Racial Differences in Weight Loss Mediated by Engagement and Behavior Change

A Systematic Narrative Review of Recent Obesity Interventions with Black Women in the United States

OBJECTIVES

This study is to comprehensively review recent obesity interventions for Black women in the United States.

METHODS

We searched PubMed and EBSCOhost for articles published between 2013 and 2022 using a comprehensive search strategy. Two reviewers screened titles, abstracts, and full texts. Data from the included articles were extracted. Qualitative themes related to the intervention designs were identified across studies.

RESULTS

Fifty-two studies were included in the review. Interventions typically aimed to reduce weight by targeting diet and/or physical activity. Intervention activities were delivered virtually and in-person via several formats including didactic content and interactive sessions. Outcomes were assessed through a variety of research designs. Across papers, we identified six key themes of intervention design: integration of technology, centering community and culture, personalization of content, use of social support, skill-building through intervention activities, and addressing comorbid health conditions.

CONCLUSIONS

To address the obesity epidemic, future research can build upon key lessons learned from recent interventions tailored to Black women.

Predictors of racial differences in weight loss: the PROPEL trial

OBJECTIVE

Studies have consistently shown that African American individuals lose less weight in response to behavioral interventions, but the mechanisms leading to this result have been understudied.

METHODS

Data were derived from the PROmoting Successful Weight Loss in Primary CarE in Louisiana (PROPEL) study, which was a cluster-randomized, two-arm trial conducted in primary care clinics. In the PROPEL trial, African American individuals lost less weight compared with patients who belonged to other racial groups after 24 months. In the current study, counterfactual mediation analyses among 445 patients in the intervention arm of PROPEL were used to determine which variables mediated the relationship between race and weight loss. The mediators included treatment engagement, psychosocial, and lifestyle factors.

RESULTS

At 6 months, daily weighing mediated 33% (p = 0.008) of the racial differences in weight loss. At 24 months, session attendance and daily weighing mediated 35% (p = 0.027) and 66% (p = 0.005) of the racial differences in weight loss, respectively. None of the psychosocial or lifestyle variables mediated the race-weight loss association.

CONCLUSIONS

Strategies specifically targeting engagement, such as improving session attendance and self-weighing behaviors, among African American individuals are needed to support more equitable weight losses over extended time periods.

Black Feminism and Womanism: A Narrative Review of the Weight Loss Literature

Objective

Black Feminism and Womanism offers an interdisciplinary lens and practice to center Black women's health, engage relevant health, and create Black women-informed solutions to address obesity. The purpose of this review article is to employ Black Feminism and Womanism to examine approaches and results of Black women-centered behavioral weight loss interventions.

Methods

A narrative review of Black women-centered behavioral weight loss interventions was conducted. To be included, articles met the following criteria: published between 2012 and 2022, standard behavioral treatment for weight loss, randomized design, weight loss outcomes stratified by race and gender, sample size of at least 75 individuals, adults at least 18 years of age, and at least 51% Black women in the sample.

Results

Eight studies met the inclusion criteria for a Black women-centered behavioral weight loss intervention and were evaluated. Findings indicate that weight loss among Black women was mostly low, below the clinical target of 5 to 10% weight loss. Intervention designs ranged widely in their approach to respond to the context of Black women's lives, with little consistency between designs.

Conclusions

To make meaningful improvement in the effectiveness of behavioral weight loss interventions for Black women, new approaches are critical. Approaches grounded in Black Feminism and Womanism can provide the essential foundation to generate new knowledge, novel hypotheses, and intervention designs that fully attend to the lived context of Black women, including consideration of the potential health effects of gendered racism.

Effect of a Plant-Based vs Omnivorous Soul Food Diet on Weight and Lipid Levels Among African American Adults: A Randomized Clinical Trial

IMPORTANCE

More African American individuals die from cardiovascular disease (CVD) than any other chronic disease condition. Despite this disparity, African American individuals are underrepresented in nutrition and CVD interventions.

OBJECTIVE

To compare the effects of an entirely plant-based (vegan) or low-fat omnivorous (omni) diet on change in body weight and lipids during a 2-year intervention.

DESIGN, SETTING, AND PARTICIPANTS

The Nutritious Eating With Soul (NEW Soul) study was a 2-year, randomized clinical trial conducted in 2 cohorts (2018-2020 and 2019-2021) that took place in a university teaching kitchen in Columbia, South Carolina (before March 2020), and via online videoconference sessions (after March 2020). Participants included African American adults aged 18 to 65 years with overweight or obesity (body mass index of 25.0-49.9) and without type 2 diabetes, uncontrolled thyroid disease, recent weight loss, or pregnancy. Data assessors and statisticians were blinded to study condition. Data analysis was performed from March to June 2022.

INTERVENTIONS

The intervention included weekly nutrition classes for 6 months biweekly classes for 6 months, and monthly classes for 12 months. Dietary interventions either emphasized no animal product intake (vegan) or a low-fat omnivorous diet (omni). Both dietary patterns emphasized soul food cuisine (traditional African American southern foodways).

MAIN OUTCOMES AND MEASURES

Primary outcomes included change in body weight and lipid measures at 12 months.

RESULTS

There were 568 participants who completed an online screening questionnaire; 409 were excluded and 159 were randomized (77 to the vegan group and 82 to the omni group). Of the 159 participants (mean [SD] age, 48.4 [10.6] years; 126 female [79%]) who began the study, the main outcome of body weight was obtained for 121 participants (76%) at 12 months. There were no differences in outcomes between groups, including 12-month changes in weight (mean, -2.39 kg [95% CI, -3.48 to -1.30 kg] for the vegan group vs -2.03 kg [95% CI, -3.07 to -1.00 kg] for the omni group; P = .64), total cholesterol (-1.05 mg/dL [95% CI, -9.60 to 7.50 mg/dL] for the vegan group vs 1.66 mg/dL [95% CI, -7.20 to 10.50 mg/dL] for the omni group; P = .67), or low-density lipoprotein cholesterol (mean, -2.56 mg/dL [95% CI, -9.52 to 4.40 mg/dL] for the vegan group vs -0.79 mg/dL [95% CI, -7.98 to 6.40 mg/dL] for the omni group; P = .73). Weight loss at 12 months among cohort 1, whose weight was assessed in 2019 before the COVID-19 pandemic, was significantly greater than that for cohort 2, whose weight was assessed summer 2020 during COVID-19 (-3.45 kg [95% CI, -4.67 to -2.22 kg] vs -1.24 kg [95% CI, -2.24 to -0.25 kg]; P = .01).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial examining weight loss and CVD risk factor reduction among African American adults, there were no differences between the groups, and the magnitude of changes overall was small.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03354377.

Group Social Support Facilitates Adoption of Healthier Behaviors Among Black Women in a Community-Initiated National Diabetes Prevention Program

The aim of this study was to better understand facilitators and barriers of the early adoption of healthy eating and physical activity behaviors among Black women participating in a community-based, community-initiated diabetes education program. We held focus groups with participants (N = 14) ages 24 to 90 years. Participants were recruited from a multisite, community-based diabetes prevention program in the Southeastern United States. Data were collected in March and June of 2017. Barriers and facilitators of change were categorized using the socioecological model with interpersonal, intrapersonal, community, and environmental factors serving as the foundation for thematic content. Participants reported the adoption of several behavioral changes resulting in positive health outcomes. They also identified several facilitators and few barriers to initial behavior change on participating in the diabetes prevention program. The greatest facilitator was interpersonal, while the greatest barriers were community and/or environmental. Understanding the factors that improve or impede the successful adoption of health behaviors among Black women participating in a behavioral lifestyle program will allow us to develop stronger, more tailored interventions that provide the greatest impact to assist in improving weight loss outcomes and reducing the burden of diabetes among Black women.

Effectiveness of a Text-Based Gamification Intervention to Improve Physical Activity Among Postpartum Individuals With Hypertensive Disorders of Pregnancy: A Randomized Clinical Trial

Importance

Hypertensive disorders of pregnancy are associated with increased risk of cardiovascular disease, yet few interventions have targeted this population to decrease long-term risk.

Objective

To determine whether a digital health intervention improves physical activity in postpartum individuals with hypertensive disorders of pregnancy.

Design, Setting, and Participants

This 12-week randomized clinical trial enrolled postpartum individuals who delivered at the University of Pennsylvania and had a hypertensive disorder of pregnancy between October 2019 and June 2020. Analysis was intention to treat.

Interventions

All participants received a wearable activity tracker, established a baseline step count, selected a step goal greater than baseline, and were randomly assigned to control or intervention. Participants in the control arm received daily feedback on goal attainment. Participants in the intervention arm were placed on virtual teams and enrolled in a game with points and levels for daily step goal achievement and informed by principles of behavioral economics.

Main Outcomes and Measures

The primary outcome was change in mean daily step count from baseline to 12-week follow-up. Secondary outcome was proportion of participant-days that step goal was achieved.

Results

A total of 127 participants were randomized (64 in the control group and 63 in the intervention group) and were enrolled a mean of 7.9 weeks post partum. Participants had a mean (SD) age of 32.3 (5.6) years, 70 (55.1%) were Black, and 52 (41.9%) had Medicaid insurance. The mean (SD) baseline step count was similar in the control and intervention arms (6042 [2270] vs 6175 [1920] steps, respectively). After adjustment for baseline steps and calendar month, participants in the intervention arm had a significantly greater increase in mean daily step steps from baseline compared with the control arm (647 steps; 95% CI, 169-1124 steps; P = .009). Compared with the control arm, participants in the intervention arm achieved their steps goals on a greater proportion of participant-days during the intervention period (0.47 vs 0.38; adjusted difference 0.11; 95% CI, 0.04-0.19; P = .003).

Conclusions and Relevance

In this study, a digital health intervention using remote monitoring, gamification, and social incentives among postpartum individuals at elevated cardiovascular risk significantly increased physical activity throughout 12 weeks.

Trial Registration

ClinicalTrials.gov Identifier: NCT03311230.

The Multi-Caregiver Role and Its Relationship to Behavioral Adherence and Weight Among Treatment Engaged Black Women

PURPOSE

To examine the relationship between the multiple caregiver role and its perceived barriers to self-care on behavioral adherence in a weight loss intervention.

DESIGN

A secondary analysis of data from a behavioral weight loss intervention.

SETTING

The study was conducted in two cohorts from March 2016 to February 2017 at the University of North Carolina at Chapel Hill.

SUBJECTS

Eighty-one Black women with overweight/obesity (age = 48.4 ± 10.9 years [M ± SD], BMI = 36.4 ± 4.5 kg/m² [M ± SD]).

MEASURES

Identification with the multiple caregiver role and barriers was assessed with the Multiple Caregiving Measurement Instrument. Weight was measured with a digital scale and height with a stadiometer. The Block food frequency questionnaire evaluated dietary intake. Moderate-to-vigorous physical activity (MVPA) was measured objectively with an accelerometer. Study adherence was measured by session attendance, self-weighing, and self-monitoring (diet and physical activity) frequency.

ANALYSIS

Generalized linear models were used to examine the relationship between the multiple caregiver scales and the outcomes of interest, controlling for study arm, cohort, and income. Chi-square tests tested correlations.

RESULTS

Greater identification with the multiple caregiver role was associated with decreased session attendance (β = -.56 [SE = .27], P < .05) and a trend towards weight gain (β = .36, [SE = .19], P = .07). Greater multiple caregiver barriers score predicted a decrease in fruit/vegetable intake (β = -.17 [SE = .07], P < .05). All regression results are unstandardized. Negative correlations between multiple caregiver barriers and MVPA (r = -.24, P = .06) and daily self-weighing (r = -.19, P = .10) approached significance.

CONCLUSIONS

Participants' identification with multiple caregiving role and barriers can reduce adherence, behavior and weight change. Interventions to address Black women's multiple roles and barriers during weight loss are needed to maximize outcomes.

Responding to Health Disparities in Behavioral Weight Loss Interventions and COVID-19 in Black Adults: Recommendations for Health Equity

COVID-19 has disproportionately impacted Black adults with high prevalence and mortality rates. Obesity is a central factor in the severity of COVID-19 and related treatment. Behavioral weight loss interventions are an efficacious treatment for obesity, but consistently, Black men and women are minimally represented, and weight loss outcomes are less than clinically significant thresholds. This commentary draws parallels between COVID-19 racial disparities, disparate obesity rates, weight loss treatment outcomes, and underlying systemic racial context. This paper also indicates paths forward to address racialized societal norms in obesity treatment to advance health equity in obesity and reduce acute disease vulnerability. Recommendations for behavioral medicine practice and policy include (1) expanding the research lens to prioritize Black scholars and institutions to generate innovative research questions, (2) creating trustworthy relationships with Black community members to bolster recruitment and retention, (3) employing qualitative methods to facilitate better intervention design and uncover influences of racialized social context, (4) centering Black adults in weight loss interventions, and (5) using multilevel approaches that integrate policy into interventions. Moving forward, this commentary aims to make plain the multilayered form and function of racism, its impact on COVID-19 and obesity, and offer pathways to improve behavioral weight loss interventions that can produce more equitable outcomes.

A Systematic Review of Literature on the Representation of Racial and Ethnic Minority Groups in Clinical Nutrition Interventions

The racial and ethnic disparities in diet-related chronic diseases are major concerns. This systematic review examines the extent to which diet-induced changes in health outcomes, such as cardiometabolic, inflammation, cancer, bone health, and kidney function outcomes, etc., have been reported and discussed by race or ethnicity in randomized trials with 2 or more diet arms that recruited both minority and non-Hispanic White groups. Databases (i.e., PubMed, Cochrane Library, and Web of Science) were searched up to August 2021. Thirty-four studies that discussed effects of defined dietary interventions on health outcomes by racial or ethnic minority group compared with non-Hispanic Whites were included in the systematic review (PROSPERO registration number: CRD42021229256). Acute trials and those with 1 diet arm that accounted for race or ethnicity in their analyses and studies that focused on a single racial or ethnic group were discussed separately. Most studies were conducted in Black compared with White adults testing effects of energy restriction, macronutrient modification, sodium reduction, or variations of the Dietary Approaches to Stop Hypertension (DASH) diet on cardiometabolic outcomes. There was limited focus on other minority groups. Evidence suggests greater blood pressure reduction for Black adults compared with Whites particularly with DASH (or similar) diets. Overall, there was limited consideration for group-specific eating patterns and diet acceptability. Overall risk of bias was low. With emerging precision nutrition initiatives that aim to optimize metabolic responses in population subgroups through tailored approaches, it is imperative to ensure adequate representation of racial and ethnic subgroups for addressing health disparities. Factors that help explain variability in responses such as socioecological context should be included and adequately powered. Given the racial and ethnic disparities in chronic diseases, studying the adoption, maintenance, and effectiveness of dietary interventions on health outcomes among different groups is critical for developing approaches that can mitigate diet-related health disparities.

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.

Predictors of engagement in an internet-based cognitive behavioral therapy program for veterans with chronic low back pain

Internet-based interventions for chronic pain have demonstrated efficacy and may address access barriers to care. Participant characteristics have been shown to affect engagement with these programs; however, limited information is available about the relationship between participant characteristics and engagement with internet-based programs for self-management of chronic pain. The current study examined relationships between demographic and clinical characteristics and engagement with the Pain EASE program, a self-directed, internet-based cognitive behavioral therapy intervention for veterans with chronic low back pain (cLBP). Veterans with cLBP were enrolled in a 10 week trial of the Pain EASE program. Engagement measures included the number of logins, access to coping skill modules, and completed study staff-initiated weekly check-in calls. Regression analyses were conducted to identify significant predictors of engagement from hypothesized predictors (e.g., race/ethnicity, age, depressive symptom severity, and pain interference). Participants (N = 58) were 93% male, 60.3% identified as White, and had a mean age of 54.5 years. Participants logged into the program a median of 3.5 times, accessed a median of 2 skill modules, and attended a median of 6 check-in calls. Quantile regression revealed that, at the 50th percentile, non-White-identified participants accessed fewer modules than White-identified participants (p = .019). Increased age was associated with increased module use (p = .001). No clinical characteristics were significantly associated with engagement measures. White-identified race/ethnicity and increased age were associated with greater engagement with the Pain EASE program. Results highlight the importance of defining and increasing engagement in internet-delivered pain care.

Weight Loss in Underserved Patients - A Cluster-Randomized Trial

BACKGROUND

Evidence of the effectiveness of treatment for obesity delivered in primary care settings in underserved populations is lacking.

METHODS

We conducted a cluster-randomized trial to test the effectiveness of a high-intensity, lifestyle-based program for obesity treatment delivered in primary care clinics in which a high percentage of the patients were from low-income populations. We randomly assigned 18 clinics to provide patients with either an intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, or usual care. Patients in the intensive-lifestyle group participated in a high-intensity program delivered by health coaches embedded in the clinics. The program consisted of weekly sessions for the first 6 months, followed by monthly sessions for the remaining 18 months. Patients in the usual-care group received standard care from their primary care team. The primary outcome was the percent change from baseline in body weight at 24 months.

RESULTS

All 18 clinics (9 assigned to the intensive program and 9 assigned to usual care) completed 24 months of participation; a median of 40.5 patients were enrolled at each clinic. A total of 803 adults with obesity were enrolled: 452 were assigned to the intensive-lifestyle group, and 351 were assigned to the usual-care group; 67.2% of the patients were Black, and 65.5% had an annual household income of less than $40,000. Of the enrolled patients, 83.4% completed the 24-month trial. The percent weight loss at 24 months was significantly greater in the intensive-lifestyle group (change in body weight, -4.99%; 95% confidence interval [CI], -6.02 to -3.96) than in the usual-care group (-0.48%; 95% CI, -1.57 to 0.61), with a mean between-group difference of -4.51 percentage points (95% CI, -5.93 to -3.10) (P<0.001). There were no significant between-group differences in serious adverse events.

CONCLUSIONS

A high-intensity, lifestyle-based treatment program for obesity delivered in an underserved primary care population resulted in clinically significant weight loss at 24 months. (Funded by the Patient-Centered Outcomes Research Institute and others; PROPEL ClinicalTrials.gov number, NCT02561221.).

The Role of Weight Perception in Race Differences in BMI Among College Graduate and Non-College Graduate Women

OBJECTIVE

Racial differences in BMI increase with education. Weight perception may be an important factor in overweight and obesity in black women. The aim of this study was to determine the mediating role of weight underassessment on race differences in BMI in college graduates compared with non-college graduates.

METHODS

Weight perception was assessed among respondents to the 2007-2014 National Health and Nutrition Examination Survey (n = 4,871). Those who had BMI-assessed overweight or obesity and self-assessed underweight or about-right weight underassessed their weight. The associations between race and BMI through weight underassessment by college graduate status were determined using a moderated mediation analysis.

RESULTS

Black women had higher BMI than white women (β = 2.72, SE = 0.28), and disparities were larger in college graduates (β = 3.50, SE = 0.25) compared with non-college graduates (β = 0.78, SE = 0.15). Non-college graduate black women were more likely to underassess their weight (z score = 0.43, SE = 0.05). Indirect associations between race and BMI through weight underassessment were found only among non-college graduates (z score = -0.02, SE = 0.01), but race differences in BMI remained after accounting for weight perception among college graduates and non-college graduates.

CONCLUSIONS

This study demonstrates that a nuanced, intersectional understanding of weight perception and BMI among women is required to address racial disparities in obesity.

Comparative effectiveness of a standard behavioral and physical activity enhanced behavioral weight loss intervention in Black women

Black women typically lose small amounts of weight in behavioral weight loss interventions, partially due to low engagement in physical activity. Culturally relevant enhancement of the physical activity component may improve weight loss. This study compared the effectiveness of a culturally-relevant, physical activity-enhanced behavioral weight loss intervention to a standard behavioral weight loss intervention in Black women (n = 85) over 6 months. The study was conducted in two cohorts from March 2016 to February 2017 at the University of North Carolina at Chapel Hill. Participants had an average age of 48.30 ± 11.02 years with an average body mass index of 36.46 ± 4.50 kg/m². Standard and enhanced groups' weight change (-2.83 kg and -2.08 kg, respectively) and change in physical activity (43.93 min/ week and 15.29 min/week, respectively) did not differ between groups. Significantly more standard group participants lost 5% of baseline weight compared to enhanced group participants. This study produced typical weight loss results in Black women. Behavioral weight loss treatment remains moderately effective for Black women. Strategies to increase attendance and self-monitoring, and the inclusion of cultural contexts to weight-related behaviors are needed to improve outcomes.

Sex and Gender Differences in Prevention of Type 2 Diabetes

Lifestyle intervention programs are effective in the prevention of type 2 diabetes mellitus (T2DM) in high risk populations. However, most studies only give limited information about the influence of sex and/or gender effectiveness of these interventions. So far, similar outcome was reported for diabetes progression and weight loss. Nevertheless, long-term data on cardiovascular outcome are sparse but favoring women regarding all-cause and cardiovascular mortality. In both men and women, sex hormone imbalances and reproductive disorders are associated with a higher risk of T2DM development. Diabetes prevention approaches are reported for polycystic ovary syndrome, gestational diabetes mellitus, and erectile dysfunction and are presented in this review. In the surgical treatment options for morbid obese patients, sex and gender differences are present. Choices and preferences of adherence to lifestyle and pharmacological interventions, expectations, treatment effects, and complications are influenced by sex or gender. In general, bariatric surgery is performed more often in women seeking medical/surgical help to lose weight. Men are older and have higher comorbidities and mortality rates and worse follow-up outcome after bariatric surgery. A more gender-sensitive clinical approach, as well as consideration of ethnicity may improve quality of life and increase health and life expectancy in men and women with a high risk for subsequent progression to T2DM.