Principal Findings
obesity, weight loss
OBESITY, RECRUITMENT
Feasibility trials provide an opportunity to pilot study procedures and measures in preparation for a large-scale efficacy trial. We assessed the feasibility of recruiting a sample of postpartum women willing and able to participate in a lifestyle intervention delivered either via Facebook or in-person groups. The in-person condition posed challenges to recruitment. Among individuals not interested in the study, 68.6% (72/105) were not interested in or could not attend in-person meetings, and 18.5% (36/195) of screened individuals were excluded because of reasons related to participating in the in-person condition. These findings are not unexpected, as the barriers to attending in-person treatment sessions documented in several previous studies [Overall, retention was 92% at 6 months and 94% at 12 months. Although based on the small numbers (approximately 15 participants per condition per wave), it appears that retention may have been higher in the Facebook condition in wave 2 when in-person assessments were not required. In wave 1, retention at 6 and 12 months was 79% and 86% versus 100% and 100%, respectively, in wave 2. For comparison, retention in the in-person condition was 93% and 93% in wave 1 and 94% and 94% in wave 2 at 6 and 12 months, respectively. It may be that women who were used to connecting with the weight loss counselor and their group remotely perceived attending an in-person visit as more burdensome. The only data collected at follow-up that required an in-person visit were weight. Providing participants digital scales in future trials would allow all follow-up assessments to be conducted remotely [Average weight losses of 3% in the Facebook condition and 5% in the in-person condition are promising, and it appears that women in the in-person condition lost more weight on average than those in the Facebook condition. Future research should explore the mechanisms through which delivering lifestyle interventions in person versus via digital platforms influences weight loss (eg, through increased accountability, stronger connections with the weight loss counselor or group members, and greater impact on participants’ motivation to engage in behavior change). However, the weight loss in this trial should be interpreted cautiously for 2 reasons. First, participants in wave 2 self-reported their weight at 6 months and 12 months owing to the COVID-19 pandemic-related disruptions in in-person research assessments. Although weights self-reported as part of a digital lifestyle intervention tend to be accurate [Whether participants stay engaged in treatment influences treatment receipt and, thus, efficacy. Digital health interventions have long been plagued by high dropout rates [In addition to examining sustained participation, we also described engagement in the Facebook-delivered intervention. Over the 6-month intervention, participants in the Facebook condition posted a median of 3 (IQR 1-7; range 0-28) original posts and a median of 88 (IQR 50-142; range 11-309) replies. Previous studies delivered a weight loss intervention based on the DPP lifestyle intervention entirely via a commercial social media platform for 12 weeks; thus, we additionally calculated engagement for the first 12 weeks of this study. Participants posted a median of 3 (IQR 1-5) original posts and a median of 65 (IQR 40-93) replies. Engagement over the first 12 weeks was higher in this study than in our previous 1-arm pilot study of a 12-week version of the Facebook-delivered intervention in which participants contributed a median of 2 (IQR 1-3) original posts and a median of 24 (IQR 15-31) replies [Despite higher engagement than other Facebook-delivered weight loss interventions, when asked to select reasons why they did not post or reply in the group, 38% (10/26) of participants endorsed “It seemed like nobody in the group was posting so I didn’t want to be the only one.” This feedback may be related to participants being hesitant to be the first one to respond to an intervention post, as we have heard from participants in previous studies [Participants also indicated that they did not post or reply in the group because they did not have anything to add to the conversation (22/26, 85%) or the topic was not relevant (6/26, 23%) or interesting (4/26, 15%) to them. In addition, 50% (13/26) of participants noted that they generally preferred lurking over visibly engaging. In one of our previous social media-delivered weight loss interventions, participants who had not used the social media platform before enrolling in the study engaged less in the intervention [Another option to increase engagement in digital weight loss groups may be to increase the number of women receiving a postpartum weight loss intervention via a private Facebook group. Pagoto et al [Although engagement in the Facebook condition in this study was higher than that in our previous work with postpartum women or previous studies with adults with obesity, participants appeared to lose less weight. Average weight loss of 3% over 6 months among participants in the Facebook condition was lower than the average weight loss of 4.8% observed in our previous 1-arm pilot study of a 12-week version of the Facebook-delivered intervention [Taken together, our findings related to the feasibility of recruitment under conditions of randomization to an in-person or Facebook condition and our findings related to participation in in-person intervention meetings indicate that an in-person weight loss program with numerous visits has limited feasibility for many postpartum persons. Further research is needed to develop and test efficacious postpartum weight loss interventions that work with postpartum persons’ busy lives. Synchronous video meetings may be an option to foster group cohesion and accountability while overcoming the logistic challenges of in-person meetings. Telehealth or video visits offer the opportunity to connect individuals and groups face-to-face while retaining many of the benefits of in-person interactions. The national telehealth landscape has changed significantly since the initiation of this study. The COVID-19 pandemic has inspired a rapid uptake of telehealth in clinical settings [This feasibility trial also provided an opportunity to pilot and reflect on how contamination was measured. When we designed this study, we defined contamination in 2 ways: participation in other digital or in-person weight loss programs and seeking weight loss information or support on Facebook or other digital social networks. As 3 of the 5 participants who responded affirmatively to a question about concurrent participation in a structured weight loss program reported activities that did not meet our definition of a structured program, in future studies, we will revise the survey question and also have staff call participants to obtain additional details about professional assistance with weight loss outside the study intervention. As the study progressed, we realized that defining seeking weight loss information or support on social media as contamination did not match our study protocols, as we directed women in both conditions to a study Pinterest account where we had compiled online resources helpful for their weight loss journeys (eg, low-calorie recipes, workout videos, and MyFitnessPal tutorial videos) and encouraged women on Facebook to create a healthy Facebook feed by following Pages by public health organizations (eg, AHALiveHealthy and EatRightNutrition). In future studies, we will focus on contamination tracking of participation in structured weight loss programs or weight loss-specific Facebook groups.