It is no secret that the US is experiencing an obesity crisis and many are embracing GLP-1 agonist weight loss drugs. Racial and ethnic minorities on the other hand, and people with low incomes or living in rural areas, still struggle with obesity/type 2 diabetes mellitus and prediabetes, especially when they live in under-resourced and medically underserved communities.
The federal National Diabetes Prevention Program offers a one-year “lifestyle change program“ (LCP) for those at risk with coaching, health guidance and a support group. But even though it is covered by many employers/insurers and a Medicare program, many in the at-risk demographics are not participating. That’s why a recent study in the journal BMC Digital Health is encouraging.
From February 1, 2021 to October 13, 2022 the study conducted by the technology company Fresh Tri, LLC. at 33 locations in 17 states, funded by the Centers for Disease Control and Prevention (CDC), sought to determine whether a “digital habit formation” app developed by the company improved diet journeys such as allowing weight to stay off longer.
The trial revealed impressive results. Participants who used a digital habit formation app approach (called “iterative”) showed a 78 percent retention rate of their weight loss at 12 months, significantly higher than standard participants. Forty-one percent of the iterative patients loss five percent of their weight versus 31 percent of non “digital habit” participants.
We sat down with the primary author of the study, Kyra Bobinet, MD, MPH who is the CEO and Founder of Fresh Tri and has written books on such new approaches to weight loss and behavioral change.
MR: First of all, please explain to our readers how an iterative mindset differs from a traditional mindset. Many are not familiar with these concepts.
KB: Yes, there is a novel mindset called the iterative mindset that has a 300 percent stronger correlation with health habit formation than say doing Weight Watchers or walking 10,000 steps a day. If you think about how a baby learns to walk, the baby doesn’t say, “I’m gonna set a SMART goal for this to happen by next Tuesday.” The baby just iterates.
The baby practices standing up, wobbling, holding onto a coffee table, and then plopping down on their diaper and then getting back up. There’s a natural process there.
MR: We lose that natural learning as we get older?
KB: When we hit school, we are trained to be performative. To perform to a test, to perform to a goal, to perform to all these things. Then we go into the workplace and the same thing happens and we lose track of our natural faculties—that we are iterative beings. The iterative mindset is associated with habit formation, whereas the performance mindset (aka performance-based goal orientation) is negatively correlated with habit formation.
MR: To maintain weight loss we need long-term habit changes?
KB: We believe that weight loss maintenance hinges on whether the brain has rewired into new habits, which is highly correlated with Iterative Mindset but not with Performance mindset, because performative methods have only been shown in the literature to work short-term, in simple tasks (and for which one has prior experience mastering).
MR: How is weight loss affected by this conceptual change including in the study?
KM: Using Iterative Mindset, in our data on thousands of users-to-date, both offers longevity of effort and fewer or shorter recovery from relapses. While this was not a primary measure for this study, we hypothesize that the superior long-term weight loss (LTWL) outcome reflected in our CDC study is based on the Iterative Mindset’s formulation to
- neutralize one’s habenula (protect from and reverse failure thinking)
- keep people in effort to practice their habit into automaticity and
- offer thousands of optional iterations on what they are trying so they easily iterate on what works for their life and preferences.
MR: Many, including me, don’t know what the habenula is…
KB: The habenula is a master control switch for our behavior, emotions and decisions--it controls dopamine, serotonin and our motivation. And when it is triggered with things like failure, disappointment, discouragement, demoralization--any negative emotion--it stops us from trying. It basically kills our motivation to keep trying.
MR: And habit formation requires brain rewiring?
KB: The iterative mindset is associated with habit formation, whereas the performance mindset (aka performance-based goal orientation) is negatively correlated with habit formation. Therefore, we believe that weight loss maintenance hinges on whether the brain has rewired into new habits, which is highly correlated with Iterative Mindset but not with the performance mindset.
MR: Could the clinical findings from your trial change the diabetes program that’s been run for 30 years?
KB: We are hopeful that this could iterate on the [federal] standard Diabetes Prevention Program, Lifestyle Change Program (DPP-LCP) in the following ways:
a. In practice, the DPP is still tooled for performative methods, such as weekly food and activity logs, weekly weight measurements and the use of outside calorie counter/tracker apps. Recommending [the Iterative app] Fresh Tri as an adjunct tool to use instead of these outside performative tool apps, would help protect people from failure and relapse caused by these performative, win-or-lose tools.
b. The DPP curricula currently switches participants week-to-week to practice a behavior that fits the lesson plan of that week—creating both switching costs and lack of opportunity to create automatic habits through longer term repetition. Instead, using Fresh Tri, the DPP lifestyle behaviors of eating healthily, being active and stress reduction/positive thinking are parsed into daily habit practices that can be personalized at an individual level and practiced long enough to achieve habit automaticity, to replace old habitual unhealthy ways.
MR: GLP-1 agonists have been a Wall Street boom for drug companies with Eli Lilly often leading the pack. What are your thoughts about the recent Lilly retatrutide trial?
KB: The Eli Lilly trial on type 2 diabetes with their drug retatrutide shows on par results against other GLP-1 class medications. These sort of ‘blunt-force’ weight loss therapies will generally cause more rapid weight loss (compared to behavioral approaches alone) that is impressive and also encouraging to dieting-weary patients. It also appears that the pill form of has a more favorable side effect and persistence profile compared to their prior studies with the injectable form.
MR: But what about long term results?
KB:.In long-term weight loss, retatrutide should be expected to perform similarly to other GLP-1 based therapies—when you remove the Rx, the weight returns and might exceed original BMI, in the absence of a behavioral approach as a companion to the Rx.
MR: Thank you and good luck in helping people form new habits surrounding eating. END