This document discusses using social media for health behavior change and weight loss interventions. It summarizes several studies on this topic. Key findings include: 1) Obesity and health habits spread through social networks, so online social networks may help support weight loss; 2) People find peer support and information from others' health experiences online helpful; 3) Early pilot studies found online social networks with coaching can support weight loss and engagement; 4) "Superusers", or participants incentivized to post frequently, helped increase engagement in a Facebook weight loss group compared to a standard online group without superusers. More research is still needed to optimize online social network interventions for health behavior change.

1. Leveraging Social Media forHealth
BehaviorChange
Sherry Pagoto, PhD
@DrSherryPagoto
Associate Professorof Medicine
Founder, UMass CenterformHealth and Social Media
University of Massachusetts Medical School

2. Social contagionSocial contagion
Obesity is “socially contagious” such that people are
significantly more likely to be obese when they have an
obese spouse and/or friends (Christakis and Fowler, 2007)
Health habits are also shared in social circles
Challenge: To get healthier, you’re gonna need to find some
healthy friends
Good news: If you adopt healthy behaviors, your family and
friends may be more inclined to.

3. Peer-to-peerhealthcarePeer-to-peerhealthcare
34% of internet
users have read
about someone else’s
experience with a
health condition on the
internet (Pew Internet Survey
2012)
Susannah Fox
CTO at Dept Health and Human
Services

4. Tweeting it off: Characteristics of PeopleTweeting it off: Characteristics of People
Who Tweet TheirWeight Loss JourneyWho Tweet TheirWeight Loss Journey
Purpose: to describe adults who use Twitter during a
weight loss attempt and to compare the positive and
negative social influence they experience from their
offline friends, online friends, and family members.
Pagoto et al 2014 Journal of American Informatics Association

5. MethodsMethods
Investigators tweeted the survey 58 times to get
100 complete responses for 1.72 surveys/tweet
Tweet: “Do you tweet about your weight loss
journey? Complete a brief survey!”
Survey evaluated:
– 5 areas of positive social influence for weight loss
(comfort, helpful, informative, supportive, fun)
– 2 areas of negative social influence for weight loss
(embarrassment, judgmental)

6. ParticipantsParticipants
• 100 surveys completed
• 82% female, mean age = 37.65 (range 21-58)
• BMI = 32.0 (SD = 8.70); 23% were normal weight,
24% were overweight, and 53% were obese
• Mean weight lost in current weight loss effort 43.72
lbs (SD=43.33; median= 28 lbs; range= 13-204 lbs)
A successful bunch of folks!

7. Positive InfluencePositive Influence
*
*p<.01

8. Negative influenceNegative influence
*
*p<.01

9. What is going on?What is going on?
People who tweet about their weight loss journey may
be lacking support from in person ties (family in
particular!)
Social network is hand-crafted,
negative forces are easier to
eliminate than in-person
connections

10. Can we deliver weight loss counseling
via an online social network?

11. Get Social Pilot StudiesGet Social Pilot Studies
Is it feasible to do weight loss counseling via an
online social network?
Can we recruit and retain people in this type of
intervention?
Might this model be especially suited for people
with depression?

12. Foursequential phasesFoursequential phases
1. Traditional12 weekly visits(nondepressed)
2. 12 weekly visits+ Twitter Coaching (depressed)
3. 12 weekly visits+ Twitter Coaching (nondepressed)
4. Twitter Coaching (1 visit) (nondepressed)

13. PrivacyPrivacy
Participantsin social network conditionsattended an
orientation meeting in which they wereassisted in
setting up private, anonymousaccountsusing
pseudonymsand avatarsand to follow each other and
thecoaches.

14. Content LibraryContent Library
ForTwitteronly group, content from DiabetesPrevention
Program Lifestyleintervention wasconverted into online
articlesand/or tweets.
Each week’stweetsfocused
on theweekly topic
Pagoto et al 2016 Adapting behavioral interventions for social media delivery, JMIR

15. ““Micro-counseling”Micro-counseling”
Coacheslogin daily to generatediscussion, post content, reply,
comment, and “favorite/like” participant posts
Interactionson social mediaarefluid and asynchronous
rather than in scheduled chats/meetings
Coach postsarestrategically timed to cuehealthy choices.
Friday afternoon: “ Anyo ne go ing o ut to eat to night? What is the
plan fo r keeping diet o n track?”

16. ““In the moment” supportIn the moment” support
POST: So this is what my work does on Halloween.
Does anyone else get a sugar rush just from
the smell of sugar? 8:30am
PEER: STEP AWAY FROM THE BREAKROOM!! 9:24a
PEER: My work has something like that too today! 9:33a
REPLIES:
PEER: Be strong! 9:08am
COACH: Imagine walking out the door knowing you resisted and how
good that feels. 9:36a
POSTER: Thanks guys. Some co-workers and I decided to have the office participate
in a 5K -- trying to build the health circuit (instead of the sugar and fat circuit). 1:39p

17. Participant Characteristics
45 participants
94% female
74% Caucasian
85% full time employment
Age = 46.79 (sd=10.97)
BMI = 34.62 (sd= 4.54)

18. 12 Week Results12 Week ResultsCONDITION N Depressed? Mean %
weight loss*
% losing
≥5%
Drop-
outs
Mean total
tweets
Traditional 12 N 3.1%
(4.1%)
33% 2 -
12 visits + Twitter
group
10 Y 1.2%
(3.6%)
20% 1 110.75
(112.40)
12 visits + Twitter
group
11 N 3.0%
(3.4%)
36% 2 121.90
(127.09)
Twitter group (1
visit)
12 N 3.0%
(3.1%)
42% 0 130.33
(124.06)
*Mean weight loss in DPP at 24 weeks was 6.9%

19. Otherresults
Total tweetswassignificantly associated with total weight lossat 12
weeks(r= -.46, p=.02)
FOCUS GROUP
Liked best:
Reading about other’sexperiences
Accountability
Postswere“nudges”
Support
Liked least: “Not surewhat to post,” somediscomfort posting about

20. Engagement conundrumEngagement conundrum
Participants enjoy reading about each other’s
experiences….but at same time were hesitant to post
about their own.

21. Where is the life of the party?Where is the life of the party?
A study of an online social
network for smokers
revealed “superusers,”
frequent posters who
facilitate discussion,
promote recruitment and retention, and are “valuable
assets to an online social network.” (de Mielo et al 2012)
Can weCan we createcreate superusers?superusers?

22. SuperuserPilot StudySuperuserPilot Study
We randomized 56 participants into two Facebook-
delivered weight loss intervention conditions:
1.Superuser: 3 randomly selected participant were
incentivized to be “superusers,” and given a
prescribed posting schedule.
2.Standard: No superusers.
Coaches were blinded to study condition.

23. SuperuserInstructionsSuperuserInstructions
Post a status update to the group at least twice a week
Ask questions and/or reply with a comment to the
counselor’s posts at least once a day
Comment on other group members’ posts
Compensation for the week ($25) provided for 2
weekly posts and 7 comments/questions
Email prompts occurred on day 5 of every week if they
were falling behind

24. What to post?What to post?
Successes or difficulties in your weight loss journey
Example: “Walked 3 miles on the treadmill today! I haven’t gone that long in over
a year!”
Example: “I couldn’t help it, was really tired last night, and caved by stopping for
Dunkin Donuts! UGH!”
Questions related to weight loss to the coach, to the group, or to an group
member
Example: “I need some very low calorie evening snack ideas. I get the urge to
snack at night but don’t have many calories left!”
Share your favorite recipes or post a pic of your creation, local events, articles,
etc.
Example: “I tried this new recipe tonight and LOVED it!! <link>

25. InterventionIntervention
12 weeks on a “secret” invitation only Facebook page
No intervention visits (only an orientation)
Posts based on evidence-based behavioral weight loss
protocol
Two coaches logged in twice a day to generate
discussion, field questions, and provide support
Fridays “weigh ins”

26. ParticipantsParticipants
Superuser(N=30) Standard
(N=26)
Sex (% female) 90% 92%
Ethnicity (% white) 90% 93%
Age 46.38 (sd=11.47) 47.21 (sd=10.32)
Weight 197.15 (46.49) 183.53 (30.04)
Work Status (% full
time)
77% 92%

27. Did SuperuserCondition engage
more than Standard Condition?
SU (n=27)* ST (n=26) P value
Original posts 6 (6) 9 (17) 0.647
Comments 51 (37) 43 (52) 0.158
Like 145 (188) 70 (89) 0.011
Total engagements 202 (215) 122 (147) 0.035
*The 3 “superusers” were not included

28. 12 Week Weight Loss Results12 Week Weight Loss Results
CONDITION N % losing ≥5% Drop-outs
SUPERUSER 30 27% 0
ALL†
No incentives‡ 27 30% 0
Incentives 3 0 0
STANDARD 26 23% 3*
*Baseline weight value carried forward used for drop-outs
† p=.11 vs standard
‡ p=.08 vs standard

29. What were “superusers” posts?What were “superusers” posts?
39% informational articles
21% asked for information
14% motivational image/meme
14% reporting a success
7% asked for help
5% shared a challenge Got the most replies per post
Got the least replies per post
Fully compliant (100% received full incentive each week)

30. Ourongoing research…Ourongoing research…
How do we identify and harness “real” superusers?
Will people engage more when their close ties are in the
group?
How can we create an environment that makes people feel
safe sharing their experience?

31. Follow me on Twitter:
@DrSherryPagoto
@UMassmHealth
Or Facebook:
UMassmHealthCenter