Problem Addressed

• A growing epidemic that increases health risks: An estimated two-thirds of Americans are overweight, including nearly a third considered to be obese. Even though Rhode Island ranks as the seventh least obese state in the nation,¹ nearly 30 percent of adult residents in the state qualify as obese. Overweight and obesity increase the risk of hypertension, diabetes, cancer, heart disease and other health conditions that can cause disability and premature death.² For example, Rhode Island has high rates of diabetes, smoking, and other health risks.³
• Unrealized potential of lifestyle programs: Intensive lifestyle programs aimed at encouraging healthy habits—such as improved diet and increased physical activity—can help to prevent and effectively treat obesity. However, these programs remain expensive and unavailable to the majority of overweight and obese Americans.²

Description of the Innovative Activity

• Marketing to potential participants: The program uses television, press releases, and distribution of marketing materials at work sites and in physician offices to reach adults living and working in Rhode Island.
• Online signup: Individuals pay $20 (sometimes covered by their employer) to sign up at the program Web site (http://www.shapeupri.org), designating themselves either as a team captain or team member. After reporting demographic information, employer, interests, and health goals, participants choose from three primary goals: weight loss, hours of physical activity, or steps walked.
• Team formation: Drawing on the information entered, participants form teams based on mutual goals, interests, and other criteria. Team captains recruit 8 to 10 team members through work, social contacts, or an online forum on the program Web site. Team members either receive an invitation from captains to join their teams or find a team looking for members through the online forum, which typically posts each team's location, primary goal, and other relevant information.
• Welcome packet: Those who sign up receive a welcome packet in the mail that includes program information, a pedometer, and a log book to record steps, hours of physical activity, or weight loss.
• Inperson and online social support: Some teams get together in person to exercise or talk about nutrition, but most use the online interface to keep in touch with team members and monitor progress. The platform's social networking tools allow team members to motivate and support each other. Developed by Shape Up The Nation (a for-profit company associated with the project), this platform includes interactive tools, forums, and other features that keep participants engaged and excited. For example, participants can issue peer-to-peer minichallenges to friends.
• Online tracking and performance feedback: Although the program deemphasizes the importance of winning, competition serves to create excitement and keeps participants engaged. To that end, participants check in online at least once every 2 weeks to record their own hours of exercise, weight, or steps walked. Individuals receive feedback based on progress towards individual and team goals. In addition, the system reports team standings each week, with final results announced at the end of the competition. Although all information is self-reported, team members see the results and know if teammates fabricate data, so the reporting system provides some degree of accountability.
• Health and nutrition events during challenges: Each challenge starts with a kickoff event with media promotion, educational activities, and workshops. Throughout the 12-week challenge, health and fitness organizations across the state host free events to promote healthy activities, such as Pilates classes, ice skating, or nutrition education. On some days, as many as 20 different free events are held in the 39 Rhode Island cities and towns included in the program. A newsletter announces upcoming events, and the Web site provides a complete list. A closing event featuring local celebrities, and political leaders recognize the efforts of participants at the end of the challenge.
• E-newsletter with health tips: During each challenge, 35,000 current and past participants get a weekly e-mail newsletter with health tips, information on free exercise and nutrition events, and other information about the program.
• Prizes and incentives: Prizes are awarded through a random drawing based on participation rather than competitive standing. Program staff choose large, exciting prizes that create buzz, such as a bicycle, kayak, or Nintendo Wii Fit. Smaller weekly prizes recognize additional forms of participation, such as submitting a favorite motivational phrase.

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Results

• Broad participation: Since 2005, nearly 5 percent of the state's population (representing more than 48,500 people) have taken part in a Shape Up RI challenge, with roughly one-third of participants being overweight or obese. In 2007, for example, there were more than 7,000 participants.
• High completion rates: Among individuals who participated in the weight-loss division in 2007, 70 percent completed the challenge (3,311 out of 4,717 individuals). Obese participants were only slightly less likely to finish than normal-weight individuals (68 vs. 72 percent). These high completion rates suggest that the program has engaged and encouraged most participants.²
• More physical activity: During the 2007 challenge focused on pedometer results, the 4,087 people who completed the program increased their average daily steps by more than 2,000. Those considered sedentary at baseline increased their daily steps by an even larger amount (more than 4,000 steps), a level of increase considered large enough to improve blood pressure, cholesterol, and glucose tolerance.² The percentage of participants who qualified as "active" (defined as more than 10,000 steps per day) more than doubled during the challenge, from 16 to 40 percent, and remained high at followup, indicating that the program had lasting effects. Participants whose employers paid the registration fee had even larger increases in average daily steps, perhaps due to company or community support.⁴
• Significant weight loss, less obesity: The average participant who completed a 2007 challenge reported losing 3.2 kg and one point of body mass index during the challenge. Nearly one-third reported clinically significant weight loss of more than 5 percent of their body weight, while 6.3 percent reported losing 10 percent of their weight. At the start of the program, 39 percent of participants qualified as obese; by the end of the program, the obesity rate had dropped to 31 percent. Data on a subgroup of 210 participants weighed at the beginning and end of the program showed similar weight loss.²

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Designing pilot program: To see how the program might work, Mr. Kumar worked with Ray Rickman, a local community leader, to set up a pilot program in 2006. Initially, they envisioned a 12-week annual competition, supported by a basic online interface for tracking data, along with e-mail for communication. With no marketing budget, they signed up 200 team captains, each of whom formed teams of 10 people, creating a total of 2,000 participants. This experience convinced them of the merits of using the enthusiasm of early adopters to help motivate others and reach a wide audience.
• Finding partner organizations and funding: With Ray Rickman's help, Mr. Kumar established a relationship with the Urban League of Rhode Island, which served as the umbrella 501(c)(3) organization for Shape Up RI until it obtained tax-exempt status. He also secured funding from Brown University Medical School, Citizens Bank, and the Urban League.
• Getting employers involved: Recognizing that large and small employers wanted to build teamwork and encourage employees to improve their health, Mr. Kumar and his colleagues met with business leaders to introduce them to the program. In particular, they emphasized the program's ability to help employers achieve their goals at minimal expense.
• Establishing a nonprofit organization: After the pilot's initial success, project leaders incorporated Shape Up RI as an independent not-for-profit 501(c)(3) organization.
• Expanding program to two challenges a year: Seeking to expand the program and offer it twice a year, Mr. Kumar and colleagues started soliciting grants and other forms of support from several organizations, including (but not limited to) Blue Cross Blue Shield and CVS/Caremark.
• Spinning off a for-profit company: Seeing the business potential for this kind of wellness program, Mr. Kumar and his Brown classmate Brad Weinberg wrote a business plan for a social networking technology platform that health plans and corporations could offer to members and employees to promote healthy behaviors. After obtaining seed money, Mr. Kumar and Mr. Weinberg launched the company, which they called Shape Up The Nation, in 2006. Today, the company serves CVS/Caremark, Highmark, Cleveland Clinic, NationalGrid, and other organizations, with services reaching 2 million individuals in 96 countries.
• Further program expansion: Starting in 2011, Shape Up RI participants can get involved in up to six challenges per year, each lasting 6 to 12 weeks. The program plans to add two more challenges in 2012. Some challenges will have a seasonal health theme, including a new component in the spring and summer in which participants will track how many days per week they eat five or more servings of fruits and vegetables. Another new summer challenge, "Flex Your Food," includes weekly goals for tracking food intake, eating breakfast each morning, cutting back on high-calorie foods and beverages, drinking water before meals, and eating more home-cooked meals. In the fall, a new flu-shot challenge will encourage participants to get flu shots and take steps to prevent the spread of colds, and a "No Gain During the Holidays" challenge will focus on avoiding weight gain during November and December. Shape Up RI also offers challenges for children during the spring and fall.

Resources Used and Skills Needed

• Staffing: Shape Up RI has four full-time staff, along with part-time consultants equivalent to another full-time employee. The founder, Mr. Rajiv Kumar, volunteers his time with the program. Staff focus primarily on program development, marketing, recruitment of employers and sponsors, and physician outreach. The consultants take care of the technical aspects of the program platform.
• Costs: The program's annual budget is just over $500,000, which covers staff salaries, office rent, utilities, promotional materials, pedometers, and mailing of welcome packets. The social networking and tracking platform is managed by Shape Up The Nation, which leases it back to Shape Up RI at no charge.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Get buy-in from community leaders: Early support from companies, politicians, and other community leaders helped the program succeed by giving it credibility with participants and employers. Mr. Kumar met with key leaders in the state to tell them about his plan and get their endorsement.
• Choose partners with care: Build trust with participants by choosing event sponsors carefully, avoiding partnerships that might cast doubt on program motives.
• Consider scope of service area: A statewide program may be effective in a state like Rhode Island that has a small population and close ties among residents. In other areas, starting at the city or county level might be a better approach. The key is to achieve high penetration within a community.
• Work through doctors' offices: Physicians often give patients general advice about exercise and diet, but not much practical support. With program materials close at hand, physicians can offer patients something more prescriptive and encourage them to sign up and get involved.
• Plan short-term activities: Focusing the program on time-limited, 12-week challenges creates more excitement and buzz than conducting activities on a rolling basis over a longer time frame.
• Be inclusive: Design the program to appeal both to fitness enthusiasts and those seeking to develop healthier habits. This approach prevents the program from becoming stigmatized as serving only a sedentary population. (Overweight individuals and those with existing health conditions should be encouraged to check with their doctor before participating.)
• Build in competition and social support: The team approach harnesses the power of competition and social support to encourage individual effort. Team members provide motivation and support to their fellow participants, leading to more sustained effort and progress.
• Cultivate word-of-mouth marketing: People looking for a team or seeking team members will talk about the program with friends, coworkers, family members, and neighbors. This kind of word-of-mouth promotion can be highly effective.

Sustaining This Innovation

• Keep platform innovative: Staying current with technological developments keeps the site fresh and people engaged. Participants generally have high expectations regarding social networking tools.
• Elicit feedback and respond accordingly: Based on participant feedback, Shape Up RI recently added the previously described focus on "fruits and vegetables" and, as noted, will be adding additional challenges in 2011 and 2012. The new challenges offer participants a way to sustain their commitment to healthy habits, and convey the message that wellness should be a year-round, lifetime goal.
• Consider targeting new age groups: As noted, Shape Up RI is building on its successful program for adults by adapting it for children.
• Collect data and monitor program impact: Data can be used to support research on what does and does not work. In addition, evidence on the program's efficacy helps retain support from program funders and can be used to stimulate continuous quality improvement, both for program services and the technology platform.

Use By Other Organizations

• As noted, Shape Up The Nation has helped launch similar programs in 96 countries that collectively reach 2 million individuals.