Elsevier

Preventive Medicine

Volume 92, November 2016, Pages 51-57
Preventive Medicine

A randomized controlled trial testing an Internet delivered cost–benefit approach to weight loss maintenance

https://doi.org/10.1016/j.ypmed.2016.04.013Get rights and content

Highlights

  • A cost–benefit intervention promotes excellent weight loss maintenance outcomes.

  • Peer-provided support may be just as effective as professional support for weight loss maintenance.

  • Ongoing social and monetary reinforcement and behavioral variety may improve adherence to internet-based interventions.

Abstract

Weight loss maintenance is a significant challenge in obesity treatment. During maintenance the “costs” of adhering to weight management behaviors may outweigh the “benefits.” This study examined the efficacy of a novel approach to weight loss maintenance based on modifying the cost–benefit ratio. Individuals who achieved a 5% weight loss (N = 75) were randomized to one of three, 10-month maintenance interventions. All interventions were delivered primarily via the Internet. The Standard arm received traditional weight maintenance strategies. To increase benefits, or rewards, for maintenance behaviors, the two cost–benefit intervention conditions received weekly monetary rewards for self-monitoring and social reinforcement via e-coaching. To decrease behavioral costs (boredom) and increase novelty, participants in the cost–benefit conditions also monitored different evidence-based behaviors every two weeks (e.g., Weeks 1 & 2: steps; Week 3 & 4: red foods). The primary difference between the cost–benefit interventions was type of e-coach providing social reinforcement: Professional (CB Pro) or Peer (CB Peer). Study procedures took place in Providence, RI from 2013 to 2014. Retention was 99%. There were significant group differences in weight regain (p = .01). The Standard arm gained 3.5 ± 5.7 kg. In contrast, participants in CB Pro and CB Peer lost an additional 1.8 ± 7.0 kg and 0.5 ± 6.4 kg, respectively. These results suggest that an Internet delivered cost–benefit approach to weight loss maintenance may be effective for long-term weight control. In addition, using peer coaches to provide reinforcement may be a particularly economic alternative to professionals. These data are promising and provide support for a larger, longer trial.

Introduction

Lifestyle interventions for obesity treatment yield excellent short-term weight losses, which reduce risk for diabetes and improve cardiovascular disease risk factors (Knowler et al., 2002, Look et al., 2007). However, weight regain begins shortly following treatment and within 2 to 3 years, most individuals regain nearly all of the weight that they lost (Jeffery et al., 2000). As such, one of the next major challenges in obesity treatment is to develop efficacious interventions for weight loss maintenance (MacLean et al., 2015).

A recent NIH meeting on the problem of weight loss maintenance highlighted the multiple barriers, including both physiological and behavioral factors, that make weight loss maintenance so challenging (MacLean et al., 2015). Since weight regain is to a large extent attributable to decreased adherence to prescribed regimens, one explanation for the decline in adherence is that over time there is a shift in the perceived costs of adherence relative to the perceived benefits (Jeffery et al., 2000, Jeffery et al., 2004, MacLean et al., 2015, Foreyt et al., 1981). During the initial period of active weight loss, there are many powerful benefits, or reinforcers, that promote continued adherence. Weight loss itself and seeing progress on the scale is inherently reinforcing; improvements in health, mood, and appearance occur; and social reinforcement, or compliments from family, friends, and intervention staff, motivate behavior change (Knowler et al., 2002, Foreyt et al., 1981, Jeffery et al., 2004, Perri et al., 1987, Anton et al., 2014, Curtis et al., 2008, Faulconbridge et al., 2012). However, during the period of weight loss maintenance, there is a substantial decrease in benefits for weight management behaviors and an increase in behavioral costs. Weight loss, the most reinforcing aspect of treatment slows or stops (Jeffery et al., 2000, Curtis et al., 2008). Social reinforcement from interventionists, family, and friends drops off (Jeffery et al., 2004, Perri et al., 1987, Wing, 2014). Moreover, health, mood, and appearance improvements plateau (Jeffery et al., 2004, Anton et al., 2014). At the same time that these salient reinforcers decrease, behavioral costs increase. Participants report becoming bored with their weight management regimen (e.g., calorie counting) and that their weight management requires more effort (Wing, 2014, Jeffery et al., 2009, Befort et al., 2008, Davis et al., 2005). According to behavior change theory, this shift in the cost–benefit ratio (decreasing rewards and increasing response costs) results in a decline in adherence over time, and weight regain occurs (H, R., 1989, JB, 2009). However, the shift in the cost–benefit ratio has never been targeted to improve weight loss maintenance outcomes.

The present trial tested an intervention designed to target the problematic cost–benefit ratio associated with weight loss maintenance. Individuals who achieved a clinically meaningful weight loss (≥ 5%) in an Internet-based program (Phase I) were randomly assigned to one of three 10-month, Internet-based weight loss maintenance interventions (Phase II): (a) a cost–benefit intervention involving a professional coach, (b) a cost–benefit intervention involving a peer coach, or (c) a standard approach. The cost–benefit interventions included treatment components that were designed to sustain benefits for engaging in weight management behaviors over time — namely, financial incentives and social reinforcement from either a professional or peer coach as well as approaches designed to reduce boredom and thus behavioral costs. The primary hypothesis was that both cost–benefit approaches, regardless of coach type, (Leahey and Wing, 2013) would yield significantly less weight regain compared to the standard approach over the 10 month maintenance program.

Section snippets

Design overview

This trial involved two phases. Phase I was an 8 week weight loss phase for all participants. Those who lost ≥ 5% of initial body weight during Phase I were eligible for Phase II, the maintenance trial. Phase II was a randomized trial comparing three different 10-month maintenance programs: (a) a standard maintenance approach (Standard), (b) a cost–benefit approach in which social reinforcement was provided by a professional coach (CB Pro), or (c) a cost–benefit approach in which social

Conclusion

Findings from this randomized trial showed that targeting the problematic cost–benefit ratio associated with weight loss maintenance may be an effective strategy for long-term weight control.

Conflict of interest statement

Dr. Leahey is currently Chief Scientist and a paid consultant at WayBetter, Inc.; however, the work presented herein is not at all related to her relationship with WayBetter. All remaining authors declare that there are no conflicts of interest to report.

Transparency Document

Transparency document.

Acknowledgments

This trial was funded by the National Institutes of Health (NIH; R18 DK083248). The NIH had no role in the design, execution, or interpretation of study results.

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