Obesity and its related health conditions, such as type 2 diabetes and cancer, are increasingly prevalent among young adults. This makes young adulthood a crucial period for implementing behaviorally-based weight management programs. Digital weight control programs offer an attractive option for this demographic, overcoming barriers to attending on-site programs like work, school, and family responsibilities. Understanding the components of digital weight management programs is crucial, as studies quantify metrics with little agreement on intervention effects. Research indicates that engagement in digital weight loss interventions correlates with weight loss, depending on the study methodology.
Engagement and Weight Loss: A Deep Dive into the HBHU Study
A secondary analysis was conducted to explore the relationship between engagement with individual intervention components and weight loss outcomes within the Healthy Body Healthy U (HBHU) digital weight management intervention for young adults. The study, which was published in the J Technol Behav Sci, assigned participants points for each engaged component per week, with a maximum of 78 points possible over six months. Engagement levels were categorized into tertiles: low (0-51%), moderate (52-66%), and high (67-100%).
Study Design and Participants
The HBHU intervention involved two intervention groups: tailored weight management and targeted weight management, along with a contact control group. The tailored group received personalized text messages based on self-reported barriers to weight loss, while the targeted group received generic weight-related tips and self-monitoring questions. The control group received generic health and wellness tips. The design, recruitment, screening, and randomization processes have been detailed in prior publications. Briefly, the study included 459 university students with overweight or obesity. Weight and height were measured at baseline and after six months using standardized procedures, and BMI was calculated from these measurements.
Engagement Metrics and Analysis
Engagement was defined as responding to at least one text message for the texting component. For the feedback report component, a point was awarded for each week the participant viewed the report. Participants received a score of 0-3 per week, with a maximum of 78 points for the first six months. Weight change in kilograms from baseline to month six was the primary outcome of interest. Statistical analyses included descriptive statistics, ANOVA, Pearson x2 tests, and linear regression models. The models adjusted for study site, age, sex, baseline weight, and baseline height.
Declining Engagement and the Importance of Tailoring
The study found that overall engagement decreased by 33.6% from weeks 1 to 26. Despite this decline, overall engagement remained moderately high, with a similar decline across all three treatment groups. High-engaged participants lost 1.8 kg more than low-engaged participants, demonstrating a statistically significant relationship between engagement and weight loss. For every 10% increase in engagement with the feedback report over six months, participants lost 0.27 kg, potentially driven by the tailored group, which saw a loss of 0.45 kg.
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The Power of Personalized Feedback
The tailored group's success highlights the importance of personalized feedback. These participants received individualized information on their progress and tips for overcoming self-reported barriers to weight loss. Tailoring is a method for increasing the relevance of intervention messaging and one’s motivation to process the message content. This may have enhanced participant engagement with the personalized feedback report.
Comparing HBHU to Other Interventions
Other technology-based weight loss interventions have reported similar or greater engagement declines over time. For example, one study indicated that the log-in percentage dropped from 82% at month 1 to 17% at month 12. Despite the decline, the HBHU study found that overall engagement was related to weight loss, with high-engaged participants losing more weight than low-engaged participants. This aligns with findings from other studies, which have shown that engagement with weight loss apps and other digital interventions is correlated with weight loss.
Establishing a Threshold for Engagement
The study suggests a threshold for engagement associated with success in digital weight loss interventions. High-engaged participants, defined as being in the highest tertile of engagement (67% or higher), experienced the most significant weight loss. This finding supports the idea that a certain level of engagement is necessary to achieve meaningful results in digital weight loss programs.
Mindless Eating: Unveiling the Hidden Calories
The art of successful weight loss remains elusive for many. Effective weight loss programs should shift their focus from outcome-based goals where we exhibit less control (e.g., losing 20 lbs. In a practice where strategies generally target diet and activity, consider adding a new strategy that incorporates elements from both, yet also addresses the impact of environmental stimuli and how they influence eating behaviors. This strategy is slowly taking center stage as a key player in tackling the challenge of weight loss . The essence of mindless eating is the fact that many are consciously unaware of the over 100 - 300 calories of snacking that is done throughout the day. The mindless 100 - 300 calories accumulated throughout the day (e.g., two small candies at a co-worker’s desk, a bite of your child’s ice-cream bar, etc.) generally fail to trigger conscious awareness. Many feel that they pay attention to everything they eat, but on average, we make more than 200 daily food decisions, although we believe we only make about 15 . The truth is that we often behave mindlessly around food and although some may discount 100 - 300 kcal daily, it can amount to a 10½ - 31 lbs.
Portion Size and Eating Pace
It is probably safe to assume we all agree portion sizes have increased steadily over the past 30 years for many reasons - technological improvements to economically mass produce food and consumer demands for more cost value. Yet, this slow and ever-expanding portion distortion, coupled with our ‘clean-plate’ mentality has spurred overeating. As portion sizes expand, so do the tools used to eat (e.g., plates, glasses, etc.). Try reducing portion sizes by mini-sizing eating tools (e.g., use smaller plates or side-plates; use taller thin glasses, rather than shorter fatter glasses which can reduce over pouring up to 37%). Try capping portion reduction to 20% as this generally goes unnoticed. This is a phenomenon defining behavioral responses that occur when regulatory actions threaten or eliminate specific behavioral freedoms .
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After eating, the presence of food in the stomach and gastrointestinal (GI) track, and the entry of food into the blood trigger neural and hormonal responses that turn off our hunger sensation. Hormones such as leptin from the fat cells and cholecystokinin released from intestinal cells can suppress the urge to eat further. On average, fast food is consumed within 11 minutes, whereas food consumed in a moderately-priced restaurant takes 28 minutes . Implement a strategy to control your client’s eating pace by taking the time to stop, sit and eat, or to sit with the slowest eater in the group. Be mindful however of the dining ‘pacesetter’, the person who may unknowingly sets standards for how much food and how fast it will be consumed . If this person eats chips and salsa, he or she may influence others to mindlessly join in and eat comparable amounts.
The Power of Sight and Food Visibility
The power of sight (what we see) can stimulate or suppress appetite, so be mindful of both. In a bottomless soup bowl study (automatically refilling bowl v. regular bowls) those eating from the bottomless bowl consumed more soup and 73% more calories (155 kcal v. 268 kcal) . On the other hand, we have also learned that sometimes what we see can raise our level of consciousness or awareness as to how much we are overeating. In a chicken wing study, when bones were left in plain sight for people to see how much they ate, they actually consumed 28% less food . Interestingly, individuals who pre-plate their food (i.e., bring all they plan to eat to the table before eating) as opposed to making several trips to the buffet line will eat 14% less food .
Researchers have also discovered that individuals consuming snacks from clear jars consumed 71% more food versus food concealed in opaque containers . Removing food visibility decreases temptations for mindless snacking (seeing, smelling or thinking). The takeaway message - if buying in bulk, immediately repackage larger containers into smaller, non-see through containers and store out of sight - this helps curb subconscious eating. Many food desires and cravings are trigged by thoughts, emotions or environmental stimuli. When we have such desires, comfort foods become a prime target to satisfy needs . People seek out comfort foods for many reasons, including rewards, celebrations, or feeling happy, bored, depressed or lonely. Once mindfully aware of triggers, strategize distractions since these thoughts and emotions are generally short-lived. Aim to satisfy the thought or emotion while simultaneously reducing the likelihood of eating (e.g., calling a friend, expressing thoughts in a journal, playing with a pet or doing an activity).
Strategies for Controlling Mindless Eating
A trade-off is another effective strategy for controlling mindless eating. Give people autonomy (ability to choose) to choose their behavioral action, but use consequential persuaders (i.e., give client the power to choose from several options, while concurrently making them aware of the consequence of each choice). This again reduces chances of psychological reactance. For example, making them aware that a 100 kcal snack is equivalent to a 23-minute walk or standing for 52 minutes . When more food choices and colors are presented, we typically imagine more enjoyment from the food. By comparison, when we have decreased food choices, we often experience a perception of less food enjoyment . Putting the same food into multiple bowls can also result in people perceiving more choices and eating more, by up to 18% . When there is more food or when we perceive there is more food, we tend to think eating more is appropriate, a concept called sensory-specific satiety . In a study using M&Ms®, researchers compared 7 colors versus 10 colors, and while each color tastes the same, those given more color choices ate 43 more M&Ms® (99 v. 56 in total) .
This approach is to make snacking a hassle and not a habit. This can be accomplished by making snacks less accessible and creating ‘pause points’ where one has a moment to consciously contemplate the consequences of snacking and possibly avoid mindless eating. In one study chocolates were placed on the corner of a desk, in a drawer, and then on a file cabinet six feet (1.85 m) away in random order . The results demonstrated that when chocolates were easily accessible (i.e., on the desk), an average of nine chocolates per day were eaten. Another classic and often-cited study looked at eating behaviors when conscious cues where utilized to help control eating. Participants were served tubes of regular Pringles® potato chips and allowed to eat as many as they wanted, but in some tubes red chips were placed at regular intervals (7th or 14th interval; 5th and 10th interval in follow-up study), a process called segmenting. Interestingly, in the tubes with no red chips, individuals ate significantly more chips whereas they ate less with the smallest red chip intervals . Individuals eating from the red chip tubes were also better at estimating how many chips they ate. The takeaway is to move snack foods outside of six feet where an individual has to physically move to access the food, giving time to structure an opportunity for a ‘pause point’ where consequences can be contemplated (e.g., that 100 kcal snack will require 20 minutes of walking).
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The Illusion of Healthy Foods and Environmental Expectations
Healthy foods continue to garner more attention and popularity, but be cautious not to lose sight that healthy does not necessarily mean fewer calories. In a study comparing individuals who ate at McDonalds® versus Subway®, it was the people who ate at Subway that underestimated total calories consumed by a larger margin (34% underestimation v. 25% at McDonalds) . The notion of healthy may give eaters a false sense of confidence, believing that choices are healthier and leaner. Many of us are unaware of our dietary danger spots, those locations where we tend to exhibit poor dietary behaviors (choices, portion sizes, or rate of food consumption). Take time to become more aware of your client’s problematic eating environments as this is certainly an area where we can help them improve. Be aware of what is called an ‘Expectation Assimilation’ which refers to the expectations that the environment may have upon current and immediate eating behaviors . In a wine study using the same wine, but labeled either as a new wine from California (known for good wines) or from North Dakota (not known for good wine), participants were served the same food from the same servers, in the exact same environment, yet those drinking California wine consumed 11% more calories, dined for 10-minutes longer, and enjoyed their experience more, indicating that the food tasted better . The findings of this study appear to be one where our expectations of the eating experience may influence choices and quantities before we even eat. Whether you’re a personal trainer or an NASM Weight Loss Specialist (WLS), it is important to simplify the process of behavioral change while motivating them with some of these simple ideas.