Using the Habit App for Weight Loss Problem Solving: Development and Feasibility Study.

BACKGROUND: Reviews of weight loss mobile apps have revealed they include very few evidence-based features, relying mostly on self-monitoring. Unfortunately, adherence to self-monitoring is often low, especially among patients with motivational challenges. One behavioral strategy that is leveraged in virtually every visit of behavioral weight loss interventions and is specifically used to deal with adherence and motivational issues is problem solving. Problem solving has been successfully implemented in depression mobile apps, but not yet in weight loss apps. OBJECTIVE: This study describes the development and feasibility testing of the Habit app, which was designed to automate problem-solving therapy for weight loss. METHODS: Two iterative single-arm pilot studies were conducted to evaluate the feasibility and acceptability of the Habit app. In each pilot study, adults who were overweight or obese were enrolled in an 8-week intervention that included the Habit app plus support via a private Facebook group. Feasibility outcomes included retention, app usage, usability, and acceptability. Changes in problem-solving skills and weight over 8 weeks are described, as well as app usage and weight change at 16 weeks. RESULTS: Results from both pilots show acceptable use of the Habit app over 8 weeks with on average two to three uses per week, the recommended rate of use. Acceptability ratings were mixed such that 54% (13/24) and 73% (11/15) of participants found the diet solutions helpful and 71% (17/24) and 80% (12/15) found setting reminders for habits helpful in pilots 1 and 2, respectively. In both pilots, participants lost significant weight (P=.005 and P=.03, respectively). In neither pilot was an effect on problem-solving skills observed (P=.62 and P=.27, respectively). CONCLUSIONS: Problem-solving therapy for weight loss is feasible to implement in a mobile app environment; however, automated delivery may not impact problem-solving skills as has been observed previously via human delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT02192905; https://clinicaltrials.gov/ct2/show/NCT02192905 (Archived by WebCite at http://www.webcitation.org/6zPQmvOF2).

Youth access to indoor tanning salons in urban versus rural/suburban communities.

BACKGROUND/PURPOSE: Research suggests that youth proximity to tanning salons may promote use; however, little is known about tanning salon proximity to schools. We assessed the proximity of tanning salons to schools in urban versus rural/suburban communities across Worcester County, Massachusetts (population > 800K). To put findings in context, we compared school proximity to tanning salons to school proximity to McDonald's restaurants, a large franchise that also caters to young people. MATERIALS & METHODS: Accessibility was measured by ArcGIS 10.2 Network Analyzer (ESRI, Redlands, CA, USA) and the most current road network data layer from Massachusetts Department of Transportation (MassDOT). RESULTS: A total of 145 schools were observed in the study area, of which about 39% of schools were within 1 mile from a tanning salon. Urban schools (53.41%) had a higher proportion within 1 mile of a tanning salon than rural/suburban schools (17.54%; P < .001). More schools (39.31%) were within 1 mile of a tanning salon than schools within 1 mile of a McDonald's (22.70%; P < .001). CONCLUSIONS: Schools may be particularly impactful for implementing skin cancer prevention programing.

Clinic Versus Online Social Network-Delivered Lifestyle Interventions: Protocol for the Get Social Noninferiority Randomized Controlled Trial.

BACKGROUND: Online social networks may be a promising modality to deliver lifestyle interventions by reducing cost and burden. Although online social networks have been integrated as one component of multimodality lifestyle interventions, no randomized trials to date have compared a lifestyle intervention delivered entirely via online social network with a traditional clinic-delivered intervention. OBJECTIVE: This paper describes the design and methods of a noninferiority randomized controlled trial, testing (1) whether a lifestyle intervention delivered entirely through an online social network would produce weight loss that would not be appreciably worse than that induced by a traditional clinic-based lifestyle intervention among overweight and obese adults and (2) whether the former would do so at a lower cost. METHODS: Adults with body mass index (BMI) between 27 and 45 kg/m2 (N=328) will be recruited from the communities in central Massachusetts. These overweight or obese adults will be randomized to two conditions: a lifestyle intervention delivered entirely via the online social network Twitter (Get Social condition) and an in-person group-based lifestyle intervention (Traditional condition) among overweight and obese adults. Measures will be obtained at baseline, 6 months, and 12 months after randomization. The primary noninferiority outcome is percentage weight loss at 12 months. Secondary noninferiority outcomes include dietary intake and moderate intensity physical activity at 12 months. Our secondary aim is to compare the conditions on cost. Exploratory outcomes include treatment retention, acceptability, and burden. Finally, we will explore predictors of weight loss in the online social network condition. RESULTS: The final wave of data collection is expected to conclude in June 2019. Data analysis will take place in the months following and is expected to be complete in September 2019. CONCLUSIONS: Findings will extend the literature by revealing whether delivering a lifestyle intervention via an online social network is an effective alternative to the traditional modality of clinic visits, given the former might be more scalable and feasible to implement in settings that cannot support clinic-based models. TRIAL REGISTRATION: ClinicalTrials.gov NCT02646618; https://clinicaltrials.gov/ct2/show/NCT02646618 (Archived by WebCite at http://www.webcitation.org/6v20waTFW).

Weight loss support seeking on twitter: the impact of weight on follow back rates and interactions.

People seek weight loss support on online social networks, but little is known about how to build a supportive community. We created four Twitter accounts portraying women interested in weight loss (two obese, two normal weight/overweight) and followed health care professional and peer accounts for 2-5 weeks. We examined follow back rates, interactions, and organic follows from professionals and peers by weight status. Follow back rates did not differ by weight status when following professionals (6.8 % normal weight/overweight vs 11.0 % for obese; p = 0.4167) or peers (6.7 % for normal weight/overweight vs 10.8 % for obese; p = 0.1548). Number of interactions and organic followers also did not differ by weight status. Peers interacted with study accounts significantly more than professionals (p = 0.0138), but interactions were infrequent. Women seeking weight loss support on Twitter may need to be present for more than 5 weeks to build an interactive weight loss community.

Engaging Moms on Teen Indoor Tanning Through Social Media: Protocol of a Randomized Controlled Trial.

BACKGROUND: Indoor tanning elevates the risk for melanoma, which is now the most common cancer in US women aged 25-29. Public policies restricting access to indoor tanning by minors to reduce melanoma morbidity and mortality in teens are emerging. In the United States, the most common policy restricting indoor tanning in minors involves parents providing either written or in person consent for the minor to purchase a tanning visit. The effectiveness of this policy relies on parents being properly educated about the harms of indoor tanning to their children. OBJECTIVE: This randomized controlled trial will test the efficacy of a Facebook-delivered health communication intervention targeting mothers of teenage girls. The intervention will use health communication and behavioral modification strategies to reduce mothers' permissiveness regarding their teenage daughters' use of indoor tanning relative to an attention-control condition with the ultimate goal of reducing indoor tanning in both daughters and mothers. METHODS: The study is a 12-month randomized controlled trial comparing 2 conditions: an attention control Facebook private group where content will be relevant to teen health with 25% focused on prescription drug abuse, a topic unrelated to tanning; and the intervention condition will enter participants into a Facebook private group where 25% of the teen health content will be focused on indoor tanning. A cohort of 2000 mother-teen daughter dyads will be recruited to participate in this study. Only mothers will participate in the Facebook groups. Both mothers and daughters will complete measures at baseline, end of intervention (1-year) and 6 months post-intervention. Primary outcomes include mothers' permissiveness regarding their teenage daughters' use of indoor tanning, teenage daughters' perception of their mothers' permissiveness, and indoor tanning by both mothers and daughters. RESULTS: The first dyad was enrolled on March 31, 2016, and we anticipate completing this study by October 2019. CONCLUSIONS: This trial will deliver social media content grounded in theory and will test it in a randomized design with state-of-the-art measures. This will contribute much needed insights on how to employ social media for health behavior change and disease prevention both for indoor tanning and other health risk behaviors and inform future social media efforts by public health and health care organizations. CLINICALTRIAL: Clinicaltrials.gov NCT02835807; https://clinicaltrials.gov/ct2/show/NCT02835807 (Archived by WebCite at http://www.webcitation.org/6mDMICcCE).

Adapting Behavioral Interventions for Social Media Delivery.

Patients are increasingly using online social networks (ie, social media) to connect with other patients and health care professionals--a trend called peer-to-peer health care. Because online social networks provide a means for health care professionals to communicate with patients, and for patients to communicate with each other, an opportunity exists to use social media as a modality to deliver behavioral interventions. Social media-delivered behavioral interventions have the potential to reduce the expense of behavioral interventions by eliminating visits, as well as increase our access to patients by becoming embedded in their social media feeds. Trials of online social network-delivered behavioral interventions have shown promise, but much is unknown about intervention development and methodology. In this paper, we discuss the process by which investigators can translate behavioral interventions for social media delivery. We present a model that describes the steps and decision points in this process, including the necessary training and reporting requirements. We also discuss issues pertinent to social media-delivered interventions, including cost, scalability, and privacy. Finally, we identify areas of research that are needed to optimize this emerging behavioral intervention modality.

Twitter-Delivered Behavioral Weight-Loss Interventions: A Pilot Series.

BACKGROUND: Lifestyle interventions are efficacious at reducing risk for diabetes and cardiovascular disease but have not had a significant public health impact given high cost and patient and provider burden. OBJECTIVE: Online social networks may reduce the burden of lifestyle interventions to the extent that they displace in-person visits and may enhance opportunities for social support for weight loss. METHODS: We conducted an iterative series of pilot studies to evaluate the feasibility and acceptability of using online social networks to deliver a lifestyle intervention. RESULTS: In Study 1 (n=10), obese participants with depression received lifestyle counseling via 12 weekly group visits and a private group formed using the online social network, Twitter. Mean weight loss was 2.3 pounds (SD 7.7; range -19.2 to 8.2) or 1.2% (SD 3.6) of baseline weight. A total of 67% (6/9) of participants completing exit interviews found the support of the Twitter group at least somewhat useful. In Study 2 (n=11), participants were not depressed and were required to be regular users of social media. Participants lost, on average, 5.6 pounds (SD 6.3; range -15 to 0) or 3.0% (SD 3.4) of baseline weight, and 100% (9/9) completing exit interviews found the support of the Twitter group at least somewhat useful. To explore the feasibility of eliminating in-person visits, in Study 3 (n=12), we delivered a 12-week lifestyle intervention almost entirely via Twitter by limiting the number of group visits to one, while using the same inclusion criteria as that used in Study 2. Participants lost, on average, 5.4 pounds (SD 6.4; range -14.2 to 3.9) or 3.0% (SD 3.1) of baseline weight, and 90% (9/10) completing exit interviews found the support of the Twitter group at least somewhat useful. Findings revealed that a private Twitter weight-loss group was both feasible and acceptable for many patients, particularly among regular users of social media. CONCLUSIONS: Future research should evaluate the efficacy and cost-effectiveness of online social network-delivered lifestyle interventions relative to traditional modalities.

Availability of tanning beds on US college campuses.

IMPORTANCE: Indoor tanning is widespread among young adults in the United States despite evidence establishing it as a risk factor for skin cancer. The availability of tanning salons on or near college campuses has not been formally evaluated. OBJECTIVE: To evaluate the availability of indoor tanning facilities on US college and university campuses (colleges) and in off-campus housing surrounding but not owned by the college. DESIGN, SETTING, AND PARTICIPANTS: This observational study sampled the top 125 US colleges and universities listed in US News and World Report. Investigators searched websites of the colleges and nearby housing and contacted them by telephone inquiring about tanning services. MAIN OUTCOMES AND MEASURES: Frequency of indoor tanning facilities on college campus and in off-campus housing facilities, as well as payment options for tanning. RESULTS: Of the 125 colleges, 48.0% had indoor tanning facilities either on campus or in off-campus housing, and 14.4% of colleges allow campus cash cards to be used to pay for tanning. Indoor tanning was available on campus in 12.0% of colleges and in off-campus housing in 42.4% of colleges. Most off-campus housing facilities with indoor tanning (96%) provide it free to tenants. Midwestern colleges had the highest prevalence of indoor tanning on campus (26.9%), whereas Southern colleges had the highest prevalence of indoor tanning in off-campus housing facilities (67.7%). Presence of on-campus tanning facilities was significantly associated with enrollment (P = .01), region (P = .02), and presence of a school of public health (P = .01) but not private vs public status (P = .18) or presence of a tobacco policy (P = .16). Presence of tanning facilities in off-campus housing was significantly associated with region (P = .002) and private vs public status (P = .01) but not enrollment (P = .38), tobacco policy (P = .80), or presence of a school of public health (P = .69). CONCLUSIONS AND RELEVANCE: Reducing the availability of indoor tanning on and around college campuses is an important public health target.

Severity of depressive symptoms and accuracy of dietary reporting among obese women with major depressive disorder seeking weight loss treatment.

An elevation in symptoms of depression has previously been associated with greater accuracy of reported dietary intake, however this association has not been investigated among individuals with a diagnosis of major depressive disorder. The purpose of this study was to investigate reporting accuracy of dietary intake among a group of women with major depressive disorder in order to determine if reporting accuracy is similarly associated with depressive symptoms among depressed women. Reporting accuracy of dietary intake was calculated based on three 24-hour phone-delivered dietary recalls from the baseline phase of a randomized trial of weight loss treatment for 161 obese women with major depressive disorder. Regression models indicated that higher severity of depressive symptoms was associated with greater reporting accuracy, even when controlling for other factors traditionally associated with reporting accuracy (coefficient  =  0.01 95% CI = 0.01 - 0.02). Seventeen percent of the sample was classified as low energy reporters. Reporting accuracy of dietary intake increases along with depressive symptoms, even among individuals with major depressive disorder. These results suggest that any study investigating associations between diet quality and depression should also include an index of reporting accuracy of dietary intake as accuracy varies with the severity of depressive symptoms.

Reliable change in depression during behavioral weight loss treatment among women with major depression.

OBJECTIVE: Although behavioral weight loss interventions generally have been shown to improve depressive symptoms, little is known as to whether some people with major depressive disorder experience worsening of depression during a weight loss intervention. DESIGN AND METHODS: Rates and predictors of change in depression symptoms among 148 obese women with major depressive disorder who participated in a trial comparing depression treatment plus behavioral weight loss treatment (Behavioral Activation; BA) to behavioral weight loss treatment alone (Lifestyle Intervention; LI) were examined. a statistically reliable change in depression was calculated as ≥9 points on the beck depression inventory in this sample. RESULTS: At 6 months, 73% of participants in BA and 54% of participants in LI showed reliable improvement in depression symptoms and 1.5% of participants in BA and 1.3% of participants in LI showed reliable worsening in depression symptoms. Rates of reliable change were similar at 12 months. Participants who experienced reliable improvement in depression lost significantly more weight than those who did not in both conditions. In the LI condition, baseline psychiatric variables and change in physical activity during treatment were also related to reliable improvement in depression. CONCLUSION: No evidence for an iatrogenic effect of behavioral weight loss treatment on depressive symptoms among obese women with major depressive disorder was detected; rather, behavioral weight loss treatment appears to be associated with significant concurrent improvement in depression. Even greater rates of reliable improvement were observed when depression treatment was added to weight loss treatment.

Depression severity, diet quality, and physical activity in women with obesity and depression.

Major depressive disorder (MDD) is prevalent in clinical weight-loss settings and predicts poor weight-loss outcomes. It is unknown whether the severity of depressive symptoms among those with MDD is associated with diet quality or physical activity levels. This knowledge is important for improving weight-loss treatment for these patients. It was hypothesized that more severe depression is associated with poorer diet quality and lower physical activity levels among individuals with obesity and MDD. Participants were 161 women with current MDD and obesity enrolled in the baseline phase of a weight-loss trial between 2007 and 2010. Depression severity was measured with the Beck Depression Inventory II. The Alternate Healthy Eating Index was applied to data from three 24-hour diet recalls to capture overall diet quality. Daily metabolic equivalents expended per day were calculated from three 24-hour physical activity recalls. Greater depression severity was associated with poorer overall diet quality (estimate=-0.26, standard error 0.11; P=0.02), but not with physical activity (estimate=0.07, standard error 0.05; P=0.18), in linear regression models controlling for income, education, depression-related appetite change, binge eating disorder, and other potential confounds. Associations with diet quality were primarily driven by greater intake of sugar (r=0.20; P<0.01), saturated fat (r=0.21; P<0.01), and sodium (r=0.22; P<0.01). More severe depression was associated with poorer overall diet quality, but not physical activity, among treatment-seeking women with MDD and obesity. Future studies should identify mechanisms linking depression to diet quality and determine whether diet quality improves with depression treatment.

The emotional eating scale. Can a self-report measure predict observed emotional eating?

We assessed the validity of the emotional eating scale (EES) by examining whether the EES predicted food intake following two negative mood inductions. Participants underwent mood inductions for anxiety, anger and neutral mood, then received snack foods in a sham palatability test. EES anxiety, but not anger, predicted intake. Participants high on EES anxiety consumed more snacks during the anxiety mood induction, whereas participants low on EES anxiety consumed less snacks. Results suggest that EES anxiety is a predictor of anxiety-driven eating and may be used to assess emotional eating when direct observation of intake is not possible.

Male inclusion in randomized controlled trials of lifestyle weight loss interventions.

The prevalence of obesity is similar for men (32.2%) and women (35.5%). It has been assumed that lifestyle weight loss interventions have been developed and tested in predominately female samples, but this has not been systematically investigated. The aim of this review was to investigate total and ethnic male inclusion in randomized controlled trials of lifestyle interventions. PUBMED, MEDLINE, and PSYCHINFO were searched for randomized controlled trials of lifestyle weight loss interventions (N = 244 studies with a total of 95,207 participants) published in the last 10 years (1999-2009). A trial must be in English, included weight loss as an outcome, and tested a dietary, exercise, and/or other behavioral intervention for weight loss. Results revealed samples were on average 27% male vs. 73% female (P < 0.001). Trials recruiting a diseased sample included a larger proportion of males than those not targeting a disease (35% vs. 21%; P < 0.001). About 32% of trials used exclusively female samples, whereas only 5% used exclusively male samples (P < 0.001). No studies in the past 10 years specifically targeted minority males. Ethnic males identified composed 1.8% of total participants in US studies. Only 24% of studies that underrepresented males provided a reason. Males, especially ethnic males, are underrepresented in lifestyle weight loss trials.