Joslin Diabetes Center: Digital Weight Loss Intervention
BACKGROUND (SOCIETAL PROBLEM & CLIENT OBJECTIVES)
Almost 10% of the US population has type 2 diabetes (21.9 million) and nearly 90% of people living with diabetes are overweight or have obesity (CDC & NIH reports). Among overweight and obese people with type 2 diabetes, modest sustained weight loss (5%) has been shown to improve glycemic control and reduce the need for glucose-lowering medications, while greater weight loss (> 7%) has been shown to further improve glycemic control (blood glucose and A1C), triglycerides, blood pressure, LDL and HDL cholesterol along with improving mobility, physical and sexual functioning, health-related quality of life and complications and costs associated with diabetes management.
While the challenge of significant and sustained weight loss is great, in-person, short-term intensive weight management programs like Joslin Diabetes Center’s Why WAIT, have been shown to achieve significant weight loss (8 - 12%) and improved glycemic control at 12-weeks, with maintained weight-loss (2.5 -12%), improved blood pressure and lipid profiles and reduced health care costs (27% on average) at 1-year and four-year follow-up.
Having the ability to scale their impact and increase reach to those who might benefit was a critical objective for the center and partnering with Mad*Pow’s team of behavior change experts, content strategists, interaction designers and developers was a perfect fit.
METHODOLOGY (PROCESS, INSIGHTS, TECHNIQUES)
Our collective goal in creating a digital behavioral weight-loss platform was not only to extend reach and cost-effectiveness but to achieve comparable outcomes in weight loss (normalized for lack of medication adjustment that occurs during the in-clinic program). Getting us there required an understanding of the active ingredients in the Why WAIT program (target behaviors, intervention functions and behavior change techniques), the style/tonality by which they are delivered, an assessment of participant barriers, preferences and experiences and an ability to effectively translate what works and what is needed from the in-clinic program to a self-guided digital intervention. Our process followed an iterative 3-step IDE approach; Insights gathering - program immersion and analysis of current program, Design - translation/adaptation of content and techniques to web format, Evaluation – acceptability, usability and feasibility pilot/impact testing.
To better understand the mechanics of the program and the experiences of its beneficiaries, our team immersed themselves as active participants within a 12-week cohort. We attended educational classes, exercised with the group, observed one-on-one coaching and medical evaluations, adhered to the diet plan and at home exercise regimen, performed behavioral experiments, and interviewed several participants, nutrition and exercise coaches, behavioral counselors, and medical doctors. We synthesized the structured educational content (diabetes symptoms, causes, complications and management – diet/nutrition, medication, exercise, behavioral / emotional skills training) with the subjective experience, observational and experimental data we gathered over the 12-weeks.
Key insights gathered in this phase were:
- Behavioral skills training and coping measures are a critical part of success away from program sessions. For example, requesting that half of your meal portion be packaged for take away when ordering out at a restaurant or having other “ready at hand” strategies / action plans for trigger / troublesome events.
- Frequent self-monitoring of behaviors (eating, exercise, medication dosing, glucose checking) and outcomes (weight, glucose levels, calories/macronutrients, mood), receiving contextual feedback and reflecting on behavior – outcome links, celebrating success or problem solving set-backs is instrumental in weight loss and glucose control.
- Social Support / Peer camaraderie was a strong motivator for program engagement, effort and adhering to treatment protocols over the course of 12-weeks.
- Collaborative goal-setting on personalized yet meaningful targets strengthens goal striving and achievement.
- Task provisioning, corrective feedback and advice is most effectively delivered with a precise rationale, encouraging tone and positive reinforcement.
As insights emerged over our 12-week immersion, we were able to communicate and evaluate key themes, features, functions, content structure and tonality with program participants and Joslin staff. Ultimately, our web-based intervention focused on 5 primary target behaviors;
1. Engage with educational content modules (videos, articles, quizzes)
2. Perform scaffolded strength training, flexibility and cardio exercise regimen (from 20 min 4x week to 60 min 6x week) (and track online)
3. Maintain restricted calorie diet (and track online)
4. Blood glucose monitoring 5 x a day (and track online)
5. Daily weigh-ins (and track online)
The structure of the intervention consists of 12 sequential modules that individuals can progress through at their own pace. Each module is based on overarching related behavioral strategies for weight loss and diabetes management and consists of educational content (videos, articles, worksheets and interactive activities), and individualized nutrition, exercise and glucose monitoring plans. Surrounding the core of the educational and behavioral content are digital tracking tools for diet (calories, carbs/macronutrients), exercise, glucose monitoring, weight, mood and personal journaling and fast facts, quick tips, and booster actions that are individually tailored to the individual based on their tracking trends, content they’ve engaged with and module quiz results. Individuals’ advance through the modules when they’ve engaged with the educational content, logged completion of their exercise plan, and completed the module end-quiz.
To energize behavior and program engagement, a program community is integrated throughout the platform. Community interactions consist of a friend/follower profile feeds, threaded commenting on article content, community generated forum content, tips, high-fives on postings and direct messaging. Additional engagement techniques include progress mechanics (modules labeled as levels, “streak” rewards for consistent achievement of goal targets), feedback messages that highlight trends in reported data (positive feedback for improvement in weight, blood glucose, calories, etc. and suggestions for improvement when trends decline), weekly email summaries with social comparison trends (if user is within 1 standard deviation) and strong call to action for new or incomplete activity.
While not quite a formal co-design process, having access to two successive Why WAIT participant groups enabled us to regularly obtain feedback throughout the design process, from proposed intervention components and structure, to early conceptual/thematic designs, to wireframe layouts, to prototype usability and acceptability tests to most importantly a pre-launch feasibility/impact pilot trial.
With development and quality testing complete, Joslin recruited a 500-person pilot sample of people with type-2 diabetes and a baseline weight above 220 lbs (BMI > 32) and HbA1c above 7 to participate in the 12-week self-guided web intervention trial. The goals of the pilot were to assess continued engagement (or drop-off) with the platform and weight loss (with an ambitious target goal of 6%).
The results of the pilot trial have been impressive. Of the 500 initial recruits 125 (25%) were able to achieve the target weight loss of 6% (compared to the 8-10% in-clinic target).
Our work together with Joslin Diabetes Center illustrates an early success story for the translation of well-designed clinical behavior change programs to digital formats. By applying rigorous behavior change analysis to identify the active ingredients that underpin successful clinical programs and translate them into digital interactions that follow best practices in human-computer interaction, we can effectively increase our reach and improve health and economic outcomes for the people that can benefit, no matter where they are.
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