Identification of minimum thresholds for dietary self-monitoring to promote weight-loss maintenance.

OBJECTIVE: Reduced schedules of dietary self-monitoring are typically recommended after the end of behavioral weight-loss programs; however, there exists little empirical evidence to guide these recommendations. METHODS: We explored potential thresholds for dietary self-monitoring during a 9-month maintenance period following a 3-month weight-loss program in 74 adults with overweight or obesity (mean [SD] age = 50.7 [10.4] years, BMI = 31.2 [4.5] kg/m2) who were encouraged to self-monitor weight, dietary intake, and physical activity daily and report their adherence to self-monitoring each week via a study website. RESULTS: Greater self-monitoring was correlated with less weight regain for thresholds of ≥3 days/week, with the largest benefit observed for thresholds of ≥5 to ≥6 days/week (all p < 0.05); significant weight gain was observed for thresholds of ≥1 to ≥2 days/week, whereas no change in weight was observed for thresholds of ≥3 to ≥4 days/week, and weight loss was observed with thresholds of ≥5 or more days/week. CONCLUSIONS: Results demonstrate that self-monitoring at least 3 days/week may be beneficial for supporting long-term maintenance, although greater benefit (in relation to weight loss) may be realized at thresholds of 5 to 6 days/week. Future research should investigate whether individuals who were randomized to self-monitor at these different thresholds demonstrate differential patterns of weight-loss maintenance.

Hunger, temptation, and dietary adherence during weight management.

Preliminary evidence suggests that hunger and temptation may predict nonadherence to dietary intake goals; however, no studies have investigated the potential interaction between hunger and temptation in relation to dietary nonadherence nor have any investigated whether these associations may be different after the end of active behavioral intervention. Thus, the current study examined the week-to-week associations between hunger, temptation, and dietary adherence in 74 adults with overweight or obesity (mean ± SD age = 50.7 ± 10.4, BMI = 31.2 ± 4.5 kg/m2) enrolled in a 12-week, Internet-based weight loss program followed by a 40-week post-intervention observational maintenance period. Each week during the study, participants completed a questionnaire on which they rated their hunger, temptation, and dietary adherence on 7-point scales. Multilevel models demonstrated that higher levels of hunger and temptation were associated with lower ratings of dietary adherence during the same week, ps < 0.0001, such that 1-point higher ratings of hunger or temptation were associated with 0.2- and 0.5-point lower ratings of dietary adherence, respectively. Further, there was an interaction between hunger and temptation such that the association between temptation and dietary nonadherence was stronger when ratings of hunger were lower, p = .028. There were no differences in associations between the initial weight loss period and the maintenance period. Results suggest that hunger and temptation may serve as potential treatment targets for interventions aimed at improving adherence to dietary intake goals. Future studies should investigate whether interventions targeting hunger and temptation can improve dietary adherence and weight loss outcomes.

Consistency With and Disengagement From Self-monitoring of Weight, Dietary Intake, and Physical Activity in a Technology-Based Weight Loss Program: Exploratory Study.

BACKGROUND: Digital self-monitoring tools offer promise to improve adherence to self-monitoring of weight and weight-related behaviors; however, less is known regarding the patterns of participant consistency and disengagement with these tools. OBJECTIVE: This study characterizes the consistency of use and time to disengagement with digital self-monitoring tools during a 6-month weight loss intervention and investigates whether the provision of phone-based intervention improved self-monitoring adherence. METHODS: Participants were 54 adults with overweight or obesity (mean age 49.6 years, SD 12.4 years; mean BMI 32.6 kg/m2, SD 3.2 kg/m2) enrolled in a pilot trial assessing the impact of self-monitoring technology (Fitbit Zip, Aria scale, and smartphone app), with and without additional interventionist contact, on weight loss. All participants received weight loss education and were asked to self-monitor weight, dietary intake, and physical activity daily throughout the 6-month program. Consistency was defined as the number of weeks that participants adhered to self-monitoring recommendations (7 out of 7 days). Disengagement was defined as the first of 2 consecutive weeks that the 7-day self-monitoring adherence goal was not met. Wilcoxon signed-rank tests were used to examine differences in consistency and disengagement by behavioral targets. t tests (2-tailed) and Cox proportional hazards models were used to examine whether providing additional interventionist contact would lead to significant improvements in consistency and time to disengagement from self-monitoring tools, respectively. Linear regressions were used to examine associations between consistency, time to disengagement, and weight loss. RESULTS: Participants consistently self-monitored physical activity for more weeks (mean 17.4 weeks, SD 8.5 weeks) than weight (mean 11.1 weeks, SD 8.5 weeks) or dietary intake (mean 10.8 weeks, SD 8.7 weeks; P<.05). Similarly, participants had a significantly longer time to disengagement from self-monitoring of physical activity (median 19.5 weeks) than weight (4 weeks) or dietary intake (10 weeks; P<.001). Participants randomized to receive additional interventionist contact had significantly greater consistency and longer time to disengagement for self-monitoring of dietary intake compared with participants who did not (P=.006); however, there were no statistically significant differences between groups for self-monitoring of weight or physical activity (P=.24 and P=.25, respectively). Greater consistency and longer time to disengagement were associated with greater weight loss for self-monitoring of weight and dietary intake (P<.001 and P=.004, respectively) but not for physical activity (P=.57). CONCLUSIONS: Results demonstrated that self-monitoring adherence differed by behavioral target, with greater consistency and longer time to disengagement associated with lower-burden tools (ie, self-monitoring of physical activity). Consistent with supportive accountability theory, additional interventionist contact improved consistency and lengthened time to disengagement from self-monitoring of dietary intake. Given the observed associations between consistency, disengagement, and weight loss outcomes, it is important to identify additional methods of increasing consistency and engagement with digital self-monitoring tools.

Using self-monitoring technology for nutritional counseling and weight management.

Self-monitoring of weight, dietary intake, and physical activity is a key strategy for weight management in adults with obesity. Despite research suggesting consistent associations between more frequent self-monitoring and greater success with weight regulation, adherence is often suboptimal and tends to decrease over time. New technologies such as smartphone applications, e-scales, and wearable devices can help eliminate some of the barriers individuals experience with traditional self-monitoring tools, and research has demonstrated that these tools may improve self-monitoring adherence. To improve the integration of these tools in clinical practice, the current narrative review introduces the various types of self-monitoring technologies, presents current evidence regarding their use for nutrition support and weight management, and provides guidance for optimal implementation. The review ends with a discussion of barriers to the implementation of these technologies and the role that they should optimally play in nutritional counseling and weight management. Although newer self-monitoring technologies may help improve adherence to self-monitoring, these tools should not be viewed as an intervention in and of themselves and are most efficacious when implemented with ongoing clinical support.

Awareness, Acceptability, and Perceived Effectiveness of Text-Based Therapy Among Graduate Students: Cross-sectional Study.

BACKGROUND: Research has suggested that there is a mental health crisis occurring among graduate students in the United States. Moreover, many students go without effective treatment owing to the limited availability of mental and behavioral health resources on college campuses. Text-based therapy may represent a viable method for increasing access to mental health support for graduate students, but little is known regarding its acceptability in this population. OBJECTIVE: The purpose of this study was to assess how graduate students perceive text-based therapy and their likelihood of seeking out this form of therapy. METHODS: In total, 265 graduate students completed a cross-sectional web-based survey that included multiple-choice and open-ended questions assessing their perceptions of text-based therapy and the likelihood of seeking out this form of therapy. Chi-square tests, ANOVAs, and nonparametric Wilcoxon signed-rank tests were used to examine differences in multiple-choice questions. The constant comparative method was used for qualitative analyses of the open-ended question responses. RESULTS: Participants (n=265) were predominately non-Hispanic White (166/265, 62.6%) and female (167/265, 63%) with a mean age of 28.3 (SD 5.1) years. Over half of the participants (139/265, 52.5%) were not aware that text-based therapy existed; however, 65.3% (173/265) reported that they would consider using text-based services, if available. In comparison to face-to-face therapy, participants reported being less likely to seek out text-based therapy and perceived it as less effective (P<.001). Qualitative results indicated that participants were concerned about the ability to effectively communicate and build rapport through text-based therapy and thought that this modality may be more effective for some mental and behavioral health concerns than others. Moreover, participants noted that text-based therapy would be best implemented as a way to supplement, rather than replace, face-to-face services. CONCLUSIONS: Altogether, the results of this study suggest that text-based therapy holds the potential to increase access to and use of mental and behavioral health services; however, graduate students remain concerned about its effectiveness and the optimal methods of implementation. Future research should investigate how therapeutic processes (eg, effective communication and rapport-building) can be facilitated in digital environments and how text-based therapy could be best implemented to supplement and extend, rather than replace, face-to-face services.

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

OBJECTIVE: This study evaluated whether the transition of a face-to-face behavioral intervention to videoconferencing-based telehealth delivery during the COVID-19 pandemic resulted in significantly smaller weight losses than those typically observed in gold-standard, face-to-face programs. METHODS: Participants were 160 adults with obesity (mean [SD] age = 49.2 [11.9] years, BMI = 36.1 [4.2] kg/m2 ) enrolled in two cohorts of a 16-week comprehensive weight-management program. Cohort 1 began in person and transitioned to telehealth (Zoom) delivery during week 11 of the intervention because of COVID-19; Cohort 2 was conducted completely remotely. A noninferiority approach (using a clinically relevant noninferiority margin of 2.5%) was used to assess whether the weight losses observed were inferior to the 8% losses from baseline typically produced by gold-standard, face-to-face lifestyle interventions. RESULTS: From baseline to postintervention, participants lost an average of 7.4 [4.9] kg, representing a reduction of 7.2% [4.6%]. This magnitude of weight change was significantly greater than 5.5% (t[159] = 4.7, p < 0.001), and, thus, was within the proposed noninferiority margin. CONCLUSIONS: These findings demonstrate that the results of behavioral weight-management interventions are robust, whether delivered in person or remotely, and that individuals can achieve clinically meaningful benefits from behavioral treatment even during a global pandemic. Pragmatic "lessons learned," including modified trial recruitment techniques, are discussed.

Randomized controlled trial of financial incentives during weight-loss induction and maintenance in online group weight control.

OBJECTIVE: This study examined the impact of a financial incentive scheme integrating process and outcome incentives across weight-loss induction and weight maintenance on 18-month weight outcomes. METHODS: This was a randomized controlled trial. Participants with overweight or obesity (n = 418; 91% female; 28% racial/ethnic minority) were randomized to an 18-month, online, group-based behavioral weight-control program (Internet-Only) or the same program with financial incentives provided for 12 months, contingent on self-regulatory weight-control behaviors (self-weighing, dietary self-monitoring, and physical activity) and weight-outcome benchmarks (Internet+Incentives). No financial incentives were provided from Months 13 to 18 to examine the durability of weight-control behaviors and outcomes without incentives. RESULTS: Weight-loss induction at Month 6 was significantly greater for Internet+Incentives than Internet-Only (6.8% vs. 4.9%, respectively, p = 0.01). Individuals receiving incentives were significantly more likely to maintain weight loss ≥ 5% at Month 12 (45% in Internet+Incentives vs. 32% in Internet-Only, p < 0.02) and remain weight stable (39% vs. 27%, respectively, p < 0.01). Internet+Incentives participants also reported significantly greater behavioral engagement through Month 12. However, once incentives ceased, there were no differences in sustained weight outcomes (Month 18), and engagement declined dramatically. CONCLUSIONS: Despite promoting greater treatment engagement and initial weight loss, financial incentives as offered in this study did not promote better extended weight control.

Weight Status and Sedentary Behavior of Alzheimer's Disease Caregivers.

Objectives: In this study, we sought to characterize the weight status, sedentary behavior, and physical activity of caregivers of individuals with Alzheimer's disease. Methods: In 2014, we surveyed caregivers of individuals with Alzheimer's disease from the South Carolina Alzheimer's Disease Registry (N = 47) about their personal health behaviors. Additionally, a subset of individuals (N = 14) wore an accelerometer for 7 days. Results: Caregivers (N = 47) were mostly overweight or obese (85%) and self-reported a daily average sedentary time of 246.5 ± 203.0 minutes and 455.8 ± 291.4 minutes, as measured by 2 questionnaires. Objective measures indicated that persons spent an average of 769.4 ± 167.6 minutes per day (77.8% of their waking day) engaged in sedentary behavior. Conclusion: Given the negative health outcomes associated with both obesity and sedentary behavior, this is a vulnerable population that likely would benefit from interventions focused on weight management and reducing sedentary behavior.

Adding Financial Incentives to Online Group-Based Behavioral Weight Control: An RCT.

INTRODUCTION: Internet-delivered behavioral weight control is promising for expanding the reach and availability of weight management, but online programs produce lower weight losses than typically achieved in person. Financial incentives have been shown to increase weight losses. This study examined whether adding financial incentives for self-monitoring and achieving target weight losses increases weight losses attained in a fully online, group-based behavioral weight management program compared with the same program alone. STUDY DESIGN: This study was an RCT. SETTING/PARTICIPANTS: Adults with overweight and obesity (n=418; 91% female; 28% minority) were recruited from 2 clinical centers. INTERVENTION: The intervention was a 24-session online group-based behavioral weight control program with weekly synchronous chat sessions (Internet-only) or the same program with weekly financial incentives for self-monitoring body weight and dietary intake daily and for achieving target weight losses at 2 and 6 months (Internet + incentives). MAIN OUTCOME MEASURES: This study measured weight loss at 6 months and treatment engagement (attendance, self-monitoring of body weight, dietary intake, and physical activity). Data were collected between February 2016 and August 2018, and analyses were completed in 2019. RESULTS: Participants randomized to the Internet + incentives group lost more weight (-6.4 [SD=5.5] kg) than those in the Internet-only group (-4.7 [SD=6.6] kg; p<0.01). Further, a higher proportion of the Internet + incentives group achieved ≥5% weight loss (55%) than those in the Internet-only group (40%; p<0.05). Treatment engagement was higher in the Internet + incentives condition, with greater self-monitoring of behaviors targeted by incentives, as well as higher rates of behaviors not targeted and higher self-reported physical activity. Study retention was higher among those in the Internet + incentives condition (91%) than those in the Internet-only condition (81%; p=0.003). CONCLUSIONS: Adding financial incentives to a program delivered fully online increases weight losses compared with the program alone and can achieve weight losses comparable to in-person programs, offering potential for substantial geographic reach. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT02688621.