Pragmatic implementation of a fully automated online obesity treatment in primary care

Thomas, J. Graham; Panza, Emily; Espel‐Huynh, Hallie; Goldstein, Carly M.; O’Leary, Kevin C.; Benedict, Noah; Puerini, Albert J.; Wing, Rena R.

doi:10.1002/oby.23502

Cited by 8 publications

(5 citation statements)

References 34 publications

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“…Compared with other stand-alone digital weight loss interventions, the magnitude of weight loss found in our study was comparable with many studies [ 10 , 25 , 27 , 29 , 36 , 99 ], higher than some [ 26 , 41 , 42 , 100 ], and lower than a recent fully automated, large-scale pragmatic trial comprising mostly non-Hispanic White participants [ 101 ]. This is an important area of research, as many barriers exist to attending in-person treatment, such as living far from a medical clinic or treatment program [ 102 ], having childcare or caregiver responsibilities, or having fluctuating working schedules.…”

Section: Discussionsupporting

confidence: 88%

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

Patel¹,

Cleare²,

Smith³

et al. 2022

JMIR Form Res

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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

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Section: Discussionsupporting

confidence: 88%

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

Patel¹,

Cleare²,

Smith³

et al. 2022

JMIR Form Res

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“…In the per-protocol analysis of maintenance-engaged participants, the number of lessons viewed was low (most often, 3 of 9 lessons), replicating findings from prior studies . As our group reported in a previous study, during the treatment phase, participants in the trial viewed 6.5 of the first 12 videos, and 37% of participants watched all 12 initial lessons, suggesting a decline in engagement over time that is common in online interventions . Nevertheless, participants who watched more lessons or self-monitored on more days had better long-term weight losses.…”

Section: Discussionsupporting

confidence: 79%

“…In the per-protocol analysis with 273 participants who engaged with the maintenance intervention, mean weight loss was 6.19 kg at 3 months, suggesting that these engaged participants likely adhered better to initial treatment recommendations and thus achieved better weight losses than unengaged participants. These outcomes are similar to the 3-month weight loss of 5.1 kg reported in our previous analysis of self-reported weight change that included only participants who engaged with the initial 3-month RxWL intervention . As in the intention-to-treat analysis, the per-protocol analysis showed that participants in the refresher and monthly maintenance groups better maintained their weight loss than those in the newsletter control maintenance group.…”

Section: Discussionmentioning

confidence: 99%

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Pragmatic Implementation of Online Obesity Treatment and Maintenance Interventions in Primary Care

Thomas,

Panza,

Goldstein

et al. 2024

JAMA Intern Med

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ImportanceBehavioral 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.ObjectiveTo 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 ParticipantsThis 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.InterventionsAll 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 MeasuresThe primary outcome was weight change at 12 months using height and weight data collected from electronic medical records through 24 months.ResultsAmong 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 RelevanceResults 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 RegistrationClinicalTrials.gov Identifier: NCT03488212

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“…More frequent meetings do not appear necessary to induce a 15–20% weight loss with the new AOMs, and some visits likely can be conducted by telephone or video-conferencing without loss of efficacy [ 31 , 99 ]. Asynchronous, digitally delivered programs, which involve minimal person-to-person contact, also are likely to be explored [ 100 ]. In traditional office practice, RDs initially would appear to be best prepared to provide lifestyle counseling, but a variety of primary care professionals including physicians, nurse practitioners, nurses, psychologists, and medical assistants have provided such care following a structured behavioral protocol [ 12 ].…”

Section: Behavioral and Psychosocial Issues Including Terminating Aomsmentioning

confidence: 99%

The Role of Lifestyle Modification with Second-Generation Anti-obesity Medications: Comparisons, Questions, and Clinical Opportunities

Wadden,

Chao,

Moore

et al. 2023

Curr Obes Rep

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Purpose of Review This review examines lifestyle modification for obesity management with the goal of identifying treatment components that could support the use of a new generation of anti-obesity medications (AOMs). Recent Findings Semaglutide reliably reduces baseline body weight by approximately 15% at 68 weeks, in contrast to 5–10% for lifestyle modification. Tirzepatide induces mean losses as great as 20.9%. Both medications reduce energy intake by markedly enhancing satiation and decreasing hunger, and they appear to lessen the need for traditional cognitive and behavioral strategies (e.g., monitoring food intake) to achieve calorie restriction. Little, however, is known about whether patients who lose weight with these AOMs adopt healthy diet and activity patterns needed to optimize body composition, cardiometabolic health, and quality of life. Summary When used with the new AOMs, the focus of lifestyle modification is likely to change from inducing weight loss (through calorie restriction) to facilitating patients’ adoption of dietary and activity patterns that will promote optimal changes in body composition and overall health.

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Pragmatic implementation of a fully automated online obesity treatment in primary care

Cited by 8 publications

References 34 publications

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

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

Pragmatic Implementation of Online Obesity Treatment and Maintenance Interventions in Primary Care

The Role of Lifestyle Modification with Second-Generation Anti-obesity Medications: Comparisons, Questions, and Clinical Opportunities

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