Peer Support Groups for Weight Loss

Abstract

Purpose of Review
Social support, especially from peers, has been found to contribute to successful weight loss and long-term weight loss maintenance. Peer support groups may represent a particularly effective intervention technique for weight loss. This review focuses upon peer support weight loss interventions with the objective of identifying common elements of successful programs.

Recent Findings
Peer support interventions often consist of expert-led educational content, supplemented by peer-led activities or discussion. Peer groups may provide support to individuals who have little social support in their normal lives. Interventions are often designed for pre-existing groups, especially high-risk groups such as women from ethnic minorities. Men are underrepresented in weight loss programs and often perceive “dieting” as feminine. However, several peer programs for male sports fans have successfully resulted in weight loss and fostering support for healthy lifestyle among male peers. In addition to professionally created peer support groups, many online weight loss communities are created and moderated by peers. Online communities allow participants to share peer support similar to in-person formats.

Summary
Many peer support interventions show significant short-term weight loss. Group members frequently report that peer support was critical to their weight loss success. A sense of community among likeminded individuals with similar goals was frequently cited. Online peer support groups are becoming increasingly prevalent, may fulfill similar needs to in-person groups, and have additional advantages in accessibility, and access to a larger peer network, and may facilitate long-term adherence.

Full text

OBESITY AND DIET (G. RAO, SECTION EDITOR)
Peer Support Groups for Weight Loss
Kelsey Ufholz
1
#The Author(s) 2020
Abstract
Purpose of Review Social support, especially from peers, has been found to contribute to successful weight loss and long-term weight
loss maintenance. Peer support groups may represent a particularly effective intervention technique for weight loss. This review focuses
upon peer support weight loss interventions with the objective of identifying common elements of successful programs.
Recent Findings Peer support interventions often consist of expert-led educational content, supplemented by peer-led activities or
discussion. Peer groups may provide support to individuals who have little social support in their normal lives. Interventions are
often designed for pre-existing groups, especially high-risk groups such as women from ethnic minorities. Men are underrepre-
sented in weight loss programs and often perceive “dieting”as feminine. However, several peer programs for male sports fans
have successfully resulted in weight loss and fostering support for healthy lifestyle among male peers. In addition to profession-
ally created peer support groups, many online weight loss communities are created and moderated by peers. Online communities
allow participants to share peer support similar to in-person formats.
Summary Many peer support interventions show significant short-term weight loss. Group members frequently report that peer
support was critical to their weight loss success. A sense of community among likeminded individuals with similar goals was
frequently cited. Online peer support groups are becoming increasingly prevalent, may fulfill similar needs to in-person groups,
and have additional advantages in accessibility, and access to a larger peer network, and may facilitate long-term adherence.
Keywords Peer support .Weight loss .Weight loss maintenance .Online support
Introduction: Challenges of Commercial
Weight Loss Programs
Obesity is a serious growing health concern. In 2017–2018,
42.4% of American adults were obese [1]. Because of the
well-known ill health associated with obesity [2] including
greater risk of cardiovascular disease [3], many obese individ-
uals enroll in weight loss programs to improve their health.
Unfortunately, very few individuals successfully lose weight:
Men with a BMI > 45 have a 1 in 5 chance of losing 5% body
weight, while women (1 in 6 to10 chance) or men with a BMI
30–44.9 face even greater odds (1 in 8 to 12 chance) [4]. Even
for those who defy the odds, long-term weight loss mainte-
nance is difficult. A meta-analysis of studies examining
weight loss among American adults enrolled in structured
weight loss programs with at least 2 years of follow-up data
found that 5 years post weight loss, only 23.4% of initial
weight loss was maintained [5].
Asystematicreviewofcommercialweightlossprograms
found only slightly greater weight loss compared with control
or education-only comparison groups. Results ranged from
0.1 greater weight loss at 12 months for Atkins to 4.0% greater
weight loss at 3–6 months, with attenuated effects thereafter,
for very low calorie programs such as Medifast [6]. One ex-
planation for both lack of initial weight loss and maintenance
is unsustainability. Most trials reviewed lasted about 12 weeks
and showed high attrition [6]. A meta-analysis of similar com-
mercial weight loss programs, such as Weight Watchers and
Biggest Losers Club, found that the majority of participants
who began these programs (57%) lost less than 5% of their
body weight. Almost half of all studies (49%) reported attri-
tion rates > 30% [7]. Conversely, longer term involvement
was associated with greater success. For example, among
Jenny Craig platinum program members, participants who
remained in the program for 40–52 weeks lost 12.0% (SD
7.2%) body weight, while those who left after 1–4 weeks lost
This article is part of the Topical Collection on Obesity and Diet
*Kelsey Ufholz
keu8@case.edu
1
Department of Family Medicine and Community Health, Case
Western Reserve University, 11100 Euclid Avenue, Suite 1056,
Cleveland, OH 44106, USA
https://doi.org/10.1007/s12170-020-00654-4
Published online: 22 August 2020
Current Cardiovascular Risk Reports (2020) 14: 19
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1.1% (SD 1.6%) body weight. Unfortunately, only 6.6% of
original enrollees were still in the program by week 52, with a
full 27% dropping out within the first month [8]. Overall,
long-term weight loss is especially difficult often because
those seeking to lose weight discontinue their efforts.
We know that social support can enhance the effectiveness
of structured weight loss programs. Despite obstacles, some
formerly overweight individuals do manage to successfully
lose weight and maintain weight loss. An often-cited review
by Elfhag and Rossner found that these individuals had sev-
eral strategies in common, including increased support from
their social network [9]. The beneficial role of social support
during weight loss and maintenance is well verified.
Participants who were recruited to a weight loss program with
a friend or family member lost more weight at 4 months,
maintained the weight loss at 10 months, and showed lower
rates of attrition compared with participants recruited to a
standard weight loss program without any accompanying so-
cial support [10]. A recent meta-analysis of factors associated
with greater adherence to a weight loss program identified the
positive impact of social support (RR 1.29; 95% CI 1.24–
1.34) [11]. Yet, while the support of loved ones can be crucial
and individuals maintaining recent weight loss cite support
from family as especially important and wanted, they also
cited these same people as obstacles, for example, tempting
them with foods which do not fit within their diet [12], possi-
bly because they are not experiencing the same process. This
explains why during focus groups about what they
found most helpful in their weight loss journey, women
maintaining recent weight loss listed a sense of shared
community among their peers [12].
Many health behavior change theories incorporate social
support as an active change element. Social cognitive theory
[13,14] is a behavior change theory often employed in the
context of socially supported weight loss (see Table 1).
Interventions guided by this model teach behavioral modifi-
cation techniques such as goal setting and self-monitoring.
The peer support format allows members to provide positive
reinforcement for success, helping them to build self-efficacy.
Peer coaches and successful members may model successful
behavior change, allowing for observational learning by less
advanced members. Self-determination theory is an alternate
theory that may be incorporated into successful peer support
weight loss programs [15]. For example, skill-building and
educational components can increase participants’sense of
competence, or ability to complete tasks and achieve goals,
while the support provided by peers will build a sense of
relatedness or sense of being valued and cared for by others.
Some interventions utilize theories, such as cognitive behav-
ioral theory, that are traditionally associated with individual-
level psychotherapy rather than groups [16] with the addition
of peer support components [17]. Such interventions often
have peer support as an adjunct rather than as the primary
active component. Other interventions are based not upon
theoretical models but upon prior successful interventions
for other conditions such as diabetes [18].
How Peer Support Groups Function
Peer support is defined as “the provision of emotional, ap-
praisal, and informational assistance by a created social net-
work member who processes experiential knowledge of a
specific behavior or stressor and similar characteristics as the
target population”[19]. A peer support group is a group of
similar individuals who, because of shared experience, are
able to provide emotional and practical support.
Peer support groups facilitate weight loss among their mem-
bers through several mechanisms. Overweight individuals may
have weak structural support, which refers to the extent to which
a person is embedded into their social groups, including family,
friends, and peer groups [12]. Overweight has been associated
with the absence of close friends [20] both among adults and
adolescents [21]. This may be partly due to bias. While over-
weight youth select possible friends without regard to BMI,
healthy weight youth were 30% more likely to choose a non-
overweight friend rather than an overweight friend [22]. For
individuals with limited social networks, peer support groups
may be necessary to provide otherwise lacking structural support.
Peer support groups also provide members with functional
support, which refers to specific actions that peers may per-
form for each other, such as providing emotional support or
helpful information. Focus groups have found that such forms
of support are highly desired, with shared community and
increased self-efficacy, both forms of functional support, per-
ceived as most helpful to weight loss maintenance [12]. Peer
support groups need not meet in person to provide functional
support. The Social Support Behavior Code lists five types of
social support: informational support, such as providing facts,
advice, and alternative perspectives upon situations; esteem
support, such as compliments and validating other’sexperi-
ences; network support, such as offering to spend time with
others or providing access to resources; tangible support, such
as offering the loan of something needed or to jointly com-
plete a task; and emotional support, such as displays of empa-
thy, sympathy, and encouragement [23,24••]. An analysis of
comments made in an online support forum for bariatric sur-
gery patients noted that, although support which could be
offered solely through anonymous written/verbal means, such
as dietary advice (informational support) and encouragement
(emotional support) were most frequently offered, network
and tangible support were still present [24••]. Peer groups also
create social norms, defined as a social group’s expectation of
appropriate behavior in a given circumstances [25,26]. Social
norms have long been known to influence eating behavior
[27], both in healthy and unhealthy ways. A systematicreview
19 Page 2 of 11 Curr Cardiovasc Risk Rep (2020) 14: 19
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Table 1 Summary of characteristics of peer support group interventions
Author Date Duration Setting Target Intervention
name
Study type Theory or model
program
Active components Outcomes
Petrel, R. J. 2016 12 weeks Hockey club
facilities
(Ontario,
Canada)
Men Hockey Fans in
Training
(Hockey FIT)
RCT with
weight list
control
Football Fans in
Training (FFIT)
Educational sessions with coaches teaching
behavior change techniques:
self-monitoring
Goal setting
Healthy eating advice
Physical activity training
*Weight lost
*Waist
circumference
*BMI change
Hunt et al. 2014 12 weeks
active +
12-month
weight
mainte-
nance phase
Football
clubs
(Scotlan-
d)
Men Football Fans in
Training
(FFIT)
RCT with
weight list
control
None given
Novel “gender
sensitized”
program
Educational sessions with coaches teaching
behavior change techniques:
self-monitoring
Goal setting
Healthy eating advice
Physical activity training
*Weight lost
(primary)
*Waist
circumference
*BMI change
*Body fat
percentage
*Blood pressure
*Self-report PA
*Self-report
sedentary time
*Self-report diet
*Alcohol
consumption
*Self-esteem
*Positive/negative
affect
*Health-related
quality of life
Dutton et al. 2015 6 months Family
medicine
practice
African-Americans
with diabetes or
prediabetes
None given Single group
pilot
Diabetes
Prevention
Program and
Look AHEAD
Educational office in primary care office
provides information on energy restriction,
increasing PA, Self-monitoring
Stimulus control, relapse prevention
Phone call with peer coaches
#Weight loss
Goldfinger
et al.
2008 10 weeks
active +
22 weeks
and 1-year
follow-up
Local
church in
Harlem,
New
York
African-Americans Project HEAL:
Healthy
Eating, Active
Lifestyle
Single group
pilot
Stanford
University
Chronic Disease
Self-Managem-
ent Program
Peer coach-led weekly action plans,
self-management, group feedback,
problem-solving
#Weight lost
#Fat consumption
#Saturated fat
#Cholesterol
#Fruit/vegetable
consumption
Physical activity
#Sedentary time,
#Health-related
quality of life
Weight loss locus
of control
Kulik et al. 2015 16 weeks NA Adolescent females None given RCT compare
standard
Cognitive
behavioral
Weight loss
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Table 1 (continued)
Author Date Duration Setting Target Intervention
name
Study type Theory or model
program
Active components Outcomes
intervention
with
enhanced peer
support
Nutrition and PA education; behavioral skills;
small group activities; peer Facebook chats;
check-in with peers
Simpson, S. 2018 12 months Glasgow,
Scotland
NA HelpMeDoIt Feasibility RCT
with a
leaflet-only
control group
Social support
theory;
social cognitive
theory; control
theory
Website to provide content on healthy eating
andPA;apptosetandmonitorweightloss
goals; users invited to recruit “helpers”from
within their social circle
BMI
Physical activity
diet
Cherrington,
A. L.
2015 8 weeks Emerging
Latino
commu-
nity
(Alabam-
a)
Latina immigrants ESENCIAL
Para Vivir
(Essential for
Life)
Single group
pilot study
Self-determination
theory; Diabetes
Prevention
Program
Promotoras provide health education *Weight loss
*Physical activity
*Diet
*Depression
Aschbrenner,
K. A. et al.
2016 24 weeks Community
mental
health
center
Adults with serious
mental illness
None given Single group
pilot study
Diabetes
Prevention
Program
Lifestyle coach delivered content; hands-on
small group activities; twice weekly
optional exercise sessions; Facebook chats;
Fitbit accelerometers
#Weight loss
#BMI
Cardiovascular
fitness
Lee et al. 2018 16 weeks Local
church
African-American
women
Supportive
Text-Messag-
ing Against
Regain
(STAR)
Single group
pilot study
Social cognitive
theory
In-person educational lectures; peer group
discussion; daily feedback/support text
messages
#Weight loss
#BMI
#Self-efficacy of
eating
Stages of change
Self-efficacy of
exercise
Perceived social
support
Perceived stress
Systolic blood
pressure
Diastolic blood
pressure, waist
circumference
Hageman
et al.
2017 6 months +
30 months
of
follow-up
Online Women in rural
communities
Women’s
Weighinfor
Wellness
(WWW)
RCT with an
online content
only control
group
Pender’sHealth
Promotion
Model/Social
Cognitive
Theory
Online delivered nutrition and physical
activity education; food diary; physical
activity tracker; supplemented with emails
from a dietician or access to a peer
discussion board
Weight loss
*Indicates greater changes compared with control
#indicates statistically significant pre-post changes
19 Page 4 of 11 Curr Cardiovasc Risk Rep (2020) 14: 19
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and meta-analysis found that both high-intake norms (standard-
ized mean difference = 0.41; 95% CI 0.20 to 0.63; p< 0.0001)
and low-intake norms (standardized mean difference = −0.35;
95% CI −0.59 to −0.10; p= 0.005) moderately influenced
amount of food eaten [28]. Peer support groups, especially those
with access to weight loss professionals, may be important to
create healthy alternate norms among members.
The focus in this review is on the impact of peer support
interventions. Usually, the primary outcome is weight lost, in
absolute terms or as a body weight percentage. Successful peer
support groups targeted at weight loss may also impact comor-
bidities commonly associated with obesity, with varying degrees
of success. A recent meta-analysis of 26 randomized controlled
trials found that compared with control, peer support interven-
tions for weight loss led to improved glycemic control,
(HbA1c = −0.22%; 95% CI −0.40 to −0.04; p=0.02) and de-
creased obesity (BMI = −0.83 kg/m
2
; 95% CI −1.58 to −0.07;
p= 0.03), but had no significant effect upon systolic blood pres-
sure (−0.90 mmHG; 95% CI −3.05 to 1.24 mmHG). The au-
thors speculate that high levels of attrition and selection bias may
have influenced results [29]. Commercial weight loss programs
not intended to improve diabetes or other cardiovascular risks
may nevertheless have a desirable effect on these conditions. A
randomized controlled trial found that participants enrolled in
Weight Watchers showed greater improvements in both weight
loss (difference = 3.3% body weight at 18 months; p<0.008)
(difference = 1.7% body weight at 24 months; p< 0.032) and
HbA1c (difference = 1.0 at 18 and 24 months; p<0.04)com-
pared with those assigned to a self-directed program created by
the National Diabetes Education Program. Furthermore, both
groups showed similar improvements in cardiovascular risk fac-
tors, including HDL cholesterol, diastolic, and systolic blood
pressure [30]. Whether interventions for obesity-related comor-
bidities will also impact BMI remains uncertain. A separate
meta-analysis found that peer support interventions for diabetes
management improved systolic blood pressure (2.07 mmHG;
95% CI 0.35 to 3.79 mmHG; p= 0.02), but not diastolic blood
pressure, cholesterol, BMI, diet, or physical activity. Because the
selected studies focused upon diabetic control, cardiovascular
risk factors, including BMI, were secondary outcomes and par-
ticipants in most studies had only normal or mildly elevated
values [31]. Overall peer support groups aimed at weight man-
agement can, but will not necessarily, also improve symptoms of
obesity-related comorbidities.
Common Traits of Peer Support Groups
A search using the terms “peer support,”“peer support
group,”“weight loss,”and related terms in various combina-
tions was carried out in PubMed, Google Scholar, etc., to
identify papers published in 2015 and later. Approximately
70 relevant papers were ultimately reviewed. Peer support
groups for weight loss showed several similarities. Much like
other weight loss programs, results tended to be mixed, with
members showing short-term results followed by later weight
regain [32]. Occasionally, comparisons of peer support inter-
ventions with control groups that did not explicitly feature
peer support, showed no difference between groups [33].
Sometimes, this may have been because participants did not
utilize the peer support features, especially if these features
were an adjunct to a traditional weight loss program [32].
Many peer support groups did not require attendance, but
allowed participants to attend or not attend according to their
interest or availability, although greater attendance was often
associated with improved outcomes. For example, a peer sup-
port group for patients following bariatric surgery showed that
the number of sessions attended in the first year was related to
weight lost in the first year. Similar results were found for
number of sessions attended 2–5 years post-surgery [34].
Many groups deliberately cultivated a sense of community
among their members by selectively recruiting from high-risk
groups. Often, these groups were a minority group or popula-
tion who are traditionally difficult to reach with mainstream
weight loss programs. For example, the STAR project was a
feasibility pre-post study of a peer support group for African-
American women [35], an ethnic group with higher rates of
obesity than many other ethnic groups [36]. Following
16 weeks of biweekly in-person peer group session and daily
text messages, the women noted modest (−3.7 lbs.; SD =
3.5 lbs.) but statistically significant (p< 0.01) weight loss
and decreased BMI (−0.6 kg/m
2
; SD = 0.6 kg/m
2
;p=
0.001) [35]. Similarly, Project HEAL, a pilot study of a
church-based peer support group for African-Americans liv-
ing in Harlem, New York, showed that participants lost
4.4 lbs. at 10 weeks (p< 0.01), 8.4 lbs. at 22 weeks (p=
0.003), and 9.8 lbs. after 1 year (p= 0.001) and reported de-
creased fat consumption (−7.6 daily fat intake in grams at
10 weeks; p=0.46) (−4.0 daily fat intake in grams at
22 weeks; p= 0.27) and sedentary time (−1.3 h/day at
10 week; p= 0.34) (−2.9 h/day at 1 year; p< 0.01). Daily
servings of fruit and vegetables also showed a modest (0.7
servings/day) but statistically significant increase at 22 weeks
(p= 0.041) and 1 year (p=0.039)[37]. Another pilot weight
loss intervention enrolled African-Americans who presented
with obesity and at least one cardiovascular risk, such as ele-
vated blood pressure or A1C. Participants were recruited
through a primary care practice and received biweekly visits
with healthcare professionals, along with phone calls from
peer coaches. After 6 months, participants lost an average of
4.5 kg and 27% lost > 5% of their body weight [18]. What
these three interventions have in common is that they were
tailored to the unique cultural needs of the African-American
population. Two out of three were based in or recruited
through churches and all actively recruited local community
leaders who worked alongside healthcare educators.
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In addition to ethnic minorities, other high-risk groups,
such as patients with serious mental illness, may benefit from
peer support groups. Individuals with serious mental illness,
such as schizophrenia or bipolar disorder, have rates of
overweight/obesity exceeding 80% [38], and this group often
struggles with finding adequate social support [39]. PeerFIT
was a 24-week peer group intervention for individual with
serious mental illness. The program consisted of weekly in-
person sessions lead by lifestyle coaches, optional twice
weekly group exercise sessions lead by fitness instructors
from the local YMCA, physical activity tracking with FitBit
accelerometers, program-related text messages, and peer-to-
peer support on social media. Post-intervention results showed
that participants lost an average of 7.76 lbs. (SD = 12.4 lbs.; p=
0.005) and decreased their BMI significantly (−1.25 kg/m
2
,
SD = 1.99 kg/m
2
;p= 0.005), with 28% achieving clinically
significantweightlossof> 5% body weight [40]. Consistent
with other peer support groups, members perceived a sense of
community, with shared goals among individuals facing the
same challenges, who could give and receive advice unique
to their common goals, as essential to their success [41].
Perceived social support was found to be positively associated
with weight loss (r= 0.59; p= 0.002) [40•], further highlighting
its importance.
Often community-based interventions make use of peer
coaches, defined as “individuals who participate in some capac-
ity in health promotion but have no formal professional health
care training and have an existing relationship or other connec-
tion with the community or population receiving care”[18]. One
example is ESENCIAL Para Vivir (Essential for Life), a peer
support intervention designed for Latina immigrants, another
ethnic group with disproportionately high rates of obesity [36].
This peer support intervention was delivered by peer coaches
known as “promotoras.”Compared with data from a historical
control group, after 8 weeks, participants showed significant
weight loss (−2.1 kg; SD = 2.6 kg; p< 0.001) although this at-
tenuated at 6 months (p= 0.67). Participants also showed im-
proved dietary habits as measured by the Dietary Behavioral
Strategies Scale (p< 0.001) and increased self-reported physical
activity, as measured by the Global Physical Activity
Questionnaire (47.1-min increase at 8 weeks; p= 0.004) (54.3-
min increase at 6 months; p=0.026) [17]. During post-
intervention focus groups, participants stated a desire for cultur-
ally sensitive programs which incorporated traditional foods and
customs, practical tips for physical activity, and involved family
members, especially husbands [17].
Peer Group Weight Loss Interventions
for Men
Obesity rates among adult men (34.3%; 95% CI 32.6–36.1)
and women (38.3%; 95% CI 36.1–40.5) are both worryingly
high [36]. Yet, many weight loss interventions are designed
solely for women. Even in interventions not designed exclu-
sively for women, the majority of participants tend to be wom-
en. Only 5% of weight loss trials utilize all-male samples,
while 32% utilize an all-female sample; 27% of all weight loss
intervention participants are men, and only 1.8% are men of
an ethnic minority [42]. While men may need weight loss
interventions, such interventions do not appeal to them.
Semi-structured interviews of men’s experience in weight
loss interventions found that men perceived behaviors such as
dieting and self-monitoring weight as feminine. Men who
attended commercial weight loss programs reported feeling
uncomfortable, ostracized, and that the program was better
suited to women [43]. A series of focus groups among men
in southwest England gathered their perspectives on diet,
physical activity, and weight loss behaviors. It was found that
these men regarded dieting, counting calories, and commer-
cial weight loss groups as a “women’sthing,”of no interest to
“proper blokes.”Physical activity was more socially accept-
able, especially in a sporting context. Few men reported re-
ceiving peer support for weight loss from friends. In contrast,
family, especially wives and girlfriends, were seen as support-
ive and knowledgeable about nutrition [44]. Collectively,
these results highlight a need for weight loss interventions
focused on men’s concerns, especially ones which cultivate
peer support for dieting, physical activity, weight monitoring,
etc. from other men.
Several recent weight loss programs have been designed
exclusively for men, taking advantage of already existing
male-oriented groups. One example is Football Fans in
Training (FFIT), an intervention for members of a Scottish
professional football club (soccer fan group). FFIT combined
educational content, such as how to self-monitor and set spe-
cific goals, with supervised physical activity. Early interven-
tion sessions emphasized the educational components, while
later sessions focused more upon physical activity. The pro-
gram was designed to tap into a pre-existing community and
“work with rather than against prevailing understandings of
masculinity.”The intervention was overseen by community
football coaches who had been trained by the research staff
and took place at the club’shomestadium[45]. Compared
with a wait-list control group who only received a weight
management book, the intervention group showed significant
changes in BMI (−1.66 kg/m
2
;95%CI−1.93 to −1.40 kg/m
2
at 12 weeks; p< 0.0001) (−1.56 kg/m
2
; 95% CI −1.82 to
−1.29 kg/m
2
at 12 months; p< 0.0001), waist circumference
(−5.57 cm; 95% CI −6.41 to −4.72 cm at 12 weeks
p< 0.0001) (−5.12 cm; 95% CI −5.97 to −4.27 cm at
12 months; p< 0.0001), body fat percentage (−2.16%; 95%
CI −2.81 to −1.51 at 12 weeks; p<0.0001) (−2.15%; 95%
CI −2.78 to −1.52%at12months;p< 0.0001), as well
as improvements in self-reported physical activity in MET-
minutes/week (median = 2.38; IQR 1.90 to 2.98 at 12 weeks;
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p< 0.0001) (median = 1.49, IQR 1.11 to 1.98 at 12 months;
p= 0.008), healthy diet as measured by Dietary Instrument
for Nutrition Education scores for fatty foods (−4.39; 95%
CI −5.16 to −3.61; p< 0.0001 at 12 weeks) (−2.74; 95%
CI −3.52 to −1.96; p< 0.0001 at 12 months), fruit and vegeta-
ble consumption (1.32; 95% CI 1.07 to 1.57; p<0.0001 at
12 weeks) (0.54; 95% CI 0.29 to 0.79; p< 0.0001 at 12 months),
sugary foods (−1.52; 95% CI −1.83 to 1.21; p<0.0001 at
12 weeks) (−0.87; 95% CI −1.18 to −0.56; p< 0.0001 at
12 months), and alcohol consumption (−4.47 units/week;
95% CI −6.09 to −2.86; p< 0.001 at 12 weeks) (−2.59 units/
week; 95% CI −4.21 to −0.97; p< 0.0017 at 12 months) [46].
During focus groups, participants expressed appreciation for a
community of men with similar interests and facing similar
challenges. Such a context allowed them to discuss weight-
related challenges without worrying about challenges to their
masculinity [47]. Weight loss programs such as this can and
have been adapted to other sporting contexts. Hockey FIT, de-
veloped for Canadian hockey fans, followed the same format as
FFIT and showed similar results. Compared with a wait-list
control, after 12 weeks, those who received Hockey FIT
showed reductions in waist circumference (−2.8 cm; 95%
CI −5.0 to −0.6 cm; p=0.01) and BMI (−0.9 kg/m
2
;95%
CI −1.4 to −0.4 kg/m
2
;p< 0.001) [45,48•]. Post-intervention,
100% of participants reported healthier diet and 78% reported
increased physical activity. Critically, many of them cited re-
ceiving support from their coaches and fellow participants as
critical for their success and found it helpful that they were part
of a community of like-minded people, reinforcing a consistent
theme among peer support groups for weight loss [48•].
Online Peer Support
While many peer support groups consist of small groups
meeting in person, other formats have advantages (see
Table 2). Online weight loss communities have become pop-
ular over the past 10 years. These websites often include
features such as chat rooms, blogs, and discussion forums.
In-person peer support groups often encounter practical bar-
riers, such as geographic distance and difficulty finding trans-
portation to in-person events. Online formats, unlike in-person
support groups, are also untethered to specific times or dates.
In-person peer groups have a tacit expectation of reciprocal
support, in contrast to online peer groups in which pleas for
assistance may be borne by the group as a whole [49]. Internet
peer support group members endorsed preference for the
Internet community because they liked the anonymity, which
allowed greater freedom to discuss more sensitive topics, and
found the interactions to be non-judgmental, especially com-
pared with people in their lives such as friends and family
members [50].
Individuals who chose online peer support groups may
have different needs compared with those who utilize in-
person support groups. A survey of users of online health-
related social groups found that these individuals were dissat-
isfied with the support they received from their in-person net-
work [49]. Members of online peer support communities may
log into those communities whenever they feel in need of
extra validation or support. Such a format allows members
to customize their level of engagement.
Despite the different format, the active change elements of
online peer support groups may be quite similar to those pres-
ent in in-person peer groups. Surveys of members of
SparkPeople, an Internet weight loss community, stated that
in the past 4 weeks, they had at least once a day read weight-
related messages on discussion forums (56.8%), replied to
messages on forums (36.1%), and started weight-related dis-
cussions (18.5%) [50]. Even more so, members of these com-
munities said they received encouragement, motivation, rec-
ognition for success, accountability to a shared community,
humor, and information [50]. In other words, support offered
by the online community mirrored support offered by in-
person peer groups. Similarly, an examination of messages
posted on a forum of a large online bariatric surgery discus-
sion website found that the majority of messages aimed at
Table 2 A comparison of in-person and online peer support groups
Pros Cons
In-person •Sense of community may be enhanced by person-to-person communication
•Members may complete physical activity together, with a professional trainer
•Skill-building activities, such as cooking classes, can be conducted in person
•Group facilitators can monitor suggestions offered for accuracy
•May have greater retention
•Outspoken members may dominate
conversation
•Group is limited to specific time and
place
•May be difficult for socially anxious
Online •Ability to recruit special populations that cannot assemble enough individuals for an in-person
group (bariatric patients, individuals with mental illness)
•Members can access support without time or geographic restrictions
•Access to larger peer support group
•Cost-effective compared with in-person
•May have greater long-term sustainability
•Members can log in whenever it is convenient or they need extra support
•Difficult to provide non-verbal,
tangible support
•Unmonitored sites can promote
unhealthy social norms
Page 7 of 11 19Curr Cardiovasc Risk Rep (2020) 14: 19
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

both those who were preparing for surgery and those who
were adjusting to post-surgical life included emotional sup-
port, such as expressions of encouragement and sympathy
following setbacks, and instrumental support, such as recom-
mendations on specific foods and reappraising frustrating sit-
uations with family in a more positive manner [24••].
Some individuals choose online weight loss options as part
of a self-directed weight loss journey rather than seeking pro-
fessional help. However, just as professionally led in-person
weight loss interventions often involve peer support as part of
their method, online peer support groups are now being inte-
grated into both in-person and online weight loss interven-
tions. An example of an online-only weight loss program
which includes peer support is Noom. Program features in-
clude logging into an mHealth application (“app”)where
members may share food logs, weight loss goals, and chal-
lenges. Results found that receiving peer support did not di-
rectly predict weight loss (p= 0.08), but peer support did pre-
dict increases in food logging among participation (path coef-
ficient = 0.45, p< 0.05), which then predicted weight loss
(path coefficient = 0.37, p<0.05)[51].
Social media is a popular venue for member-created peer
support groups. Such venues have several unique features. As
of February 2019, 73% of American adults have used
YouTube and 69% have used Facebook, with many reporting
that they access social media platforms daily [52], suggesting
access to a very large peer support group. The level of ano-
nymity and detail varies based on media platform.
Comparisons of two branches of an online weight loss pro-
gram, one with an online discussion board and one with access
to a Facebook community, found that individuals who utilized
Facebook reported greater emotional support compared with
those who used the online discussion forum (1.0 point differ-
ence, p< 0.05). The authors speculated that these effects may
derive from differences in the nature of these media, in which
Facebook social support may be traced to specific individuals
via their detailed profiles, in contrast to anonymous discussion
posts. Noteworthy, active (5–6% body weight) and non-active
(6.1% body weight) users of the online program showed sim-
ilar weight loss results at 6 weeks (p> 0.108). Active users
were more satisfied with the program (0.3–0.7 point differ-
ence), reported greater compliance (0.3–1.0 point difference),
more perceived success (0.1–0.8 point difference), and greater
emotional (1.0–2.3 point difference), informational (1.1–2.4
point difference), and instrumental support (0.1–1.2 point dif-
ference) (p< 0.05, all differences), which may translate into
more sustained usage and greater success long term [53].
There may be limits to what can be achieved via online support.
A web-based weight loss program for rural women supplemented
with an online peer-led discussion blog was found to result in
modest weight loss (4.0–5.8 kg at 6 months). However, the weight
lost was no greater compared with the program without the peer
support blog (0.9 kg; 95% CI −0.8 to 2.7 kg at 6 months; p= 0.36)
or compared with a program supplemented by emails from a
professional counselor (−1.7 kg; 95% CI −3.4 to 0.0 kg at
6 months; p= 0.56). Only about half (45%) the women with ac-
cess to the peer-led discussion blog used it in the first 6 months of
the study, and this percentage dropped further (22%) over the
course of the study. The authors speculated that participants may
have never felt like they were part of a community, essentially
making their intervention the same as the control group [32]and
once again highlighting the importance of shared community for
the success of peer support groups.
Practical Recommendations on Fostering
Shared Community
A consistent theme among peer support groups is the need for
a sense of shared community among members. This may be
achieved through several overlapping methods. To foster a
sense of relatedness, so that members feel heard and valued,
all members should be given a chance to share and express
opinions at each meeting. Members may be encouraged to
offer varied types of functional support, including emotional
support, informational support, and when possible tangible
support. Community may already exist if group members
are recruited from already existing groups, such as members
of the same church or employees at the same office.
Facilitators who share similar characteristics as group mem-
bers or advanced group members who transition into facilita-
tor roles may be perceived as more relatable and credible.
Some peer support groups incorporate hand-on educational
activities such as cooking classes. Such activities may, in addi-
tion to practical skills, give participants a sense of working to-
wards a common goal such as a shared meal. Group exercise
classes have the added benefits of friendly competition, fun, and
a break from monotony. Peers may actively support one another
such as holding a peer’s feet during sit-ups and cheering encour-
agement while jogging. Group exercises may be particularly
beneficial in community building for male participants, who tend
to incline towards physical activity [44], and for quieter group
members who may not engage as often in group conversations.
Ideally, exercise classes will include aerobic, strength-based, and
stretching exercises. To ensure safety, supervision by a profes-
sional fitness instructor is highly recommended.
Virtual support groups, especially those which operate
solely online, have special challenges creating community
and connectedness. Online support groups tend to be more
successful when participants feel seen as unique individuals
and have enough knowledge about their fellow group mem-
bers to also see them as unique individuals [53]. Smaller
groups allow greater time for each member to speak. Use of
both visual and audio during meetings may help foster con-
nection. Group activities may be possible online if they make
use of minimal, commonly available equipment.
19 Page 8 of 11 Curr Cardiovasc Risk Rep (2020) 14: 19
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Conclusion: Future of Peer Support
Interventions
Weight loss interventions need to be more than just effective at
helping participants lose weight in the short term. A truly suc-
cessful program must support behavior change that can be main-
tained over years rather than weeks. To maintain this sustainabil-
ity, the program must be cost-effective enough that participants
can maintain membership long term and must be able to occa-
sionally reengage in an on-going group when necessary [54].
Peer support groups may help fulfill this function.
Pre-existing online forums may represent a natural medium
for peer support groups, and such venues have several advan-
tages, not the least of which is their accessibility from any
location. Thus far, social media has largely served as a sup-
plement to other active elements within weight loss programs,
such as group educational content or counseling; comparative-
ly, little is known about social media’s independent effect
within these programs [55•]. Given social media’subiquity
and popularity, there is great potential there; with social me-
dia’s well-known ability to propagate misinformation [56,57]
and harmful norms [58], guidance from healthcare profes-
sionals or trained peer coaches may be necessary safeguards.
To summarize, peer-led support groups represent a novel
and potentially effective form of weight loss interventions,
especially when the intervention successfully creates a sense
of shared community among its members. Peer support
groups appear to be particularly effective in supporting vul-
nerable at-risk populations, such as ethnic minorities. The
utility of online peer support as an adjunct to in-person peer
support may not greatly improve short-term study outcomes
but is positively perceived by participants and may improve
long-term adherence.
Compliance with Ethical Standards
Conflict of Interest Kelsey Ufholz declares she has no conflicts of
interest.
Human and Animal Rights and Informed Consent This study does not
contain any studies with human or animal subjects performed by the
author.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing, adap-
tation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, pro-
vide a link to the CreativeCommons licence,and indicate if changes were
made. The images or other third party material in this article are included
in the article's Creative Commons licence, unless indicated otherwise in a
credit line to the material. If material is not included in the article's
Creative Commons licence and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/.
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