Jennifer E. Fassbender

Financial Incentive Based Approaches for Weight Loss: A Randomized Trial

CONTEXT Identifying effective obesity treatment is both a clinical challenge and a public health priority due to the health consequences of obesity. OBJECTIVE To determine whether common decision errors identified by behavioral economists such as prospect theory, loss aversion, and regret could be used to design an effective weight loss intervention. DESIGN, SETTING, AND PARTICIPANTS Fifty-seven healthy participants aged 30-70 years with a body mass index of 30-40 were randomized to 3 weight loss plans: monthly weigh-ins, a lottery incentive program, or a deposit contract that allowed for participant matching, with a weight loss goal of 1 lb (0.45 kg) a week for 16 weeks. Participants were recruited May-August 2007 at the Philadelphia VA Medical Center in Pennsylvania and were followed up through June 2008. MAIN OUTCOME MEASURES Weight loss after 16 weeks. RESULTS The incentive groups lost significantly more weight than the control group (mean, 3.9 lb). Compared with the control group, the lottery group lost a mean of 13.1 lb (95% confidence interval [CI] of the difference in means, 1.95-16.40; P = .02) and the deposit contract group lost a mean of 14.0 lb (95% CI of the difference in means, 3.69-16.43; P = .006). About half of those in both incentive groups met the 16-lb target weight loss: 47.4% (95% CI, 24.5%-71.1%) in the deposit contract group and 52.6% (95% CI, 28.9%-75.6%) in the lottery group, whereas 10.5% (95% CI, 1.3%-33.1%; P = .01) in the control group met the 16-lb target. Although the net weight loss between enrollment in the study and at the end of 7 months was larger in the incentive groups (9.2 lb; t = 1.21; 95% CI, -3.20 to 12.66; P = .23, in the lottery group and 6.2 lb; t = 0.52; 95% CI, -5.17 to 8.75; P = .61 in the deposit contract group) than in the control group (4.4 lb), these differences were not statistically significant. However, incentive participants weighed significantly less at 7 months than at the study start (P = .01 for the lottery group; P = .03 for the deposit contract group) whereas controls did not. CONCLUSIONS The use of economic incentives produced significant weight loss during the 16 weeks of intervention that was not fully sustained. The longer-term use of incentives should be evaluated. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00520611.

Trial of Family and Friend Support for Weight Loss in African American Adults

BACKGROUND Family and friend participation may provide culturally salient social support for weight loss in African American adults. METHODS SHARE (Supporting Healthy Activity and eating Right Everyday) was a 2-year trial of a culturally specific weight loss program. African American women and men who enrolled alone (individual stratum, 63 index participants) or together with 1 or 2 family members or friends (family stratum, 130 index participants) were randomized, within strata, to high or low social support treatments; 90% were female. RESULTS At 6 months, the family index participants lost approximately 5 to 6 kg; the individual index participants lost approximately 3 to 4 kg. The mean weight change was not different in high vs low social support in either stratum and generally not when high or low support treatments were compared across strata. The overall intention-to-treat mean weight change at 24 months was -2.4 kg (95% confidence interval, -3.3 kg to -1.5 kg). The family index participant weight loss was greater among the participants whose partners attended more personally tailored counseling sessions at 6 months in the high-support group and at 6, 12, and 24 months in the low-support group (all P < .05). Also, in the 6-month intention-to-treat analysis, the percentage of weight loss of the family index participants was greater if partners lost at least 5% vs less than 5% of their baseline weight (respectively, -6.1% vs -2.9% [P = .004], high support; and -6.1% vs -3.1% [P = .01], low support). CONCLUSIONS Being assigned to participate with family members, friends, or other group members had no effect on weight change. Enrolling with others was associated with greater weight loss only when partners participated more and lost more weight. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00146081.

One-Year Results of the Think Health! Study of Weight Management in Primary Care Practices

The Think Health! study evaluated a behavioral weight loss program adapted from the Diabetes Prevention Program (DPP) lifestyle intervention to assist primary care providers (PCPs) and auxiliary staff acting as lifestyle coaches (LCs) in offering weight loss counseling to their patients. In a randomized trial conducted at five clinical sites, study participants were randomly assigned in a 1:1 ratio within each site to either “Basic Plus” (n = 137), which offered PCP counseling every 4 months plus monthly LC visits during the first year of treatment, or “Basic” (n = 124), which offered only PCP counseling every 4 months. Participants were primarily (84%) female, 65% African American, 16% Hispanic American, and 19% white. In the 72% of participants in each treatment group with a 12‐month weight measurement, mean (95% CI) 1‐year weight changes (kg) were −1.61 (−2.68, −0.53) in Basic Plus and −0.62 (−1.45, 0.20) in Basic (difference: 0.98 (−0.36, 2.33); P = 0.15). Results were similar in model‐based estimates using all available weight data for randomized participants, adjusting for potential confounders. More Basic Plus (22.5%) than Basic (10.2%) participants lost ≥5% of their baseline weight (P = 0.022). In a descriptive, nonrandomized analysis that also considered incomplete visit attendance, mean weight change was −3.3 kg in Basic Plus participants who attended ≥5 LC visits vs. + 0.53 kg in those attending <5 LC visits. We conclude that the Basic Plus approach of moderate‐intensity counseling by PCPs and their staff can facilitate modest weight loss, with clinically significant weight loss in high program attenders.

Design, recruitment and start up of a primary care weight loss trial targeting African American and Hispanic adults

Primary care offices are critical access points for obesity treatment, but evidence for approaches that can be implemented within these settings is limited. The Think Health! (¡Vive Saludable!) Study was designed to assess the feasibility and effectiveness of a behavioral weight loss program, adapted from the Diabetes Prevention Program, for implementation in routine primary care. Recruitment of clinical sites targeted primary care practices serving African American and Hispanic adults. The randomized design compares (a) a moderate-intensity treatment consisting of primary care provider counseling plus additional counseling by an auxiliary staff member (i.e., lifestyle coach), with (b) a low-intensity, control treatment involving primary care provider counseling only. Treatment and follow up duration are 1 to 2 years. The primary outcome is weight change from baseline at 1 and 2 years post-randomization. Between November 2006 and January 2008, 14 primary care providers (13 physicians; 1 physician assistant) were recruited at five clinical sites. Patients were recruited between October 2007 and November 2008. A total of 412 patients were pre-screened, of whom 284 (68.9%) had baseline assessments and 261 were randomized, with the following characteristics: 65% African American; 16% Hispanic American; 84% female; mean (SD) age of 47.2 (11.7) years; mean (SD) BMI of 37.2(6.4) kg/m(2); 43.7% with high blood pressure; and 18.4% with diabetes. This study will provide insights into the potential utility of moderate-intensity lifestyle counseling delivered by motivated primary care clinicians and their staff. The study will have particular relevance to African Americans and women.

Two-Year Results of Think Health! ¡Vive Saludable!: A Primary Care Weight-Management Trial: Think Health! Primary Care Trial 2-Year Results

Think Health! ¡Vive Saludable! evaluated a moderate‐intensity, lifestyle behavior‐change weight‐loss program in primary care over 2 years of treatment. Final analyses examined weight‐change trajectories by treatment group and attendance.