Online Obesity Treatment in Primary Care (Rhode Island, USA)
Online Obesity Treatment in Primary Care (Rhode Island, USA)
Behavioral obesity treatment produces clinically significant weight loss; for the greatest
 impact, it should be made available in the primary care setting where it can reach the many
 patients with overweight/obesity. The investigators developed a 3-month automated online
 behavioral weight loss program, Rx Weight Loss (RxWL), and showed that it produces clinically
 significant weight losses among primary care patients. The investigators' early efforts at
 pragmatic implementation of RxWL have been promising, and have shed light on challenges
 associated with implementation, and the need to study longer-term effectiveness. The
 investigators will therefore conduct a pragmatic study to improve the implementation and
 effectiveness of this behavioral obesity intervention delivered in routine and representative
 healthcare settings. The investigators are partnering with the Rhode Island Primary Care
 Physicians Corporation (RIPCPC), a large primary care network of 58 practices with 100
 physicians and 16 nurse care managers. Using the framework for Effectiveness-Implementation
 Hybrid Designs, the investigators will simultaneously target effectiveness and implementation
 to maximize the public health impact of the research. Half of the 16 nurse care managers, and
 the practices they serve, will be randomized to either Basic Implementation (alerts generated
 using the electronic medical record [EMR] to direct eligible patients to RxWL), or to the
 Enhanced Implementation (alerts, clinician skills training to motivate and support weight
 loss, clinician dashboard with reports on patient progress and tools to facilitate patient
 engagement and behavior change). The investigators will test the hypothesis that the Enhanced
 Implementation will increase the proportion of patients directed to, enrolling, and
 completing the weight loss program. Because maintenance of weight loss is a critical problem,
 this project will also involve randomization of 600 patients with overweight/obesity and type
 2 diabetes, hypertension, and/or hypercholesterolemia to the 3 month RxWL intervention
 followed by one of three maintenance conditions: (a) Control- 9 monthly online education
 sessions; (b) Monthly Lessons and Feedback- 9 monthly online video lessons teaching
 self-regulation with automated feedback on the self-monitoring record; (c) Refresher
 Campaigns- 9 monthly on-line video sessions, teaching self-regulation and providing two
 4-week courses with novel strategies and behavioral challenges to improve long-term outcomes.
 The investigators will test the hypothesis that 12-month weight losses are better with
 Refresher Campaigns than Monthly Lessons and Feedback, and both are better than Control.
 Secondary outcomes include changes in weight, CVD risk factors, and medication use over a
 full 24 months. The project is significant and innovative because: it uses an empirically
 validated approach to obesity treatment that is integrated into the primary care setting,
 leveraging existing staff and EMR capabilities; it has a dual focus on improving
 effectiveness and implementation; it has a pragmatic design in partnership with a large
 primary care network that treats a diverse patient population; and it has potential to it
 provides a scalable, sustainable approach that can serve as a model for broader dissemination
 of obesity treatment intervention.
Inclusion Criteria:

 -  Body mass index (BMI) between 25-45 kg/meters-squared

 -  one or more cardiovascular risk factor (type 2 diabetes, hypercholesterolemia, or
 hypertension)

 Exclusion Criteria:

 -  currently in another active weight loss program

 -  taking weight loss medication

 -  currently pregnant, lactating

 -  <6 months post-partum

 -  plan to become pregnant during the next 12 months

 -  a medical condition that would affect the safety of participating in unsupervised
 physical activity

 -  inability to walk 2 blocks without stopping