Text Messages Promote Weight Loss in Spanish Speakers

Miriam E Tucker

March 02, 2016

Text-message support can lead to clinically significant weight loss in Spanish-speaking patients with prediabetes, a new study finds.

Results from the randomized clinical trial were published online February 16 in Diabetes Care by Henry H Fischer, MD, an internist at the Denver Health and Hospital Authority, Colorado, and colleagues.

The yearlong study in a Denver medical center involved 163 low-income English- and Spanish-speaking participants with prediabetes. Overall, those randomized to receive text messages achieved 2 lbs greater weight loss than controls, as well as greater reductions in HbA1c and blood pressure.

"This study shows promise for a tool that doctors can offer a patient to promote lifestyle change when they walk out the clinic door. The operational costs are low, and though the weight loss is not dramatic, it is enough to prevent cases of diabetes and incrementally improve metabolic outcomes," Dr Fischer told Medscape Medical News.

The text messages were delivered in either English or Spanish and related to nutrition, physical activity, and motivation. The content was based on the interventions used in the Diabetes Prevention Program, the landmark National Institutes of Health Study demonstrating that lifestyle modification (or metformin) can delay or prevent the development of type 2 diabetes and continues to show benefit years later.

Text-message themes — also refined with patient focus group input — included meal recipes or positive messages such as: "Change is hard, but a healthy lifestyle is worth it," "Start with little changes and gradually work up," and "You can do it!" Some incorporated seasonality and local cultural influences such as Denver Broncos games and links to community resources, while others encouraged family and/or friends to engage in participant involvement.

"While patients helped shape our text-message content, we do not know which particular messages or themes were most influential," Dr Fischer told Medscape Medical News.

Lifestyle Intervention via Text

The investigators used a commercially available, customizable platform (Microsoft Dynamics Customer Relationship Management ([CRM]). There are a variety of vendors of CRM platforms with text-message capability, and many electronic health records have this capability as well. Or custom applications can be developed, Dr Fisher said.

The intervention group received six text messages a week along with a once-weekly text asking participants to report their most recent weight.

Individual motivational interviewing appointments with a health coach were also provided, typically by phone.

Controls did not receive texts or motivational sessions, but, like the intervention group, were also eligible for standard-of-care weight-loss resources at Denver Health, including DPP-based classes and individual appointments with a nutritionist or nurse for diet support.

The primary outcome of mean weight decreased by 2.6 lbs in the text-message group vs just 0.6 lb in the controls (P = .05). A 3% weight loss from baseline was achieved by 38.5% of the text-message group, compared with 21.5% of the controls (P = .02), but there was no significant difference between these groups in terms of who lost 5% of their baseline weight.

Mean HbA1c decreased by 0.09 percentage points in the text-message group, while rising by 0.19 percentage points among the controls (P = .07). Mean systolic blood pressure increased by 0.35 mm Hg in the text-message group vs by 6.4 mm Hg in the controls (P = .01)

"The impact on HbA1c — a 0.28 difference — is about what you would expect for this degree of weight loss. It is not dramatic, but it is enough to prevent progression to diabetes in some patients," Dr Fischer noted.

Effect Seen Only in Spanish-Speakers

When broken down by the language used in the text messages, the impact of the intervention on weight loss was significant only for the Spanish-speaking group.

Spanish speakers who received the texts lost an average of 5.1 lbs, while the control group lost a mean of 0.5 lbs. The proportions who lost 3% of baseline weight were 47.1% vs 20.6%, respectively, but there were no differences in the proportions losing 5% of body weight.

The English speakers, in contrast, did not differ in weight loss or HbA1c between those receiving text messages and the controls, although the intervention group did achieve a 1.9-mm-Hg drop in mean systolic blood pressure vs a 4.9-mm-Hg increase in the controls (P = .06).

"We are intrigued by the increased efficacy of the program for our Spanish speakers," Dr Fischer said, noting that his group is currently working on a manuscript to further explore this by analyzing end-study focus group and survey data.

"Preliminary themes suggest key differences by language in the motivational impact of the messages, as well as divergent strategies in incorporating family and friends in weight-loss efforts."

Cost Calculations

Total program operational cost was estimated at $22,113.61 over the 1-year intervention, equating to a monthly cost of $1842.80 and an average per message cost of $0.75. Technical costs included phone-line charges of $17 per month (total $204) and message-handling charges of $0.01 per message (total $293.24).

Personnel hours (627.6 hours, total cost $21,616) included an average 17 hours per month of consultation from a supervising physician and 35 hours per month of direct participant support from research personnel, including daily review and management of text messages received from participants and conducting participant outreach via phone call based on identified need.

"A yet-unanswered question is whether the text-message support approach can be operationalized outside of a study setting to reach large numbers of patients and remain clinically effective at low cost," the authors conclude.

This study was conducted with support through a grant from the Agency for Health Care Research and Quality. The authors have no relevant financial relationships.

Diabetes Care.Published online February 16, 2016. Abstract

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