Impact of transition from face-to-face to telehealth on behavioral obesity treatment during the COVID-19 pandemic

Randomized non-inferiority trial comparing an asynchronous remotely-delivered versus clinic-delivered lifestyle intervention

OBJECTIVE

Lifestyle interventions are effective, but those delivered via in-person group meetings have poor scalability and reach. Research is needed to establish if remotely delivered lifestyle interventions are non-inferior to in-person delivered lifestyle interventions.

METHODS

We conducted a randomized non-inferiority trial (N = 329) to compare a lifestyle intervention delivered remotely and asynchronously via an online social network (Get Social condition) to one delivered via in-person groups (Traditional condition). We hypothesized that the Get Social condition would result in a mean percent weight loss at 12 months that was not inferior to the Traditional condition. Additional outcomes included intervention delivery costs per pound lost and acceptability (e.g., convenience, support, modality preferences).

RESULTS

At 12 months, no significant difference in percent weight change was observed between the Get Social and Traditional conditions (2.7% vs. 3.7%, p = 0.17) however, criteria for non-inferiority were not met. The Get Social condition costs $21.45 per pound lost versus $26.24 for the Traditional condition. A greater percentage of Get Social condition participants rated participation as convenient (65% vs 44%; p = 0.001).

CONCLUSIONS

Results revealed a remotely-delivered asynchronous lifestyle intervention resulted in slightly less weight loss than an in-person version but may be more economical and convenient.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02646618; https://clinicaltrials.gov/ct2/show/NCT02646618 .

Remote delivery of a weight management intervention for adults with intellectual disabilities: Results from a randomized non-inferiority trial

BACKGROUND

Remote delivery of multi-component weight management interventions results in clinically meaningful weight loss in adults without intellectual disabilities (ID), but the effectiveness of remotely delivered weight management interventions in adults with ID has not previously been evaluated.

OBJECTIVE

To determine if a weight management intervention delivered remotely could achieve weight loss (kg) at 6 months that is non-inferior to in-person visits in adults with ID and overweight or obesity (BMI ≥25 kg/m2).

METHODS

Participants were randomized to a 24-mo. trial (6 mos weight loss,12 mos weight maintenance, 6 mos. no-contact follow up) to compare weight loss achieved with the same multicomponent intervention delivered to individual participants in their home either remotely (RD) or during face-to-face home visits (FTF).

RESULTS

One hundred twenty adults with ID (∼32 years of age, 53 % females) were randomized to the RD (n = 60) or the FTF arm (n = 60). Six-month weight loss in the RD arm (-4.9 ± 7.8 kg) was superior to 6-month weight loss achieved in the FTF arm (-2.1 ± 6.7 kg, p = 0.047). However, this may be partially attributed to the COVID-19 pandemic, since weight loss in the FTF arm was greater in participants who completed the intervention entirely pre-COVID (n = 33,-3.2 %) compared to post-COVID (n = 22, -0.61 %). Weight loss across did not differ significantly between intervention arms at 18 (p = 0.33) or 24 months (p = 0.34).

CONCLUSION

Our results suggest that remote delivery is a viable option for achieving clinically relevant weight loss and maintenance in adults with ID.

NCT REGISTRATION

NCT03291509.

The Potential of a Digital Weight Management Program to Support Specialist Weight Management Services in the UK National Health Service: Retrospective Analysis

BACKGROUND

Digital weight management interventions (DWMIs) have the potential to support existing specialist weight management services (SWMS) in the National Health Service (NHS) to increase access to treatment for people living with obesity and type 2 diabetes. At present, there is limited real-world evidence and long-term outcomes on the potential effectiveness of DWMIs to support such services.

OBJECTIVE

This study aimed to examine real-world data to evaluate the impact of Second Nature's 12-month DWMI for patients living with obesity with or without type 2 diabetes, referred from NHS primary care services, on sustained weight loss over a 2-year period.

METHODS

Retrospective data were extracted in August 2023 for participants who participated in the program between January 1, 2017, and January 8, 2021. Eligible participants were adults with a BMI ≥35 kg/m2, with or without type 2 diabetes. The primary outcomes were weight change in kilograms and percentage weight change at 2 years. Secondary outcomes were weight loss at 1 year, program engagement, and the proportion of participants who achieved >5% and >10% weight loss. Differences in weight loss between baseline and the 1- and 2-year follow-up points were compared using paired 2-tailed t tests. Linear regression models were used to examine whether participants' ethnicity, indices of multiple deprivation, presence of type 2 diabetes, or program engagement were associated with weight loss at 1 year or 2 years.

RESULTS

A total of 1130 participants with a mean baseline BMI of 46.3 (SD 31.6) kg/m2 were included in the analysis. Of these participants, 65% (740/1130) were female (mean age 49.9, SD 12.0 years), 18.1% (205/339) were from Black, Asian, mixed, or other ethnicities, and 78.2% (884/1130) had type 2 diabetes. A total of 281 (24.9%) participants recorded weight readings at 2 years from baseline, with a mean weight loss of 13.8 kg (SD 14.2 kg; P<.001) or 11.8% (SD 10.9%; P<.001). A total of 204 (18.1%) participants achieved ≥5% weight loss, and 130 (11.5%) participants reached ≥10% weight loss. Weight loss did not significantly differ by ethnicity, indices of multiple deprivation, presence of type 2 diabetes, or engagement in the program.

CONCLUSIONS

The findings suggested that Second Nature's DWMI has the potential to support people living with obesity and type 2 diabetes remotely to achieve clinically significant and sustained weight loss at 2 years from baseline. Further research is needed to compare the intervention to standard care and assess integration with multidisciplinary clinical teams and pharmacotherapy in order to support this study's findings.

Health care providers' attitudes and counseling behaviors related to obesity

Background

Obesity affects over 42% of the U.S. adult population, yet it remains undertreated. Many healthcare providers are biased in their perceptions and attitudes regarding obesity management and lack knowledge about how to treat it.

Methods

The authors analyzed the results of the 2021 DocStyles survey to examine primary care providers' treatment and perceptions of obesity. The sample consisted of primary care physicians and nurse practitioners/physician assistants. Questions assessed healthcare providers' attitudes and counseling behaviors related to obesity, including referrals, use of medical therapy, barriers to care, and perceived risk factors for obesity.

Results

1168 primary care providers who treat obesity participated in the survey. About half of the providers reported referring patients for obesity treatment. Almost two-thirds of providers had prescribed anti-obesity medications in the last 12 months. Those who did not prescribe anti-obesity medications reported a lack of familiarity with the medications or concerns about safety. Over three-quarters of providers indicated at least one barrier to treating obesity. Over half of the providers reported that poverty and food insecurity contributed significantly to the high prevalence of obesity in communities of color.

Conclusion

Increased familiarity with anti-obesity medications may improve treatment. Reasons for patients' low priority accorded to obesity care remain the focus of future research.

Retention and weight outcomes after transitioning an intensive behavioral weight management program from an in-person to a virtual format

Background

Virtual care offers many potential advantages over traditional in-person care for people with chronic diseases including obesity. Before the COVID-19 pandemic, virtual care was not broadly implemented because of regulatory, legal, and reimbursement barriers.

Objective

To evaluate the impact of the transition from an entirely in-person format to a virtual format during the COVID-19 pandemic on retention and weight reduction in a 2-year, structured, intensive behavioral weight management program for people with moderate to severe obesity.

Methods

Retrospective cohort study of 1313 program participants stratified according to the phase of the program during which the transition to virtual visits occurred.

Results

Age, sex, and baseline weight were independent predictors of program retention. Transition to virtual visits was associated with greater 2-year program retention. Retention but not mode of program delivery was associated with reduction in weight at 2-year.

Conclusions

Transition from in-person to virtual program delivery improved retention and by doing so, indirectly improved weight loss at 2 years. Telemedicine has the potential to overcome many of the limitations associated with traditional in-person weight loss interventions.

Clinical Trial Registration

This research was reviewed and approved by the University of Michigan Institutional Review Board and registered on ClinicalTrials.gov (NCT02043457). All participants provided written informed consent.

Overlooked and under-evidenced: Community health and long-term care service needs, utilization, and costs incurred by people with severe obesity

Numbers of people with severe obesity (BMI ≥ 40 kg/m² ), with need for community health and long-term care (LTC) services, are increasing, but documentation is lacking. We identified individuals with severe obesity known to community health and care professionals in a representative United Kingdom region and used an investigator-administered questionnaire to record needs and use of community health and LTC services. Data were verified against health and LTC records. Local and published sources informed detailed micro-costing. Twenty-five individuals (15 women) consented, aged 40-87 (mean = 62) years, BMI 40-77 (mean = 55) kg/m² : 20 participants (80%) were housebound. Twenty-two different cross-sector community health and LTC services were used, including community equipment service (n = 23), district nursing (n = 20), occupational therapy (n = 14), and LTC (n = 12). Twenty-four (96%) participants used three or more services, with longest care episode lasting over 14 years. Total annual service costs incurred by participants varied from £2053 to £82 792; mean £26 594 (lower estimate £80 064; mean £22 462/upper estimate £88 870; mean £30 726), with greatest costs being for LTC. Individual costs for equipment (currently provided) and home adaptations (ever provided) ranged widely, from zero to £35 946. Total mean annual costs increased by ascending BMI category, up to BMI 70 kg/m² . This study provides a framework with which to inform service provision and economic analysis of weight management interventions. People with severe obesity may need sustained care from multiple community care services.

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.

Assessing the Suitability of a Virtual 'Pink Warrior' for Older Breast Cancer Survivors during COVID-19: A Pilot Study

The COVID-19 pandemic impacted the conduct of in-person physical activity (PA) interventions among older survivors of BC, who need such interventions to stay active and prevent functional decline. We tested the feasibility of virtually delivering an exergame-based PA intervention to older BC survivors. We enrolled 20 female BC survivors ≥55 years and randomly assigned them to two groups. The intervention group (Pink Warrior 2) received 12 weekly virtual exergame sessions with behavioral coaching, survivorship navigation support, and a Fitbit for self-monitoring. The control group received 12 weekly phone-based survivorship discussion sessions and wore a Mi Band 3. Feasibility was evaluated by rates of recruitment (≥0.92 participants/center/month), retention (≥80%), and group attendance (≥10 sessions), percentage of completed virtual assessments, and number of technology-related issues and adverse events. Intervention acceptability was measured by participants' ratings on a scale of 1 (strongly disagree) to 5 (strongly agree). The recruitment rate was 1.93. The retention and attendance rates were 90% and 88% (≥10 sessions), respectively. Ninety-six percent completed virtual assessments without an adverse event. Acceptability was high (≥4). The intervention met benchmarks for feasibility. Additional research is needed to further understand the impact of virtually delivered PA interventions on older BC survivors.

Effects of Face-to-Face and eHealth Blended Interventions on Physical Activity, Diet, and Weight-Related Outcomes among Adults: A Systematic Review and Meta-Analysis

An increasing number of studies are blending face-to-face interventions and electronic health (eHealth) interventions to jointly promote physical activity (PA) and diet among people. However, a comprehensive summary of these studies is lacking. This study aimed to synthesize the characteristics of blended interventions and meta-analyze the effectiveness of blended interventions in promoting PA, diet, and weight-related outcomes among adults. Following the PRISMA guidelines, PubMed, SPORTDiscus, PsycINFO, Embase, and Web of Science were systematically searched to identify eligible articles according to a series of inclusion criteria. The search was limited to English language literature and publication dates between January 2002 and July 2022. Effect sizes were calculated as standardized mean difference (SMD) for three intervention outcomes (physical activity, healthy diet, and weight-related). Random effect models were used to calculate the effect sizes. A sensitivity analysis and publication bias tests were conducted. Of the 1561 identified studies, 17 were eligible for the systematic review. Studies varied in participants, intervention characteristics, and outcome measures. A total of 14 studies were included in the meta-analyses. There was evidence of no significant publication bias. The meta-analyses indicated that the blended intervention could lead to a significant increase in walking steps (p < 0.001), total PA level (p = 0.01), and diet quality (p = 0.044), a significant decrease in energy intake (p = 0.004), weight (p < 0.001), BMI (p < 0.001), and waist circumferences (p = 0.008), but had no influence on more moderate-to-vigorous physical activity (MVPA) or fruit and vegetable intake among adults, compared with a control group. The study findings showed that blended interventions achieve preliminary success in promoting PA, diet, and weight-related outcomes among adults. Future studies could improve the blended intervention design to achieve better intervention effectiveness.

The effect of phone and video counselling given to participants living with obesity on weight loss and quality of life during the COVID-19 pandemic: a randomised controlled trial

BACKGROUND

Although remote dietary counselling practices have increased in the COVID-19 pandemic, it is not known which method is more effective. This study aimed to determine the effect of diet counselling by phone or video on weight loss and to compare it with the traditional follow-up method.

METHODS

Forty-six participants living with obesity were randomised into the phone counselling (n = 15), video counselling (n = 15), and traditional follow-up groups (n = 16), and were followed for 10 weeks. The anthropometric measurements, quality-of-life questionnaire (SF-36) scores and total calorie/macronutrient intakes were recorded and compared at baseline and at the end of the study.

RESULTS

In the phone counselling, video counselling and traditional follow-up groups body weight (-4.8 ± 0.9, -5.7 ± 1.8 and -3.3 ± 0.8 kg, respectively) and SF-36 general health scores (14.2 ± 4.2, 15.9 ± 3.6 and 10.2 ± 3.7, respectively) of the participants changed significantly compared to baseline (group × time interaction, p < 0.05). The change in the body weight and SF-36 general health score was more in the phone counselling and video counselling groups relative to the traditional follow-up group (group × time interaction, p < 0.01). The highest decrease in total calorie (-301.4 ± 112.2 kcal) and carbohydrate (-26.6 ± 11.2 g) intake was in the video counselling group compared to the other groups (group × time interaction, p < 0.01).

CONCLUSION

Video counselling and phone counselling were effective in weight loss in the COVID-19 pandemic. It is important to maintain remote dietary counselling practices to support weight management when face-to-face meetings are not possible.

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.