I'd like to introduce, then, for the first talk, Dr. Robert Kushner, who is professor of medicine at Northwestern University in Chicago. He's one of the leaders in the field of obesity medicine and has been so for more than two decades. His expertise is across the board in treating obesity, but in particular, he has a focus on how to approach lifestyle interventions with novel ways, including new technologies, new methods of organizing health care, and in particular, likes to emphasize the importance of healthy interactions between providers and patients. He's going to talk to us today on expanding options for lifestyle coaching, telehealth, smart devices, and apps. Dr. Kushner, welcome. Thank you, Lee, and good morning to everybody. I'm pleased to start the whole seminar for all of you. I'm going to be talking, as Lee said, about a resource that's going to be extremely helpful for all of you to know about, and that is using telehealth, smart devices, and apps. I think a friend to all of you who are not engaged full-time in obesity care and have the bandwidth to provide the lifestyle and behavioral support needed in addition to the interventional devices, so this will be very, very helpful for you. These are my disclosures. I think over the past year, in particular, as the world has turned upside down, a lot of us who do outpatient care have turned to telehealth and other virtual resources to provide obesity care, so the timing of this is perfect. Just for a definition point of view, we think of the term digital health interventions as an umbrella term. Under digital health interventions, we have eHealth, which are things like email, internet, social media, and smartphone apps. Here we have mobile health, which are mobile devices. Then we have, under that same umbrella term, telehealth, which is telephone coaching and videoconferencing, and I think a lot of us have been doing telehealth, but not so much these other eHealth interventions, which can be very, very helpful. I want to start off with just two studies that I found that are fairly recent to give you a sense of the effectiveness or what are the elements that have been found to be useful in changing behavior. This is one study published last year in Obesity Reviews that looks at a meta-analysis of mobile interventions, particularly looking at behavior change techniques, called BCT, that were helpful in helping to change nutrition or nutrition-related health outcomes. They looked at 27 randomized controlled trials. Most of the interventions were composed of four behavior change techniques that are very important that I'm highlighting for you. They were goals and planning, feedback and monitoring, social support, and shaping knowledge. This is just important for you to know because in your own healthcare system, if there are applications available, you kind of want to make sure that these four behavioral change strategies are covered. Simply giving knowledge alone has not been effective in shaping behavior, whether it's our behavior and changing our own practice or our patient's behavior in taking better care of themselves. The other techniques that are to the right were also helpful, but really it's these four that help to change behavior, and that's what you're going to be looking for when you select an application. So in summary for this, app-based mobile interventions can be effective for changing nutrition behavior and their main nutrition-related health outcomes. There's just one other study published in the past year that I wanted to bring to your attention, and what this looked at is the effect of motivational interviewing in electronic health or telehealth interventions, and this was a systematic review. And I think all of you remember from medical school, you know, motivational interviewing is this coaching style, which is collaborative and shared decision-making. And in this review, they looked at 15 articles. Most of them were actually on the telephone, and most of them, the interventions were for 12 months. And what you're looking at is actually mixed results was the conclusion, but what you're looking at is mHealth or mobile health or electronic health seemed to cause more weight loss during the intervention. Not a great deal, but in many of the cases, significantly more than the active comparator, which was either in-person or another comparison, or actually no treatments at all. So it is mixed results, but there is some data that shows that this kind of intervention can be helpful. This also was looked at quite some time ago by our colleague, Tom Wadden, in an article in Circulation. He concluded, his authors and him conclude that the most successful internet programs that provide weekly email feedback to participants will induce weight loss of approximately two-thirds the size of those achieved by traditional on-site behavioral programs. So kind of the bottom line regarding the evidence-based, kind of a quick review, is that there is an evidence-based that these types of interventions can be helpful. Most of them do show it's not as effective as in-person, but again, we live in a new world and virtual is becoming the new norm, and that's something you should all be considering when you're doing an intervention, a obesity intervention on an individual, what else can you actually provide? I want to now turn with this kind of a background to some more specific brand names and some of that data around it for you to be thinking about and be aware of. So as far as mHealth obesity programs, I divide them into three different categories for convenience. The first are free self-monitoring apps. Examples would be MyFitnessPal, LoseIt, and MyPlate, and that's something you want to become familiar with and utilize in your treatment, because that's a way for self-monitoring that the patient can do, and I'll go over that a little bit more with you later. We also have commercial programs that have apps, Weight Watcher, used to be Weight Watchers, now it's called WW, and NOOM are two examples that you can refer a patient to. And then lastly, our very comprehensive programs, they're commercial programs, and they're in the category of disease management programs, usually B2B or business between two different businesses or employees, and examples there would be VitaHealth, AmadaHealth, Livongo, and Virgin Pulse, and I'll show a little bit about that as well. So let me dive into some of these and give you some of the features and what that actually looks like. So first, I do want to emphasize this whole idea of why self-monitoring changes behavior. If you're going to do anything with your patients at all, at the very least, get them to self-monitor their behavior. It makes a difference, and that is coming out of two principles that you may or may not remember from school or just general knowledge. One of them is called the Heisenberg Principle, which is a very active observing a phenomenon and alters that phenomenon in some way, and the other is called the Hawthorne Effect, which actually comes out of the Chicagoland area, where Hawthorne industries, they were not being as productive as they wanted to, so they brought in a bunch of observers to see how these factory workers actually perform. And interestingly, just bringing in a group of people to observe the factory workers, they increase their performance, and that was called the Hawthorne Effect based on that. So the very nature of someone watching you is likely to change your behavior or you're watching your own behavior. This is the principle why, if you're doing wildlife observations, you have to hide in the bush. The animal can't see you, because as soon as the animal sees you, the animal changes its behavior. So these are the principles of why we do it, and I just took this picture in my own community. We use this all the time in public health and in our own communities. We often put these monitoring things up, where if you see what the speed limit is and you see your own speed in your car, typically people slow down. Sometimes it gets you speed up just to see that number shoot up, but I think most law-abiding citizens actually try to reduce their speed in order to conform with what the speed limit is. So how does self-monitoring make a difference? We know self-monitoring is helpful in medicine across the board, in blood pressure, in diabetes, people self-monitor all the time, and of course, obesity, you self-monitor your weight. So you want to encourage this and utilize these modalities with your patients. There are many electronic tracking and interactive programs available for self-monitoring or for interaction. So something like MyFitnessPal or CalorieKing or LoseIt, a patient is just self-monitoring their own diet. Some of these programs, of course, combine self-monitoring with different social medias, would be example, WW and Noom, others would be MyPlate, which is from the government. Some of these are free, some of these you have to pay for. So that's self-monitoring your diet. Likewise, you can have your patients self-monitor their physical activity. And these are just examples of the most commonly used wearables that we have. Garmin is well-known, of course, the Apple Watch, which is not on this slide, unfortunately, but smartphone all the way to the right, mostly have activity monitors in them as well. The exciting feature of combining all of these together is that you have an energy balance dashboard. This is a concept I talk about all the time with patients. If you have someone who's analytical, you know them, right? Not that they have a slide rule in their pocket anymore, but they're very analytical. They like measuring things, they like metrics, they're very organized. We can now encourage that obsessive behavior by having them self-monitor their diet, self-monitor their physical activity, and self-monitor their weight. This happens to be a Wi-Fi unloadable scale to the right, so you have an electronic dashboard of energy balance. So it's very, very helpful in changing behavior. So let me show you just two screenshots. One is Noom, and I'll show you some data and then Weight Watchers. Noom not only does self-monitoring, but also has other features in which the individual gets input on stress management, on sleep, on behavior change, and it's a cognitive behavioral program. This is what the user would be looking at, and as they scroll down their screen, they're able to get a lot of information, self-monitor, and coaching. There is at least, there's probably a few, but I happen to choose one article from the literature published in 2016, which they actually looked at the outcome of Noom users. In this study, they had 15,000 participants that had data that went out at least to six months. And what you see, it's divided up into female, male, and total, if you just look at the total, you see most of the users in the six-month period of time are losing 10% of their body weight or less, and that's actually very, very good. You have some users that are losing, of course, more than 10%, and that's just that bell-shaped curve that you see in any intervention. So there does appear to be data using Noom. You're probably all familiar with it. If you watch TV for more than 10 minutes, you probably see a commercial for Noom, and it is a self-help program. The other one, probably the biggest player globally, is WW, and again, this is a screenshot. You can see that WW now is not your grandmother's weight loss program anymore. They're now looking at things like sleep and workout, and are you drinking water? Are you doing all kinds of other mindset activities? It does allow you to track your diet as well, and it uses points rather than calories. There's actually dozens of WW articles that have been published. I just gave you an example of one article. It's not using its app. It's actually going to in-person treatment, but I wanted to show it because it's very powerful. It was published in Lancet about three years ago, which shows a two-year outcome trial of using this, and you can see that a 52-week program really did lead to significant weight loss, although they do gradually gain weight thereafter. There are also disease management programs to be aware of. That's a little bit different. That's where your company will usually reach out to the employees of the company and ask if you belong to a disease management program, and it's much more encompassing. It's just an example of a retrofit, which was brought up by Livongo a little bit later, but it emphasizes this whole idea of self-monitoring, and that's why I put this study up here. This was a six-month study in which there's coaching, a Wi-Fi scale, accelerometer, food logging, and so on, and individuals lost about 5% of their body weight, which is pretty reasonable, but what's shown in these two graphs, which the top one looks at the frequency of self-weighing, the bottom graph is the average steps taken, and what you see is that there's a diminishment in the activity over six months for both of these, but those that kept the activity to the highest, it would be the blue line in both of them, ended up losing more weight. That is, the more that you self-weighed and got on the scale, and the more steps you logged in, the more likely you're going to lose more weight. This was seen, by the way, in Noom as well, which I didn't mention before, and they found that the most successful weight loss reduction in that program was the input in the frequency of diet, weight, and exercise, so self-monitoring by itself, to get back to highlight an important point I want to make, self-monitoring alone is not going to be helpful unless you look at the data, so if you have a patient who puts on a Fitbit, but never looks at the data, and wearing a Fitbit's not going to change your behavior. You actually have to look at the data, use it as an incentive, and mark your progress, so that's just something else you want to tell individuals. And lastly, there are disease-related companies, which are much more comprehensive, and I just want to show you what that looks like, Livongo, that you may have heard of, a lot of your patients may belong to a company that has hired Livongo to come in and do disease management. These individuals get this whole set of materials and tools sent to their home, particularly for diabetes, that's where it made most of its name, but now it's launched into blood pressure, hypertension, and so forth. Here's a screenshot from Omada that many of you may have heard of as well, very comprehensive, so if you have a patient who has this opportunity, it's a wonderful way for them to receive the self-monitoring they're looking for. And then lastly is VitaHealth, which is another big player in this area, and you can see all of the behaviors that VitaHealth is likely to support a patient on, in addition to obesity. You notice, interesting, obesity is not on here, isn't that interesting? But when they look at exercise and eating better and sleep, excuse me, weight loss is here, now I just see it, apologize for that, I didn't see it earlier. So those are all the things. And lastly, I think it's near my last slide, is Healthcare 2020 and Beyond. This is an article that was published in 2015 that I really thought was very interesting and provocative. And what it depicts is that units in the future, kind of integrated practice units, which all of you would potentially be part of this, is that by doing an intervention and connecting individuals through eHealth or mobile health and looking at analytics, we're more likely to help patients be more successful. I just want to put a plug in for the American Board of Obesity Medicine for any of you wanting to increase your knowledge and develop a competency in obesity and take an exam for it. I would consider, this is the growth of the organization. I would encourage you to visit abum.org for it to be a diplomat, the American Board of Obesity Medicine, which requires an examination. This is my conclusion, mHealth is a reasonable treatment option to support lifestyle weight management. There are a variety of interventions that are available ranging from free self-monitoring apps, digital commercial weight loss apps and programs, and more comprehensive employee-based program through your employee. Outcome data, however, is limited in short term, but thus far, I think it would be very useful for you to consider this type of support. Thank you very much, Lee. Hand it back to you.

telehealth

smart devices

apps

lifestyle coaching

obesity care