Low-Income, Obese Patients Lose Weight With Texts, Coaching

Marlene Busko

October 30, 2018

Low-income, obese adults who were randomly assigned to a "digital" weight-loss intervention delivered over a mobile phone lost more weight at 1 year than those who received usual care, researchers report.

The intervention in the Track study consisted of daily text messages with immediate automated feedback about goal attainment plus frequent over-the-phone counseling from a dietician and occasional brief counseling from a primary care provider.

At the end of the year-long intervention, significantly more patients in the intervention than usual care group had lost 5% or more of their baseline weight (40% vs 17%; P < .001), which is associated with health benefits.

The study, by Gary G. Bennett, PhD, Duke Global Health Institute, Durham, North Carolina, and colleagues was published online October 22 in the American Journal of Preventive Medicine.

The findings show that in a disadvantaged, high-risk population, "we can produce clinically meaningful weight loss at a very low price point if we use digital strategies," Bennett told Medscape Medical News.

With the free app, he said, "every day, a patient is using their cell phone to track how well they are doing in achieving a series of highly personalized goals. They get highly personalized feedback and responses, and that keeps them engaged for the year that it's going to take them to lose the weight."

"We [took] the data from the patient and [immediately gave] it to those two different providers: the primary care physician and a dietician, " he continued.

"When a patient met with their primary care provider, a doctor knew exactly what to say (we gave them a script), and the registered dietician knew exactly what to say because they were following a protocol."

On "Track" to Lose Weight

In the United States, despite multiple weight-loss research trials, "we have almost no strategies that work in medically vulnerable populations," such as low-income patients with cardiovascular risk factors, said Bennet.

As described earlier (Contemp Clin Trials. 2016;48:12-20), the Track study aimed to see if disadvantaged obese patients could attain greater weight loss after a 1-year digital intervention compared with usual care.  

The researchers enrolled 351 men and women aged 21 to 65 years who had a body mass index (BMI) of 30 to 45 kg/m2 plus hypertension, diabetes, and/or hyperlipidemia who were being treated at one of four community health centers serving rural North Carolina in 2013 to 2014.

All patients had a mobile phone and were willing to send/receive three to nine text messages per week. 

They were a mean age of 51 years and 68% were women. About half were black (52%), and the others were white (29%) or Hispanic (12.5%). They had a mean BMI of 36 kg/m2.

About half (51%) lived alone. On average there were 2.8 people per household.  

Half had an annual household income below $25,000. Three in 10 had a household income below the poverty threshold in 2014, and 16% had a household income around the poverty threshold.   

Almost all patients had hypertension, either alone (29%) or with diabetes (12%), with hyperlipidemia (20%), or with both (21%).

One in five patients had depression and 26% smoked.

The patients were randomly assigned to receive usual care or the intervention.

Patients in the usual care group received self-help materials and counseling from their primary care provider.

Those in the intervention group received:

  • Individualized behavior goals that changed every 8 weeks (for example, walk 7000 to 10,000 steps/day; practice portion control; no sugary drinks; no fast food; eat at least five fruits and vegetables a day).

  • Daily text message and immediate feedback about these goals.

  • 18 weight-loss counseling coaching calls with a registered dietician (weekly for 1 month, biweekly for 6 months, and monthly for 8 months).

  • Brief primary care physician weight-loss counseling at medical visits.

Patients in the intervention group were asked to weigh themselves daily and enter data about their goal attainment into the app.  

The app gave immediate personalized feedback and a short tip.


The participants also received regular 10- to 15-minute coaching phone calls from a registered dietician and had a median of three visits with a primary care provider during which the physician could deliver a 2-minute, individualized weight-loss-counseling script.

At 6 months, on average, patients in the intervention group had lost 4.4 kg compared with baseline, whereas those in the standard care group had lost 0.3 kg (mean difference, –4.4 kg; 95% CI, –5.5 to –3.3 kg; P < .001).

At 12 months, patients in the intervention group had lost 4.0 kg, whereas those in the standard care group had lost 0.1 kg (mean difference, –3.8 kg; 95% CI, – 5.1 to – 2.5 kg; P < .001).

"With rapidly increasing uptake of digital technologies," Bennett and colleagues conclude, approaches such as those used in the Track study "might have beneficial health impacts for patients, including those who have been historically challenging for the health system to reach and treat."

The trial was funded by the National Institutes of Health and National Institute of Diabetes and Digestive and Kidney Diseases. Bennett has reported holding equity in Coeus Health and serving on the advisory board of Nutrisystem.

The researchers are about to begin enrollment for the second phase of a new Charge study that will evaluate a text messaging-based app for weight loss. Patients with a BMI of at least 25 kg/m2 will be able to join the study at: www.chargestudy.com

Am J Prev Med. Published online October 22, 2018. Full text

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