Racial and ethnic minority enrollment in randomized clinical trials of behavioural weight loss utilizing technology: a systematic review

Ethnic Minority Participation in Clinical Trials from Latin America and the Caribbean: A Scoping Review

We summarize the clinical trials (CTs) main characteristics, including members of ethnic minorities from Latin America. We carried out a systematic search in six databases. We made a descriptive synthesis of CTs, summarizing the characteristics, interventions, main findings, results, and conclusions reported. 4411 studies were acquired in search strategy, leaving 24 CTs in the final selection. Of these, ten were randomized, four were non-randomized, and the remainder had other designs. Most of the studies were carried out in the population of infants and children (08), ten of the studies included only women, and two studies included men. Nine studies were conducted in Mexico, with the Mayan ethnic minority being mostly evaluated (05). In only 15 it was mentioned that their research was approved by a research ethics committee. Finally, half of the CTs reported funding from international agencies and third reported funding from government agencies. Our results show that that CTs in ethnic minorities are limited and reduced to a few native peoples of the continent.

Differences in weight-loss outcomes among race-gender subgroups by behavioural intervention delivery mode: An analysis of the POWER trial

Prior in-person behavioural intervention studies have documented differential weight loss between men and women and by race, with Black women receiving the least benefit. Remotely delivered interventions are now commonplace, but few studies have compared outcomes by race-gender groups and delivery modality. We conducted a secondary analysis of POWER, a randomized trial (NCT00783315) designed to determine the effectiveness of 2 active, lifestyle-based, weight loss interventions (remote vs. in-person) compared to a control group. Participants with obesity and at least one cardiovascular disease risk factor (N = 415) were recruited in the Baltimore, MD area. Data from 233 white and 170 Black individuals were used for this analysis. Following an intention-to-treat approach, we compared the mean percent weight loss at 24 months by race-gender subgroups using repeated-measures, mixed-effects models. Everyone lost weight in the active interventions however, weight loss differed by race and gender. white and Black men had similar results for both interventions (white: in-person (-7.6%) remote (-7.4%); Black: in-person (-4.7%) remote (-4.4%)). In contrast, white women lost more weight with the in-person intervention (in-person (-7.2%) compared to the remote (-4.4%)), whereas Black women lost less weight in the in-person group compared to the remote intervention at 24 months (-2.0% vs. -3.0%, respectively; p for interaction <.001). We found differences between the effectiveness of the 2 weight loss interventions-in-person or remote-in white and Black women at 24 months. Future studies should consider intervention modality when designing weight loss interventions for women.

Lack of racial and ethnic diversity in pediatric ophthalmology clinical trials from 2000 to 2022

PURPOSE

To examine the prevalence of and factors associated with racial and ethnic reporting and trends in such reporting and to assess whether categories of race and ethnicity have been under- or over-represented in pediatric ophthalmology randomized control trials (RCTs) in the United States.

METHODS

We systematically searched the literature on pediatric ophthalmology RCTs in high-impact factor ophthalmology journals published between 2000 and 2022. Logistic regression was used to assess parameters linked to race/ethnicity reporting; linear regression, to gauge the relationship between publication year and race/ethnicity reporting. The racial and ethnic composition of RCTs was contrasted with 2010 US census data by calculating percentage difference.

RESULTS

Of 170 eligible articles, 89 (52.4%) included race/ethnicity data. Multivariable analysis showed that academic (OR = 12.19; 95% CI, 3.34-44.44) and government (OR = 3.91; 95% CI, 1.20-12.72) funding was linked to data reporting. During the study period, publication year and race/ethnicity reporting had a nonstatistically significant 1.0% annual increase (r = 0.29, P = 0.18). White participants were over-represented, with a percentage difference of 16.7% (95% CI, 11.8%-21.7%), whereas Hispanic individuals were under-represented, with a percentage difference of -7.6% (95% CI, -11.2% to -4.1%) compared to the 2010 US census data.

CONCLUSIONS

Our results indicate a gradual rise in reported race and/or ethnicity in published pediatric ophthalmology RCTs, though not statistically significant, both in the United States and globally. Notably, under-representation of Hispanic, over-representation of White, and proportional representation of Black and Asian individuals were observed in US-based studies.

CHARACTERISTICS OF PARTICIPANTS IN DIABETIC RETINOPATHY CLINICAL RESEARCH CLINICAL TRIALS WHO WERE LOST TO FOLLOW-UP

PURPOSE

Our study describes the racial/ethnic composition and the broad health status/severity of disease of the cohorts of Diabetic Retinopathy Clinical Research clinical trials and compares the rates of noncompletion of the trial with the first data report (lost to follow-up).

METHODS

This study is a retrospective cohort study of participants in Diabetic Retinopathy Clinical Research Retina Network clinical trials who met our inclusion criteria. The primary outcome was the lost to follow-up rates and their associated risk factors.

RESULTS

Eight clinical trials with 3,492 participants met our inclusion criteria. Participants who were lost to follow-up were more likely to be younger, Hispanic or Black, had Type 1 diabetes mellitus, had worse baseline best-corrected visual acuity, had higher hemoglobin A1c, had higher blood pressure, and had proliferative diabetic retinopathy (PDR) (Diabetic Retinopathy Severity Score >66).

CONCLUSION

Participants who were lost to follow-up during Diabetic Retinopathy Clinical Research clinical trials tended to be younger, Hispanic or Black, and had worse diabetes and hypertension. This study highlights the importance of ensuring that a representative population is maintained through the end of the study period.

The Effectiveness of eHealth Interventions for Weight Loss and Weight Loss Maintenance in Adults with Overweight or Obesity: A Systematic Review of Systematic Reviews

PURPOSE OF REVIEW: The purpose of this study is to evaluate the effectiveness of eHealth interventions for weight loss and weight loss maintenance among adults with overweight or obesity through a systematic review of systematic reviews. RECENT FINDINGS: This study included 26 systematic reviews, covering a total of 338 original studies, published between 2018 and 2023. The review indicates that eHealth interventions are more effective than control interventions or no care and comparable to face-to-face interventions. The effect sizes remain relatively small when comparing eHealth interventions to any control conditions, with mean differences of weight loss results from - 0.12 kg (95% CI - 0.64 to 0.41 kg) in a review comparing eHealth interventions to face-to-face care to - 4.32 kg (- 5.08 kg to - 3.57 kg) in a review comparing eHealth interventions to no care. The methodological quality of the included studies varies considerably. However, it can be concluded that interventions with human contact work better than those that are fully automated. In conclusion, this systematic review of systematic reviews provides an updated understanding of the development of digital interventions in recent years and their effectiveness for weight loss and weight loss maintenance among adults with overweight or obesity. The findings suggest that eHealth interventions can be a valuable tool for delivering obesity care to more patients economically. Further research is needed to determine which specific types of eHealth interventions are most effective and how to best integrate them into clinical practice.

An Evaluation of a Personalized Multicomponent Commercial Digital Weight Management Program: Single-Arm Behavioral Trial

BACKGROUND

Digital behavioral weight loss programs are scalable and effective, and they provide an opportunity to personalize intervention components. However, more research is needed to test the acceptability and efficacy of personalized digital behavioral weight loss interventions.

OBJECTIVE

In a 6-month single-arm trial, we examined weight loss, acceptability, and secondary outcomes of a digital commercial weight loss program (WeightWatchers). This digital program included a personalized weight loss program based on sex, age, height, weight, and personal food preferences, as well as synchronous (eg, virtual workshops and individual weekly check-ins) and asynchronous (eg, mobile app and virtual group) elements. In addition to a personalized daily and weekly PersonalPoints target, the program provided users with personalized lists of ≥300 ZeroPoint foods, which are foods that do not need to be weighed, measured, or tracked.

METHODS

We conducted a pre-post evaluation of this 6-month, digitally delivered, and personalized WeightWatchers weight management program on weight loss at 3 and 6 months in adults with overweight and obesity. The secondary outcomes included participation, satisfaction, fruit and vegetable intake, physical activity, sleep quality, hunger, food cravings, quality of life, self-compassion, well-being, and behavioral automaticity.

RESULTS

Of the 153 participants, 107 (69.9%) were female, and 65 (42.5%) identified as being from a minoritized racial or ethnic group. Participants' mean age was 41.09 (SD 13.78) years, and their mean BMI was 31.8 (SD 5.0) kg/m2. Participants had an average weight change of -4.25% (SD 3.93%) from baseline to 3 months and -5.05% (SD 5.59%) from baseline to 6 months. At 6 months, the percentages of participants who experienced ≥3%, ≥5%, and ≥10% weight loss were 63.4% (97/153), 51% (78/153), and 14.4% (22/153), respectively. The mean percentage of weeks in which participants engaged in ≥1 aspects of the program was 87.53% (SD 23.40%) at 3 months and 77.67% (SD 28.69%) at 6 months. Retention was high (132/153, 86.3%), and more than two-thirds (94/140, 67.1%) of the participants reported that the program helped them lose weight. Significant improvements were observed in fruit and vegetable intake, physical activity, sleep quality, hunger, food cravings, quality of life, and well-being (all P values <.01).

CONCLUSIONS

This personalized, digital, and scalable behavioral weight management program resulted in clinically significant weight loss in half (78/153, 51%) of the participants as well as improvements in behavioral and psychosocial outcomes. Future research should compare personalized digital weight loss programs with generic programs on weight loss, participation, and acceptability.

A Comparison of the Readiness of Youth Service Agencies to Implement a Technology-Based Toolkit to Support Treatment Delivery

Implementation initiatives and technology-based resources aim to address barriers to Evidence-Based Practice (EBP) use by creating generalizable techniques that can be used for a variety of youth-serving agencies. However, research has not carefully examined unique differences between agency types or individual programs in readiness to use such technologies and implementation strategies. The current study explored differences between community mental health clinics and child advocacy centers on organizational cultural factors (e.g., ability to change and commitment for change) to implement a novel technology-based toolkit to support delivery of Trauma Focused Cognitive Behavioral Therapy (TF-CBT). Results indicated that TF-CBT providers from child advocacy centers reported greater commitment to change and more support to use the technology-based system than those from community mental health centers. Findings suggest that implementation initiatives should address the needs of individual agencies and service settings and adaptations should be explored to best meet the needs of these settings.

A randomized clinical trial comparing low-fat with precision nutrition-based diets for weight loss: impact on glycemic variability and HbA1c

BACKGROUND

Recent studies have demonstrated considerable interindividual variability in postprandial glucose response (PPGR) to the same foods, suggesting the need for more precise methods for predicting and controlling PPGR. In the Personal Nutrition Project, the investigators tested a precision nutrition algorithm for predicting an individual's PPGR.

OBJECTIVE

This study aimed to compare changes in glycemic variability (GV) and HbA1c in 2 calorie-restricted weight loss diets in adults with prediabetes or moderately controlled type 2 diabetes (T2D), which were tertiary outcomes of the Personal Diet Study.

METHODS

The Personal Diet Study was a randomized clinical trial to compare a 1-size-fits-all low-fat diet (hereafter, standardized) with a personalized diet (hereafter, personalized). Both groups received behavioral weight loss counseling and were instructed to self-monitor diets using a smartphone application. The personalized arm received personalized feedback through the application to reduce their PPGR. Continuous glucose monitoring (CGM) data were collected at baseline, 3 mo and 6 mo. Changes in mean amplitude of glycemic excursions (MAGEs) and HbA1c at 6 mo were assessed. We performed an intention-to-treat analysis using linear mixed regressions.

RESULTS

We included 156 participants [66.5% women, 55.7% White, 24.1% Black, mean age 59.1 y (standard deviation (SD) = 10.7 y)] in these analyses (standardized = 75, personalized = 81). MAGE decreased by 0.83 mg/dL per month for standardized (95% CI: 0.21, 1.46 mg/dL; P = 0.009) and 0.79 mg/dL per month for personalized (95% CI: 0.19, 1.39 mg/dL; P = 0.010) diet, with no between-group differences (P = 0.92). Trends were similar for HbA1c values.

CONCLUSIONS

Personalized diet did not result in an increased reduction in GV or HbA1c in patients with prediabetes and moderately controlled T2D, compared with a standardized diet. Additional subgroup analyses may help to identify patients who are more likely to benefit from this personalized intervention. This trial was registered at clinicaltrials.gov as NCT03336411.

Is the uptake, engagement, and effectiveness of exclusively mobile interventions for the promotion of weight-related behaviors equal for all? A systematic review

Mobile health interventions are promising behavior change tools. However, there is a concern that they may benefit some populations less than others and thus widen inequalities in health. This systematic review investigated differences in uptake of, engagement with, and effectiveness of mobile interventions for weight-related behaviors (i.e., diet, physical activity, and sedentary behavior) based on a range of inequality indicators including age, gender, race/ethnicity, and socioeconomic status. The protocol was registered on PROSPERO (CRD42020192473). Six databases (CINAHL, EMBASE, ProQuest, PsycINFO, Pubmed, and Web of Science) were searched from inception to July 2021. Publications were eligible for inclusion if they reported the results of an exclusively mobile intervention and examined outcomes by at least one inequality indicator. Sixteen publications reporting on 13 studies were included with most reporting on multiple behaviors and inequality indicators. Uptake was investigated in one study with no differences reported by the inequality indicators studied. Studies investigating engagement (n = 7) reported differences by age (n = 1), gender (n = 3), ethnicity (n = 2), and education (n = 2), while those investigating effectiveness (n = 9) reported differences by age (n = 3), gender (n = 5), education (n = 2), occupation (n = 1), and geographical location (n = 1). Given the limited number of studies and their inconsistent findings, evidence of the presence of a digital divide in mobile interventions targeting weight-related behaviors is inconclusive. Therefore, we recommend that inequality indicators are specifically addressed, analyzed, and reported when evaluating mobile interventions.

Passive recruitment reach of a lifestyle management program to address obesity in the deep south during the COVID-19 pandemic

Obesity is a significant public health concern, especially in the Deep South and in Mississippi where prevalence is among the worst in the nation paired, with other poor health outcomes and socioeconomic conditions. Lifestyle management programs that address modifiable risk factors, such as nutrition and physical activity, can be effective mitigation strategies to halt weight accumulation patterns and ameliorate metabolic risk factors for some populations. However, there is limited evidence regarding the implementation of effective practice models to address obesity risk in underserved and underrepresented populations, such as African Americans, and people in the stage of earlier adulthood. Furthermore, there is growing evidence supporting the impact of the COVID-19 pandemic on lifestyle management programs that should be considered in these populations. The purpose of this manuscript was to describe the development and telehealth implementation of a weight management program during the COVID-19 pandemic and provide a preliminary examination of recruitment strategies and baseline characteristics for enrolled participants. Passive recruitment (social media, web, email, and other media advertisements) resulted in 157 screening initiations, and 79 of those participants met the study inclusion criteria. Further, of the 79 eligible participants, 38 completed all study enrollment requirements and presented with metabolic abnormalities. The study findings add to the emerging body of evidence for how the pandemic may have impacted lifestyle management programs and is representative of an understudied and underrepresented population.

Detailed Versus Simplified Dietary Self-monitoring in a Digital Weight Loss Intervention Among Racial and Ethnic Minority Adults: Fully Remote, Randomized Pilot Study

BACKGROUND

Detailed self-monitoring (or tracking) of dietary intake is a popular and effective weight loss approach that can be delivered via digital tools, although engagement declines over time. Simplifying the experience of self-monitoring diet may counteract this decline in engagement. Testing these strategies among racial and ethnic minority groups is important as these groups are often disproportionately affected by obesity yet underrepresented in behavioral obesity treatment.

OBJECTIVE

In this 2-arm pilot study, we aimed to evaluate the feasibility and acceptability of a digital weight loss intervention with either detailed or simplified dietary self-monitoring.

METHODS

We recruited racial and ethnic minority adults aged ≥21 years with a BMI of 25 kg/m² to 45 kg/m² and living in the United States. The Pacific time zone was selected for a fully remote study. Participants received a 3-month stand-alone digital weight loss intervention and were randomized 1:1 to either the detailed arm that was instructed to self-monitor all foods and drinks consumed each day using the Fitbit mobile app or to the simplified arm that was instructed to self-monitor only red zone foods (foods that are highly caloric and of limited nutritional value) each day via a web-based checklist. All participants were instructed to self-monitor both steps and body weight daily. Each week, participants were emailed behavioral lessons, action plans, and personalized feedback. In total, 12 a priori benchmarks were set to establish feasibility, including outcomes related to reach, retention, and self-monitoring engagement (assessed objectively via digital tools). Acceptability was assessed using a questionnaire. Weight change was assessed using scales shipped to the participants' homes and reported descriptively.

RESULTS

The eligibility screen was completed by 248 individuals, of whom 38 (15.3%) were randomized, 18 to detailed and 20 to simplified. At baseline, participants had a mean age of 47.4 (SD 14.0) years and BMI of 31.2 (SD 4.8) kg/m². More than half (22/38, 58%) were identified as Hispanic of any race. The study retention rate was 92% (35/38) at 3 months. The detailed arm met 9 of 12 feasibility benchmarks, while the simplified arm met all 12. Self-monitoring engagement was moderate to high (self-monitoring diet: median of 49% of days for detailed, 97% for simplified; self-monitoring steps: 99% for detailed, 100% for simplified; self-monitoring weight: 67% for detailed, 80% for simplified). Participants in both arms reported high satisfaction, with 89% indicating that they would recommend the intervention. Weight change was -3.4 (95% CI -4.6 to -2.2) kg for detailed and -3.3 (95% CI -4.4 to -2.2) kg for simplified.

CONCLUSIONS

A digital weight loss intervention that incorporated either detailed or simplified dietary self-monitoring was feasible, with high retention and engagement, and acceptable to racial and ethnic minority adults.

TRIAL REGISTRATION

ASPREDICTED #66674; https://aspredicted.org/ka478.pdf.

Exploring ethnic representativeness in diabetes clinical trial enrolment from 2000 to 2020: a chronological survey

AIMS/HYPOTHESIS

Ethnic representativeness of participant enrolment in diabetes RCTs involving multiple ethnicities remains unknown. The aims of this study were to evaluate the status and temporal trend of ethnic representativeness in enrolment to diabetes RCTs, and to assess under-enrolment of non-white ethnic groups and explore trial characteristics associated with under-enrolment.

METHODS

We conducted a chronological survey by systematically searching the literature to include eligible RCTs published between January 2000 and December 2020. We assessed temporal trends in enrolment of ethnic groups in the included trials. Univariable logistic regression was used to explore the association between trial characteristics and under-enrolment of non-white groups, using a participant to prevalence ratio of <0.8 to define under-enrolment. This study was registered in PROSPERO (CRD42021229100).

RESULTS

We included 405 RCTs for analysis (327 multi-country trials, 69 conducted in the USA and nine conducted in the UK). The median enrolment rate of all non-white groups was 24.0% in the overall RCTs. Trials conducted in the USA and the UK had median enrolment rates of 29.0% and 12.0% for all non-white groups, respectively. There was a temporal trend towards increased participation of non-white ethnic groups in the overall RCTs; however, no significant improvement over time was found in the US or UK trials. Non-white groups were under-enrolled in most included trials: 62.3% (43/69) in US trials and 77.8% (7/9) in UK trials. The US trials with a high female proportion were associated with lower odds of under-enrolment of all non-white groups (OR 0.22; 95% CI 0.07, 0.65), while trials receiving funding from industry showed increased odds of under-enrolment (OR 4.64; 95% CI 1.50, 14.35). Outpatient enrolment and intervention duration were significantly associated with under-enrolment of Black participants. Only a small proportion of trials reported subgroup results or explored the effect modification by ethnicity.

CONCLUSIONS/INTERPRETATION

A temporal trend towards increased non-white ethnic enrolment was found in diabetes RCTs globally, but not in the USA or the UK. Non-white ethnic groups were under-represented in the majority of diabetes trials conducted in the USA and the UK. Some trial characteristics may be associated with non-white under-enrolment in diabetes trials. These findings provide some evidence for non-white ethnic representativeness in diabetes trials over the past two decades, and highlight the need for more effective strategies and endeavours to alleviate under-enrolment of non-white ethnic groups.

A systematic review of inequalities in the uptake of, adherence to, and effectiveness of behavioral weight management interventions in adults

The extent to which behavioral weight management interventions affect health inequalities is uncertain, as is whether trials of these interventions directly consider inequalities. We conducted a systematic review, synthesizing evidence on how different aspects of inequality impact uptake, adherence, and effectiveness in trials of behavioral weight management interventions. We included (cluster-) randomized controlled trials of primary care-applicable behavioral weight management interventions in adults with overweight or obesity published prior to March 2020. Data about trial uptake, intervention adherence, attrition, and weight change by PROGRESS-Plus criteria (place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic status, social capital, plus other discriminating factors) were extracted. Data were synthesized narratively and summarized in harvest plots. We identified 91 behavioral weight loss interventions and 12 behavioral weight loss maintenance interventions. Fifty-six of the 103 trials considered inequalities in relation to at least one of intervention or trial uptake (n = 15), intervention adherence (n = 15), trial attrition (n = 32), or weight outcome (n = 34). Most trials found no inequalities gradient. If a gradient was observed for trial uptake, intervention adherence, and trial attrition, those considered "more advantaged" did best. Alternative methods of data synthesis that enable data to be pooled and increase statistical power may enhance understanding of inequalities in behavioral weight management interventions.

Development and Evaluation of a Measure for Social Support Provided by Friends during Lifestyle Management Programs

Obesity is a public health crisis that contributes to chronic disease prevalence, morbidity, and mortality. Nutrition and physical activity are risk factors for many chronic diseases including cancer and cardiovascular disease, the leading causes of death in the United States. Lifestyle management programs to address obesity and potential sequelae such as chronic conditions have shown efficacy, with social support an important factor in interventions. Instruments that assess social support specifically provided by friends are lacking but could be important predictors of program success. The purpose of this study was to examine the reliability and validity of the 10-item Social Support to Eat Better and Move More instrument that was developed and designed to measure support from friends that influence dietary and physical activity behaviors during lifestyle management programs. Data were collected during a cross-sectional study using purposive sampling strategies among adult residents of two southern states. Statistical analysis was conducted to examine latent factors, internal consistency, and convergent and predictive validity. These preliminary results indicated that the Social Support to Eat Better and Move More instrument had excellent internal consistency for the overall measure (α = 0.96) as well as for informational support (α = 0.97), emotional support (α = 0.96), and encouragement (α = 0.97). The tool related well to another general social support measure as well as to diet, physical activity, and health-related variables, and it can be a useful measure in lifestyle management studies.

Outcomes Following eHealth Weight Management Interventions in Adults With Overweight and Obesity From Low Socioeconomic Groups: Protocol for a Systematic Review

BACKGROUND

Obesity is a complex health condition with multiple associated comorbidities and increased economic costs. People from low socioeconomic status (SES) backgrounds are more likely to be overweight and obese and are less successful in traditional weight management programs. It is possible that eHealth interventions may be more successful in reaching people from low SES groups than traditional face-to-face models, by overcoming certain barriers associated with traditional interventions. It is not yet known, however, if eHealth weight management interventions are effective in people living with overweight and obesity from a low SES background.

OBJECTIVE

The primary aim of this study is to evaluate the efficacy of eHealth weight management interventions for people with overweight and obesity from low SES groups.

METHODS

A systematic review on relevant electronic databases (MEDLINE, Embase, Emcare, and CINAHL) will be undertaken to identify eligible studies published in English up until May 2021. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement to guide the systematic review, two reviewers will independently screen, select, and extract data and complete a risk of bias assessment of search results according to predefined criteria. Studies that have investigated an eHealth weight management intervention within a low SES population will be included. Primary outcomes include weight, BMI, and percentage weight change compared at baseline and at least one other time point. Secondary outcomes may include a range of anthropometric and physical fitness and activity measures. If sufficient studies are homogeneous, then we will pool results of individual outcomes using meta-analysis.

RESULTS

Searches have been completed, resulting in 2256 studies identified. Once duplicates were removed, 1545 studies remained for title and abstract review.

CONCLUSIONS

The use of eHealth in weight management programs has increased significantly in recent years and will continue to do so; however, it is uncertain if eHealth weight management programs are effective in a low SES population. The results of this systematic review will therefore provide a summary of the evidence for interventions using eHealth for people living with overweight and obesity and from a low SES background.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021243973; https://tinyurl.com/2p8fxtnw.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34546.

eHealth interventions targeting nutrition, physical activity, sedentary behavior, or obesity in adults: A scoping review of systematic reviews

A vast body of evidence regarding eHealth interventions for nutrition, physical activity, sedentary behavior, and obesity exists. This scoping review of systematic reviews aimed to evaluate the current level of evidence in this growing field. Seven electronic databases were searched for systematic reviews published until October 27, 2019. The systematic reviews must have included adult participants only and have evaluated eHealth behavioral interventions with the primary aim of changing nutrition, physical activity, and sedentary behavior or treating or preventing overweight and obesity. One hundred and six systematic reviews, published from 2006 to 2019, were included. Almost all (n = 98) reviews evaluated the efficacy of interventions. Over half (n = 61) included interventions focused on physical activity, followed by treatment of obesity (n = 28), nutrition (n = 22), prevention of obesity (n = 18), and sedentary behavior (n = 6). Many reviews (n = 46) evaluated one type of eHealth intervention only, while 60 included two or more types. Most reviews (n = 67) were rated as being of critically low methodological quality. This scoping review identified an increasing volume of systematic reviews evaluating eHealth interventions. It highlights several evidence gaps (e.g., evaluation of other outcomes, such as reach, engagement, or cost effectiveness), guiding future research efforts in this area.

Systematically developing a family-based health promotion intervention for women with prior gestational diabetes based on evidence, theory and co-production: the Face-it study

BACKGROUND

Women with prior gestational diabetes mellitus (GDM) are at high risk of developing type 2 diabetes; however, this risk can be reduced by engaging in positive health behaviours e.g. healthy diet and regular physical activity. As such behaviours are difficult to obtain and maintain there is a need to develop sustainable behavioural interventions following GDM. We aimed to report the process of systematically developing a health promotion intervention to increase quality of life and reduce diabetes risk among women with prior GDM and their families. We distil general lessons about developing complex interventions through co-production and discuss our extensions to intervention development frameworks.

METHODS

The development process draws on the Medical Research Council UK Development of complex interventions in primary care framework and an adaptation of a three-stage framework proposed by Hawkins et al. From May 2017 to May 2019, we iteratively developed the Face-it intervention in four stages: 1) Evidence review, qualitative research and stakeholder consultations; 2) Co-production of the intervention content; 3) Prototyping, feasibility- and pilot-testing and 4) Core outcome development. In all stages, we involved stakeholders from three study sites.

RESULTS

During stage 1, we identified the target areas for health promotion in families where the mother had prior GDM, including applying a broad understanding of health and a multilevel and multi-determinant approach. We pinpointed municipal health visitors as deliverers and the potential of using digital technology. In stage 2, we tested intervention content and delivery methods. A health pedagogic dialogue tool and a digital health app were co-adapted as the main intervention components. In stage 3, the intervention content and delivery were further adapted in the local context of the three study sites. Suggestions for intervention manuals were refined to optimise flexibility, delivery, sequencing of activities and from this, specific training manuals were developed. Finally, at stage 4, all stakeholders were involved in developing realistic and relevant evaluation outcomes.

CONCLUSIONS

This comprehensive description of the development of the Face-it intervention provides an example of how to co-produce and prototype a complex intervention balancing evidence and local conditions. The thorough, four-stage development is expected to create ownership and feasibility among intervention participants, deliverers and local stakeholders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03997773 , registered retrospectively on 25 June 2019.

Translating evidence-based behavioral weight loss into a multi-level, community intervention within a community-based participatory research framework: the Wellness Engagement (WE) Project

Black Americans and individuals from economically disadvantaged backgrounds are at disproportionate risk for obesity, yet are underrepresented in behavioral weight loss (BWL) trials and experience less benefit from traditional programs. The Wellness Engagement (WE) Project sought to translate evidence-based BWL within a CBPR framework to promote change across multiple domains of influence in an under-resourced, predominantly Black community. The purpose of this paper is to describe the efforts we undertook to translate data from our extensive formative phase into programming well suited to meet the needs of the Petersburg community. In addition, we present data from our pilot work on feasibility and acceptability. Formative data were collected using a variety of methods including a community-wide survey, asset mapping, house chats, focus groups, and key informant interviews. In collaboration with key stakeholders and community members, evidence-based approaches to weight loss were adapted to meet the needs of the community with respect to both content and delivery modality. Materials were adapted to focus on small, realistic changes appropriate for the specific context. Behavioral groups, experiential nutrition and exercise sessions, and walking groups leveraged existing assets and were open to all community members. Feasibility and acceptability ratings were promising. Furthermore, the WE Project appeared to contribute to a culture of wellness. CBPR might be a viable approach for engaging under-resourced Black communities in behavioral weight management; larger scale implementation and evaluation efforts are needed.

Self-Monitoring via Digital Health in Weight Loss Interventions: A Systematic Review Among Adults with Overweight or Obesity

OBJECTIVE

Self-monitoring is a core component of behavioral obesity treatment, but it is unknown how digital health has been used for self-monitoring, what engagement rates are achieved in these interventions, and how self-monitoring and weight loss are related.

METHODS

This systematic review examined digital self-monitoring in behavioral weight loss interventions among adults with overweight or obesity. Six databases (PubMed, Embase, Scopus, PsycInfo, CINAHL, and ProQuest Dissertations & Theses) were searched for randomized controlled trials with interventions ≥ 12 weeks, weight outcomes ≥ 6 months, and outcomes on self-monitoring engagement and their relationship to weight loss.

RESULTS

Thirty-nine studies from 2009 to 2019 met inclusion criteria. Among the 67 interventions with digital self-monitoring, weight was tracked in 72% of them, diet in 81%, and physical activity in 82%. Websites were the most common self-monitoring modality, followed by mobile applications, wearables, electronic scales, and, finally, text messaging. Few interventions had digital self-monitoring engagement rates ≥ 75% of days. Rates were higher in digital- than in paper-based arms in 21 out of 34 comparisons and lower in just 2. Interventions with counseling had similar rates to standalone interventions. Greater digital self-monitoring was linked to weight loss in 74% of occurrences.

CONCLUSIONS

Self-monitoring via digital health is consistently associated with weight loss in behavioral obesity treatment.

Who Enrolls in an Online Cancer Survivorship Program? Reach of the INSPIRE Randomized Controlled Trial for Hematopoietic Cell Transplantation Survivors

The internet can be a valuable tool in delivering survivorship care to hematopoietic cell transplantation (HCT) cancer survivors. We describe the reach of INSPIRE, an Internet and social media-based randomized controlled trial, to address healthcare and psychosocial needs of HCT survivors. All survivors 2-10 years after HCT for hematologic malignancy or myelodysplasia from 6 transplantation centers in the US were approached by mail and follow-up calls. Eligible participants had access to the Internet, an email address, and did not have active disease in the past 2 years. We used logistic regression to determine characteristics of eligible survivors who were more or less likely to enroll. Of 2578 eligible HCT survivors, 1065 (41%) enrolled in the study. The mean age of enrollees was 56.3 ± 12.6 years (range, 19 to 89 years), 52% were male, and 94% were white. Survivors less likely to enroll included those who were male, age <40 years, and who received an autologous transplant (all P < .001). Compared with white survivors, African Americans were less likely to enroll (P < .001), whereas Native Americans/Alaska Natives were more likely to join the study (P = .03). The reach of the INSPIRE program was broad, including to survivors who traditionally have less access to resources, such as Native Americans/Alaskan Natives and rural residents. Strategies are still needed to improve the enrollment of online studies of survivorship resources for males, young adults, African American, and autologous HCT survivors because their use may improve outcomes.

Using targeting to recruit men and women of color into a behavioral weight loss trial

Background

The majority of participants in weight loss trials are non-Hispanic White women, while men and women of color are underrepresented. This study presents data obtained from non-targeted and targeted recruitment approaches in a trial of behavioral weight loss programs to (1) describe the yields from each approach and (2) compare the demographics, weight control histories, and study involvement of samples recruited by each approach.

Methods

Data for this observational study include source of recruitment, demographic information, weight loss experiences (e.g., lifetime weight loss, current weight loss behaviors), and completion of the 6-month assessment visit.

Results

Men comprised 14.2% of participants who responded to non-targeted recruitment efforts, while targeted efforts yielded 50.4% men. Similarly, people of color comprised 12.8% of those who responded to non-targeted approaches, whereas targeted recruitment methods yielded 47.2% people of color. Men recruited through targeted methods were younger (p = 0.01) than men recruited through non-targeted means but were otherwise similar. Women of color recruited through targeted methods reported use of fewer weight loss strategies relative to women of color recruited through non-targeted means (p = 0.006) but were otherwise similar. There were no differences by recruitment method on retention to the study.

Conclusions

Using targeted recruitment methods increased the ethnic and gender diversity of the recruited sample without reducing study retention. This targeting also increased the enrollment of women with less weight loss experience who may not have otherwise sought out a weight loss program. Developing and implementing a targeted recruitment plan should be considered early in the clinical trial development process.

Trial registration

Clinicaltrials.gov, NCT02368002. Registered on 20 February 2015.

Digital tools for the recruitment and retention of participants in randomised controlled trials: a systematic map

BACKGROUND

Recruiting and retaining participants in randomised controlled trials (RCTs) is challenging. Digital tools, such as social media, data mining, email or text-messaging, could improve recruitment or retention, but an overview of this research area is lacking. We aimed to systematically map the characteristics of digital recruitment and retention tools for RCTs, and the features of the comparative studies that have evaluated the effectiveness of these tools during the past 10 years.

METHODS

We searched Medline, Embase, other databases, the Internet, and relevant web sites in July 2018 to identify comparative studies of digital tools for recruiting and/or retaining participants in health RCTs. Two reviewers independently screened references against protocol-specified eligibility criteria. Included studies were coded by one reviewer with 20% checked by a second reviewer, using pre-defined keywords to describe characteristics of the studies, populations and digital tools evaluated.

RESULTS

We identified 9163 potentially relevant references, of which 104 articles reporting 105 comparative studies were included in the systematic map. The number of published studies on digital tools has doubled in the past decade, but most studies evaluated digital tools for recruitment rather than retention. The key health areas investigated were health promotion, cancers, circulatory system diseases and mental health. Few studies focussed on minority or under-served populations, and most studies were observational. The most frequently-studied digital tools were social media, Internet sites, email and tv/radio for recruitment; and email and text-messaging for retention. One quarter of the studies measured efficiency (cost per recruited or retained participant) but few studies have evaluated people's attitudes towards the use of digital tools.

CONCLUSIONS

This systematic map highlights a number of evidence gaps and may help stakeholders to identify and prioritise further research needs. In particular, there is a need for rigorous research on the efficiency of the digital tools and their impact on RCT participants and investigators, perhaps as studies-within-a-trial (SWAT) research. There is also a need for research into how digital tools may improve participant retention in RCTs which is currently underrepresented relative to recruitment research.

REGISTRATION

Not registered; based on a pre-specified protocol, peer-reviewed by the project's Advisory Board.

Impact of Race and Ethnicity on Weight-Loss Outcomes in Pediatric Family-Based Obesity Treatment

INTRODUCTION

Minority children are disproportionately affected by obesity and little is known about how race/ethnicity impacts outcomes in pediatric weight-loss treatment. This study aimed to evaluate whether race/ethnicity affected weight-loss outcomes in a pediatric obesity intervention. Secondary aims included evaluating whether race/ethnicity was associated with energy intake, exercise, program adherence, acceptability, and attendance.

METHODS

One hundred fifty parent/child dyads (age 8-12 years, BMI% 85-99.9; 32% Hispanic, 24% Non-Hispanic, Non-White, 44% Non-Hispanic White) participated in a randomized control trial evaluating weight loss in family-based behavioral treatment with (FBT) or without child participation (i.e., Parent-Based Treatment, PBT). Assessments occurred at baseline, mid-treatment (month 3), post-treatment (month 6), and follow-up (months 12 and 24). Analyses included linear mixed effect models, linear models, and a negative binomial model.

RESULTS

Weight loss in Hispanic, Non-Hispanic White, and Non-Hispanic, Non-White children was not significantly different by race/ethnicity at months 6, 12, and 24 (p = 0.259) and was similar across both treatments (FBT = - 0.16 BMIz; PBT = - 0.21 BMIz; p = 0.61). There were no differences in energy intake, physical activity, acceptability ratings, or adherence to treatment (as measured by a post-treatment survey) (p's > 0.123). However, Hispanic families attended fewer treatment visits than Non-Hispanic White families (p = 0.017).

CONCLUSION

On average, children lost weight participating in our pediatric obesity treatment and there was no statistical difference in weight loss between groups. Future research evaluating whether culturally adapted treatments would be more effective for racial/ethnic minorities or whether the personalization inherent in family-based behavioral treatment may be sufficient is needed.

Recruiting low-income postpartum women into two weight loss interventions: in-person versus Facebook delivery

Several studies, such as the Diabetes Prevention Program (DPP), have provided foundational evidence for the efficacy of lifestyle interventions on weight loss and cardiometabolic prevention. However, translating these interventions to real-world settings and engaging at-risk populations has proven difficult. Social media-delivered interventions have high potential for reaching high-risk populations, but there remains a need to understand the extent to which these groups are interested in social media as a delivery mode. One potential way to this is by examining recruitment rates as a proxy for interest in the intervention delivery format. The aim of this study was to describe the recruitment rates of overweight and obese low-income postpartum women into two asynchronous behavioral weight loss interventions: one delivered in-person and the other delivered via Facebook. Both interventions used the same recruitment methods: participants were overweight low-income postpartum women who were clients of Women, Infants, and Children (WIC) clinics in Worcester, MA, screened for the study by nutritionists during routine WIC visits. Similarly, eligibility criteria were the same for both interventions except for a requirement for the Facebook-delivered intervention to currently use Facebook at least once per week. Among women pre-eligible for the in-person intervention, 42.6% gave permission to be contacted to determine full eligibility and 24.1% of eligible women enrolled. Among women pre-eligible for the Facebook intervention, 31.8% gave permission to be contacted and 28.5% of eligible women enrolled. Recruitment rates for a Facebook-based weight loss intervention were similar to recruitment rates for an in-person intervention, suggesting similar interest in the two program delivery modes among low-income postpartum women.

Racial/ethnic representation in lifestyle weight loss intervention studies in the United States: A systematic review

Obesity remains a persistent public health and health disparity concern in the United States. Eliminating health disparities, particularly among racial/ethnic minority groups, is a major health priority in the US. The primary aim of this review was to evaluate representation of racial/ethnic sub-group members in behavioral weight loss interventions conducted among adults in the United States. The secondary aims were to assess recruitment and study design approaches to include racial/ethnic groups and the extent of racial/ethnic sub-group analyses conducted in these studies. PubMed, PsycInfo, Medline, and CINAHL were searched for behavioral weight loss intervention trials conducted in 2009–2015 using keywords: weight, loss, overweight, obese, intervention and trial. Most of the 94 studies included a majority of White participants compared to any other racial/ethnic group. Across the included studies, 58.9% of participants were White, 18.2% were African American, 8.7% were Hispanic/Latino, 5.0% were Asian and 1.0% were Native Americans. An additional 8.2% were categorized as “Other”. Nine of the 94 studies exclusively included minority samples. Lack of adequate representation of racial and ethnic minority populations in behavioral trials limits the generalizability and potential public health impact of these interventions to groups that might most benefit from weight loss. Given racial/ethnic disparities in obesity rates and the burden of obesity and obesity-related diseases among minority groups in the United States, greater inclusion in weight loss intervention studies is warranted.

•

Describes racial/ethnic minority inclusion in behavioral weight loss studies

•

Majority of studies continue to include a majority white sample.

•

Modest increases in the representation of some racial/ethnic minority groups.

•

Lack of adequate representation of minority groups limits generalizability.

•

Greater racial/ethnic inclusion in weight loss intervention studies is warranted.

A Theoretically-Grounded Investigation of Perceptions About Healthy Eating and mHealth Support Among African American Men and Women in New Orleans, Louisiana

There has been a surge in diet-related mobile health (mHealth) interventions. However, diet-related mHealth research targeted toward racial/ethnic populations has been relatively limited. Focus groups with African American men and women from New Orleans, Louisiana, were conducted to (1) describe perceptions about healthy eating, (2) determine the acceptability of mHealth interventions, and (3) identify preferred mHealth intervention features. Descriptive statistics and thematic content analyses were performed. Qualitative data were organized within the context of the Theory of Planned Behavior and Social Cognitive Theory's theoretical components. Results may inform the development of mHealth research to improve eating behaviors among the target population.