Project on EHR-Integrated Lifestyle Interventions for Adults Aged Fifty and Older (PIVOT)

Obesity and cardiometabolic comorbidities are leading chronic conditions among middle-aged and older adults. Unhealthy lifestyle habits and obesity have continued to worsen, especially among those with multiple chronic conditions. Middle to older aged adults with underlying multimorbid conditions are particularly vulnerable and are the target population for this study. This study capitalizes on our decades-long translational research on the efficacious Diabetes Prevention Program (DPP) and DPP-based Group Lifestyle Balance (GLB) interventions; our extensive experience in using electronic health records (EHR) for patient identification and monitoring; and our partnerships with multisector stakeholders in digital health and wellness solutions. This multisite clinical trial uses a 2-stage sequential randomization design to test the adaptive and nonadaptive augmentation of an EHR-integrated, validated base (GLB video) intervention using problem solving treatment (PST), a proven behavior therapy. Adults in the United States (N=1029), ≥50 years of age with a body mass index ≥27 and ≥1 cardiometabolic conditions, will be randomized at baseline to base intervention or waitlist control. Responders to the base intervention, defined by ≥3% weight loss at 6 weeks, will continue the base intervention; participants with <3% weight loss or missing weight data (i.e., nonresponders) will be re-randomized to continue the base intervention alone or augmented with PST coaching via videoconference. Waitlist participants will be re-randomized after a 12-week control period to receive the base or the augmented intervention, but without tailoring based on early weight loss. The base intervention will use EHR-integrated delivery of the self-directed GLB videos, 1 per week for 12 weeks, followed by digital behavior change and motivational messages. The augmented intervention includes base intervention + PST videoconference coaching. All participants will receive a tablet, wireless weight scale, and wearable activity tracker and will be followed for 52 weeks after baseline randomization. Aim 1 is to demonstrate intervention effects on weight loss, behavior change, and patient-reported outcomes. We hypothesize: (1) the augmented intervention will be more effective than the base intervention both among early nonresponders to the base intervention (adaptive) and among participants in the waitlist group (nonadaptive) at 52 weeks; (2) the adaptive augmented intervention will be more efficacious than the base intervention and more efficacious than the waitlist control group at 12 weeks. Aim 2 is to identify predictors of clinically significant (5%) weight loss for individual patients, using sociodemographic, clinical and behavioral engagement characteristics. The proposed interventions are poised to have immediate and widespread impact on access, reach, delivery, effectiveness, scalability and sustainability. This study, if successful, will point the way toward an inexpensive, scalable intervention that would likely be adopted by insurers.