Smoking cessation researchers at Fred Hutchinson Cancer Research Center in Seattle may have come up with the perfect pandemic pivot: using their tried-and-tested behavioral therapy techniques to help people lose weight.
“It’s a significant pivot for my research team,” said Dr. Jonathan Bricker, a clinical psychologist and public health researcher who for the last 20 years has focused on developing techniques and tools to help people stop smoking. “Weight loss is one of the leading public health problems in our society, but now people who are obese are at more risk for complications from COVID-19, and people are becoming more overweight because they’re inside more and eating more. So, the timeliness is also significant.”
Bricker and his team just published results from a pilot study that paired telephone coaching with Acceptance and Commitment Therapy, or ACT, a type of behavioral therapy that drives change by helping people notice, then move past, unhealthy cravings.
In the past, Bricker has successfully paired ACT therapy with coaching via telephone or chatbot to help people get past cigarette cravings; now, it’s being used to deal with cravings for food.
The study, published today in the Journal of Translational Behavioral Medicine, found a one-year telephone coaching program using ACT had “very encouraging levels of weight loss success compared to standard behavioral therapy coaching.” With the award of a new $3.7 million grant from the National Institute of Health, the team is now recruiting for a full-scale randomized controlled trial.
The WeLNES pilot, short for the Weight Loss, Nutrition, Exercise Study, pitted ACT against standard behavioral therapy (or SBT) in a group of just over 100 people, with 52 people receiving SBT and 53 receiving ACT.
Participants, all of whom were overweight or obese, received a total of 25 sessions with a weight-loss coach via telephone. Calls one through 16 were weekly, calls 17 through 23 biweekly, and calls 24 and 25 monthly. All participants received nutritional education and physical activity education. They all set calorie goals (1,200 to 1,800 a day depending on weight) as well as physical activity and weight loss goals. All participants kept track of their diet, exercise and weight and identified and removed problematic foods from their home and work environments. All used a wireless smart scale that was programmed to transmit their weight back to the research team at intervals.
“I really felt that the human touch was the most helpful. There’s only so much you can get out of a Fitbit.”
Trial participant Megan Moloney
The only difference was the type of behavioral therapy used in the telephone coaching sessions.
SBT-only participants were guided by a “control what you can” framework that focused on what they themselves could modify, like whether or not they stocked their kitchen with devil’s food cupcakes, caramel popcorn and other trigger foods. The coaches helped participants cope with cravings and triggers by reinforcing avoidance, that is, telling them to “ignore their cravings” and just focus on their weight loss goal itself.
ACT-only participants were guided by a “control what you can and accept what you can’t” approach. Their coaches taught them to distinguish between what could be modified (cupcakes in the house) versus things that were not under their control, like emotions and food cravings. Instead of ignoring the cravings, participants in the ACT arm were coached to accept the cravings, to notice and allow them, with the goal of just “letting the urge be.” The coaches also advised them to focus on the values that guide their eating behaviors and on physical activity.
Overall, Bricker said he was “very pleased” with the results.
“Considering the fact our comparison arm was the gold standard in weight loss intervention which made it a challenging comparison, I think we did really well,” he said.
The study’s primary outcome was a 10% or more loss in total body weight, as reported by the scale and by each participant’s own tracking. Bricker said that 10% weight loss is clinically significant; losing that amount of weight can help prevent diabetes, heart disease and other weight-related health issues.
At three months, data retrieved from the scale found 15% of the ACT participants had lost 10% or more of their weight compared to just 4% of those receiving standard behavioral therapy. At six months, scale data showed 24% of ACT participants had lost 10% or more of their weight compared to just 13% of those in the control SBT arm. At 12 months, however, the scale-reported data showed no change between people who used ACT or SBT. Both arms indicated 30% of participants had lost 10% or more of their total body weight.
Why the weird discrepancy in those last six months? The researchers experienced a technical glitch with the scale.
“We used one that researchers had used before and recommended, but as with all technology you don’t really know how it will perform in your study until you field test it,” Bricker said. “We had a lot of technical problems. The first six months, it wasn’t too bad. But by the time we got to 12 months, they’d started to break down and stopped sending the data.”
Bricker and his team, which included collaborator Dr. Evan Forman of Drexel University in Philadelphia, were able to gather data from the scale for the initial follow-ups. But the only reliable data for the full 12 months came from the participants’ self-reported weight. Those results showed 35% of those who’d used ACT lost 10% or more of their body weight after a year compared to 20% of those who used SBT.
“There was almost perfect concordance between self-report and scale-report, like .999, so we had some trust in it,” Bricker said.
Even the scale snafu provided valuable data, Bricker said.
“We did extensive field testing with six different types after that,” he said. “This was one of the ways we spent our time during the pandemic.”
Bricker said he and others members of the HABIT Lab (Health and Behavioral Innovations in Technology) took the scales home and field tested them, trying them out them on carpet, linoleum and wood floors; weighing themselves at different times of day, using different wireless connections. The team checked to make sure the instructions were easy to follow and that the scales would reliably sync and deliver data.
“I remember having all the scales laid out in my bedroom and my wife came in and said, ‘What are you doing?’” Bricker said. “It was hilarious. But we had to try each one and rate them and find the best one. The experience of that lost data at 12 months was very valuable. With pilot studies, you learn what’s not working and what you have to change and that’s what happened. It was quite an adventure.”
The field testing led the team to select a different smart scale for the larger trial, for which they’re now recruiting participants. This time, the study will enroll 400 people and run for two years instead of one. Bricker’s team of 11 will be joined by Hutch epidemiologist Dr. Anne McTiernan, whose research focuses on preventing disease through lifestyle change.
Trial design will be a much-improved version of the pilot, with the snazzy new scale, the addition of a smartwatch, a bit of training in technical troubleshooting, refinements to the coaching programs, a revised resource guide for participants and the extra year of “booster calls.”
“They’ll get 24 calls in year one and then nine calls in year two,” he said. “It’s a two-year commitment that will address the common problem of weight regain. We also added a Fitbit watch to passively track steps and physical activity and sleep. We’re curious to see if this program has any impact on sleep. And we’ll have a new digital scale tracking their weight, one that’s well-designed with software that’s reliable and syncs well.”
Bricker said digital tools like wearables, smart scales and smartwatches were “very valuable” in the realm of public health research as they can unobtrusively monitor study participants’ weight and activity and (usually) deliver the data to scientists safely.
But the power of both the pilot and the new trial, he said, “is the successful combination of the human touch with the digital touch.”
Megan Moloney, one of the trial participants, heartily agreed.
“I liked my counselor a lot,” said the 50-year-old pharmacy informaticist from Las Vegas. “I really felt that the human touch was the most helpful. There’s only so much you can get out of a Fitbit.”
Moloney lost 10 pounds during the trial period and has since gone on to lose 15 more using the same principles. She said her coach was a big part of her success, providing praise and positive feedback and helping her brainstorm different ways to fit in exercise while on the road.
“Before COVID hit, I traveled full-time for work,” she said. “My sleep wasn’t regular, my meals weren’t regular, exercise was difficult to fit in. I was struggling a lot. This program showed me how to make things work, how to create a schedule for myself. And I really enjoyed being able to talk to a person. A lot of it was learning to think outside the box. I ended up running stairs and doing laps in the hotels where I stayed.”
Bricker said the participants all seemed to love the personalized coaching — and the accountability it provided.
“This is very much a study of well-trained coaches,” he said. “Technology is great, but it will never replace the power of a well-trained caring coach. They can tailor the experience to the person and technology can’t do that. That’s something that only a trained coach can do – that’s what makes this study valuable.”
The WeLNES pilot study was funded by donors via the 2018 Hutch Award Luncheon. The new five-year, $3.7 million grant from the NIH’s National Institute of Diabetes, Digestive and Kidney Diseases will extend through 2025.
Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she blogs at doublewhammied.com and tweets @double_whammied. Email her at firstname.lastname@example.org.
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