Examination of the relationship between lapses and weight loss in a smartphone-based just-in time adaptive intervention

Addressing the psychology of weight loss and maintenance: A feasibility study of the Skills for weight loss and Maintenance weight management programme

OBJECTIVES

Building on prior theory, we aimed to evaluate the feasibility and acceptability of integrating novel, weight loss maintenance strategies into existing weight management programmes. We also piloted recruitment and data collection procedures for future research.

DESIGN

Two phases of action research nested within a single-arm feasibility study. The intervention was refined between phases using feedback from intervention fidelity analysis and qualitative exploration of patient and provider experiences. Changes in outcomes were assessed up to 18 months post-baseline.

METHODS

One hundred adults with a mean body mass index of 37 kg/m2 were offered the Skills for weight loss and Maintenance (SkiM) intervention. This included existing weight management programme content and additional weight loss maintenance techniques delivered fortnightly for 6 months in local community centres to groups of 11-15 people.

RESULTS

Of the 100 participants, 65%, 58% and 56% provided data at 7, 12 and 18 months. Across both phases, the mean initial weight loss was 4.2 kg (95% CI: 2.4-5.9) and 3.1 kg at 18 months (95% CI: .8-5.5). In Phase 2, we observed better weight loss maintenance (.5 kg [13.2%] regain from 7 to 18 months, vs. 1.7 kg [36.2%] in Phase 1). Variation in outcomes, high early dropout rates and qualitative feedback indicated that, although delivery of the intervention and trial procedures was feasible and acceptable, there was scope to refine the intervention to engage a wider range of participants. Intervention fidelity was acceptable, particularly in Phase 2.

CONCLUSIONS

The SkiM intervention seems promising, but more research is needed to improve recruitment and retention prior to further evaluation.

Personal motivation, self-regulation barriers and strategies for weight loss in people with overweight and obesity: a thematic framework analysis

OBJECTIVE

To explore motivations, self-regulation barriers and strategies in a multi-ethnic Southeast Asian population with overweight and obesity.

DESIGN

Qualitative design using semi-structured face-to-face and videoconferencing interviews. Data were analysed using thematic framework analysis and constant comparison method.

SETTING

Specialist weight management clinic.

PARTICIPANTS

Twenty-two participants were purposively sampled from 13 April to 30 April 2021. Median age and BMI of the participants were 37·5 (interquartile range (IQR) = 13·3) and 39·2 kg/m² (IQR = 6·1), respectively. And 31·8 % were men, majority had a high intention to adopt healthy eating behaviours (median = 6·5; IQR = 4·8-6·3) and 59 % of the participants had a medium level of self-regulation.

RESULTS

Six themes and fifteen subthemes were derived. Participants were motivated to lose weight by the sense of responsibility as the family's pillar of support and to feel 'normal' again. We coupled self-regulation barriers with corresponding strategies to come up with four broad themes: habitual overconsumption - mindful self-discipline; proximity and convenience of food available - mental tenacity; momentary lack of motivation and sense of control - motivational boosters; and overeating triggers - removing triggers. We highlighted six unique overeating triggers namely: trigger activities (e.g. using social media); eating with family, friends and colleagues; provision of food by someone; emotions (e.g. feeling bored at home, sad and stressed); physiological condition (e.g. premenstrual syndrome); and the time of the day.

CONCLUSIONS

Future weight management interventions should consider encompassing participant-led weight loss planning, motivation boosters and self-regulation skills to cope with momentary overeating triggers.

Combining passive eating monitoring and ecological momentary assessment to characterize dietary lapses from a lifestyle modification intervention

Dietary lapses (i.e., specific instances of nonadherence to recommended dietary goals) contribute to suboptimal weight loss outcomes during lifestyle modification programs. Passive eating monitoring could enhance lapse measurement via objective assessment of eating characteristics that could be markers for lapse (e.g., more bites consumed). The purpose of this study was to evaluate if passively-inferred eating characteristics (i.e., bites, eating duration, and eating rate), measured via wrist-worn device, could distinguish dietary lapses from non-lapse eating. Adults (n = 25) with overweight/obesity received a 24-week lifestyle modification intervention. Participants completed ecological momentary assessment (EMA; repeated smartphone surveys) biweekly to self-report on dietary lapses and non-lapse eating episodes. Participants wore a wrist device that captured continuous wrist motion. Previously-validated algorithms inferred eating episodes from wrist data, and calculated bite count, duration, and rate (seconds per bite). Mixed effects logistic regressions revealed no simple effects of bite count, duration, or eating rate on the likelihood of dietary lapse. Moderation analyses revealed that eating episodes in the evening were more likely to be lapses if they involved fewer bites (B = -0.16, p < .05), were shorter (B = -0.54, p < .05), or had a slower rate (B = 1.27, p < .001). Statistically significant interactions between eating characteristics (Bs = -0.30 to -0.08, ps < .001) revealed two distinct patterns. Eating episodes that were 1. smaller, slower, and shorter than average, or 2. larger, quicker, and longer than average were associated with increased probability of lapse. This study is the first to use objective eating monitoring to characterize dietary lapses throughout a lifestyle modification intervention. Results demonstrate the potential of sensors to identify non-adherence using only patterns of passively-sensed eating characteristics, thereby minimizing the need for self-report in future studies. CLINICAL TRIALS REGISTRY NUMBER: NCT03739151.

Eating disorders early app use mediates treatment effect on clinical improvement

OBJECTIVE

Eating disorders (EDs) contribute considerably to the global burden of disease. However, most affected individuals do not receive treatment. Mobile apps present an enormous opportunity to increase access to mental healthcare services. This study examined whether the degree of usage of a self-help app for EDs mediated the app's effects on the clinical response by individuals with EDs.

METHOD

App usage measures included the total number of cognitive-behavioral meal logs, total number of days spent using the app, and the last day the app was used during the study period. Mediation analysis was performed using the MacArthur framework.

RESULTS

All usage variables met the analytic requirements for testing mediation (group means (sd) for app and standard app, respectively: logs = 74 (108) vs. 51.4 (88.1), days spent = 14.3 (17.5) vs. 10.6 (15.0), p-values from Wilcox rank sum tests p < .01). Regression coefficients indicated mediation effects. The mediation effects demonstrated support that increased engagement (as measured by logs and time spent on the app) was related to an increased likelihood of achieving a significant clinical change by the end of the trial.

DISCUSSION

Greater and longer engagement in an ED app mediates its efficacy in terms of ED remission.

Dietary lapses are associated with meaningful elevations in daily caloric intake and added sugar consumption during a lifestyle modification intervention

Objective

Lapses from the dietary prescription in lifestyle modification interventions for overweight/obesity are common and impact weight loss outcomes. While it is expected that lapses influence weight via increased consumption, there are no studies that have evaluated how dietary lapses affect dietary intake during treatment. This study examined the association between daily lapses and daily energy and macronutrient intake during a lifestyle modification intervention.

Methods

This study used an intensive longitudinal design to observe participants throughout a 6-month lifestyle modification intervention. Participants (n = 32) were adults with overweight/obesity (body mass index 25-50 kg/m²) and a diagnosed cardiovascular disease risk factor (e.g., hypertension) with a desire to lose weight. Participants underwent a gold-standard individual in-person lifestyle modification protocol consisting of 3 months of weekly sessions with 3 months of monthly sessions. Each participant's dietary prescription included a calorie target range that was based on their starting weight. Participants completed ecological momentary assessment (EMA; repeated daily smartphone surveys) every other week to self-report on dietary lapses and telephone-based 24-h dietary recalls every 6 weeks.

Results

On days with EMA and recalled intake (n = 210 days), linear mixed models demonstrated significant associations between daily lapse and higher total daily caloric intake (B = 139.20, p < 0.05), more daily grams of added sugar (B = 16.24, p < 0.001), and likelihood of exceeding the daily calorie goal (B = 0.89, p < 0.05). The associations between daily lapse and intake of all other daily macronutrients were non-significant.

Conclusions

This study contributes to literature suggesting that dietary lapses pose a threat to weight loss success. Results indicate that reducing lapse frequency could reduce overall caloric intake and added sugar consumption.

Affective responses to overeating episodes in women participating in a behavioral weight loss program

BACKGROUND

Much research has focused on precursors to dietary lapses in weight loss programs, but less is known about how individual responses to lapses may influence future non-adherence and program success. The current study examined affective responses to overeating lapses and their influence on subsequent overeating and overall weight loss.

METHODS

Women (n = 60) with overweight or obesity (BMI (mean ± SD): 34.3 ± 3.9 kg/m²; age: 48.1 ± 10.1 years) participated in a 3-month group behavioral weight loss intervention (BWLI). At baseline and 3 months, participants completed anthropometric assessments and a 10-day ecological momentary assessment protocol sent 5 times per day reporting on overeating and affect (stress, shame, anxiety, and feeling good about oneself). Across time points, multilevel models were used to examine affective responses to overeating and to predict likelihood of subsequent overeating. Linear regression models were used to examine the effect of affective responses to overeating (at baseline and collapsed across time points) on weight loss.

RESULTS

Following self-reported overeating episodes, compared to non-overeating episodes, feeling good about oneself decreased. These decreases lessened with time from overeating. Overeating predicted subsequent overeating episodes, with decreases in feeling good about oneself following overeating marginally predicting increased likelihood (p = 0.065). Neither overeating frequency at baseline nor change in overeating frequency predicted weight loss; however, greater decreases in anxiety following overeating were associated with less weight loss.

CONCLUSIONS

Self-reported overeating during a BWLI was associated with negative affective responses and may have increased the likelihood of subsequent overeating, but did not affect overall weight loss in this sample.

Momentary predictors of dietary lapse from a mobile health weight loss intervention

Identifying factors that influence risk of dietary lapses (i.e., instances of dietary non-adherence) is important because lapses contribute to suboptimal weight loss outcomes. Existing research examining lapse risk factors has had methodological limitations, including retrospective recall biases, subjective operationalizations of lapse, and has investigated lapses among participants in gold-standard behavioral weight loss programs (which are not accessible to most Americans). The current study will address these limitations by being the first to prospectively assess several risk factors of lapse (objectively operationalized) in the context of a commercial mobile health (mHealth) intervention, a highly popular and accessible method of weight loss. N = 159 adults with overweight or obesity enrolled in an mHealth commercial weight loss program completed ecological momentary assessments (EMAs) of 15 risk factors and lapses (defined as exceeding a point target for a meal/snack) over a 2-week period. N = 9 participants were excluded due to low EMA compliance, resulting in a sample of N = 150. Dietary lapses were predicted by momentary increases in urges to deviate from one's eating plan (b = .55, p < .001), cravings (b = .55, p < .001), alcohol consumption (b = .51, p < .001), and tiredness (b = .19, p < .001), and decreases in confidence related to meeting dietary goals (b = -.21, p < .001) and planning food intake (b = -.15, p < .001). This study was among the first to identify prospective predictors of lapse in the context of a commercial mHealth weight loss program. Findings can inform mHealth weight loss programs, including just-in-time interventions that measure these risk factors, calculate when risk of lapse is high, and deliver momentary interventions to prevent lapses.