Obesity treatment in disadvantaged population groups: where do we stand and what can we do?

Obesity is now the second leading cause of death and disease in the United States leading to health care expenditures exceeding $147 billion dollars. The socioeconomically disadvantaged and racial/ethnic minority groups are at significantly increased risk for obesity. Despite this, low income and minority individuals are underrepresented in the current obesity treatment literature. Additionally, weight loss outcomes for these high risk groups are well below what is typically produced in standard, well-controlled behavioral interventions and reach and access to treatment is often limited. The use of telecommunications technology may provide a solution to this dilemma by expanding dissemination and allowing for dynamic tailoring. Further gains may be achieved with the use of material incentives to enhance uptake of new behaviors. Regardless of what novel strategies are deployed, the need for further research to improve the health disparities associated with obesity in disadvantaged groups is critical. The purpose of this manuscript is to review the weight loss intervention literature that has targeted socioeconomically disadvantaged and racial/ethnic minority populations with an eye toward understanding outcomes, current limitations, areas for improvement and need for further research.

Examining weekly facilitated group sessions and counselor-crafted self-monitoring feedback on treatment outcome in digital weight control: A pilot factorial study.

Objective: Weight control programs that incorporate group sessions produce greater weight losses, but this has not been explored in the context of online programs. Further, counselor-crafted self-monitoring feedback is a core element of lifestyle interventions, although pre-scripted, modular feedback which does not require detailed counselor review may adequately promote weight loss. The current study explored the weight losses achieved in an online program that included facilitated group sessions, as well as outcomes when counselor-crafted self-monitoring feedback was provided. Methods: A 2 × 2 pilot factorial randomized participants (90% women) with overweight/obesity (N = 73) to facilitated group sessions (yes/no) and type of feedback (counselor-crafted/pre-scripted, modular) within a 16-week online behavioral weight control program. Weight change outcomes were collected digitally. Treatment engagement and intervention delivery time were also tracked. Results: Individuals offered weekly facilitated online group sessions lost more weight (-5.3% ± 4.9%) than those receiving the same digital program without group sessions (-3.1% ± 4.0%; p = 0.04). Those receiving group sessions also demonstrated significantly greater treatment engagement. Individuals receiving pre-scripted, modular feedback lost significantly more weight (-5.3% ± 4.8%) than those receiving the more traditional counselor-crafted feedback (-3.1% ± 4.1%; p = 0.04), but treatment engagement did not differ between conditions. However, interventionist time required to provide feedback was markedly lower for pre-scripted than counselor-crafted feedback (1.4 vs. 3.5 h per participant over 16 weeks, respectively, p = 0.01). Conclusions: Incorporating weekly facilitated online group sessions significantly increased weight losses achieved in a digital lifestyle program. Further, pre-scripted, modular feedback required significantly less staff time than counselor-crafted feedback without diminishing weight losses. Thus, group sessions and pre-scripted feedback warrant consideration when designing digital lifestyle programs.

Association of self-reported executive function and mood with executive function task performance across adult populations.

Executive function (EF) impacts behavior associated with health outcomes. EF can be measured using self-report and/or performance measures, but the correlations between these types of measures are mixed in the extant literature. This study examined self-report and performance-based measures of EF using data from 6 studies, including community and clinical populations (410 participants, ages 19-80, 71% female). Partial correlations revealed significant relationships between performance on the Trail making, Delay Discounting, and Stop Signal tasks with self-reported EF (p < .006 after controlling for age). Mood scores were significantly related to all self-reported domains of EF (p < .0001), and mood and EF scores were correlated over time. When also controlling for mood, correlations between delay discounting and stop signal tasks with self-reported EF remained significant (p < .006). Finally, examining EF scores in participants with and without clinically elevated mood scores showed a wider distribution of self-reported EF scores among those with clinically elevated mood symptoms than among those without. We conclude that self-reported EF is associated with tasks measuring delay discounting and response inhibition in our large, heterogenous population and that assessing EF may be particularly important for those with high levels of mood symptoms.

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.

The accuracy of weight reported in a web-based obesity treatment program.

OBJECTIVE: The overall goal of the study was to understand the accuracy of self-reported weight over a 6-month Web-based obesity program. MATERIALS AND METHODS: As part of a larger study, subjects (n=323; 93% female; 28% African American) were randomized to a 6-month Internet-based behavioral weight loss program with weekly group meetings delivered either: (1) entirely by online synchronous chats or (2) by a combination of online chats plus monthly in-person group sessions. Observed weights were obtained at 0 and 6 months for all participants. Self-reported weights were submitted weekly to the study Web site. Differences in Observed and Reported weights were examined by gender, race, and condition. RESULTS: Observed and Reported weight were significantly correlated at 0 and 6 months (r=0.996 and 0.996, ps <0.001 respectively). However, Reported weight underestimated Observed weight by 0.86 kg (p<0.001) at 6 months. Further, there was a significant weight loss effect (p<0.001) with those losing more weight more accurately estimating their Reported weight at 6 months. Additionally, 6-month Reported weight change differed from Observed weight change (difference=0.72 kg, p<0.001), with weight change using Reported weights estimating a slightly larger weight loss than Observed weights. CONCLUSIONS: In general, the accuracy of self-reported weight is high for individuals participating in an Internet-based weight loss treatment program. Accuracy differed slightly by amount of weight lost and was not improved with periodic in-person assessment. Importantly, weight change by self-report was comparable to observed, suggesting that it is suitable for Web-based obesity treatment.

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.