), and that their eating choices were less consistent with their goals (p < 0.001).

CONCLUSIONS

These findings identify important differences between early non-responders and initial responders, offering potential intervention targets for rescuing early non-responders (i.e. making it easier for individuals to choose healthier foods, reducing boredom in Internet-delivered weight loss programs and providing strategies to limit exposure to dietary temptations).

Persuasive System Design Principles and Behavior Change Techniques to Stimulate Motivation and Adherence in Electronic Health Interventions to Support Weight Loss Maintenance: Scoping Review

BACKGROUND

Maintaining weight after weight loss is a major health challenge, and eHealth (electronic health) solutions may be a way to meet this challenge. Application of behavior change techniques (BCTs) and persuasive system design (PSD) principles in eHealth development may contribute to the design of technologies that positively influence behavior and motivation to support the sustainable health behavior change needed.

OBJECTIVE

This review aimed to identify BCTs and PSD principles applied in eHealth interventions to support weight loss and weight loss maintenance, as well as techniques and principles applied to stimulate motivation and adherence for long-term weight loss maintenance.

METHODS

A systematic literature search was conducted in PsycINFO, Ovid MEDLINE (including PubMed), EMBASE, Scopus, Web of Science, and AMED, from January 1, 2007 to June 30, 2018. Arksey and O'Malley's scoping review methodology was applied. Publications on eHealth interventions were included if focusing on weight loss or weight loss maintenance, in combination with motivation or adherence and behavior change.

RESULTS

The search identified 317 publications, of which 45 met the inclusion criteria. Of the 45 publications, 11 (24%) focused on weight loss maintenance, and 34 (76%) focused on weight loss. Mobile phones were the most frequently used technology (28/45, 62%). Frequently used wearables were activity trackers (14/45, 31%), as well as other monitoring technologies such as wireless or digital scales (8/45, 18%). All included publications were anchored in behavior change theories. Feedback and monitoring and goals and planning were core behavior change technique clusters applied in the majority of included publications. Social support and associations through prompts and cues to support and maintain new habits were more frequently used in weight loss maintenance than weight loss interventions. In both types of interventions, frequently applied persuasive principles were self-monitoring, goal setting, and feedback. Tailoring, reminders, personalization, and rewards were additional principles frequently applied in weight loss maintenance interventions. Results did not reveal an ideal combination of techniques or principles to stimulate motivation, adherence, and weight loss maintenance. However, the most frequently mentioned individual techniques and principles applied to stimulate motivation were, personalization, simulation, praise, and feedback, whereas associations were frequently mentioned to stimulate adherence. eHealth interventions that found significant effects for weight loss maintenance all applied self-monitoring, feedback, goal setting, and shaping knowledge, combined with a human social support component to support healthy behaviors.

CONCLUSIONS

To our knowledge, this is the first review examining key BCTs and PSD principles applied in weight loss maintenance interventions compared with those of weight loss interventions. This review identified several techniques and principles applied to stimulate motivation and adherence. Future research should aim to examine which eHealth design combinations can be the most effective in support of long-term behavior change and weight loss maintenance.

Web-based intervention to promote weight-loss maintenance using an activity monitor: A randomized controlled trial

The present study examined whether a web-based intervention could promote weight-loss maintenance, after weight loss. The study was a two-phase, 27-month, randomized controlled trial conducted in Ibaraki, Japan, from 2014 to 2017; 133 participants were recruited through local newspaper advertisements. The eligibility criteria were as follows: age of 40–64 years, body mass index of 25–40 kg/m², and having at least one metabolic syndrome component. In phase 1, a 3-month, group-based weight-loss program was provided to all eligible participants (n = 119). We then randomly assigned (1:1) participants who had lost 5% or more of their weight during phase 1 (n = 95) to either the self-help (mean 3-month weight loss 7.30 kg) or the web-support group (7.00 kg). Participants in the web-support group regularly reported their body weight and physical activity through a web-based system. They received monthly personalized feedback from a study staff for 24 months. The primary outcome, 27-month body-weight change (mean ± standard deviation), in the self-help and web-support groups were − 5.3 ± 5.0 kg and −4.5 ± 4.9 kg, respectively. There was no significant difference. An exploratory secondary analysis demonstrated that those with greater 27-month increases in their step count, assessed with an accelerometer, lost more weight with no difference in changes in energy intake. The mean 27-month body-weight change in the 4th quartile of changes in step count was −7.78 kg. Although web-based intervention using an activity monitor failed to promote weight-loss maintenance, increased physical activity was associated with successful weight-loss maintenance.

•

Web-based intervention using an activity monitor delivered no benefit on weight.

•

Participants with larger increases in step count lost more weight.

•

Increased physical activity was associated with successful weight loss maintenance.

Results From a Trial of an Online Diabetes Prevention Program Intervention

INTRODUCTION

Online Diabetes Prevention Programs (DPPs) can be scaled up and delivered broadly. However, little is known about real-world effectiveness and how outcomes compare with in-person DPP. This study examined online DPP weight loss and participation outcomes and secondarily compared outcomes among participating individuals with parallel in-person interventions.

STUDY DESIGN

A large non-randomized trial supplemented by a comparative analysis of participating individuals from a concurrent trial of two parallel in-person programs: in-person DPP and the Veterans Administration's standard of care weight loss program (MOVE!).

SETTING/PARTICIPANTS

Obese/overweight Veterans with prediabetes enrolled in online DPP (n = 268) between 2013 and 2014. Similar eligibility criteria were used to enroll in-person participants between 2012 and 2014 (n = 273 in-person DPP, n = 114 MOVE!) within a separate trial.

INTERVENTION

Online DPP included a virtual group format, live e-coach, weekly modules delivered asynchronously, and wireless home scales. In-person programs included eight to 22 group-based, face-to-face sessions.

MAIN OUTCOMES MEASURES

Weight change at 6 and 12 months using wirelessly uploaded home scale data or electronic medical record weights from clinical in-person visits. Outcomes were analyzed between 2015 and 2017.

RESULTS

From 1,182 invitations, 268 (23%) participants enrolled in online DPP. Among these, 158 (56%) completed eight or more modules; mean weight change was -4.7kg at 6 months and -4.0kg at 12 months. In a supplemental analysis of participants completing one or more sessions/modules, online DPP participants were most likely to complete eight or more sessions/modules (87% online DPP vs 59% in-person DPP vs 55% MOVE!, p < 0.001). Online and in-person DPP participants lost significantly more weight than MOVE! participants at 6 and 12 months; there was no significant difference in weight change between online and in-person DPP.

CONCLUSIONS

An intensive, multifaceted online DPP intervention had higher participation but similar weight loss compared to in-person DPP. An intensive, multifaceted online DPP intervention may be as effective as in-person DPP and help expand reach to those at risk.

Erickson health coaching: An innovative approach for weight management in obese patients with obstructive sleep apnoea?

Obstructive sleep apnoea (OSA) is a highly prevalent medical condition and amajor cardiovascular risk factor. Obesity is present in ∼70% of patients with OSA, nevertheless, continuous positive airway pressure (CPAP) ventilation - the gold standard therapy for moderate and severe OSA - has no appreciable long-term beneficial effects on obesity, body composition, energy metabolism, physical activities or the incidence of major cardiovascular events. Therefore, effective weight loss strategies in conjunction with CPAP therapy in OSA are critically needed. Since lifestyle interventions may positively impact body weight, there is a strong rationale to testing the hypothesis that Erikson coaching intervention as a form of lifestyle intervention to obese patients with OSA may increase their adherence to healthy lifestyle behaviour and thus result in weight reduction, improved body composition (reduction in %body fat) and improvements in glucose and lipid metabolism. There are three lines of evidence to justify testing this hypothesis: First, health coaching significantly facilitates uptake of healthy behaviours across a broad variety of chronic conditions; second, several randomized clinical trials suggested positive impact of health coaching on weight management and on cardiometabolic risk factors in overweight/obese otherwise healthy persons; third, Erickson coaching approach empowers the three key elements of health coaching (patient-centeredness, patient-determined goals, use of a self-discovery process) further, namely by introducing two other specific core elements into the coaching process: a) solution-focus and outcome frame, b) orientation at the patient-formulated positive outcomes (i.e., positive values resulting from behavioural change). Importantly, results of our recent pilot observational cohort study suggested that Erickson coaching is a powerful tool to address behavioural modification in obesity. In conclusion, testing our hypothesis may have significant clinical implications: if clinical randomized trials indicate that Erickson health coaching is an efficient approach to behavioural change and weight management in OSA then combining Erickson coaching with CPAP therapy may result in reductions in cardiovascular morbidity and mortality in these high-risk patients.

Self-management of dietary intake using mindful eating to improve dietary intake for individuals with early stage chronic kidney disease

Using mindful eating to improve specific dietary recommendations has not been adequately studied. This feasibility study examined an intervention, self-management of dietary intake using mindful eating, with 19 participants that had mild to moderate chronic kidney disease, using a prospective, single group, pretest-posttest design. The intervention had six weekly classes focused on self-management using mindful eating, goal-setting, problem-solving, and food label reading. Weight, body mass index (BMI), 3-day 24-h dietary recalls and fasting blood samples were measured. Participants improved significantly in mean weight (203.21 ± 42.98 vs 199.91 ± 40.36 lbs; P = 0.03) and BMI (32.02 ± 5.22 vs 31.57 ± 5.27 kg/m2; P = 0.04), but not in dietary intake nor blood measures with the exception of cis-beta-carotene levels (0.020 + 0.012 vs 0.026 + 0.012 mcg/mL; P = 0.008), which correlates to fruit and vegetable servings. These promising results warrant further testing of the intervention in randomized control trials.

Engagement and outcomes in a digital Diabetes Prevention Program: 3-year update

OBJECTIVE

Translations of the Diabetes Prevention Program (DPP) have proliferated in recent years, with increasing expansion to digital formats. Although these DPP translations have consistently shown favorable clinical outcomes, long-term data for digital formats are limited. This study's objective was to examine clinical outcomes up to 3 years post-baseline and the relationship between program engagement and clinical outcomes in a digital DPP.

RESEARCH DESIGN AND METHODS

In a single-arm, non-randomized trial, 220 patients previously diagnosed with prediabetes were enrolled in the Omada Health Program, a commercially available, 16-week DPP-based weight loss intervention followed by an ongoing weight maintenance intervention. Changes in body weight and A1c were assessed annually. Relationships between program engagement during the first year and clinical outcomes across 3 years were examined.

RESULTS

Participants were socioeconomically diverse (62% women, 50.2% non-Hispanic white, 51.7% college educated or higher). From baseline to 3 years, those participants who completed four or more lessons and nine or more lessons achieved significant sustained weight loss (-3.0% and -2.9%, respectively) and an absolute reduction in A1c (-0.31 and -0.33, respectively) with an average remission from the prediabetes range to the normal glycemic range. Factor analysis of engagement metrics during the first year revealed two underlying dimensions, one comprising lesson completion and health behavior tracking consistency, and the other comprising website logins and group participation. When these two factors were used to predict weight loss, only the logins and group participation factor was a significant predictor of weight loss at 16 weeks and 1 year.

CONCLUSIONS

This study demonstrates significant long-term reductions in body weight and A1c in a digital DPP and identifies patterns of program engagement that predict weight loss.

Editorial: 3rd Special Issue on behavior change, health, and health disparities

This Special Issue of Preventive Medicine (PM) is the 3rd that we have organized on behavior change, health, and health disparities. This is a topic of critical importance to improving U.S. population health. There is broad scientific consensus that personal behaviors such as cigarette smoking, other substance abuse, and physical inactivity/obesity are among the most important modifiable causes of chronic disease and its adverse impacts on population health. Hence, effectively promoting health-related behavior change needs to be a key component of health care research and policy. There is also broad recognition that while these problems extend throughout the population, they disproportionately impact economically disadvantaged populations and other vulnerable populations and represent a major contributor to health disparities. Thus, behavior change represents an essential step in curtailing health disparities, which receives special attention in this 3rd Special Issue. We also devote considerable space to the longstanding challenges of reducing cigarette smoking and use of other tobacco and nicotine delivery products in vulnerable populations, obesity, and for the first time food insecurity. Across each of these topics we include contributions from highly accomplished policymakers and scientists to acquaint readers with recent accomplishments as well as remaining knowledge gaps and challenges.

Some current dimensions of the behavioral economics of health-related behavior change

Health-related behaviors such as tobacco, alcohol and other substance use, poor diet and physical inactivity, and risky sexual practices are important targets for research and intervention. Health-related behaviors are especially pertinent targets in the United States, which lags behind most other developed nations on common markers of population health. In this essay we examine the application of behavioral economics, a scientific discipline that represents the intersection of economics and psychology, to the study and promotion of health-related behavior change. More specifically, we review what we consider to be some core dimensions of this discipline when applied to the study health-related behavior change. Behavioral economics (1) provides novel conceptual systems to inform scientific understanding of health behaviors, (2) translates scientific understanding into practical and effective behavior-change interventions, (3) leverages varied aspects of behavior change beyond increases or decreases in frequency, (4) recognizes and exploits trans-disease processes and interventions, and (5) leverages technology in efforts to maximize efficacy, cost effectiveness, and reach. These dimensions are overviewed and their implications for the future of the field discussed.