[This is a preview of some of the exciting mHealth research being presented at the mHealth Summit on December 3-5, 2012. This abstract and others are candidates for the iMedicalApps-mHealth Summit Research Award]
By: Michael K. Lin and Lawrence J. Cheskin, MD
iMedicalApps-mHealth Summit Award Finalist
While obesity continues to escalate as an important clinical and public health problem, it remains a challenge for physicians to help obese patients lose weight. Therapeutic options for weight control are broad, ranging from behavior management and medications to bariatric surgery. While these options are effective for certain populations, they are limited in their impact both because of cost and availability, and because they may require intensive in-person contact that may not be convenient or desired by patients. Mobile technology provides an opportunity to remotely deliver behavioral obesity interventions that are cost effective and widely accessible.
We have developed Tailored Rapid Interactive Mobile Messaging (TRIMM), an automated text message program for weight loss. Our purpose was to develop a cost-effective, proven, and scalable obesity intervention that can be deployed as a sustainable treatment option for obesity.
We’ve begun by conducting a randomized clinical trial of the TRIMM program supplementing standard care, compared with standard care, among overweight and obese adults in Baltimore seeking weight loss.
Study Design and Population
Our study is a two-arm randomized controlled trial of 118 participants. We recruited participants from inner city Baltimore churches. Eligibility criteria included BMI > 27, age 21-65, and having a phone with SMS capability. Exclusion criteria included substance abuse and health conditions that would make it unsafe or inappropriate to participate. All participants were African American with a mean age of 51.
In general, the recruitment process for this trial was much less stringent than those typically used for efficacy trials. We did not screen for motivation level or adherence to study procedures, which suggests that the results of our study might be closer to results obtained in a real-world setting. Additionally, we recruited participants from an underserved population that traditionally performs poorly in health behavior change interventions, which contrasts most weight loss studies.
With the control group, we aimed to capture the standard care for an obese patient. Participants in this group received an initial clinic assessment and follow-up at months 3, 6, and 12 at the Johns Hopkins Weight Management Center. At the initial clinic assessment, each participant received individual feedback sessions with a dietitian and physician, education materials about diet and physical activity, and a pedometer. When participants returned for their month 3 and 6 follow-up, they received additional education materials and were offered a brief feedback session with a dietitian. Participants returned at month 12 for their final weigh-in.
The intervention group received daily TRIMM text messages in addition to standard care. We designed TRIMM as an automated, 6-month text message program that tailored itself in two main ways to offer individualized interaction and content for weight control.
First, we targeted relevant behaviors at the opportune times by personalizing the program to each individual’s weight control challenges and daily routine. Second, we engaged participants with daily interactive messages that asked participants a question regarding their weight, motivation level, or health behavior. Upon receiving a participant’s response, we delivered finely-tailored feedback automatically, promoting accountability and self-monitoring. TRIMM also tailored itself to each participant’s progress in weight loss.
We captured our primary outcome data, 6-month weight loss, and we’ll share our early analyses here. Final results from this study will be available early spring 2013, since 12-month follow-up visits are scheduled through January.
Complete case analysis (42% of participants) indicates that the TRIMM group achieved more weight loss than the standard care group (8.0 lb vs 1.3 lb, p<0.03). The TRIMM group also achieved a significantly greater percent body weight loss (3.7% vs 0.6%, p<0.02).
Engagement and Satisfaction
We’ve begun analyzing participant engagement with TRIMM through the percentage of days in which participants responded to the daily interactive message. Our analysis indicates a mean engagement of about 60%. We also found that each additional percentage of engagement predicted about an additional 0.25 lb weight loss at 6 months.
Participant satisfaction with the 6-month TRIMM program averaged at 4.4 on a 5-point scale. We received substantially positive feedback from TRIMM participants.
Limitations & Challenges
Our study has limitations. The duration of the TRIMM program was only 6 months, and our study population was recruited exclusively from Baltimore churches. The trial had low rates of follow-up occurring within our protocol defined 6-month window, resulting in an underpowered study. It is worth noting that 80% of participants came in for the intended 6-month follow-up visit.
Challenges in scheduling of the follow-up visits during clinic hours and participants’ transportation to the clinic, and our lack of anticipation of these issues, led to many follow-up visits occurring past the defined window.
The results of this small pilot study supports the use of carefully designed, personalized, and automated interventions to help tackle obesity. For those participants who returned for their 6-month follow-up visit on time, our entirely automated program (that requires no personnel efforts beyond enrollment) resulted in significantly more weight loss when added to standard care.
We did observe encouragingly high levels of participant engagement and satisfaction with TRIMM. These results suggest that TRIMM can help some fraction of overweight and obese individuals lose weight. TRIMM’s low cost (< $1/week for an individual), scalability, and reach (no smartphone required) further supports its potential as a tool in the battle against obesity.
The Program’s Future
We are further developing TRIMM in duration, degree of tailoring, and sophistication. In parallel, we are focused on exploring TRIMM’s integration into clinical practice settings. We have begun collaborations with clinics and other organizations across the country to further pilot TRIMM. As more patients use TRIMM, we will have an opportunity to better understand for whom it works best, and how it can be improved to help more people struggling to achieve and sustain a healthy weight. We are actively seeking partners in implementing and advancing this promising initiative. The study was funded by a McKesson Foundation Mobilizing for Health grant. The authors conduct research at the Johns Hopkins Weight Management Center.
Michael K. Lin is a Johns Hopkins medical student on hiatus and is supported by the Doris Duke Clinical Research Fellowship. Disclosures: team member, Reify Health, LLC.
Lawrence J. Cheskin, MD is Associate Professor of Health, Behavior & Society at the Johns Hopkins Bloomberg School of Public Health and Director of the Johns Hopkins Weight Management Center. Disclosures: consultant, Medifast, Inc. and Vivus, Inc.