Effect of Electronic Health Record-Based Coaching on Weight Maintenance: A Randomized Trial

Design and implementation of electronic health record-based tools to support a weight management program in primary care

Objectives

This paper reports on a mixed methods formative evaluation to support the design and implementation of information technology (IT) tools for a primary care weight management intervention delivered through the patient portal using primary care staff as coaches.

Methods

We performed a qualitative needs assessment, designed the IT tools to support the weight management program, and developed implementation tracking metrics. Implementation tracking metrics were designed to use real world electronic health record (EHR) data.

Results

The needs assessment revealed IT requirements as well as barriers and facilitators to implementation of EHR-based weight management interventions in primary care. We developed implementation metrics for the IT tools. These metrics were used in weekly project team calls to make sure that project resources were allocated to areas of need.

Conclusion

This study identifies the important role of IT in supporting weight management through patient identification, weight and activity tracking in the patient portal, and the use of the EHR as a population management tool. An intensive multi-level implementation approach is required for successful primary care-based weight management interventions including well-designed IT tools, comprehensive involvement of clinic leadership, and implementation tracking metrics to guide the process of workflow integration. This study helps to bridge the gap between informatics and implementation by using socio-technical formative evaluation methods early in order to support the implementation of IT tools.

Trial registration

clinicaltrials.gov, NCT04420936. Registered June 9, 2020.

Implementing weight maintenance with existing staff and electronic health record tools in a primary care setting: Baseline results from the MAINTAIN PRIME trial

BACKGROUND

There is need for interventions that can assist with long-term maintenance of healthy body weight and be sustainably integrated into existing primary care teams. The goal of MAINTAIN PRIME (Promoting Real (World) IMplEmentation) is to evaluate whether a successful electronic health record (EHR)-based weight maintenance intervention can be adapted to a new clinical setting with primary care staff serving as coaches.

METHODS

EHR tools include tracking tools, standardized surveys, and standardized "SmartPhrases" for coaching. Inclusion criteria were age 18-75 years, voluntary 5% weight loss in the past 2 years with prior BMI ≥ 25 kg/m2, and no bariatric procedures in past 2 years. Participants were randomized 1:1 to tailored online coaching with EHR tracking tools (coaching) or EHR tracking tools alone (tracking).

RESULTS

We screened 405 individuals between September 2021 and April 2023; 269 participants enrolled (134 coaching; 135 tracking). The most common reason for not enrolling was ineligibility (55%). At baseline, participants were 50.3 (SD 15.02) years old, 66.4% female, and 84% White; 83.7% reported moderate physical activity. Average weight and BMI at baseline were 205.0 (SD 48.9) lbs. and 33.2 (6.8) kg/m2, respectively. Participants lost an average of 10.7% (SD 5.2) of their body weight before enrolling. We recruited 39 primary care coaches over the same period. Conclusion The study successfully identified and recruited primary care patients with recent intentional weight loss for participation in a weight maintenance program that uses EHR-based tools. We also successfully recruited and trained primary care staff as coaches.

Pragmatic Implementation of Online Obesity Treatment and Maintenance Interventions in Primary Care: A Randomized Clinical Trial

Importance

Behavioral weight loss interventions have achieved success in primary care; however, to our knowledge, pragmatic implementation of a fully automated treatment that requires little researcher oversight has not been tested. Moreover, weight loss maintenance remains a challenge.

Objective

To evaluate the long-term effectiveness of an automated, online, behavioral obesity treatment program (Rx Weight Loss [RxWL]) at 12 months (primary end point) and 24 months when delivered pragmatically in primary care and to compare the effectiveness of 3 weight loss maintenance approaches.

Design, Setting, and Participants

This randomized clinical trial of RxWL, an online weight loss program, recruited patients from a Rhode Island primary care network with approximately 60 practices and 100 physicians. Eligible participants were primary care patients aged 18 to 75 years with overweight or obesity who were referred by their nurse care manager and enrolled between 2018 and 2020. All participants were included in the intention-to-treat analysis, whereas only those who engaged with maintenance intervention were included in the per-protocol analysis. Data were analyzed from August 2022 to September 2023.

Interventions

All participants were offered the same 3-month weight loss program, with randomization to one of three 9-month maintenance programs: control intervention (monthly online newsletters), monthly intervention (9 monthly video lessons and 1 week of self-monitoring per month), or refresher intervention (an introductory session and two 4-week periods of lessons and self-monitoring at 7 and 10 months).

Main Outcomes and Measures

The primary outcome was weight change at 12 months using height and weight data collected from electronic medical records through 24 months.

Results

Among the 540 participants (mean [SD] age, 52.8 [13.4] years; 384 females [71.1%]) in the intention-to-treat analysis, mean estimated 3-month weight loss was 3.60 (95% CI, -4.32 to -2.88) kg. At the 12-month primary end point, the amount of weight regained in the monthly (0.37 [95% CI, -0.06 to 0.81] kg) and refresher (0.45 [95% CI, 0.27 to 0.87] kg) maintenance groups was significantly less than that in the newsletter control maintenance group (1.28 [95% CI, 0.85 to 1.71] kg; P = .004). The difference in weight regain between the monthly and refresher maintenance groups was not statistically significant. This pattern persisted at 24 months. In the per-protocol analysis of 253 participants, mean weight loss at the end of the initial 3-month intervention was 6.19 (95% CI, -7.25 to -5.13) kg. Similarly, at 12 months there was less weight regain in the monthly (0.61 kg) and refresher (0.96 kg) maintenance groups than in the newsletter control maintenance group (1.86 kg).

Conclusions and Relevance

Results of this randomized clinical trial indicate that pragmatic implementation of a 12-month automated, online, behavioral obesity treatment that includes 9 months of active maintenance produces clinically significant weight loss over 2 years in primary care patients with overweight or obesity. These findings underscore the importance of providing ongoing maintenance intervention to prevent weight regain.

Trial Registration

ClinicalTrials.gov Identifier: NCT03488212.

The Impact of Health Coaching on Weight and Physical Activity in Obese Adults: A Randomized Control Trial

Health Coaching (HC) is an evidence-based, patient-centered approach to assisting individuals in achieving their health-related goals. Studies have generally shown positive effects of HC on weight loss in obese adults. However, limitations do exist, that if addressed would further clarify HC's viability as a clinical, obesity treatment approach. To examine the effects of HC on weight loss, moderate-to-vigorous physical activity (MVPA), and psychosocial constructs in obese adults. A randomized control trial with 44 [Mean body mass index (BMI) 36.5] middle-aged, White adults. Participants were randomly assigned to HC (n = 22) or control (n = 22) groups. A certified health coach provided bi-weekly, in-person and telehealth HC for 12 weeks. Percent excess weight loss was 15.7% in HC vs. 2.5% in controls (p< .001). The change in MVPA was significantly greater in HC (+50.3 min/wk) vs controls (+7.1 min/wk). Psychosocial constructs also changed more favorably in HC than controls. Health coaching is an effective approach for weight loss in obese adults. The results of this study support the consideration of HC as a treatment option for obese adults looking to lose weight.

Lifestyle strategies after intentional weight loss: results from the MAINTAIN-pc randomized trial

Introduction/Purpose

Weight maintenance following intentional weight loss is challenging and often unsuccessful. Physical activity and self-monitoring are strategies associated with successful weight loss maintenance. However, less is known about the type and number of lifestyle strategies used following intentional weight loss. The purpose of this study was to determine the types and amounts of strategies associated with successful long-term weight loss maintenance.

Methods

Data from the 24-month Maintaining Activity and Nutrition Through Technology-Assisted Innovation in Primary Care (MAINTAIN-pc) trial were analyzed. MAINTAIN-pc recruited adults (n=194; 53.4±12.2 years of age, body mass index (BMI): 30.4±5.9 kg/m2, 74% female) with recent intentional weight loss of ≥5%, randomized to tracking tools plus coaching (i.e., coaching group) or tracking tools without coaching (i.e., tracking-only group). At baseline, 6, 12, and 24 months, participants reported lifestyle strategies used in the past 6 months, including self-monitoring, group support, behavioral skills, and professional support. General linear models evaluated changes in the number of strategies over time between groups and the consistency of strategies used over the 24-month intervention.

Results

At baseline, 100% used behavioral skills, 73% used group support, 69% used self-monitoring, and 68% used professional support in the past 6 months; at 24 months, these rates were 98%, 60%, 75%, and 61%, respectively. While the number of participants utilizing individual strategies did not change significantly over time, the overall number of strategies participants reported decreased. More strategies were used at baseline and 6 months compared to 12- and 24-month follow-ups. The coaching group used more strategies at months 6 and 12 than the tracking-only group. Consistent use of professional support strategies over the 24-month study period was associated with less weight regain.

Conclusion

Weight loss maintenance interventions that incorporate continued follow-up and support from healthcare professionals are likely to prevent weight regain after intentional weight loss.

Impact of electronic health record-coaching features in weight change: A secondary analysis from the MAINTAIN-pc randomized trial

OBJECTIVE

This study aimed to evaluate whether coaching features were successfully transmitted via electronic health record (EHR) communication and to evaluate their relationship with weight change in a previously tested EHR-based coaching intervention.

METHODS

A secondary analysis from the Maintaining Activity and Nutrition through Technology-Assisted Innovation in Primary Care (MAINTAIN-pc) study randomized clinical trial was conducted in nine primary care practices and one specialty practice (endocrinology) affiliated with the University of Pittsburgh Medical Center. Eligibility included age 18 to 75 years, intentional 5% weight loss in the previous 2 years, access to an internet-connected computer, and receipt of care from a University of Pittsburgh Medical Center primary care provider. Survey data were collected during the randomized clinical trial.

RESULTS

Participants content with intervention delivery via the EHR and those who felt a strong connection to their coach had significantly less weight regain (p = 0.013 and p < 0.01, respectively). Participants who had needs unmet by the intervention (e.g., "in-person" support in a group setting or individual settings) regained more weight (p < 0.01).

CONCLUSIONS

The data suggest heterogeneity in the patient population regarding preference for in-person versus EHR-based coaching formats. Such heterogeneity might result in the differential success of EHR-based interventions.

The Most Undertreated Chronic Disease: Addressing Obesity in Primary Care Settings

PURPOSE OF REVIEW

While obesity-related comorbidities are frequently addressed and treated in primary care (PC), obesity itself is undertreated. We review the current treatments for obesity and provide potential provider and system-level strategies for integrating weight management and improving longer term obesity care within PC settings.

RECENT FINDINGS

We now understand that the body develops multiple mechanisms to resist weight loss and promote weight regain, making both weight loss and weight loss maintenance challenging. Therefore, weight management often requires medically supervised interventions and should be treated on a long-term basis. However, there are multiple barriers to improving obesity care within PC settings. Clinically, utilizing strategies such as a shared decision-making approach and the 5As to discuss treatment options can facilitate formulating an obesity treatment plan. Utilizing telehealth, a team-based approach, and community partnering can increase patient access to intensive behavioral interventions. Future studies should evaluate other cost-effective methods to implement obesity care into the PC setting.

Lifestyle Habits Associated with Weight Regain After Intentional Loss in Primary Care Patients Participating in a Randomized Trial

BACKGROUND

Though long-term weight loss maintenance is the treatment goal for obesity, weight regain is typical and few studies have evaluated lifestyle habits associated with weight regain.

OBJECTIVE

To identify dietary and physical activity habits associated with 6- and 24-month weight regain among participants in a weight loss maintenance clinical trial.

DESIGN

Secondary analysis of randomized clinical trial data.

PARTICIPANTS

Adult primary care patients with recent, intentional weight loss of at least 5%.

MAIN MEASURES

Lifestyle habits included consumption of low-fat foods, fish, desserts, sugary beverages, fruits, and vegetables and eating at restaurants from the Connor Diet Habit Survey; moderate-vigorous physical activity by self-report; steps recorded by a pedometer; and sedentary behavior by self-report. The outcome variable was weight change at 6 and 24 months. Linear regression models estimated adjusted associations between changes in weight and changes in dietary and physical activity habits.

KEY RESULTS

Overall, participants (mean (SD): 53.4 (12.2) years old; 26% male; 88% white) maintained weight loss at 6 months (n = 178, mean (SD): - 0.02 (5.70)% change) but began to regain weight by 24 months (n = 157, mean (SD): 4.22 (9.15)% increase). When considered all together, more eating at restaurants, reduced fish consumption, and less physical activity were most consistently associated with weight regain in fully adjusted models at both 6 and 24 months of follow-up. In addition, more sedentary behavior was associated with weight regain at 6 months while reduced consumption of low-fat foods, and more desserts and sugary beverages were associated with weight regain at 24 months.

CONCLUSIONS

Consuming less fish, fewer steps per day, and more frequent restaurant eating were most consistently associated with weight regain in primary care patients. Primary care providers may consider addressing specific lifestyle behaviors when counseling patients after successful weight loss.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01946191.