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Hindawi Publishing Corporation
Journal of Obesity
Volume 2016, Article ID 9372515, 7 pages
http://dx.doi.org/10.1155/2016/9372515
Research Article
Implementation of an Internet Weight Loss
Program in a Worksite Setting
Kathryn M. Ross and Rena R. Wing
Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University and The Miriam Hospital,
Providence, RI 02906, USA
Correspondence should be addressed to Kathryn M. Ross; kathryn ross@brown.edu
Received 20 November 2015; Accepted 13 January 2016
Academic Editor: Eliot Brinton
Copyright © 2016 K. M. Ross and R. R. Wing. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Background. Worksite wellness programs typically produce modest weight losses. We examined whether an efficacious Internet
behavioral weight loss program could be successfully implemented in a worksite setting. Methods. Participants were 75 overweight
or obese employees/dependents of a large healthcare system who were given access to a 12-week Internet-based, multicomponent
behavioral weight loss program. Assessments occurred at baseline, Month 3 (end of intervention), and Month 6 (follow-up). Results.
Retention was excellent (93% at Month 3 and 89% at Month 6). Intent-to-treat analyses demonstrated that participants lost an
average (±SE) of ?5.8 ± .60 kg from baseline to Month 3 and regained 1.1 ± .31 kg from Month 3 to Month 6; overall, weight
loss from baseline to Month 6 was ?4.7 ± .71 kg, ?? < .001. Men lost more weight than women, ?? = .022, and individuals who had a college degree or higher lost more weight than those with less education, ?? = .005. Adherence to viewing lessons (8 of 12) and self-monitoring (83% of days) was excellent and significantly associated with weight loss, ??s < .05. Conclusions. An Internetbased behavioral weight management intervention can be successfully implemented in a worksite setting and can lead to clinically significant weight losses. Given the low costs of offering this program, it could easily be widely disseminated. 1. Introduction With two-thirds of the United States population considered overweight or obese [1], there is a need for effective weight loss interventions that can be widely disseminated at minimal cost. Traditional behavioral weight loss programs, which typically include weekly or biweekly in-person or groupbased meetings with a trained interventionist, are effective in helping obese and overweight individuals lose weight [2], but the reach of these programs is often limited due to high cost and time burden for both providers and participants. Consequently, efforts have been made to increase the dissemination potential of these interventions through alternate delivery modalities such as Internet-based programs. Early research on Internet-based weight management programs, however, demonstrated weight losses that were inconsistent and smaller than those typically observed in traditional face-to-face behavioral interventions [3]. Despite these early findings, more recent research has demonstrated that integrating additional treatment components (such as interactive multimedia lessons, small financial incentives, and automated tailored feedback based on participants’ goal progress) demonstrates promise for improving the efficacy of Internet-based behavioral weight management programs [4–6]. Two recent studies investigating the use of a 12-week Internet-based behavioral weight loss program with small financial incentives [5] and secondarily in a primary care setting [7] demonstrated weight losses of 6.4% and 5.8% of baseline weight at immediate posttest (3 months), respectively, with maintenance of these weight losses at 6 months. Given the efficacy of newer Internet-based weight management programs, an important next step is to identify avenues for dissemination. Corporate wellness programs offer an ideal platform for the dissemination of evidencebased weight management programs, as corporations have vested financial interest in improving employee health. Obesity costs employers up to $73.1 billion dollars per year in medical costs and absenteeism; per employee costs range 2 from $322 to $6087 (from overweight to the highest category of obesity) in men, and from $797 to $6694 in women [8]. A 2012 survey found that almost 80% of companies employing over 1,000 people had corporate wellness programs [9], and this number is likely to increase with funding provisions in the Affordable Care Act [10]. Systematic reviews of worksite-based behavioral interventions suggest that these programs typically produce statistically significant but modest weight losses [11, 12]. In a recent review, Anderson and colleagues reported a pooled estimate for weight loss of ?1.27 kg (range: +1.63 kg to ?6.70 kg compared to control) at either 6- or 12-month follow-up compared to control across nine randomized controlled trials in worksite settings [11]. Moreover, Internet programs implemented in this setting have had limited efficacy, with 7 of 15 studies showing no significant changes in body weight [13]. Thus, it is important to determine whether a specific Internet program that has been shown to produce weight loss in other settings can be effectively implemented within a worksite or corporate wellness program. For the current study, we used an Internet-based behavioral weight management that has been demonstrated to be efficacious within a community-level health program [4, 5] and in a primary care medical setting [7] (with mean weight losses of 6% over the 3-month program in these settings) and investigated its implementation within an existing corporate worksite wellness program. We report on the average weight losses achieved, the percent of participants who obtained a clinically significant weight loss (?5% of baseline body weight), and whether the program was differentially effective for specific subgroups [14]. 2. Methods 2.1. Participants. Participants were employees or dependents of employees who were enrolled in the worksite healthcare reward program of a large healthcare corporation in Providence, Rhode Island. Recruitment was limited to 100 eligible individuals. Potential participants (between the ages of 18 and 70 years and who had BMIs of at least 25 kg/m2 ) were contacted in one of two ways: (1) by the healthcare rewards program (separate from the research team) through targeted e-mails and texts and (2) through advertisements placed on the worksite intranet. The emails, texts, and advertisements instructed participants to provide their name and email on a hospital voicemail system, after which they were sent an email with a unique link to our study website. This link provided additional information about the study and allowed participants who were still interested to complete a prescreen questionnaire that assessed basic eligibility criteria (e.g., age, BMI, or self-report of medical conditions that would contraindicate weight loss). After completing this prescreen, potentially eligible individuals were invited to schedule an in-person orientation visit at the Weight Control and Diabetes Research Center (WCDRC) in Providence, Rhode Island. This visit provided potential participants with a thorough introduction to the study and research procedures, after which written informed consent was collected. After providing consent, participants had their height and weight Journal of Obesity measured and were asked to complete baseline assessment questionnaires. Potential participants were excluded if their weight was >150 kg (a restriction of in-home body weight scales provided
as part of the study), if they were unable to attend the
assessment visits, if they reported that they were currently
pregnant or planned to become pregnant in the next 12
months, if they were currently enrolled in another weight loss
program or research study or had completed a study at our
center within the past 2 years, or if they did not have access to
a computer/Internet at home. Further, participants with medical conditions that would contraindicate weight loss behaviors (e.g., uncontrolled hypertension or diabetes, undergoing
treatment for cancer, recent history of coronary heart disease,
self-report of an eating disorder, inability to walk at least
2 blocks without stopping, or weight loss of ?4.5 kg in the
month prior to enrollment) or factors that would render the
participant unlikely to complete the study (e.g., plans to relocate, substance abuse, terminal illness, severe psychiatric conditions, or dementia) were excluded. Approval for this study
was obtained from the Miriam Hospital Institutional Review
Board.
2.2. Procedure. All participants were provided with a 12week, multicomponent Internet-based lifestyle weight management program that combined an initial hour-long, intensive in-person group visit with an Internet-based intervention, in-home body weight scale, paper food records, financial
incentives for self-report of weekly data, and optional inperson counseling sessions if participants achieved only minimal weight loss at 4 weeks. This program has demonstrated
efficacy for weight loss in community and primary care
settings [5, 7].
The program started with an in-person group visit, at
which participants learned how to use the study website and
were given basic education regarding weight management
and prescribed calorie, dietary fat, and physical activity
goals. All participants were instructed to consume 1200–
1800 kcal/day, depending on their initial body weight, and
to reduce dietary fat intake to less than 30% of total daily
calories. Participants were further instructed to gradually
increase their engagement in moderate-intensity physical
activity (primarily through brisk walking), eventually reaching a goal of 200 minutes per week. Finally, participants
were taught how to self-monitor caloric intake, fat intake,
and physical activity and how to enter this information
into the study website. Participants were given an in-home
body weight scale that transmitted their weight data to the
WCDRC, a calorie reference book, and paper food records to
use during the 12-week weight management program.
2.2.1. Internet-Based Program. The Internet-based program
was delivered weekly over a 12-week period. At the beginning
of each week, participants were provided with a new, 15minute multimedia lesson. These lessons presented standard
behavioral weight loss strategies and were adapted from
the Diabetes Prevention Program [15], Look AHEAD [16],
and other behavioral weight loss programs. To increase
participant engagement, the interactive lessons incorporated
Journal of Obesity
video, animation, audio, quizzes, and exercises for goal setting
and problem-solving [17]. While only one new lesson was
provided per week, participants could view previous weeks’
lessons at any time.
A key component of the program was self-monitoring
and participants were asked to record their daily weight,
calorie and fat intake, and minutes of physical activity. Participants were asked to submit their self-monitoring data at
least once a week and received tailored, automated feedback
(generated using an algorithm) related to their goals for
weekly and overall weight loss, caloric intake, and physical
activity minutes. Reinforcement and support were provided
for goals that were met, and encouragement, along with
specific behavioral strategies to try, was provided for goals
which were unmet. The website also provided a chart displaying a participant’s weight change to date, healthy recipes, and
additional weight control information that they could access
if desired. The Internet program lasted for 3 months, after
which participants no longer had access to the intervention
website (i.e., the weight chart, intervention lessons, and other
intervention materials). Between months 3 and 6 participants
were encouraged to continue to self-monitor caloric intake,
minutes of physical activity, and body weight but no feedback
was provided.
As previous literature has demonstrated that initial
weight loss predicts long-term outcome, participants who
had lost only small amounts of weight ( 158.8 kg n = 2
(ii) BMI < 27 n = 3 (iii) Age < 18 n = 1 (iv) Pregnancy n = 3 (v) Medical n = 7 (vi) Other wt programs n = 5 Excluded prior to consent n = 22 (i) Did not attend orientation n = 16 (ii) Not interested n = 4 (iii) Not affiliated with Lifespan n = 2 Excluded during baseline: 6 (i) Weight > 158.8 kg n = 1
(ii) Other weight loss programs n = 3
(iii) Not affiliated with Lifespan n = 1
(iv) Did not complete baseline n = 1
Did not schedule/attend WL 101
n=2
Completed 6 M
n = 67 (89.3%)
Included in analyses
n = 75
Figure 1: Participant flow through recruitment and intervention.
was stopped due to a recruitment goal of ?? = 100) and
75 enrolled in the current study; see Figure 1 for participant
flow through recruitment and assessment. Seventy of the 75
participants (93.3%) returned for the Month 3 assessment and
67 (89.3%) returned for the Month 6 assessment. Baseline and
demographic data are presented in Table 1. There were no
differences between participants who did and did not return
for the Month 6 assessment in terms of age (?? = .750),
sex (?? = .532), or race/ethnicity (?? = .623). There was
a significant difference in attrition by education, such that
individuals who did not return for the Month 6 assessment
were less likely to have a college or graduate degree (Fisher’s
exact ?? = .001).
3.1. Weight Change. On average, participants lost a mean
(±SE) of ?5.78 ± 0.60 kg (?6.37±0.60% from baseline) during
the course of the 12-week intervention, ??(74) = ?9.70, ?? < .0001. From Month 3 to Month 6, participants regained an average of 1.10 ± .31 kg (1.39 ± 0.40%), ??(74) = 3.60, ?? = .009. Overall, from baseline to Month 6, participants lost a total of ?4.68 ± 0.71 kg (?5.03 ± 0.76%), ??(74) = ?6.60, ?? < .0001. Mean changes with BOCF were almost identical. The 15 participants who were given additional support had a mean weight loss of ?0.30±1.19% at 4 weeks, which increased to ?1.64 ± 1.50% at 6 weeks; however, weight loss for these participants at 6 months was 0.27 ± 1.86%, far below the Variable Age, years Weight, kg BMI, kg/m2 Gender Female Male Ethnicity (%) African American Asian Caucasian Hispanic Other/multiple Marital status Single Married or living with a partner Separated/divorced Household income, dollars 25,000–50,000 50,001–75,000 75,001–100,000 100,001–125,000 125,001+ Not reported Education High school or less Vocational training Some college College or university degree Graduate degree Total sample ?? = 75 Mean SD 50.76 10.38 86.42 1.94 31.19 4.41 ?? % 52 23 69.3 30.7 4 1 63 2 5 5.3% 1.3% 84.0% 2.7% 6.7% 5 61 9 6.7% 81.3% 12.0% 7 16 18 10 22 2 9.3% 21.3% 24.0% 13.3% 29.3% 2.7% 6 2 14 34 19 8.0% 2.7% 18.7% 45.3% 25.3% ?6.22 ± 0.80% experienced by the 60 participants who did not receive additional intervention. We also examined the percent of participants who achieved a clinically significant weight loss of at least 5% of initial body weight [14]. At the end of the 12-week intervention, 60.0% of the sample (?? = 45 of the 75) experienced a weight loss of ?5%. Further, following a 3-month maintenance period wherein participants received no further contact or intervention, 53.3% of participants (?? = 40 of the 75) maintained a weight loss of ?5% at 6 months. Percent weight loss from baseline to Month 6 did not differ between participants considered “overweight” (BMIs between 25.00 and 29.99 kg/m2 ) at baseline compared to those who were considered “obese” (BMIs above 30.00 kg/ m2 ) at baseline, ?? = .666; participants who were overweight at baseline lost an average (±SE) of ?4.67±1.12% of their baseline weight, compared to a ?5.33 ± 1.53% loss experienced by participants who were obese at baseline. Investigating other baseline factors, there was a significant association between Journal of Obesity 5 Table 2: Website engagement and adherence to self-monitoring during the intervention, and the association between these factors and weight loss at Month 3. Frequency per participant Correlation with percent weight change ?? SD ?? ?? Website log-ins Video lessons viewed? 39.65 8.05 27.94 3.44 ?.098 ?.319 .438 .009 % SD Self-reporting body weight Self-reporting caloric intake Self-reporting physical activity 83.24 82.44 80.37 23.8 24.04 35.85 ?.362 ?.374 ?.409 .034 .030 .014 ? Of 12 video lessons. sex and percent weight loss, such that men had a significantly greater percent weight loss than women from baseline to Month 6 (?7.69 ± 1.35% versus ?3.85 ± 1.61%), ??(74) = 2.39, ?? = .020. Further, there was a significant association between baseline education and percent weight loss from Months 0 to 6; participants who reported attaining a college degree or higher lost significantly more weight than those who reported less than a college degree (mean ± SE weight change = ?6.41 ± 1.62% versus ?1.71 ± 1.40%, resp.), ??(74) = 2.90, ?? = .005. There was no difference in percent weight change from baseline to Month 6 by age, race/ethnicity, income, or marital status, all ??s > .05.
3.2. Use of the Internet Program. Table 2 provides data on
user engagement (measured via website log-ins and video
lessons viewed per person) and adherence to self-monitoring
of weight, caloric intake, and physical activity, and the association between these factors and percent weight change from
baseline to Month 3. As shown, participants viewed on average 8 of the 12 lessons and self-reported their weight on the
website on 83% of the days; adherence to both of these aspects
of the program was associated with weight loss.
4. Discussion
The current study investigated the impact of a multicomponent, Internet-based behavioral weight management program on weight loss in a workplace setting. Participants in the
current study lost an average of 6.4% of their baseline weight
during the 12-week intervention, and maintained a loss of
5.0% of their baseline weight at a follow-up at 24 weeks from
baseline (Month 6). Sixty percent of the participants were able
to lose at least 5% of their body weight, and despite experiencing some regain in the 3 months following intervention, over
half were able to maintain a clinically significant weight loss at
a three-month follow-up (Month 6).
Many eHealth and Internet-based weight management
programs have suffered from low program engagement and
adherence [17]; however, website utilization in the current
study was high. Participants watched on average 8 of the 12
lessons and submitted their weight on 83% of the days during
the initial 3-month program. Both the number of video
lessons viewed and adherence to self-monitoring (via selfmonitoring of weight, caloric intake, and physical activity)
were significantly associated with weight loss at the end of the
intervention.
The clinically significant weight losses observed coupled
with the high participant engagement in the current study
support the use of the current intervention package in a
workplace setting. Moreover, the results suggest that the
program was as efficacious in the worksite setting as it was in
primary care and community programs [4, 5, 7]. Based on a
prior series of programmatic studies, the following key components of the current Internet program used in community
settings have been identified. The video lessons were shown to
have only a small impact on weight losses when presented as a
single component, but lessons combined with the provision of
weekly automated feedback to participants was demonstrated
to significantly improve weight loss outcome [6]. Adding
small weekly incentives for self-monitoring adherence further improved these results [5]. Thus, these aspects of the program may also have been related to its success in the worksite
setting.
The current study demonstrates that a low-intensity, multicomponent Internet-based approach may be beneficial in a
workplace setting. Further, this intervention was particularly
effective in men. Although gender differences are often seen
in mean weight losses, adjusting for baseline weight typically
removes this difference. In the present study, men had a 7.7%
reduction in body weight compared to 3.9% in women, suggesting that this type of program may be particularly effective
for men. As behavioral weight management studies typically
have a higher enrollment of women compared to men, future
studies should seek to increase the recruitment of men since
this program appears particularly effective for these individuals.
Strengths of the current study include minimal attrition,
objective measures of body weights at assessments, and the
use of intent-to-treat analysis to account for missing data.
Whereas many investigations into the efficacy of worksite
weight loss programs have suffered from high attrition and
failure to adjust for this attrition in subsequent analyses
(e.g., using completers-only analyses) [12], the current study
demonstrated good retention and conducted a conservative,
intent-to-treat analyses; both multiple imputation and baseline observation carried forward approaches were used to
6
manage missing data. Limitations to the current study include
the lack of a no-treatment control group and the inability to
assess relative impact of program components. The current
study was procedurally limited in that the healthcare system
that funded the intervention requested a weight management
program that would be open to any eligible employee and
would not involve the possibility of randomization to a control group or to programs with different components (which
could then differ in their efficacy). Because there was no control group included in the current study, however, we cannot
rule out other factors beyond intervention participation that
may affect weight change over time. Additionally, participants
self-selected to enroll in this trial, which may lead to a sample
of highly motivated individuals; without including a no or
minimal treatment control condition, we cannot control for
the impact of self-selection on weight loss.
Finally, the current study did not include a maintenance
component following the end of initial weight loss intervention (Month 3). Since research has demonstrated that
providing extended-care interventions following the end of
weight loss treatment programs improves long-term weight
loss outcomes [19], a next step would be to develop and test
an Internet-based maintenance component. Previous studies
have demonstrated that an Internet-based maintenance component led to similar maintenance of weight loss (following
an interactive-TV based weight loss intervention) when compared to a group that continued to meet face-to face [20]; it
is unknown whether an Internet-based maintenance component would have similar impact following an Internet-based
weight loss program.
5. Conclusion
The current study demonstrated that a 12-week, Internetbased weight loss intervention can be successfully implemented in a workplace setting and produce clinically significant weight losses. Participant engagement with the intervention website was high, as was adherence to self-monitoring
of weight, caloric intake, and physical activity. Future studies
should examine ways to improve the long-term maintenance
of weight loss following the use of an Internet-based behavioral intervention in a workplace setting and determine the
effect of the intervention on outcomes of particular interest
to worksites, including medical expenditures and workplace
productivity.
Conflict of Interests
Intervention content used in this study has been licensed to
commercial partners by Rena R. Wing. The investigators on
the project are employees of Lifespan.
Acknowledgments
Support for this study was provided by the Lifespan Corporation and by the National Institute of Diabetes Digestive and
Kidney Diseases (National Institutes of Health) under Award
no. F32DK100069 awarded to Kathryn M. Ross.
Journal of Obesity
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