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Goal language is associated with attrition and weight loss on a digital program: Observational study [1]

['Annabell Suh Ho', 'Academic Research', 'Noom', 'Inc.', 'New York', 'United States Of America', 'Heather Behr', 'Department Of Integrative Health', 'Saybrook University', 'Pasadena']

Date: 2022-08 

Behavioral weight loss reduces risk of weight-related health complications. Outcomes of behavioral weight loss programs include attrition and weight loss. There is reason to believe that individuals’ written language on a weight management program may be associated with outcomes. Exploring associations between written language and these outcomes could potentially inform future efforts towards real-time automated identification of moments or individuals at high risk of suboptimal outcomes. Thus, in the first study of its kind, we explored whether individuals’ written language in actual use of a program (i.e., outside of a controlled trial) is associated with attrition and weight loss. We examined two types of language: goal setting (i.e., language used in setting a goal at the start of the program) and goal striving (i.e., language used in conversations with a coach about the process of striving for goals) and whether they are associated with attrition and weight loss on a mobile weight management program. We used the most established automated text analysis program, Linguistic Inquiry Word Count (LIWC), to retrospectively analyze transcripts extracted from the program database. The strongest effects emerged for goal striving language. In striving for goals, psychologically distanced language was associated with more weight loss and less attrition, while psychologically immediate language was associated with less weight loss and higher attrition. Our results highlight the potential importance of distanced and immediate language in understanding outcomes like attrition and weight loss. These results, generated from real-world language, attrition, and weight loss (i.e., from individuals’ natural usage of the program), have important implications for how future work can better understand outcomes, especially in real-world settings.

In efforts to improve outcomes of weight management programs such as weight loss and dropout, research has started to explore automated interventions that act based on models of digitally collected data. To build good models, it may be helpful to identify variables that are relevant for the outcomes and therefore should be considered. In this study, we explored whether the language that individuals write during a weight management program is relevant for outcomes; this question has not been studied yet. Previous research has shown that psychologically distanced language (e.g., what the situation means) is associated with better outcomes like academic performance or emotional control, while more immediate language (e.g., the details of the situation) is related to worse outcomes. We explored whether language during actual use of a program (Noom Weight) was associated with weight loss and dropout. We examined language data gathered from the program database using automatic language processing. We found that in interactions with a coach, distanced language was associated with better outcomes (less dropout and more weight loss) and immediate language was associated with worse outcomes (more dropout and less weight loss). These results raise many directions for future intervention development and highlight that this language should be considered and evaluated in the future.

Introduction

According to recent estimates, obesity affects more than 37% of adults in the US alone and is associated with increased risk of cardiovascular and metabolic conditions [1,2]. Moderate weight loss may significantly reduce the risk of weight-related health complications [3,4]. Behavioral weight loss programs help individuals to achieve moderate weight loss through behavior change education and support [5]. Measurable outcomes of these programs include weight loss and attrition, or the extent to which individuals drop off the program before receiving the full intervention. Understanding what behavioral factors are associated with weight loss and attrition can be an initial step towards “offering special assistance, structure, therapist contact and/or a more targeted intervention for those at highest risk of dropout” in future programs, with the ultimate goal of improving outcomes [6–9]. As an example, recent research has sought to understand how to improve outcomes by leveraging continuously collected data on digital (e.g., smartphone) platforms to identify real-time moments to intervene [10–12]. Algorithmic models are built to predict real-time at-risk moments, and they are initially informed by knowledge about which characteristics or behaviors are associated with the outcomes of interest [10,13]. Data such as self-reports of eating instances or smartphone metadata (e.g., accelerometry and geospatial location) have been used in this context so far [14,13]. In this study, we explore whether a new source of data, individuals’ language, reveals associations with attrition and weight loss. Exploring these associations is a first step towards future efforts in real-time identification or intervention that, ultimately, could help to improve outcomes [10].

Specifically, in this study, we focus on individuals’ language during regular use of a weight management program. In many programs, individuals write an initial goal (e.g., “Lose 10 pounds”, “become healthier”) or interact with a coach about their goals. This investigation is theoretically and empirically motivated in two ways. First, the study is motivated by previous research on individuals’ language. According to psycholinguistic theories, individuals’ words reveal key information about their perspective, thoughts, or focus [15,16]. Decades of research have shown that individuals’ words explain significant variation in health outcomes such as the likelihood of alcohol relapse, physical and psychological health, and to some extent, weight loss [17–20]. For example, there is a positive association between the number of words individuals use related to processing and coming to new insights (e.g., “realize”, “because”) and health improvements [16]. For goals specifically, an important predictive factor may be distanced (vs. immediate) language. Various terms are used in the literature, such as narrative vs. categorical or analytical [21,22], or psychologically close vs. distanced [23,24]. Generally, individuals’ words range on a spectrum from immediate (e.g., focused on the details of the present moment) to distanced (i.e., focused on abstract or analytical connections between concepts) [21–25]. Work has demonstrated that immediate writing is marked by using more words tied to the present situation such as personal pronouns (e.g., “I”, “you”), present-tense words, auxiliary verbs (“is”, “are”), and discrepancy words (“should”, “would”). Distanced language, on the other hand, has more markers of abstract or analytical thinking such as articles (“the”, “a”) and prepositions (“with”, “among”) [21,23,26]. As an illustration, consider a sentence such as, “I should try harder to stick to my plan today” (immediate) compared to, “the idea of ignoring the food is stressful” (distanced). Language that has markers of distanced language (vs. immediate language) is associated with better (vs. worse) self-regulation and self-reported health in correlational and experimental work [23–26]. This is likely because focusing on the details of the present (e.g., how tasty this food smells) can deter individuals from their goals, while having a more distanced, abstract, and higher level perspective could focus one’s attention on broader motivations and reasons (e.g., why this food isn’t healthy) [27]. Therefore, the types of words individuals use, such as markers of psychological distance, could be associated with attrition and weight loss.

Second, the study is motivated by research suggesting that individuals’ written language about goals may provide insight into outcomes such as weight loss success and attrition. To our knowledge, there are no previous studies specifically exploring the relationship between writing about goals and attrition or weight loss. However, previous work has shown that in weight management interventions more broadly, individuals’ goals for weight loss are associated with attrition and weight loss [8,28,29], suggesting that exploring goals may be informative in the context of this study. Moreover, studies have shown that the way individuals write about their goals is associated with outcomes in other domains such as subjective well-being and academic performance [30,31]. This could be because, according to goal construal theory, the way one frames a goal influences how well one can self-regulate towards that goal; for example, as described previously, framing goals in terms of the “how” instead of the “why” may focus attention on immediate temptations rather than a higher level motivation [27,32,33]. Further, goal-setting theory stipulates that the way individuals conceive of their goals, such as how important or difficult they perceive the goal to be, influences self-regulatory behaviors and outcomes [34]. For instance, individuals show more goal persistence and success when they perceive the goal to be sufficiently difficult [34]. Based on these studies, we speculate that the way individuals conceive of, and ultimately express, their goals in writing could relate to attrition and weight loss.

Therefore, in this study, we explore whether the words individuals use to describe their goals are associated with attrition and weight loss. Additionally, the study expands on previous work by distinguishing between goal setting and goal striving, two distinct components of goals [30,35]. Goal setting describes setting an initial goal, while goal striving is the process through which goals are pursued. In this retrospective study, we leverage a unique dataset allowing us to examine the words that individuals used in goal setting and goal striving during actual use of a digital program [36]. We collected the language used in goal setting (i.e., setting their overall goal at the start of the program) and goal striving (i.e., in goal striving conversations with coaches) by users of Noom Weight, a mobile behavior change program. Using automated text analysis, we explored if this language was associated with attrition and weight loss. Since this is the first study of its kind in the domain of weight management, we used the closest equivalent studies to choose language variables and form hypotheses [19,23,37]. We hypothesized that articles, auxiliary verbs, and prepositions (i.e, markers of distanced language) would be associated with lower attrition and greater weight loss. We also hypothesized that personal pronouns, present-tense words, auxiliary verbs, and discrepancy words (i.e., markers of immediate language) would be associated with greater attrition and less weight loss. Additionally, based on the patterns found in prior studies of language on weight loss blog posts [19,37], we hypothesized that positive emotion words (“happy”), negative emotion words (“sad”), cognitive processing words (“realize”, “know”), ingestion words (“eat”, “food”), social words (“spouse”), and certainty words (“certain”, “definitely”) would be associated with lower attrition and greater weight loss. We also hypothesized that tentative words would show the opposite pattern (“maybe”, “perhaps”). We also explored future tense words since an orientation towards the future could be beneficial for goal striving [38]. We did not a priori expect different results for goal setting and goal striving.

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[1] Url: https://journals.plos.org/digitalhealth/article?id=10.1371/journal.pdig.0000050

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