The Impact of Integrating an Internet Weight Control Program Into Primary Care
Condition: Overweight; Obese
MeSH terms: Overweight
Study type: Interventional

Summary: 
      The investigators will conduct a randomized controlled trial comparing the effects of three
      interventions on weight loss at 12 months. The investigators propose to test the impact of
      integrating an effective automated Internet weight control program into primary care by
      recruiting patients and randomizing them to one of three conditions: A) Brief physician
      counseling plus usual care, B) Brief physician counseling plus referral and access to the
      Internet weight control program and, C) Brief physician counseling plus referral and access
      to the Internet weight control program plus brief follow-up email notes of support and
      accountability from Primary Care Physicians. The investigators hypothesize that an online
      program for weight control can be more effective by enhancing online follow-up with PCPs.
    

Detailed description: 
      Every year, roughly 700 of the 750 million visits that overweight and obese patients make
      with primary care providers (PCPs) occur without any weight counseling. The main reasons for
      this are that PCPs are poorly trained to help their patients lose weight and that there are
      no consistently effective interventions for primary care settings. Though in-person and
      telephone-based weight control programs have been difficult to disseminate in primary care,
      online weight control programs are increasingly effective and may lend themselves to be used
      in these settings. Given the growing number of effective online programs, for obesity and for
      other conditions seen in primary care (e.g., depression, insomnia) it is important to
      understand whether these programs can be effective when integrated into primary care and
      whether they are enhanced by provider involvement. Research on the 5 A's model of primary
      care behavior change suggests that the most effective, yet least used feature of primary care
      interventions is arranging follow-up, where providers hold patients accountable to adhering
      to treatments and achieving specific outcomes.

      The 5 A's model provides a useful framework for integrating behavior change interventions
      into primary care. In this model, providers ASK about weight, ADVISE patients to lose weight,
      ASSESS readiness to change, ASSIST the patient in making changes and ARRANGE follow-up.
      Unfortunately, though PCPs are uniquely positioned to ARRANGE follow-up, given their
      long-term relationship with the patient, and studies show that ARRANGING follow-up may be the
      most effective of the 5 A's, it is the least often used. In a study of 481 encounters with
      overweight patients, Pollak (Consultant) and colleagues observed that PCPs ARRANGED follow-up
      in only 5% of visits, though it was the only one of the 5 A's associated with future weight
      loss. Kottke and colleagues similarly observed that primary care smoking cessation
      interventions that included more "reinforcing sessions" with PCPs were the most effective.
      This is consistent with conclusions by Whitlock and colleagues that "Simply notifying
      patients that follow-up will occur seems to be a powerful motivating factor". These findings
      have been extended to online interventions, where two meta-analyses concluded that the impact
      of online interventions for depression and anxiety is enhanced by follow-up that includes
      being accountable to and supported by a human being.

      The investigators have created a simple method for integrating an Internet weight control
      program into primary care settings, by allowing PCPs to monitor their patients' adherence and
      outcomes and email them pre-written, tailored follow-up messages. PCPs in the investigators'
      pilot work believed that this would help to overcome key barriers to helping their patients
      lose weight.
    

Intervention name(s): Usual Care; Brief Physician Counseling; Referral and access to an internet weight control program; Brief follow up email notes from PCPs
Intervention type(s): Other; Behavioral; Behavioral; Behavioral
Intervention description(s): Standard care; Primary Care Physician (PCP) will review a goal setting worksheet for weight loss with the participant and then collaboratively set a goal for weight loss.; Participants will receive a login and password for the weight loss website. The website will encourage patients to set a new weight goal every 3 months and work towards a total weight loss goal of 10%. Patients will also receive an email prompt each week alerting them to new content and reminding them to check-in to the website to report their weight, intake and activity.; Patients will receive a biweekly email from their primary care physician on how they are doing with their weight loss.
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment