E235: A Successful Interactive Obesity Treatment Approach

Traditional clinical weight loss interventions can be costly, time consuming, and inaccessible to low-income populations and people without adequate health insurance. Today's guest, Dr. Gary Bennett, has developed an Interactive Obesity Treatment Approach, or iOTA for short, that represents a real advance in this area. Dr. Bennett is Professor of Psychology and Neuroscience, Medicine and Global Health at Duke University, where he is also Dean of Trinity College of Arts and Sciences.

Interview Summary

You know, in this time when people are talking about more expensive, and kind of more intrusive interventions, like the big weight loss drugs, it's nice to know that there may be alternatives that could be accessible to more people. Could we start off with you telling our listeners what the iOTA approach is and how it works?

Sure. This is an approach for weight management. It's useful for weight loss or preventing weight gain or maintaining one's weight after you've lost weight. The idea here is that it's a technology that's designed to be highly accessible, and useful for a range of different types of populations. So, as you described, we have developed and tested this primarily for folks who are medically vulnerable, who are low income, who are racial, ethnic minority, who live in rural communities, and where we have traditionally had real difficulty reaching populations with effective weight loss tools. So, iOTA is a fully digital approach. It uses technologies smartphone apps, but it can also use text messaging, interactive voice response, those are like robocalls, automated telephone calls, websites. We've tested this on a wide range of different types of technology platforms, and we've tested it in a range of different types of populations all over the country and indeed even in other countries.

So, give us some examples of what kind of information people might be receiving through these various forms of media.

The underlying kind of technology, the underlying approach, I should say, for iOTA is actually reasonably simple. It operates from the perspective that creating weight loss is really about making an energy deficit. That is to say, helping people to consume fewer calories than they are expending. The realization we had years ago is that you can get there, you can create that calorie deficit in a whole host of different ways. Some people diet, some people try to get more active, there are limitations around that kind of approach. But fundamentally, you can also just get there by asking people to do some reasonably straightforward behaviors. Like not consuming sugary beverages, or consuming fewer chips, cookies and candies. Or changing the amount of red meat that they put on the plate. And, if you frame those things out as goals, then you can prescribe those goals to people in ways that make sense to them personally. The trick though is actually in the idea of personalizing those goals to the given individual. And that's where technology comes in and gets very helpful. The case is, if you have a large library of these goals, you'd want to try to provide these in a highly personalized way. That really are aligned with what people's needs are and noting that those needs may change over time. So, what we do with iOTA is deliver a very short survey. That survey then helps us to be able to look into our library of goals and pick the ones that are most useful for our users. We prescribe those goals, and then we ask folks to self-monitor those goals. Self-monitoring or tracking is an extraordinarily powerful part of behavior change science. And so, we ask them to track using one of our technologies: the chat bot or the text message or interactive voice response or the smartphone app. Every time that we receive data from one of our users, we give them highly personalized feedback that is designed around principles of behavior change science. And then over time we also give them support. We do support sometimes from a coach or sometimes from a layperson, sometimes it's even from a physician. And over time what we find is that this kind of an iOTA approach helps people to lose weight, prevent weight gain, have weight loss maintenance, but it also has a cascade of other types of effects, some of which we didn't really even anticipate producing.

This reminds me of something that I've fought for years, that nutrition and weight control can get incredibly complicated and down on the weeds in a fascinating way from a academic point of view. But that you can get to the goal line with just a few simple things. You might be 80% to the goal line just by eating less junk food and eating more fruits and vegetables and getting mired in that last 20% becomes confusing. It sounds like that's exactly what you're doing. That you kind of picked some of the big things that people can do, establish goals around them, and then provide a behavioral path for getting to those goals.

That's precisely our thinking. And the thing I'd add to that is part of the challenge in weight control is making those types of changes for long amount period of time that it takes to produce and sustain weight losses. One of the things we know is that any kind of behavior change, but particularly behavior change for weight control purposes just requires an extraordinary amount of engagement over a very, very long time. So, I'm fond of saying to our teams and to others I'm really much less concerned with strategies that produce weight changes at a month or two months. Because the real question for us is how do we create technologies that can support users as they enter the 10th month or the 12th month? Fundamentally, what we're really after here. It's not really weight loss, but it's really the changes in a whole range of health parameters. So cardiometabolic function, the indicators of the development of various cancers, diabetes parameters, those kinds of things. And it takes time and effort to produce those changes via the weight control, changes that we're hoping to produce with these technologies.

What kind of results are you getting from this and does the iOTA program in fact make it easier for people to stay on track with their health goals?

Yes, it's a really interesting set of findings over more than a half dozen trials in the last bunch of years. If I were to summarize, I'd say we get pretty modest weight losses relative to say, what you might get with a very intensive weight loss intervention or with a drug or certainly with surgery. But what's different is that those weight changes do tend to be sustained over time. So, they're modest, but they last. And the really interesting finding for us is that people stay very engaged with these technologies. On average, people tend to use new apps pretty feverishly in the first month after they downloaded, or they put it on their phone one way or another. And then most people, about 70% of the time, people move away from those apps, they disengage. When we look back about a year after people started using iOTA, it's very, very common for people to be engaged with our technologies 80-85% of the time. That is to say, they're still tracking their goals at about 80% fidelity after a year. That's really terrific. and it's one of the reasons I think that we're able to see sustained losses, even though those losses aren't very large. And again, my goal here is much less - this is a public health approach - I'm much less interested here in trying to produce large weight losses for cosmetic reasons and those kinds of things. This is really an effort to try to create a very highly disseminatable, inexpensive treatment that is accessible to large numbers of folks. In trials, we certainly have seen changes in blood pressure and various cardiometabolic parameters like lipids. Those changes tend to be larger in certain populations. When we tested this in China, we saw very, very large dips in lipids. And those too also do tend to be sustained. The biggest surprise for us over the years has been a relatively consistent set of findings that suggest that people have improved wellbeing on the backend of participating in one of these kinds of treatments. They tend to feel less stressed, have more energy, and have better quality of life. In fact, we've seen very, very large reductions in depressive symptoms in study after study. I'll just add tangentially that's notable for us in the populations in which we work, because these are not populations for whom weight is very closely tied with one's emotional state. That is to say, the patient populations in which we work tend to have more tolerance for heavier body weights compared to other populations. So, when we see weight loss in our trials, we don't often expect to see that accompanied by improvements in depressive symptoms. But we see it in study after study after study. So, we've been really pleased with this broad array of impacts that this technology seems to produce.

It's nice to hear the positive results. And I also like your aspirations because a smaller weight loss, better maintained is a much better outcome than a larger weight loss regain, which is typically the case. And the fact that you're getting these corollary effects in other areas of life, like mental health and things like that is very impressive. Are there other stories you could tell from people that have been on the program that might be illustrative?

Oh yes. What happens most often in our studies is that at some point one of our patients approaches me and says, "You know, I've tried everything. I've tried dieting, tried this app and that app and this is just so easy. I've been able to stick with it for a long time." That happens a lot. And it always, always pleases me greatly because at the end of the day we're really trying to create these technologies for real people to use over a very, very long period of time. I find that exciting. We've had a number of people over the years who have gotten off their hypertension medications or have had seen changes in their diabetes, their A1Cs as a measure of diabetes. And it's just really exciting because then it's one of the things that I think gets us up in the mornings to do this work.

That is exciting. How has it been especially influential among people who otherwise have limited access to care?

We really started this work because of a series of observations that I made early in my career when I started working in community health centers. Community health centers are often primary care units in many major metropolitan areas, and often in rural settings as well. Their primary intention is to serve patients who are medically vulnerable, and often patients who are poor. On those settings, the providers in those settings are just doing extraordinary work. And I started to spend time there and was trying to understand how we might think about situating this kind of technology and these kinds of public health style interventions within those care settings. And the observation I made over and over and over again was that, even in these care settings that are really designed to serve patients who have low income or come from limited income backgrounds, weight control and behavior change in general was just not the highest priority. These physicians are dealing with all manner of acute and chronic health crises. And they just didn't feel that managing a patient's weight was the best use of their limited clinical time and attention with patients. The challenge of that, of course, is that, for patients who have obesity, that can be a primary cause of many of the acute and chronic conditions that my physician colleagues were treating. And so what I began to observe was that patients who have the greatest need for comprehensive obesity care are often the least likely to receive it. And this is borne out by national data, which suggests that if you're a person from a medically vulnerable background and you have obesity, you're dramatically less likely to receive high quality care from the health system. And then there are a whole range of financial constraints that limit your ability to be able to acquire that care in the commercial market. And so there are really many, many people, really, tens of millions of folks out there without options. So, that's really why we started developing these tools. And I'm very pleased to say that the underlying approach that we develop with iOTA has been leveraged in a variety of weight control interventions that are being used in other places. The next frontier for us is to really think about how to disseminate this in a more widely accessible way. We've begun having conversations with metropolitan areas. Cities where health departments are thinking about doing these kinds of things. Some of these technologies have found their way into other systems. And increasingly as we have begun to test these approaches in clinical care settings, we certainly have seen ongoing use of these technologies in the community health centers where we originally came up with some of these ideas. So, much more work there to be done but I'm hopeful.

Do you see a role for this approach in conjunction with or as a companion to the weight loss medications that are getting so much attention now?

Yes, I do. One of the things that's notable about this generation of weight loss medications is that they do not have an indication that they should be accompanied with a behavior change intervention. So, the other way to say that is that most weight loss drugs that we've seen in years past have received FDA approval, contingent on their combination, their use, alongside a behavior change intervention. And the GLPs, the ones that are most recently emerged, don't have that indication. Nevertheless, we know a couple of things. One is that these are medications that are designed to be used for very long time in order for fat, weight loss to be sustained. And there are a number of people who increasingly are interested in transitioning off of these medications and beginning to engage weight control on their own. So, my sense is that technologies like iOTA can be very useful in helping people make those transitions off of drug. I think the technologies we've created can be very, very useful as an adjunct to try to help to maintain motivation for weight loss. And to think about addressing some of the related behaviors that can help people to experience an overall improvement in their health. So, becoming more physically active and making changes in stress and wellbeing as an adjunct to the weight loss that's being produced by the drugs. I have to tell you, I'm very, very concerned about the cost of these medications. I'm very pleased by their efficacy, but I'm extraordinarily concerned about their cost and their limited accessibility. I expect that will change. But during this period of time, I'm very concerned about the creation of additional disparities, patient's ability to seek really high-quality care.

I'm glad you raised that point. So, where do you see the work going next with IOTA?

Well, I see it going in two directions. One, we are thinking about dissemination. Where can you embed this kind of approach inexpensively in ways that allow the greatest number of users. The emergence of artificial intelligence technologies, notably the large language models, really help in that regard because they allow us to deliver that kind of core iOTA special sauce more flexibly in a range of different technologies. And even more inexpensively than we can do right now. iOTA is extremely cost effective and with AI delivery it could be even more so. And then the other path I see is really what you asked before. And it's how do we think about using these technologies as an adjunct to medication treatment, which I think will become even more common over the next couple of years. I hope that it becomes a more common approach that's used to treat the patients who have the highest risk of obesity and all of the chronic health conditions that travel along with it.

Bio

Gary Bennett, a professor in the department of Psychology & Neuroscience who also holds appointments in Global Health, Medicine and Nursing, is the founding director of the Duke Digital Health Science Center. For 20 years, he has been studying how incorporating digital strategies into clinical treatment of obesity can improve health outcomes. His development of the Interactive Obesity Treatment Approach (iOTA) has been supported by over $20 million in grants from the National Institutes of Health.