Michele A. DeBiasse

Evidence-based strategies in weight-loss mobile apps

BACKGROUND Physicians have limited time for weight-loss counseling, and there is a lack of resources to which they can refer patients for assistance with weight loss. Weight-loss mobile applications (apps) have the potential to be a helpful tool, but the extent to which they include the behavioral strategies included in evidence-based interventions is unknown. PURPOSE The primary aims of the study were to determine the degree to which commercial weight-loss mobile apps include the behavioral strategies included in evidence-based weight-loss interventions, and to identify features that enhance behavioral strategies via technology. METHODS Thirty weight-loss mobile apps, available on iPhone and/or Android platforms, were coded for whether they included any of 20 behavioral strategies derived from an evidence-based weight-loss program (i.e., Diabetes Prevention Program). Data on available apps were collected in January 2012; data were analyzed in June 2012. RESULTS The apps included on average 18.83% (SD=13.24; range=0%-65%) of the 20 strategies. Seven of the strategies were not found in any app. The most common technology-enhanced features were barcode scanners (56.7%) and a social network (46.7%). CONCLUSIONS Weight-loss mobile apps typically included only a minority of the behavioral strategies found in evidence-based weight-loss interventions. Behavioral strategies that help improve motivation, reduce stress, and assist with problem solving were missing across apps. Inclusion of additional strategies could make apps more helpful to users who have motivational challenges.

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.

Enhancing physical and social environments to reduce obesity among public housing residents: Rationale, trial design, and baseline data for the Healthy Families study

Intervention programs that change environments have the potential for greater population impact on obesity compared to individual-level programs. We began a cluster randomized, multi-component multi-level intervention to improve weight, diet, and physical activity among low-socioeconomic status public housing residents. Here we describe the rationale, intervention design, and baseline survey data. After approaching 12 developments, ten were randomized to intervention (n=5) or assessment-only control (n=5). All residents in intervention developments are welcome to attend any intervention component: health screenings, mobile food bus, walking groups, cooking demonstrations, and a social media campaign; all of which are facilitated by community health workers who are residents trained in health outreach. To evaluate weight and behavioral outcomes, a subgroup of female residents and their daughters age 8-15 were recruited into an evaluation cohort. In total, 211 households completed the survey (RR=46.44%). Respondents were Latino (63%), Black (24%), and had ≤ high school education (64%). Respondents reported ≤2 servings of fruits & vegetables/day (62%), visiting fast food restaurants 1+ times/week (32%), and drinking soft drinks daily or more (27%). The only difference between randomized groups was race/ethnicity, with more Black residents in the intervention vs. control group (28% vs. 19%, p=0.0146). Among low-socioeconomic status urban public housing residents, we successfully recruited and randomized families into a multi-level intervention targeting obesity. If successful, this intervention model could be adopted in other public housing developments or entities that also employ community health workers, such as food assistance programs or hospitals.

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.

Weight loss using evidence-based strategies in mobile apps. Authors' response.

In their letter to the editor, Nesmith and Petakov expressed concern over the methodology we used to evaluate the inclusion of behavioral strategies in weightloss mobile apps. Their main concern was that we did not use apps long enough to capture all functions. Two raters downloaded each app, signed up for accounts, entered all information requested by the app, and explored its functions via use for a maximum of 5 days. Although not without limitations, this methodology improves upon previous app reviews that relied on the descriptions of apps and reflects how a typical consumer might select a weight-loss app. The purpose of our review was to explore to what extent apps have translated traditionally counselordelivered behavioral strategies in the mobile environment. For many strategies, this may be highly challenging because true fidelity to the behavioral strategy must capture a process inherent to human-to-human counseling interactions, which may be difficult to replicate with current artificial intelligence capabilities. We suspect this is why many behavioral strategies were missing in apps. The engagement-dependent content we observed in the Noom app was in the form of pop-up tips. The challenge in using the app is that the user is not made aware of how many tips are to come and for what length of time. It was and remains unclear how long one needs to use the app to see all of the tips. The tips we observed in our review were very limited in terms of actually qualifying as a formal behavioral strategy, even though they were at times consistent with the spirit of a behavioral strategy. Behavioral strategies in a lifestyle intervention are far more than “tips,” but rather most involve a process that includes (1) explaining and practicing the strategy; (2) identifying barriers to employing the strategy and plans for overcoming those barriers; and (3) making a specific plan for how and when the strategy will be employed by the patient. Each step is highly tailored to each patient. We believe that our definition of a behavioral strategy is quite different from that of Nesmith and Petakov. Our team includes clinical psychologists, physicians, and a dietitian, with decades of

Feasibility and Acceptability of Dietary Intake Assessment Via 24-Hour Recall and Food Frequency Questionnaire among Women with Low Socioeconomic Status

BACKGROUND Comprehensive evaluation of dietary interventions depends on effective and efficient measurement to quantify behavior change. To date, little is known regarding which self-reported measure of dietary intake is most feasible and acceptable for use in evaluation of the effectiveness of diet intervention studies among underserved populations. OBJECTIVE This research focused on evaluating feasibility and acceptability of two self-report measures of diet. DESIGN Cross-sectional. PARTICIPANTS/SETTING Two interviewer-administered 24-hour recalls and a 110-item food frequency questionnaire (FFQ) were administered to both English- and Spanish-speaking participants (n=36) by native English- and Spanish-speaking research assistants. On completion of both dietary assessments, participants were interviewed regarding their preference of measure. MAIN OUTCOME MEASURES Feasibility for completion of the dietary assessment measures was determined for contacts and retention. Acceptability of the measures was determined through responses to open- and closed-ended questions. RESULTS During the 5-month trial, 36 participants were enrolled; 29 completed both intake measures, and 26 completed both measures and the interview. Participants were mainly Hispanic/Latina (72%), with a mean age of 37.0 (±7.6) years. Feasibility targets were met for contacts (1.9, 1.6, 1.8 contact attempts to complete each diet assessment measure with a target of ≤2) and for retention with 89% and 91% completing two 24-hour recalls and the FFQ, respectively. Participants indicated both diet assessment methods were generally acceptable; both positive and negative comments were received for use of the FFQ. CONCLUSION Dietary assessment with the use of 24-hour recalls or an FFQ can be feasible and acceptable among women with low socioeconomic status, although care should be taken to address cultural appropriateness in the selection of the measurement method.