Equivalent weight loss for weight management programs delivered by phone and clinic

The past, present, and future of behavioral obesity treatment

Over the last century, hundreds of evaluations have been conducted to examine weight-management interventions related to diet, physical activity, and behavior therapy. These investigations have contributed to a growing body of knowledge that has consistently advanced the field of obesity treatment, while also revealing some persistent challenges. This narrative review summarizes key findings from randomized controlled trials conducted in adults that have combined diet, physical activity, and behavior therapy, an approach variously referred to as behavioral treatment, comprehensive lifestyle modification, or intensive lifestyle intervention. The review shows that current behavioral approaches induce average reductions in baseline body weight of 5 to 10% at 6 to 12 months. Such losses have proven effective in reducing the risk of type 2 diabetes in persons with impaired glucose tolerance and in improving other obesity-related complications. These benefits have also been associated with reductions in healthcare costs. Despite these advances, behavioral treatment is challenged by the need for larger losses to achieve optimal improvements in health, by difficulties associated with maintaining weight loss, and by barriers limiting access to treatment. New anti-obesity medications, when combined with behavioral obesity treatment, hold promise of addressing the first two issues.

Medical Nutrition Therapy, In-Person, or Telephone Group Lifestyle Intervention for Type 2 Diabetes? A Qualitative Study of Patient Perceptions and Treatment Preferences

PURPOSE

The purpose of the study was to explore the thoughts, feelings, motivations, and assignment preferences of community health center patients with type 2 diabetes considering participation in a 2-year lifestyle intervention trial aimed at weight loss and increased physical activity. The reasons for patients' delivery mode preferences were also explored to aid in the design of future interventions for controlled trials.

METHODS

Using structured telephone interview guides, 57 patients with type 2 diabetes receiving primary care at 3 community health centers affiliated with an academic medical center were interviewed regarding the perceived pros and cons of each of the 3 possible treatment assignments: telephone conference group, in-person group, or individual medical nutrition therapy. The interview data were organized using NVIVO and analyzed using content analysis. Findings on whether preferences varied by age, gender, or diabetes duration were also examined.

RESULTS

Six categories related to patient treatment preferences were identified: (1) perception of time, (2) learning style, (3) comfort, (4) prior experience with weight loss programs and conference calls, (5) desire for support/idea exchange, and (6) accountability. Preferences did not seem to vary by age, gender, or diabetes duration.

CONCLUSIONS

Key factors influencing preference of treatment assignment included schedule demands, belief about learning style, and past experiences. These findings demonstrate the importance of having a variety of nutrition and lifestyle treatment options available to meet the needs of people with type 2 diabetes.

Remote delivery of a weight management intervention for adults with intellectual disabilities: Results from a randomized non-inferiority trial

BACKGROUND

Remote delivery of multi-component weight management interventions results in clinically meaningful weight loss in adults without intellectual disabilities (ID), but the effectiveness of remotely delivered weight management interventions in adults with ID has not previously been evaluated.

OBJECTIVE

To determine if a weight management intervention delivered remotely could achieve weight loss (kg) at 6 months that is non-inferior to in-person visits in adults with ID and overweight or obesity (BMI ≥25 kg/m2).

METHODS

Participants were randomized to a 24-mo. trial (6 mos weight loss,12 mos weight maintenance, 6 mos. no-contact follow up) to compare weight loss achieved with the same multicomponent intervention delivered to individual participants in their home either remotely (RD) or during face-to-face home visits (FTF).

RESULTS

One hundred twenty adults with ID (∼32 years of age, 53 % females) were randomized to the RD (n = 60) or the FTF arm (n = 60). Six-month weight loss in the RD arm (-4.9 ± 7.8 kg) was superior to 6-month weight loss achieved in the FTF arm (-2.1 ± 6.7 kg, p = 0.047). However, this may be partially attributed to the COVID-19 pandemic, since weight loss in the FTF arm was greater in participants who completed the intervention entirely pre-COVID (n = 33,-3.2 %) compared to post-COVID (n = 22, -0.61 %). Weight loss across did not differ significantly between intervention arms at 18 (p = 0.33) or 24 months (p = 0.34).

CONCLUSION

Our results suggest that remote delivery is a viable option for achieving clinically relevant weight loss and maintenance in adults with ID.

NCT REGISTRATION

NCT03291509.

Weight management in rural health clinics: Results from the randomized midwest diet and exercise trial

Introduction

Rural living adults have higher rates of obesity compared with their urban counterparts and less access to weight management programs. Previous research studies have demonstrated clinically relevant weight loss in rural living adults who complete weight management programs delivered by university affiliated interventionists. However, this approach limits the potential reach, adoption, implementation, and maintenance of weight management programs for rural residents. Weight management delivered through rural health clinics by non-physician clinic associated staff, for example, nurses, registered dieticians, allied health professionals, etc. has the potential to improve access to weight management for rural living adults. This trial compared the effectiveness of a 6-month multicomponent weight management intervention for rural living adults delivered using group phone calls (GP), individual phone calls (IP) or an enhanced usual care control (EUC) by rural clinic associated staff trained by our research team.

Methods

Rural living adults with overweight/obesity (n = 187, age ∼ 50 years 82% female, body mass index ∼35 kg/m2) were randomized (2:2:1) to 1 of 3 intervention arms: GP, which included weekly ∼ 45 min sessions with 7-14 participants (n = 71), IP, which included weekly ∼ 15 min individual sessions (n = 80), or EUC, which included one-45 min in-person session at baseline.

Results

Weight loss at 6 months was clinically relevant, that is, ≥5% in the GP (-11.4 kg, 11.7%) and the IP arms (-9.1 kg, 9.2%) but not in the EUC arm (-2.6%, -2.5% kg). Specifically, 6 month weight loss was significantly greater in the IP versus EUC arms (-6.5 kg. p ≤ 0.025) but did not differ between the GP and IP arms (-2.4 kg, p > 0.025). The per participant cost per kg. weight loss for implementing the intervention was $93 and $60 for the IP and GP arms, respectively.

Conclusions

Weight management delivered by interventionists associated with rural health clinics using both group and IP calls results in clinically relevant 6 months weight loss in rural dwelling adults with overweight/obesity with the group format offering the most cost-effective strategy. Clinical trial registration: ClinicalTrials.gov (NCT02932748).

Telehealth acceptance and commitment therapy for weight loss: Protocol of the WeLNES full scale randomized controlled trial

Behavioral interventions delivered via one-on-one telephone coaching (hereafter referred to as telehealth) for weight loss have had great population-level reach but to date limited efficacy. Acceptance and Commitment Therapy (ACT) has promise to improve behavioral weight loss treatment efficacy by addressing the fundamental challenges of weight loss and maintenance: overeating in response to internal (e.g., stress) and external (e.g., high calorie foods) cues. Here we describe the Weight Loss, Nutrition, and Exercise Study (WeLNES) randomized controlled trial that is testing the efficacy of an ACT-based telehealth coaching intervention for weight loss in comparison to a Standard Behavioral Therapy (SBT)-based telehealth coaching intervention. A total of 398 adults with overweight or obesity are being recruited and randomized to either ACT or SBT telehealth coaching. Participants in both arms are offered twenty-five telehealth coaching sessions in year one and nine booster sessions in year two. All participants receive a Bluetooth-enabled scale to self-monitor weight and a Fitbit Inspire + Fitbit app for tracking diet and physical activity. The primary aim is to determine whether a greater proportion of ACT participants will achieve a clinically significant weight loss of ≥10% compared with SBT participants at 12-months. Secondary outcomes include change in weight from baseline to 6, 12, and 24-months. Whether the effect of ACT on weight loss is mediated by ACT processes and is moderated by baseline factors will also be examined. If ACT proves efficacious, ACT telehealth coaching will offer an effective, broadly scalable weight loss treatment-thereby making a high public health impact.

A 4-year Retrospective Study on the Impact of the Dietary Program on Anthropometric and Metabolic Parameters among Overweight and Obese Subjects in Primary Health Care Centers in Qatar

Aim. Obesity is a worldwide epidemic and one of the risk factors for many diseases including heart disease, diabetes mellitus, kidney disease, and cancer. The aim of this study was to review the impact of the local dietary program on anthropometric and metabolic parameters among overweight and obese subjects attending Primary Health Care Centers in Qatar from 2016 to 2019. Methods. A 4-year retrospective cohort study. Results. Among 10451 patients, the overall success rate of BMI reduction was 10% while 22.22% of population had ≥5% reduction in BMI from baseline. The median time for weight reduction was 3.2 years, with women showing earlier significant weight loss than men. The patients with 3–5 number of visits had earlier significant weight reduction than those with ≤3 visits and >5 number of visits. Greater weight reduction was seen in those with chronic diseases and who had constant follow up visits in the dietetic clinic during the study period. Conclusion. Our results are encouraging, showing improvement in the management of adult obesity with medical nutrition therapy through involvement and guidance in the community dietetic clinics. The dietetic clinic services could be an operative strategy to prevent expensive diabetic and cardiovascular events, mainly in high-risk patients.

Encouraging appropriate gestational weight gain in high-risk gravida: A randomized controlled trial

Trial Design

Excessive gestational weight gain (GWG) can increase pregnancy morbidity and is particularly problematic for women with pregestational obesity. A lifestyle modification intervention was introduced to gravida with obesity to decrease excessive GWG as compared to usual care (UC).

Methods

A randomized controlled trial was conducted to improve healthy lifestyle behaviors to manage appropriate GWG. Consenting participants with prepregnancy obesity and singletons ≤17 weeks were randomized to (1) Usual Care (UC): usual written educational materials and counseling by obstetric provider or (2) Enhanced Care (EC): UC plus (a) personalized letter from physician detailing appropriate GWG; (b) access to individualized GWG chart; (c) ongoing counseling with registered dietitian/nutritionist (RDN). The primary outcome was proportion with GWG ≤9.1 kg, as this is upper limit recommended by Institute of Medicine (IOM). Total GWG and GWG as less than/within/greater than IOM recommendations (in aggregate and stratified by obesity class), and pregnancy/neonatal outcomes were evaluated as secondary outcomes.

Results

Analyses included 105 participants in EC and 109 in UC arms. The groups had similar demographics: 46% with class I obesity, 26% class II, and 28% class III. There were no group differences for any GWG, pregnancy, or neonatal outcomes when analyzed in aggregate. As compared to those randomized to the EC arm, participants in UC arm with class I obesity gained 1.4 kg less and those with class II obesity were significantly more likely to gain within IOM guidelines (14.8% vs. 40.0%, adjusted p = 0.04). Participants with class III obesity randomized to EC arm were more likely to gain within IOM guidelines as compared to participants randomized to UC arm (29.0% vs. 6.7%, adjusted p = 0.02).

Conclusion

There were no differences in GWG observed between groups when analyzing participants in aggregate. However, a physician's letter detailing appropriate GWG, patient portal access to a personalized GWG chart, and RDN consultation were helpful for encouraging GWG within IOM guidelines for women with prepregnancy class III obesity. Women with class I or II obesity had better GWG outcomes without these additional interventions.

Examination of three-factor eating questionnaire subscale scores on weight loss and weight loss maintenance in a clinical intervention

Background

The purpose of this study is to examine three-factor eating questionnaire (TFEQ) scores at baseline and post-intervention (6 months) on successful weight loss and weight maintenance in an 18-month behavioral weight management intervention for adults with overweight and obesity.

Methods

TFEQ and weight were assessed at baseline, 6, and 18 months. Logistic regression models were used to examine scores at baseline on disinhibition, restraint, and perceived hunger factors in the TFEQ on 5% body weight loss at 6 months and 6-month scores to predict 5% weight maintenance at 18 months while controlling for age, sex, and baseline weight.

Results

Participants (n = 287; age = 43.8 ± 10.36 years; female = 64.1%; weight = 222.5 ± 39.02 pounds; BMI = 34.73 ± 4.56) were included for analysis. Dietary restraint at baseline was the only significant predictor of 5% weight loss at 6 months. None of the TFEQ subscale scores at 6 months predicted 5% weight maintenance at 18 months. The model examining weight loss at 6 months accounted for 7% of the variance of the outcome and 11% of the variance of weight maintenance at 18 months.

Conclusion

Dietary restraint is a unique eating behavior associated with weight loss at 6 months beyond other eating behaviors measured by the TFEQ in an adult sample enrolled in a weight loss intervention. No other subscale scores were significant at 6 months or at 18 months. Future research should consider how to promote flexible control and discourage adoption of rigid restraint behaviors since the latter is associated with disordered eating patterns.

Impact of transition from face-to-face to telehealth on behavioral obesity treatment during the COVID-19 pandemic

OBJECTIVE

This study evaluated whether the transition of a face-to-face behavioral intervention to videoconferencing-based telehealth delivery during the COVID-19 pandemic resulted in significantly smaller weight losses than those typically observed in gold-standard, face-to-face programs.

METHODS

Participants were 160 adults with obesity (mean [SD] age = 49.2 [11.9] years, BMI = 36.1 [4.2] kg/m² ) enrolled in two cohorts of a 16-week comprehensive weight-management program. Cohort 1 began in person and transitioned to telehealth (Zoom) delivery during week 11 of the intervention because of COVID-19; Cohort 2 was conducted completely remotely. A noninferiority approach (using a clinically relevant noninferiority margin of 2.5%) was used to assess whether the weight losses observed were inferior to the 8% losses from baseline typically produced by gold-standard, face-to-face lifestyle interventions.

RESULTS

From baseline to postintervention, participants lost an average of 7.4 [4.9] kg, representing a reduction of 7.2% [4.6%]. This magnitude of weight change was significantly greater than 5.5% (t[159] = 4.7, p < 0.001), and, thus, was within the proposed noninferiority margin.

CONCLUSIONS

These findings demonstrate that the results of behavioral weight-management interventions are robust, whether delivered in person or remotely, and that individuals can achieve clinically meaningful benefits from behavioral treatment even during a global pandemic. Pragmatic "lessons learned," including modified trial recruitment techniques, are discussed.

Efficacy of Telephone Health Coaching Integration with Standard Multidisciplinary Care for Adults with Obesity Attending a Weight Management Service: A Pilot Study

Australia has one of the highest prevalences of obesity in the developed world with recognised gaps in patient access to obesity services. This non-randomised before and after study investigated the health benefits and patient acceptability of integrating the Get Healthy Service, a state-funded telephone-delivered coaching service in Australia, as an adjunct to multidisciplinary care for adults attending a public obesity service. Forty-one participants received multidisciplinary care alone while 39 participants were subsequently allocated to receive adjunctive treatment with the Get Healthy Service. Weight, body mass index, glycosylated haemoglobin, measurement of hepatic steatosis and liver enzymes were collected at baseline and 6 months. Participant evaluation was obtained post intervention. Statistically significant reductions from baseline were achieved for both control and intervention with respect to weight (−6.7 ± 2.2 kg, p = 0.01; −12.6 ± 3.2, p = 0.002), body mass index (−2.3 ± 0.8, p = 0.01; −4.8 ± 1.2 kg/m², p = 0.002) and glycosylated haemoglobin (−0.2 ± 0.2%, p = 0.2 (NS); −0.7 ± 0.2%, p = 0.02), respectively. There were no significant differences in steatosis or liver enzymes or in outcomes between control and intervention cohorts. A high level of patient acceptability was reported. Integrating telephone-delivered coaching provided non-inferior care and high levels of patient satisfaction. Telephone coaching aligned with the principles of an obesity service should be trialled to improve patient access to obesity interventions.

Weight Loss Interventions for Adolescents With Intellectual Disabilities: An RCT

OBJECTIVES

In this randomized trial, we compared the effectiveness of 2 diets (enhanced stop light diet [eSLD] versus conventional meal plan diet [CD]) and 2 delivery strategies (face-to-face [FTF] versus remote delivery [RD]) on weight loss across 6 months in adolescents with intellectual and developmental disabilities who were overweight or obese.

METHODS

Participants were randomly assigned to 1 of 3 arms (FTF/CD, RD/CD, or RD/eSLD) and asked to attend one-on-one sessions with a health educator every 2 weeks to aid in maintaining compliance with recommendations for a reduced-energy diet and increased physical activity. The CD followed the US dietary guidelines. The eSLD used the stop light guide and was enhanced with portion-controlled meals. The FTF arm was delivered during in-person home visits. The RD arms were delivered by using video conferencing.

RESULTS

A total of 110 adolescents with intellectual and developmental disabilities (aged ∼16 years, 53% female, BMI 33) were randomly assigned to the FTF/CD (n = 36), RD/CD (n = 39), or RD/eSLD (n = 35) group. Body weight at 6 months was obtained from 97%, 100%, and 86% of participants in the FTF/CD, RD/CD, and RD/eSLD arms, respectively. The eSLD elicited significantly greater weight loss than the CD: RD/eSLD (-5.0 ± 5.9 kg; -6.4%) versus RD/CD (-1.8 ± 4.0 kg; -2.4%) (P = .01). However, weight loss did not differ by delivery strategy: FTF/CD (-0.3 ± 5.0 kg; -0.2%) versus RD/CD (-1.8 ± 4.0 kg; -2.4%) (P = .20).

CONCLUSIONS

The eSLD elicited significantly greater 6-month weight loss compared with a CD when both interventions were delivered remotely. Minimal 6-month weight loss, which did not differ significantly between FTF delivery and RD, was observed with a CD.

A prenatal group based phone counseling intervention to improve breastfeeding rates and complementary feeding: a randomized, controlled pilot and feasibility trial

Background

Despite numerous benefits for both mom and baby, few infants are exclusively breastfed for the recommended first six months. Additionally, infants are given solids too early. Prenatal education increases rates of breastfeeding initiation and we hypothesize it can also improve exclusive breastfeeding rates and prevent the early introduction of solids. We conducted a randomized controlled pilot and feasibility trial to understand the feasibility and maternal acceptance of a prenatal behavioral lifestyle intervention (PBLI) delivered via group based phone counseling (GBPC) and its effectiveness on rates of exclusive breastfeeding up to six months postpartum. Secondary aims included rates of any breastfeeding up to six months, rates of early introduction of solids, and infant feeding progression.

Methods

Forty-one pregnant women were recruited from a Kansas City Metropolitan Obstetrics and Gynecology office and randomly assigned to a usual care group or a PBLI. Women in the PBLI participated in six GBPC sessions where they learned about breastfeeding and introducing solids. Feeding questionnaires to assess breastfeeding and introduction of solids were sent at two weeks, two months, four months, and six months postpartum. Structured interviews were also conducted after the intervention and at six months postpartum to assess maternal acceptance and intervention feasibility.

Results

Participants overwhelmingly found the intervention acceptable and beneficial.

Rates of exclusive breastfeeding and any breastfeeding did not differ between groups at any time point. No between group differences were found for early introduction of solids or infant feeding progression.

Conclusions

Mothers discontinue breastfeeding earlier than recommended despite high rates of initiation. A PBLI delivered via GBP is feasible, acceptable to participants, and showed positive impacts such as maternal empowerment for both breastfeeding and introducing solids. Future interventions should incorporate both prenatal and postpartum components.

Trial registration

Study protocols were approved by the University of Kansas Medical Center’s Human Subjects Committee (STUDY00140506) and registered at ClinicalTrials.gov on 02/22/2018 (NCT03442517, retrospectively registered). All participants gave written informed consent prior to data collection.

Group Lifestyle Phone Maintenance for Weight, Health, and Physical Function in Adults Aged 65-80 Years: A Randomized Clinical Trial

BACKGROUND

Group lifestyle sessions with phone maintenance could improve weight, health, and function in vulnerable older adults.

METHODS

Community-dwelling adults (N = 322) with body mass index (BMI, kg/m2) ≥27 and additional risk factors received 12 one-hour in-person behavioral weight management group sessions then were randomized to 8 half-hour telephone sessions (n = 162) or newsletter control (n = 160) from 4 to 12 months with no treatment contact thereafter. Primary outcome was 0- to 12-month weight change. Cardiometabolic, short physical performance battery (SPPB), and self-reported activity changes were assessed at 12 and 24 months.

RESULTS

At baseline, the mean (SD) age was 71.2 (4.3) and BMI was 33.8 (5.1). Participants were 77% women, 13% Black, 85% retired, averaging 4 medical conditions, and taking blood pressure (67.4%) and lipid-lowering (51.6%) medications. At 12 months, a greater proportion of the phone group (66.0%) achieved ≥5% weight loss compared with newsletter control (53.2%; p = .02). Mean (95% CI) weight loss was greater for phone (-6.6 kg [-7.5, -5.8]) than newsletter (-5.1 kg [-7.2, -3.0]); p = .01. Modest lipid, glucose, and blood pressure improvements were found, but did not differ significantly between groups. Small SPPB and activity improvements were maintained at 12 and 24 months in both groups.

CONCLUSIONS

Brief phone contacts compared to newsletters enhanced weight loss maintenance among older high-risk adults at 1 year, but not cardiometabolic outcomes. Modest functional improvements were observed in both. Lower-intensity maintenance contacts (phone or newsletter) for weight, health, and physical function in older adults warrant further study.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03192475.

Commercial Weight Loss Programs in the Management of Obesity: an Update

PURPOSE OF REVIEW

Comprehensive lifestyle programs are cornerstones of obesity management, but clinician referrals may be limited by program availability. Commercial weight loss programs may be an alternative, but clinicians may be unaware of their efficacy and safety. This review describes the evidence for commercial programs, particularly 12-month weight loss, among individuals with obesity.

RECENT FINDINGS

Several programs are concordant with evidence-based recommendations (i.e., lower-calorie diet, increased physical activity, and behavioral strategies). Among the guideline-concordant programs, National Diabetes Prevention Program, WW, Jenny Craig, Medifast, and OPTIFAST have demonstrated 12-month weight loss efficacy and safety. While other programs show promise, more evidence is needed before clinician referral may be recommended. Clinical practice guidelines support referrals to commercial weight loss programs that have peer-reviewed evidence to support their efficacy and safety. Clinicians should consider the available evidence, patient preference, and cost when considering referrals to these programs for weight management.

Effect of Behavioral Therapy With In-Clinic or Telephone Group Visits vs In-Clinic Individual Visits on Weight Loss Among Patients With Obesity in Rural Clinical Practice: A Randomized Clinical Trial

IMPORTANCE

Rural populations have a higher prevalence of obesity and poor access to weight loss programs. Effective models for treating obesity in rural clinical practice are needed.

OBJECTIVE

To compare the Medicare Intensive Behavioral Therapy for Obesity fee-for-service model with 2 alternatives: in-clinic group visits based on a patient-centered medical home model and telephone-based group visits based on a disease management model.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial conducted in 36 primary care practices in the rural Midwestern US. Inclusion criteria included age 20 to 75 years and body mass index of 30 to 45. Participants were enrolled from February 2016 to October 2017. Final follow-up occurred in December 2019.

INTERVENTIONS

All participants received a lifestyle intervention focused on diet, physical activity, and behavior change strategies. In the fee-for-service intervention (n = 473), practice-employed clinicians provided 15-minute in-clinic individual visits at a frequency similar to that reimbursed by Medicare (weekly for 1 month, biweekly for 5 months, and monthly thereafter). In the in-clinic group intervention (n = 468), practice-employed clinicians delivered group visits that were weekly for 3 months, biweekly for 3 months, and monthly thereafter. In the telephone group intervention (n = 466), patients received the same intervention as the in-clinic group intervention, but sessions were delivered remotely via conference calls by centralized staff.

MAIN OUTCOMES AND MEASURES

The primary outcome was weight change at 24 months. A minimum clinically important difference was defined as 2.75 kg.

RESULTS

Among 1407 participants (mean age, 54.7 [SD, 11.8] years; baseline body mass index, 36.7 [SD, 4.0]; 1081 [77%] women), 1220 (87%) completed the trial. Mean weight loss at 24 months was -4.4 kg (95% CI, -5.5 to -3.4 kg) in the in-clinic group intervention, -3.9 kg (95% CI, -5.0 to -2.9 kg) in the telephone group intervention, and -2.6 kg (95% CI, -3.6 to -1.5 kg) in the in-clinic individual intervention. Compared with the in-clinic individual intervention, the mean difference in weight change was -1.9 kg (97.5% CI, -3.5 to -0.2 kg; P = .01) for the in-clinic group intervention and -1.4 kg (97.5% CI, -3.0 to 0.3 kg; P = .06) for the telephone group intervention.

CONCLUSIONS AND RELEVANCE

Among patients with obesity in rural primary care clinics, in-clinic group visits but not telephone-based group visits, compared with in-clinic individual visits, resulted in statistically significantly greater weight loss at 24 months. However, the differences were small in magnitude and of uncertain clinical importance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02456636.

A Randomized Trial Evaluating Exercise for the Prevention of Weight Regain

OBJECTIVE

This study aimed to evaluate the effectiveness of three levels of exercise on weight regain subsequent to clinically meaningful weight loss (WL).

METHODS

Adults with overweight or obesity (n = 298) initiated a 3-month behavioral WL intervention, which included reduced energy intake, increased exercise, and weekly behavioral counseling. Participants achieving ≥5% WL (n = 235) began a 12-month behavioral WL maintenance intervention and were randomized to 150 min/wk (n = 76), 225 min/wk (n = 80), or 300 min/wk (n = 79) of partially supervised moderate-to-vigorous-intensity exercise.

RESULTS

Participants randomized to 150, 225, and 300 minutes of exercise completed 129 ± 30, 153 ± 49 and 179 ± 62 min/wk of exercise (supervised + unsupervised), respectively. Mean WL at 3 months (9.5 ± 3.1 kg) was similar across randomized groups (P = 0.68). Weight change across 12 months was 1.1 ± 6.5 kg, 3.2 ± 5.7 kg, and 2.8 ± 6.9 kg in the 150, 225, and 300 min/wk groups, respectively. Intent-to-treat analysis revealed no significant overall trend across the three treatment groups (P = 0.09), effects for group (P = 0.08), or sex (P = 0.21).

CONCLUSIONS

This study found no evidence for an association between the volume of moderate-to-vigorous-intensity exercise and weight regain across 12 months following clinically relevant WL. Further, results suggest that exercise volumes lower than those currently recommended for WL maintenance, when completed in conjunction with a behavioral weight-maintenance intervention, may minimize weight regain over 12 months.

5-Year Follow-Up of a Telephone Intervention to Increase Fruit and Vegetable Consumption in Preschoolers: The 'Healthy Habits' Cluster Randomised Trial

Little is known about the long-term impact of telephone-based interventions to improve child diet. This trial aimed to assess the long-term effectiveness (after 5 years) of a telephone-based parent intervention in increasing children's fruit and vegetable consumption. Parents of 3-5 year olds were recruited from 30 Australian preschools to participate in a cluster randomised controlled trial. Intervention parents received four, weekly, 30-min support calls aimed at modifying the home food environment. Control parents received printed materials. Consumption was assessed using the Fruit and Vegetable subscale of the Children's Dietary Questionnaire (F&V-CDQ) (children) and daily servings of fruit and vegetables (children and parents) via parent telephone interview. Of the 394 parents who completed baseline, 57% (99 intervention, 127 control) completed follow-up. After 5-years, higher intervention F&V-CDQ scores, bordering on significance, were found in complete-case (+1.1, p = 0.06) and sensitivity analyses (+1.1, p = 0.06). There was no difference in parent or child consumption of daily fruit servings. Complete-case analysis indicated significantly higher consumption of child vegetable servings (+0.5 servings; p = 0.02), which was not significant in sensitivity analysis (+0.5 servings; p = 0.10). This telephone-based parent intervention targeting the family food environment may yield promising improvements in child fruit and vegetable consumption over a 5-year period.

Weight management for adults with mobility related disabilities: Rationale and design for an 18-month randomized trial

Adults with mobility related disabilities (MRDs) represent an underserved group with a high prevalence of overweight/obesity and limited options for weight management. We previously demonstrated clinically meaningful 12-month weight loss in adults with MRDs (-6.2%, 36% ≥5% of baseline weight) using an enhanced Stop Light Diet (eSLD) delivered using at home face-to-face behavioral sessions and optional physical activity. However, the costs/logistics associated with intervention delivery by individual home visits limits the potential for scaling and implementation of this approach. Thus, we will conduct a two-arm randomized trial in 128 overweight/obese adults with MRDs to compare weight loss (6 mos.) and maintenance (12 mos.) between interventions utilizing the eSLD, behavioral counseling, and increased physical activity delivered to individual participants in their homes or delivered to groups of participants in their homes remotely via video conferencing. The primary aim will compare weight loss between interventions arms across 6 months. Secondarily, we will compare weight loss (0-18 mos.), the proportion of participants who achieve clinically meaningful weight loss (≥5%) from 0 to 6 and 0 to18 months, and changes in quality of life from 0 to 6 and 0 to 18 months between interventions arms. We will also conduct cost, cost-effectiveness and contingent valuation comparisons and explore the influence of behavioral session attendance, compliance with the recommendations for diet and physical activity, self-monitoring of diet and physical activity, barriers to physical activity, sleep quality, and medications on weight change across 6 and 18 months. NCT REGISTRATION: NCT04046471.

Effect of Adding Telephone-Based Brief Coaching to an mHealth App (Stay Strong) for Promoting Physical Activity Among Veterans: Randomized Controlled Trial

Background

Though maintaining physical conditioning and a healthy weight are requirements of active military duty, many US veterans lose conditioning and rapidly gain weight after discharge from active duty service. Mobile health (mHealth) interventions using wearable devices are appealing to users and can be effective especially with personalized coaching support. We developed Stay Strong, a mobile app tailored to US veterans, to promote physical activity using a wrist-worn physical activity tracker, a Bluetooth-enabled scale, and an app-based dashboard. We tested whether adding personalized coaching components (Stay Strong+Coaching) would improve physical activity compared to Stay Strong alone.

Objective

The goal of this study is to compare 12-month outcomes from Stay Strong alone versus Stay Strong+Coaching.

Methods

Participants (n=357) were recruited from a national random sample of US veterans of recent wars and randomly assigned to the Stay Strong app alone (n=179) or Stay Strong+Coaching (n=178); both programs lasted 12 months. Personalized coaching components for Stay Strong+Coaching comprised of automated in-app motivational messages (3 per week), telephone-based human health coaching (up to 3 calls), and personalized weekly goal setting. All aspects of the enrollment process and program delivery were accomplished virtually for both groups, except for the telephone-based coaching. The primary outcome was change in physical activity at 12 months postbaseline, measured by average weekly Active Minutes, captured by the Fitbit Charge 2 device. Secondary outcomes included changes in step counts, weight, and patient activation.

Results

The average age of participants was 39.8 (SD 8.7) years, and 25.2% (90/357) were female. Active Minutes decreased from baseline to 12 months for both groups (P<.001) with no between-group differences at 6 months (P=.82) or 12 months (P=.98). However, at 12 months, many participants in both groups did not record Active Minutes, leading to missing data in 67.0% (120/179) for Stay Strong and 61.8% (110/178) for Stay Strong+Coaching. Average baseline weight for participants in Stay Strong and Stay Strong+Coaching was 214 lbs and 198 lbs, respectively, with no difference at baseline (P=.54) or at 6 months (P=.28) or 12 months (P=.18) postbaseline based on administrative weights, which had lower rates of missing data. Changes in the number of steps recorded and patient activation also did not differ by arm.

Conclusions

Adding personalized health coaching comprised of in-app automated messages, up to 3 coaching calls, plus automated weekly personalized goals, did not improve levels of physical activity compared to using a smartphone app alone. Physical activity in both groups decreased over time. Sustaining long-term adherence and engagement in this mHealth intervention proved difficult; approximately two-thirds of the trial’s 357 participants failed to sync their Fitbit device at 12 months and, thus, were lost to follow-up.

Trial Registration

ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293

International Registered Report Identifier (IRRID)

RR2-10.2196/12526

Dietitians Australia position statement on telehealth

It is the position of Dietitians Australia that clients can receive high‐quality and effective dietetic services such as Medical Nutrition Therapy (MNT) delivered via telehealth. Outcomes of telehealth‐delivered dietetic consultations are comparable to those delivered in‐person, without requiring higher levels of additional training nor compromising quality of service provision. Dietitians Australia recommends that policy makers and healthcare funders broaden the recognition for telehealth‐delivered dietetic consultations as a responsive and cost‐effective alternative or complement to traditional in‐person delivery of dietetic services. The successful implementation of telehealth can help to address health and service inequalities, improve access to effective nutrition services, and support people with chronic disease to optimise their diet‐related health and well‐being, regardless of their location, income or literacy level, thereby addressing current inequities.

Effect of Telehealth Extended Care for Maintenance of Weight Loss in Rural US Communities: A Randomized Clinical Trial

IMPORTANCE

Lifestyle interventions for obesity produce reductions in body weight that can decrease risk for diabetes and cardiovascular disease but are limited by suboptimal maintenance of lost weight and inadequate dissemination in low-resource communities.

OBJECTIVE

To evaluate the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted from October 21, 2013, to December 21, 2018, in Cooperative Extension Service offices of 14 counties in Florida. A total of 851 individuals were screened for participation; 220 individuals did not meet eligibility criteria, and 103 individuals declined to participate. Of 528 individuals who initiated a 4-month lifestyle intervention, 445 qualified for randomization. Data were analyzed from August 22 to October 21, 2019.

INTERVENTIONS

Participants were randomly assigned to extended care delivered via individual or group telephone counseling or an education control program delivered via email. All participants received 18 modules with posttreatment recommendations for maintaining lost weight. In the telephone-based interventions, health coaches provided participants with 18 individual or group sessions focused on problem solving for obstacles to the maintenance of weight loss.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in body weight from the conclusion of initial intervention (month 4) to final follow-up (month 22). An additional outcome was the proportion of participants achieving at least 10% body weight reduction at follow-up.

RESULTS

Among 445 participants (mean [SD] age, 55.4 [10.2] years; 368 [82.7%] women; 329 [73.9%] white), 149 participants (33.5%) were randomized to individual telephone counseling, 143 participants (32.1%) were randomized to group telephone counseling, and 153 participants (34.4%) were randomized to the email education control. Mean (SD) baseline weight was 99.9 (14.6) kg, and mean (SD) weight loss after the initial intervention was 8.3 (4.9) kg. Mean weight regains at follow-up were 2.3 (95% credible interval [CrI], 1.2-3.4) kg in the individual telephone counseling group, 2.8 (95% CrI, 1.4-4.2) kg for the group telephone counseling group, and 4.1 (95% CrI, 3.1-5.0) kg for the education control group, with a significantly smaller weight regain observed in the individual telephone counseling group vs control group (posterior probability >.99). A larger proportion of participants in the individual telephone counseling group achieved at least 10% weight reductions (31.5% [95% CrI, 24.1%-40.0%]) than in the control group (19.1% [95% CrI, 14.1%-24.9%]) (posterior probability >.99).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that providing extended care for obesity management in rural communities via individual telephone counseling decreased weight regain and increased the proportion of participants who sustained clinically meaningful weight losses.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02054624.

Role of Commercial Weight-Loss Programs in Medical Management of Obesity

Rates of obesity counseling are low among physicians because of the lack of time and training in this area. In recognition of this challenge, recent national guidelines encourage physicians to refer patients with obesity to intensive, comprehensive lifestyle programs to lose weight. Some commercial weight-loss programs meet these criteria, and this article reviews the evidence from randomized controlled trials regarding such programs' weight-loss efficacy and safety as well as glycemic outcomes among patients with and without diabetes mellitus. A discussion of how physicians might approach the referral process and continued management of patients participating in these programs is included.

Effects of media-assisted therapeutic approaches on physical activity of obese adults: a systematic review

BACKGROUND

The number of patients with obesity continues to increase in our society. At the same time, digitalization defines our everyday life. Therefore, the question arises whether to use digital media for effective treatments against obesity. Aim of this review is a concise presentation of effects of media-assisted therapeutic approaches.

METHODS

A systematic literature research in multiple scientific databases, PubMed, Web of Science and Cochrane Library, was performed for literature published in the last 10 years (cut-off date 12.07.2017). Only randomized controlled trials using digital support for treatment and/or aftercare of obese adults aged between 18 to 70 years were included into the analysis.

RESULTS

Overall, 14 trials with data on a total of 4979 participants were included in this review. Generally, there are positive trends for increased moderate to vigorous physical activity by the use of digital media. A simultaneous usage of various digital media, which focus on important aspects of activity behavior, has proven to be effective. A combination of various digital media shows the greatest positive effect and could significantly increase physical activity. However, the biggest potential was found in mixed approaches combining digital devices and personal face-to-face support.

CONCLUSIONS

Therapeutic approaches using digital media for supporting obesity treatment did not show superior benefit over traditional personal therapeutic methods. Nevertheless, using both methods together offered the greatest potential for successful obesity therapy. However, there is a backlog of transparency concerning information about the content of treatment. Furthermore, there is a lack of valid data about aftercare and follow-up.

Design of the Rural LEAP randomized trial: An evaluation of extended-care programs for weight management delivered via group or individual telephone counseling

Obesity is a major contributor to the greater prevalence of chronic disease morbidity and mortality observed in rural versus nonrural areas of the U.S. Nonetheless, little research attention has been given to modifying this important driver of rural/urban disparities in health outcomes. Although lifestyle treatments produce weight reductions of sufficient magnitude to improve health, the existing research is limited with respect to the long-term maintenance of treatment effects and the dissemination of services to underserved populations. Recent studies have demonstrated the feasibility of delivering lifestyle programs through the infrastructure of the U.S. Cooperative Extension Service (CES), which has >2900 offices nationwide and whose mission includes nutrition education and health promotion. In addition, several randomized trials have shown that supplementing lifestyle treatment with extended-care programs consisting of either face-to-face sessions or individual telephone counseling can improve the maintenance of weight loss. However, both options entail relatively high costs that inhibit adoption in rural communities. The delivery of extended care via group-based telephone intervention may represent a promising, cost-effective alternative that is well suited to rural residents who tend to be isolated, have heightened concerns about privacy, and report lower quality of life. The Rural Lifestyle Eating and Activity Program (Rural LEAP) is a randomized trial, conducted via CES offices in rural communities, targeted to adults with obesity (n = 528), and designed to evaluate the effectiveness and cost-effectiveness of extended-care programs delivered via group or individual telephone counseling compared to an education control condition on long-term changes in body weight.

Assessing Effectiveness and Cost-Benefit of the Trinity Hospital Twin City Fit For Life Program for Weight Loss and Diabetes Prevention in a Rural Midwestern Town

Introduction

Obesity is a top public health priority in the United States. This article reports on the Fit For Life (FFL) health education program designed to address the determinants of obesity in rural settings and help participants lose weight.

Purpose and Objectives

We evaluated the implementation of the original FFL program, a replication program, and a diabetes-focused program.

Intervention Approach

The original FFL program (2006 to 2012) was a 12-week session of classes meeting once weekly. Lecture topics included stress management, nutrition, healthy eating, reading food labels, fitness, disease prevention, and healthy aging. The replication program, conducted in 4 locations from 2012 to 2015, helped determine if the FFL program could be implemented on a larger scale, with outcomes similar to the original program. The longer, more-intensive FFL diabetes prevention program, conducted in 2016 and 2017, sought to reduce the number of rural adults at risk for diabetes.

Evaluation Methods

We evaluated FFL participation and outcome data from 2009 through first quarter 2017. We calculated rates of course participation and completion and measured changes in several health indicators. We constructed a linear regression model to examine the impact of health behaviors on weight loss and calculated program cost-effectiveness.

Results

From 2009 to 2017, FFL was delivered to over 1,200 people; 82% of participants completed the program. Completing participants lost an average of 2.7 kg or 3% of their total weight. Overall, 68% of participants said they exercised more per week at the end of the program than at the beginning. Estimated cost per kilogram lost for replication sites was between $73 and $101 for original FFL, in line with other programs. The more resource-intensive diabetes prevention program cost per kilogram lost was $151 to $171.

Implications for Public Health Practice

Weight loss and lifestyle management are major ways to counteract obesity. Improving program options, especially in rural locales, should be a key policy priority. These programs should be considered for population-based expansion, perhaps by health departments or public–private health care consortiums.

High intensity lifestyle intervention and long-term impact on weight and clinical outcomes

BACKGROUND

Obesity increases the risk for diabetes and cardiovascular events, with a corresponding growth in medical costs. High intensity lifestyle intervention (HILI) is the cornerstone for weight management. We assessed the effectiveness of clinic-based HILI on weight loss and associated clinical outcomes by duration of program participation and comorbid conditions.

METHODS

This was a retrospective cohort study of patients who enrolled in HILI weight management programs at Health Management Resources (HMR) clinics located across the U.S. Patients completed health risk assessments (HRA) and were enrolled for up to 24 months at the time of follow-up HRA. HMR programs provide weekly group coaching to achieve reduced calorie intake, increased fruit/vegetable intake, and physical activity ≥2,000 kcal/wk. A Markov model predicted avoidance of diabetes and cardiovascular events and projected cost savings due to weight loss.

RESULTS

Of the 500 patients included in the analysis, 67% were female and mean age was 54.1 years (s.d. 11.6). The baseline weight and BMI were 243.5 lbs (range 144.0-545.0) and 38.8 kg/m2 (range 25.4-85.0), respectively. Overall, patients lost an average of 47.4 lbs (18.9% of initial body weight [IBW]); the amount of weight loss was consistent among those with diabetes/pre-diabetes (50%), high/moderate risk for dyslipidemia (60%), hypertension/pre-hypertension (86%), and severe obesity (37%). The mean IBW lost was 16.4%, 19.3%, 20.7% for ≤6 months (n = 165), 7-12 months (n = 140), 13-24 months (n = 195) of program participation, respectively. The simulation model estimated 22 diabetes and 30 cardiovascular events and $1,992,370 medical costs avoided over 5 years in the 500 patients evaluated.

CONCLUSION

Patients in the HMR clinic-based HILI program achieved substantial weight loss regardless of duration of program participation, risk profile and comorbid status. The HMR program could be an effective strategy to prevent costly diabetes and cardiovascular events, particularly in high risk patients.

The Science of Obesity Management: An Endocrine Society Scientific Statement

The prevalence of obesity, measured by body mass index, has risen to unacceptable levels in both men and women in the United States and worldwide with resultant hazardous health implications. Genetic, environmental, and behavioral factors influence the development of obesity, and both the general public and health professionals stigmatize those who suffer from the disease. Obesity is associated with and contributes to a shortened life span, type 2 diabetes mellitus, cardiovascular disease, some cancers, kidney disease, obstructive sleep apnea, gout, osteoarthritis, and hepatobiliary disease, among others. Weight loss reduces all of these diseases in a dose-related manner-the more weight lost, the better the outcome. The phenotype of "medically healthy obesity" appears to be a transient state that progresses over time to an unhealthy phenotype, especially in children and adolescents. Weight loss is best achieved by reducing energy intake and increasing energy expenditure. Programs that are effective for weight loss include peer-reviewed and approved lifestyle modification programs, diets, commercial weight-loss programs, exercise programs, medications, and surgery. Over-the-counter herbal preparations that some patients use to treat obesity have limited, if any, data documenting their efficacy or safety, and there are few regulatory requirements. Weight regain is expected in all patients, especially when treatment is discontinued. When making treatment decisions, clinicians should consider body fat distribution and individual health risks in addition to body mass index.

Implementation evaluation of the Telephone Lifestyle Coaching (TLC) program: organizational factors associated with successful implementation

The Telephone Lifestyle Coaching (TLC) program provided telephone-based coaching for six lifestyle behaviors to 5321 Veterans at 24 Veterans Health Administration (VHA) medical facilities. The purpose of the study was to conduct an evaluation of the TLC program to identify factors associated with successful implementation. A mixed-methods study design was used. Quantitative measures of organizational readiness for implementation and facility complexity were used to purposively select a subset of facilities for in-depth evaluation. Context assessments were conducted using interview transcripts. The Consolidated Framework for Implementation Research (CFIR) was used to guide qualitative data collection and analysis. Factors most strongly correlated with referral rates included having a skilled implementation leader who used effective multi-component strategies to engage primary care clinicians as well as general clinic structures that supported implementation. Evaluation findings pointed to recommendations for local and national leaders to help anticipate and mitigate potential barriers to successful implementation.

Weight management in rural health clinics: The Midwest diet and exercise trial

Obesity prevalence is higher in rural compared to urban residents. Rural health clinics offer a potential venue for delivery of weight management. However, traditional programs require travel to attend on-site meetings which is impractical or inconvenient for rural residents. Clinic staff in most rural settings are unlikely to be trained to provide effective weight management. Remote delivery using group phone conferences (GP) or individual phone calls (IP), by staff associated with rural clinics eliminates the need for travel to attend on-site meetings. The effectiveness of these approaches will be the focus of this trial. Staff at five primary care clinics, serving primarily rural residents, will be trained to deliver GP and IP interventions and an enhanced usual care (EUC), (i.e., individual face-to-face meetings (~45 min) at clinic site, four times across 18 mos.). Two hundred overweight/obese adults (BMI ≥ 25.0-45.0 kg/m², age ≥ 21 yrs.) will be recruited through each clinic and randomized to GP (n = 80), IP (n = 80), or EUC (n = 40) to compare weight loss (0-6 mos.), weight maintenance (7-18 mos.), and weight change during a 6 mo. no contact follow-up (19-24 mos.) between intervention arms. The GP and IP interventions will be identical in lesson plan content, diet, and physical activity. The only difference between groups will be the delivery format (group vs. individual) and session duration (GP ~45 min/session; IP ~15 min/session). Primary (body weight) and secondary outcomes (waist circumference, energy/macronutrient intake, physical activity) will be assessed at baseline, 6, 12, 18 and 24 mos. Cost and contingent valuation analyses will also be completed.

NCT REGISTRATION

NCT02932748.

Telephone based weight loss intervention: Relevance for developing countries

Obesity is a major public health challenge not only for developed but developing countries as well. The World Health Organization recommends the immediate use of effective, efficient and widely accessible weight loss interventions. Telephone based weight loss intervention could provide a cheaper and wider reach of obese participants. Previous systematic reviews on telephone based weight loss interventions either excluded studies that had obese participants with co-morbidities or were silent on their inclusion. Obese/overweight individuals with co-morbidities constitute an important population in any weight loss intervention study due to the strong association of obesity with major chronic health conditions. This paper, reviews the efficacy of telephone based weight loss intervention solely in overweight/obese individuals with obesity related diseases and discusses its relevance for developing countries.

A Randomized Trial of Lorcaserin and Lifestyle Counseling for Maintaining Weight Loss Achieved with a Low-Calorie Diet

OBJECTIVE

Improving the maintenance of lost weight remains a critical challenge, which can be addressed by long-term behavioral and/or pharmacological interventions.

METHODS

This study investigated the efficacy of combined behavioral and pharmacological treatment in facilitating weight loss maintenance (WLM) in 137 adults (86.1% female; 68.6% black; BMI = 37.0 ± 5.6 kg/m² ) who had lost ≥ 5% of initial weight during a 14-week low-calorie diet (LCD) program (mean = 9.3 ± 2.9%). Participants were randomly assigned to lorcaserin (10 mg twice a day) or placebo and were provided 16 group WLM counseling sessions over 52 weeks.

RESULTS

At 24 weeks post randomization, more lorcaserin-treated than placebo-treated participants maintained a ≥ 5% loss (73.9% vs. 57.4%; P = 0.033), and the lorcaserin-treated participants lost an additional 2.4 ± 0.8 kg versus a 0.6 ± 0.8 kg gain for placebo (P = 0.010). However, at week 52, groups did not differ on either co-primary outcome; 55.1% and 42.6%, respectively, maintained ≥ 5% loss (P = 0.110), with gains from randomization of 2.0 ± 0.8 kg and 2.5 ± 0.8 kg (P = 0.630), respectively. From the start of the LCD, groups maintained reductions of 7.8% and 6.6%, respectively (P = 0.318).

CONCLUSIONS

Combined behavioral and pharmacological treatment produced clinically meaningful long-term weight loss in this group of predominantly black participants. Lorcaserin initially improved upon weight loss achieved with WLM counseling, but this advantage was not maintained at 1 year.

The use of smartphones to influence lifestyle changes in overweight and obese youth with congenital heart disease: a single-arm study: Pilot and feasibility study protocol: Smart Heart Trial

Background

Both obesity and congenital heart disease (CHD) are risk factors for the long-term cardiovascular health of children and adolescents. The addition of smart mobile technology to conventional lifestyle counseling for weight management offers great potential to appeal to technologically literate youth and can address a large geographical area with minimal burden to participants. This pilot study seeks to examine the influence of a 1-year lifestyle intervention on nutrition and physical activity-related health outcomes in overweight or obese children and adolescents with CHD.

Methods

This is a pilot and feasibility study which utilizes a single-arm, prospective design with a goal to recruit 40 overweight and obese patients. The feasibility metrics will evaluate the integrity of the study protocol, data collection and questionnaires, recruitment and consent, and acceptability of the intervention protocol and primary outcome measures. The primary clinical outcome metrics are anthropometry, body composition, and cardiorespiratory exercise capacity. The secondary clinical metrics include quality of life, nutrition and physical activity behavior, lung and muscle function, and cardio-metabolic risk factors. Outcomes are assessed at baseline, 6 months, and 1 year. To date, a total of 36 children and youth (11 girls), aged 7–17 years (mean = 14.4 years), have commenced the intervention. Recruitment for the study was initiated in June 2012 and is currently ongoing.

Discussion

The information provided in this paper is intended to help researchers and health professionals with the development and evaluation of similar lifestyle intervention programs. Since the application of smartphones to pediatric cardiac health and obesity management is a novel approach, and continued research in this area is warranted, this paper may serve as a foundation for further exploration of this health frontier and inform the development of a broader strategy for obesity management in pediatric cardiology.

Trial registration

This pilot study was retrospectively registered at the www.ClinicalTrials.gov registry as NCT02980393 in November 2016, with the study commencing in May 2012. Study protocol version 15OCT2014.

Electronic supplementary material

The online version of this article (10.1186/s40814-017-0207-y) contains supplementary material, which is available to authorized users.

Distance learning strategies for weight management utilizing online social networks versus group phone conference call

OBJECTIVE

The increase in technology and online social networks (OSNs) may present healthcare providers with an innovative modality for delivering weight management programmes that could have an impact on health care at the population level. The objective of this study was to evaluate the feasibility and efficacy of using an OSN to deliver a weight loss programme to inform future, large-scale trials.

METHODS

Seventy individuals (age = 47 ± 12.4, minority = 24.3%) with obesity (BMI = 36.2 ± 4.0) completed a 6-month weight loss intervention and were randomized to either a conference call or OSN delivery group. Weight loss was achieved by reducing energy intake by 500-700 kcal·d-1 below estimated total daily energy expenditure and progressing physical activity to 300 min/week. Behavioural weight loss strategies were delivered weekly throughout the intervention.

RESULTS

Conference call and OSN groups produced clinically meaningful weight loss of ≥5% from baseline to 6 months (phone = -6.3 ± 6.4%, OSN = -5.8 ± 6.7%). There was no significant difference in weight change between groups (p = 0.765).

CONCLUSION

The phone and OSN groups met the American Heart Association/American College of Cardiology/The Obesity Society's Guidelines by reducing baseline weight by 5-10% within 6 months. OSNs appear to be a viable delivery platform for weight loss interventions; however, larger scale adequately powered trials are needed.

Do weight management interventions delivered by online social networks effectively improve body weight, body composition, and chronic disease risk factors? A systematic review

Introduction Currently, no systematic review/meta-analysis has examined studies that used online social networks (OSN) as a primary intervention platform. Therefore, the purpose of this review was to evaluate the effectiveness of weight management interventions delivered through OSN. Methods PubMed, EMBASE, PsycINFO, Web of Science, and Scopus were searched (January 1990-November 2015) for studies with data on the effect of OSNs on weight loss. Only primary source articles that utilized OSN as the main platform for delivery of weight management/healthy lifestyle interventions, were published in English language peer-reviewed journals, and reported outcome data on weight were eligible for inclusion in this systematic review. Five articles were included in this review. Results One-hundred percent of the studies ( n = 5) reported a reduction in baseline weight. Three of the five studies (60%) reported significant decreases in body weight when OSN was paired with health educator support. Only one study reported a clinical significant weight loss of ≥5%. Conclusion Using OSN for weight management is in its early stages of development and, while these few studies show promise, more research is needed to acquire information about optimizing these interventions to increase their efficacy.

Applying Psychological Theories to Promote Long-Term Maintenance of Health Behaviors

Behavioral health theory provides a framework for researchers to design, implement, and evaluate the effects of health promotion programs. However, limited research has examined theories used in interventions to promote long-term maintenance of health behaviors. The purpose of this review was to evaluate the available literature and identify prominent behavioral health theories used in intervention research to promote maintenance of health behaviors. We reviewed theories used in intervention research assessing long-term maintenance (≥ 6 months post-intervention) of physical activity, weight loss, and smoking cessation. Five prominent behavioral theories were referenced by the 34 studies included in the review: Self-Determination Theory, Theory of Planned Behavior, Social Cognitive Theory, Transtheoretical Model, and Social Ecological Model. Descriptions and examples of applications of these theories are provided. Implications for future research are discussed.

Weight loss maintenance strategies among rural breast cancer survivors: The rural women connecting for better health trial

OBJECTIVE

Obesity is a risk factor for breast cancer recurrence. Rural women have higher obesity rates compared with urban women and are in need of distance-based interventions that promote long-term weight loss.

METHODS

In this two-phase trial, rural breast cancer survivors who lost >5% of their starting weight during a 6-month lifestyle intervention (delivered through weekly group conference calls) were randomized to one of two 12-month interventions for weight loss maintenance: continued biweekly phone-based group counseling or mailed newsletters. The primary outcome was weight regain from 6 to 18 months. Secondary outcomes included dichotomous measures of weight change and costs.

RESULTS

Mean weight loss at 6 months was 14.0 ± 5.1%. Participants in the group phone condition regained less weight (3.3 ± 4.8 kg) compared with participants in the newsletter condition (4.9 ± 4.8 kg; P = 0.03). At 18 months, 75.3% of participants in the group phone condition remained ≥5% below baseline weight compared with 57.8% in the newsletter condition (P = 0.02). Incremental cost-effectiveness ratios were $882 to keep one more person ≥5% below baseline weight.

CONCLUSIONS

A lifestyle intervention incorporating group phone-based support improved the magnitude of weight loss maintained and increased the proportion of survivors who maintained clinically significant reductions.

Voxel-based morphometry reveals brain gray matter volume changes in successful dieters

OBJECTIVE

To compare regional brain volume predictors of percent weight loss (WL) in dieters with obesity (DwO) and in the same participants categorized as "successful" (≥7% WL) or "unsuccessful" dieters (<7% WL).

METHODS

DwO (n = 72) and participants with healthy weight (n = 22) completed a structural MRI at baseline and 3 months. All DwO participants were enrolled in a 12-week program consisting of a reduced calorie diet, increased physical activity, and behavioral modification. SPM8-based voxel-based morphometry processing streams were used for measurements of regional gray (GMV) and white matter volume and longitudinal changes in volume. Correlations between WL and baseline brain volume and change in brain volume, as well as differences between groups, were then tested.

RESULTS

%WL was positively correlated with baseline GMV in right parahippocampal and orbitofrontal gyri in DwO. Successful dieters showed greater GMV loss in the left precentral gyrus and the insula compared with unsuccessful dieters. A negative correlation was found between %WL and GMV change from baseline in the left prefrontal regions.

CONCLUSIONS

Findings illustrate that WL is related to volumetric changes in brain areas previously linked to interoception and food motivation.

A 6-month telephone-based weight loss intervention in overweight and obese subjects with idiopathic intracranial hypertension

Objectives

The purpose of this paper is to measure the change in body weight after a 6‐month telephone‐based weight loss intervention in overweight and obese subjects with idiopathic intracranial hypertension (IIH) and mild visual loss randomized to receive either acetazolamide or placebo.

Methods

One hundred sixty‐five subjects with IIH, aged 29.1 ± 7.5 (mean ± SD) and BMI 39.9 + 8.3 kg/m², enrolled at 38 academic and private practice sites in North America, participated in this trial. This was a randomized, double‐masked, placebo‐controlled trial of acetazolamide in subjects with IIH and mild visual loss. All participants received a reduced‐sodium, weight‐reduction diet and a 6‐month telephone‐based weight loss intervention. Six‐month changes from baseline in body weight, perimetric mean deviation as assessed by automated perimetry and quality of life using the National Eye Institute Visual Function Questionnaire 25 and the 36‐item Short Form Health Survey were measured.

Results

Mean percent weight change at 6 months was −5.9% ± 6.7% of initial body weight overall, −3.5% ± 5.9% in the placebo group and −7.8% ± 6.8% in the acetazolamide group. Weight change was not associated with changes in either mean deviation or quality of life scores.

Conclusion

Patients with IIH and mild visual loss assigned to either acetazolamide or placebo, all of whom received a 6‐month telephone‐based weight loss intervention, lost an average of 5.9% of initial body weight, consistent with NHLBI guidelines of 5% to 10% of body weight loss for clinically significant health benefit.

Distance learning strategies for weight management utilizing social media: A comparison of phone conference call versus social media platform. Rationale and design for a randomized study

Management of obesity in the context of the primary care physician visit is of limited efficacy in part because of limited ability to engage participants in sustained behavior change between physician visits. Therefore, healthcare systems must find methods to address obesity that reach beyond the walls of clinics and hospitals and address the issues of lifestyle modification in a cost-conscious way. The dramatic increase in technology and online social networks may present healthcare providers with innovative ways to deliver weight management programs that could have an impact on health care at the population level. A randomized study will be conducted on 70 obese adults (BMI 30.0-45.0 kg/m(2)) to determine if weight loss (6 months) is equivalent between weight management interventions utilizing behavioral strategies by either a conference call or social media approach. The primary outcome, body weight, will be assessed at baseline and 6 months. Secondary outcomes including waist circumference, energy and macronutrient intake, and physical activity will be assessed on the same schedule. In addition, a cost analysis and process evaluation will be completed.

Longitudinal Weight Loss Patterns and their Behavioral and Demographic Associations

BACKGROUND

Identification of weight change patterns may allow tailored interventions to improve long-term weight loss.

PURPOSE

To identify patterns of weight change over 18 months, and assess participant characteristics and intervention adherence factors associated with weight change patterns in a sample of 359 overweight/obese adults.

METHODS

Weight loss (0-6 months) was achieved with reduced energy intake and increased physical activity (PA). Maintenance (7-18 months) provided adequate energy to maintain weight and continued PA.

RESULTS

Latent profile analysis identified three weight change profiles. During weight loss/maintenance, participants in profiles 2 and 3 (18-month weight loss ∼14 %) attended more behavioral sessions and performed more PA compared with profile 1 (18-month weight loss <1 %). Self-efficacy for both weight management and exercise barriers were higher in profiles 2 and 3 compared with profile 1 following weight loss and during maintenance.

CONCLUSION

Weight change patterns can be identified and are associated with both participant characteristics and intervention adherence.

Pediatric Primary Care-Based Obesity Prevention for Parents of Preschool Children: A Pilot Study

BACKGROUND

The Healthy Homes/Healthy Kids Preschool (HHHK-Preschool) pilot program is an obesity prevention intervention integrating pediatric care provider counseling and a phone-based program to prevent unhealthy weight gain among 2- to 4-year-old children at risk for obesity (BMI percentile between the 50th and 85th percentile and at least one overweight parent) or currently overweight (85th percentile ≤ BMI < 95th percentile). The aim of this randomized, controlled pilot study was to evaluate the feasibility, acceptability, and potential efficacy of the HHHK-Preschool intervention.

METHODS

Sixty parent-child dyads recruited from pediatric primary care clinics were randomized to: (1) the Busy Bodies/Better Bites Obesity Prevention Arm or the (2) Healthy Tots/Safe Spots safety/injury prevention Contact Control Arm. Baseline and 6-month data were collected, including measured height and weight, accelerometry, previous day dietary recalls, and parent surveys. Intervention process data (e.g., call completion) were also collected.

RESULTS

High intervention completion and satisfaction rates were observed. Although a statistically significant time by treatment interaction was not observed for BMI percentile or BMI z-score, post-hoc examination of baseline weight status as a moderator of treatment outcome showed that the Busy Bodies/Better Bites obesity prevention intervention appeared to be effective among children who were in the overweight category at baseline relative to those who were categorized as at risk for obesity (p = 0.04).

CONCLUSIONS

HHHK-Preschool pilot study results support the feasibility, acceptability, and potential efficacy in already overweight children of a pediatric primary care-based obesity prevention intervention integrating brief provider counseling and parent-targeted phone coaching. What's New: Implementing pediatric primary care-based obesity interventions is challenging. Previous interventions have primarily involved in-person sessions, a barrier to sustained parent involvement. HHHK-preschool pilot study results suggest that integrating brief provider counseling and parent-targeted phone coaching is a promising approach.

A virtual reality intervention (Second Life) to improve weight maintenance: Rationale and design for an 18-month randomized trial

Despite the plethora of weight loss programs available in the US, the prevalence of overweight and obesity (BMI≥25kg/m(2)) among US adults continues to rise at least, in part, due to the high probability of weight regain following weight loss. Thus, the development and evaluation of novel interventions designed to improve weight maintenance are clearly needed. Virtual reality environments offer a promising platform for delivering weight maintenance interventions as they provide rapid feedback, learner experimentation, real-time personalized task selection and exploration. Utilizing virtual reality during weight maintenance allows individuals to engage in repeated experiential learning, practice skills, and participate in real-life scenarios without real-life repercussions, which may diminish weight regain. We will conduct an 18-month effectiveness trial (6 months weight loss, 12 months weight maintenance) in 202 overweight/obese adults (BMI 25-44.9kg/m(2)). Participants who achieve ≥5% weight loss following a 6month weight loss intervention delivered by phone conference call will be randomized to weight maintenance interventions delivered by conference call or conducted in a virtual environment (Second Life®). The primary aim of the study is to compare weight change during maintenance between the phone conference call and virtual groups. Secondarily, potential mediators of weight change including energy and macronutrient intake, physical activity, consumption of fruits and vegetables, self-efficacy for both physical activity and diet, and attendance and completion of experiential learning assignments will also be assessed.

Efficacy of a Text Message-Delivered Extended Contact Intervention on Maintenance of Weight Loss, Physical Activity, and Dietary Behavior Change

Background

Extending contact with participants after the end of an initial intervention is associated with successful maintenance of weight loss and behavior change. However, cost-effective methods of extending intervention contact are needed.

Objective

This study investigated whether extended contact via text message was efficacious in supporting long-term weight loss and physical activity and dietary behavior change in breast cancer survivors.

Methods

Following the end of an initial 6-month randomized controlled trial of a telephone-delivered weight loss intervention versus usual care, eligible and consenting intervention participants received a 6-month extended contact intervention via tailored text messages targeting a range of factors proposed to influence the maintenance of behavior change. In this single-group, pre-post designed study, within group changes in weight, moderate-to-vigorous physical activity (Actigraph GT3X+ accelerometers), and total energy intake (2x24 hour dietary recalls) were evaluated from baseline to end of initial intervention (6 months), end of extended contact intervention (12 months), and after a no-contact follow-up (18 months) via linear mixed models. Feasibility of implementation was assessed through systematic tracking of text message delivery process outcomes, and participant satisfaction was assessed through semistructured interviews.

Results

Participants at baseline (n=29) had a mean age of 54.9 years (SD 8.8), body mass index of 30.0 kg/m² (SD 4.2), and were recruited a mean 16.6 months (SD 3.2) post diagnosis. From baseline to 18 months, participants showed statistically significantly lower mean weight (-4.2 kg [95% CI -6.0 to -2.4]; P<.001) and higher physical activity (mean 10.4 mins/day [95% CI 3.6-17.2]; P=.003), but no significant differences in energy intake (P=.200). Participants received a mean of 8 text messages every 2 weeks (range 2-11) and reported a high rate of satisfaction.

Conclusions

In comparison to interventions without extended contact, results suggest text message–delivered extended contact may support the attenuation of weight regain and promote the maintenance of physical activity.

Portion-controlled meals provide increases in diet quality during weight loss and maintenance

BACKGROUND

Behavioural weight-loss interventions utilising portion-controlled meals (PCMs) produce significant decreases in weight. However, their impact on diet quality during weight maintenance is unknown. The present study aimed to assess the influence of a weight management intervention employing PCMs and increased physical activity on diet quality during weight loss and weight maintenance.

METHODS

One hundred and ninety-seven overweight and obese adults [67% women; mean (SD) BMI = 34.0 (4.6) kg m(-2); age = 46.1 (8.9) years] completed an 18-month trial. The weight-loss phase (0-6 months) consisted of energy restriction, which was achieved using PCMs plus fruits and vegetables and increased physical activity. During weight maintenance (6-18 months), participants consumed a diet designed to maintain weight loss. Body weight and dietary intake were assessed at baseline, and at 6, 12 and 18 months. The Healthy Eating Index-2010 (HEI) was calculated using data obtained from 3-day food records.

RESULTS

Mean (SD) body weight was 14.3% (6.6%) and 8.7% (8.0%) below baseline at 6 and 18 months, respectively. The mean (SD) HEI-2010 score after weight loss [66.6 (9.4)] was significantly higher than baseline [46.4 (8.9)] and remained significantly higher than baseline at 18 months [57.7 (10.6)] (both P < 0.001).

CONCLUSIONS

A weight management intervention using PCMs resulted in both clinically significant weight loss and increased diet quality scores, demonstrating that the use of PCMs during weight loss allows for meaningful changes in diet quality during weight maintenance.

Brain function predictors and outcome of weight loss and weight loss maintenance

Obesity rates are associated with public health consequences and rising health care costs. Weight loss interventions, while effective, do not work for everyone, and weight regain is a significant problem. Eating behavior is influenced by a convergence of processes in the brain, including homeostatic factors and motivational processing that are important contributors to overeating. Initial neuroimaging studies have identified brain regions that respond differently to visual food cues in obese and healthy weight individuals that are positively correlated with reports of hunger in obese participants. While these findings provide mechanisms of overeating, many important questions remain. It is not known whether brain activation patterns change after weight loss, or if they change differentially based on amount of weight lost. Also, little is understood regarding biological processes that contribute to long-term weight maintenance. This study will use neuroimaging in participants while viewing food and non-food images. Functional Magnetic Resonance Imaging will take place before and after completion of a twelve-week weight loss intervention. Obese participants will be followed though a 6-month maintenance period. The study will address three aims: 1. Characterize brain activation underlying food motivation and impulsive behaviors in obese individuals. 2. Identify brain activation changes and predictors of weight loss. 3. Identify brain activation predictors of weight loss maintenance. Findings from this study will have implications for understanding mechanisms of obesity, weight loss, and weight maintenance. Results will be significant to public health and could lead to a better understanding of how differences in brain activation relate to obesity.

Behavioral treatment of obesity in patients encountered in primary care settings: a systematic review

IMPORTANCE

In 2011, the Centers for Medicare & Medicaid Services (CMS) approved intensive behavioral weight loss counseling for approximately 14 face-to-face, 10- to 15-minute sessions over 6 months for obese beneficiaries in primary care settings, when delivered by physicians and other CMS-defined primary care practitioners.

OBJECTIVE

To conduct a systematic review of behavioral counseling for overweight and obese patients recruited from primary care, as delivered by primary care practitioners working alone or with trained interventionists (eg, medical assistants, registered dietitians), or by trained interventionists working independently.

EVIDENCE REVIEW

We searched PubMed, CINAHL, and EMBASE for randomized controlled trials published between January 1980 and June 2014 that recruited overweight and obese patients from primary care; provided behavioral counseling (ie, diet, exercise, and behavioral therapy) for at least 3 months, with at least 6 months of postrandomization follow-up; included at least 15 participants per treatment group and objectively measured weights; and had a comparator, an intention-to-treat analysis, and attrition of less than 30% at 1 year or less than 40% at longer follow-up.

FINDINGS

Review of 3304 abstracts yielded 12 trials, involving 3893 participants, that met inclusion-exclusion criteria and prespecified quality ratings. No studies were found in which primary care practitioners delivered counseling that followed the CMS guidelines. Mean 6-month weight changes from baseline in the intervention groups ranged from a loss of 0.3 kg to 6.6 kg. In the control group, mean change ranged from a gain of 0.9 kg to a loss of 2.0 kg. Weight loss in both groups generally declined with longer follow-up (12-24 months). Interventions that prescribed both reduced energy intake (eg, ≥ 500 kcal/d) and increased physical activity (eg, ≥150 minutes a week of walking), with traditional behavioral therapy, generally produced larger weight loss than interventions without all 3 specific components. In the former trials, more treatment sessions, delivered in person or by telephone by trained interventionists, were associated with greater mean weight loss and likelihood of patients losing 5% or more of baseline weight.

CONCLUSIONS AND RELEVANCE

Intensive behavioral counseling can induce clinically meaningful weight loss, but there is little research on primary care practitioners providing such care. The present findings suggest that a range of trained interventionists, who deliver counseling in person or by telephone, could be considered for treating overweight or obesity in patients encountered in primary care settings.