Study: Helping low-income obese patients lose weight

Using a free phone app, low-income obese patients achieved clinically meaningful weight loss when paired with coaching from primary care providers.

In the Duke University study released Monday, a group of 351 participants who were at risk of cardiovascular disease used the Track app for a year to self-monitor behavior changes weekly. Over the 12 months, a health clinic dietician or student also made regular coaching calls to each individual.

Duke’s researchers say it’s among the first studies to report successful weight loss within a low-income population – a group that suffers from rising rates of obesity.

“Obesity continues to wreak havoc on the health of our country, and we’ve had the most difficulty treating low-income Americans, those who are most affected by the condition,” said lead author and Duke professor Gary Bennett.

“This study shows we can help patients who are most at risk by embedding treatment in primary-care settings and keeping patients engaged using a simple app.”

Among study participants, more than 40 percent lost at least 5 percent of baseline weight, a standard associated with health benefits. Those people who used the Track app and received coaching fared better than a control group that received routine care.

Participants were residents in a rural area and mostly employed full or part-time, study results said. About 67 percent of individuals reported annual household income at less than $35,000.

“Digital health approaches hold promise for extending the reach of highly personalized, low-cost, evidence-based obesity treatments to a range of clinical care settings,” the study said.

In the Spokane area, at least two programs are staking similar ground in offering low-cost, longer-term obesity treatment along with regular counseling by health providers. The local approaches weren’t part of the study and aren’t using the app, but similarities include coaching and regular follow-up.

This past summer, Community Health Association of Spokane launched its new program inviting small groups of 10-15 patients to do an eight-week session of weight-loss counseling and regular exercise, alongside once-a-week talks by providers and dieticians at YMCA facilities.

CHAS modeled it after a program started by Heritage Health in Coeur d’Alene in partnership with the Salvation Army Kroc Center, said Dr. Bill Lockwood, CHAS’ chief medical office.

“They started a program about three years ago,” he said. “In a couple-year period, they had about 1,500 patients go through the program and universally they lost weight, their diabetes measures improved, their depression improved, pain levels improved, they had lower anxiety.

“Across the board, it lead to improved health.”

For CHAS, clinic providers recruit participants for the program called Pathways to Wellness, done in partnership with the YMCA and currently out of CHAS’s Maple Street, Spokane Valley and downtown Denny Murphy clinics.

The Pathways program eventually is expected to be offered at all CHAS clinics. For participants who complete the eight-week session including exercise about three times a week, CHAS then supplements their YMCA membership for an entire year, Lockwood said.

“With the hope they will continue exercising,” he said. “The experience at the Kroc is people do continue to exercise.”

That’s the bigger challenge, he added, how do health care providers help patients sustain long-term changes in nutrition, activity and weight loss. “One of the ways you do that is using dieticians.” CHAS has six dieticians for counseling patients at all clinics.

He said what are common among the Duke study and programs like ones for CHAS and Heritage Health are ongoing support, follow-up and accountability.

Lockwood said a number of “social determinant” factors affect low-income residents, many who do have higher rates of obesity.

“Many work two jobs,” Lockwood said. “Maybe they grew up where healthy habits weren’t taught. They have difficulty getting time off from work to make doctor appointments. There might be transportation issues or they live in an unhealthy environment.

“I think in addition to that, the challenge we have as health-care providers is we see patients for 20 minutes maybe once or twice a year. That’s a blink of the eye. There is not a lot you can accomplish. The similarity that approaches such as this app study and our program has is ongoing support.

“It’s regular ongoing support rather than a one-time recommendation or handing them an app and saying good luck.”

Other actions to fight obesity require societal changes such as walkable cities and residents’ access to affordable fresh foods, said Washington State University Spokane associate professor Pablo Monsivais.

He does research on societal interventions for the department of nutrition and exercise physiology.

Monsivais said while it’s positive that the Duke study with digital and clinical coaching reached a low-income group for weight loss, he also believes society societal changes will sustain healthy patterns long-term.

“I’m familiar with Gary Bennett’s work; he’s a classic obesity interventionist,” Monsivais said. “And he’s absolutely right, that there’s not much done for low-income people who have disproportionately higher rates of obesity.

“I’m often just stuck with the question about how this fits into a bigger picture, because pretty much every dietary intervention eventually fails. This study result seems to work, but the problem of any dietary intervention is if you don’t stick with it, your weight comes back.

“The intervention in my view that needs to be made is societal intervention. With respect to weight and related chronic diseases, it’s the fact that being physically active can be difficult. Our world is engineered for being sedentary.”

Not only do we spend more times in cars and have easy access to high-calorie food, in low-income populations, there is more food insecurity, and that also can cause unhealthy patterns of eating, he said.

“We do need to make communities more healthy, including more bicycle paths, walk-ability, and improving healthy eating food sources in neighborhoods.”

He said the study’s intervention length of one year likely helped to establish habits, but he questions what that will look like in another year. He said smartphone apps might be used more in the future for intervention, but they’re more effective in conjunction with professional health advice.

“We’re kind of teaching people to swim faster in unsafe water,” he said. “Maybe we need to build a safer swimming environment rather than just teaching everyone to swim faster.”