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Roddy MK, Pfammatter AF, Mayberry LS. Optimizing adaptive stepped-care interventions to change adults' health behaviors: A systematic review. J Clin Transl Sci 2023; 7:e190. [PMID: 37745938 PMCID: PMC10514691 DOI: 10.1017/cts.2023.618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
Chronic diseases are ubiquitous and costly in American populations. Interventions targeting health behavior change to manage chronic diseases are needed, but previous efforts have fallen short of producing meaningful change on average. Adaptive stepped-care interventions, that tailor treatment based on the needs of the individual over time, are a promising new area in health behavior change. We therefore conducted a systematic review of tests of adaptive stepped-care interventions targeting health behavior changes for adults with chronic diseases. We identified 9 completed studies and 13 research protocols testing adaptive stepped-care interventions for health behavior change. The most common health behaviors targeted were substance use, weight management, and smoking cessation. All identified studies test intermediary tailoring for treatment non-responders via sequential multiple assignment randomized trials (SMARTs) or singly randomized trials (SRTs); none test baseline tailoring. From completed studies, there were few differences between embedded adaptive interventions and minimal differences between those classified as treatment responders and non-responders. In conclusion, updates to this work will be needed as protocols identified here publish results. Future research could explore baseline tailoring variables, apply methods to additional health behaviors and target populations, test tapering interventions for treatment responders, and consider adults' context when adapting interventions.
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Affiliation(s)
- McKenzie K. Roddy
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angela F. Pfammatter
- College of Education, Health, and Human Sciences, University of Tennessee, Knoxville, TN, USA
| | - Lindsay S. Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
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2
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Williams LB, Moser DK, Gustafson A, Waters TM, Rayens MK, Karle ER, Kriska AM. Reaching high-risk Black adults for diabetes prevention programming during a pandemic: The design of Fit & Faithful a randomized controlled community trial. Contemp Clin Trials 2022; 123:106973. [PMID: 36334705 PMCID: PMC10155857 DOI: 10.1016/j.cct.2022.106973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 10/14/2022] [Accepted: 10/20/2022] [Indexed: 11/08/2022]
Abstract
Obesity is a key risk factor for Type 2 diabetes (T2D). Alarmingly, 87% of US adults have overweight or obesity, with non-Hispanic black adults having higher obesity and T2D prevalence than non-Hispanic white. The Diabetes Prevention Program (DPP) demonstrated the clinical benefits of lifestyle intervention (LI). While the DPP LI is effective, some participants don't achieve clinically significant weight loss in the current group-based translation paradigm. Black adults have the lowest adjusted weight loss (3.2%) among all racial/ethnic groups. Early intervention nonresponse defined as ≤1% weight loss at intervention week 4 is linked to lower probability of achieving weight loss goals. This paper describes the design and methods of a cluster randomized controlled trial among black weight loss nonresponders nested in 20 community sites (primarily churches). Descriptions of the adaptations made to transition the program to virtual format during the COVID-19 pandemic are also included. Trained community health workers deliver a group-based, 6-month long DPP over 18 sessions via Zoom. Additionally, nonresponders in the enhanced group receive weekly telephone support to provide individual-level intervention to help overcome weight loss barriers. Outcomes include weight, physical activity level, blood pressure, and dietary behaviors; these are compared between nonresponders in the enhanced intervention group and nonresponders in the active control group. Cost, mediators, and moderators are explored. If found to efficacious, these enhanced strategies could be standardized as a supplement for use with DPP nonresponders.
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Affiliation(s)
- Lovoria B Williams
- University of Kentucky, College of Nursing, 751 Rose Street, Lexington, KY 40536, United States.
| | - Debra K Moser
- University of Kentucky, College of Nursing, 751 Rose Street, Lexington, KY 40536, United States
| | - Alison Gustafson
- University of Kentucky, College of Agriculture, Department of Dietetics and Human Nutrition, 206g Funkhouser, Lexington, KY 40536, United States
| | - Teresa M Waters
- University of Kentucky, College of Public Health Department of Health Management and Policy, 111 Washington Avenue, Lexington, KY 40536, United States
| | - Mary Kay Rayens
- University of Kentucky, College of Nursing, 751 Rose Street, Lexington, KY 40536, United States; University of Kentucky, College of Public Health Department of Health Management and Policy, 111 Washington Avenue, Lexington, KY 40536, United States
| | - Erika R Karle
- University of Kentucky, College of Nursing, 751 Rose Street, Lexington, KY 40536, United States
| | - Andrea M Kriska
- University of Pittsburgh, Graduate School of Public Health, Department of Epidemiology, 130 Desoto Street, Pittsburgh, PA 15261, United States
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Moss SA, Serbetci D, O'Brien K, Alexi N. The Validated Features of Psychological Interventions for Weight Loss: An Integration. Behav Med 2022; 48:147-161. [PMID: 33226915 DOI: 10.1080/08964289.2020.1842316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Many psychological inclinations, such as maladaptive beliefs, can diminish the capacity of individuals to manage their weight effectively and sustainably. Yet, interventions that purportedly address these psychological inclinations and improve weight management are not always beneficial. To be effective, these interventions should offer participants several choices, should be devoid of features that have not been validated in isolation, and should arrange the various activities in an efficient and effective sequence. Few if any programs fulfill these criteria. The aim of this paper was to construct an intervention that assimilates all the validated features of interventions that overcome the psychological impediments to weight loss. To achieve this goal, we blended a technique called intervention component analysis with thematic analysis. Specifically, we extracted refereed journal articles about weight loss from PsycInfo, distilled the practical recommendations from these articles, excluded recommendations that had not been validated in isolation of other features, integrated overlapping recommendations, and applied several principles to arrange these recommendations into the most effective sequence. This procedure generated an intervention that could comprise up to 43 features and activities, including self-affirmation to foster openness to change, anecdotes about dramatic improvements, ambitious rather than modest targets, an emphasis on strategies rather than targets, rewards for attempts, implementation intentions with partners, self-hypnosis, cognitive reframing, and distancing. If these features are unsuccessful, practices that demand more resources-such as group disclosure, virtual environments, motivational interviewing, and customized programs-were also recommended.
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Affiliation(s)
- Simon A Moss
- College of Health and Human Sciences, Charles Darwin University, Darwin, Australia
| | - Duygu Serbetci
- College of Health and Human Sciences, Charles Darwin University, Darwin, Australia
| | - Kerry O'Brien
- School of Social Sciences, Monash University, Melbourne, Australia
| | - Nektarios Alexi
- College of Health and Human Sciences, Charles Darwin University, Darwin, Australia
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Pellegrini M, Carletto S, Scumaci E, Ponzo V, Ostacoli L, Bo S. The Use of Self-Help Strategies in Obesity Treatment. A Narrative Review Focused on Hypnosis and Mindfulness. Curr Obes Rep 2021; 10:351-364. [PMID: 34050891 PMCID: PMC8408071 DOI: 10.1007/s13679-021-00443-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this narrative review was to summarize the evidence evaluating the possibilities and limitations of self-hypnosis and mindfulness strategies in the treatment of obesity. RECENT FINDINGS Psychological factors, such as mood disorders and stress, can affect eating behaviors and deeply influence weight gain. Psychological approaches to weight management could increase the motivation and self-control of the patients with obesity, limiting their impulsiveness and inappropriate use of food. The cognitive-behavioral therapy (CBT) represents the cornerstone of obesity treatment, but complementary and self-directed psychological interventions, such as hypnosis and mindfulness, could represent additional strategies to increase the effectiveness of weight loss programs, by improving dysfunctional eating behaviors, self-motivation, and stimulus control. Both hypnosis and mindfulness provide a promising therapeutic option by improving weight loss, food awareness, self-acceptance of body image, and limiting food cravings and emotional eating. Greater effectiveness occurs when hypnosis and mindfulness are associated with other psychological therapies in addition to diet and physical activity. Additional research is needed to determine whether these strategies are effective in the long term and whether they can be routinely introduced into the clinical practice.
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Affiliation(s)
- Marianna Pellegrini
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Torino, Italy
| | - Sara Carletto
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Elena Scumaci
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Torino, Italy
| | - Valentina Ponzo
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Torino, Italy
| | - Luca Ostacoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Simona Bo
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Torino, Italy.
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Sherwood NE, Crain AL, Seburg EM, Butryn ML, Forman EM, Crane MM, Levy RL, Kunin-Batson AS, Jeffery RW. BestFIT Sequential Multiple Assignment Randomized Trial Results: A SMART Approach to Developing Individualized Weight Loss Treatment Sequences. Ann Behav Med 2021; 56:291-304. [PMID: 34415011 DOI: 10.1093/abm/kaab061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND State-of-the-art behavioral weight loss treatment (SBT) can lead to clinically meaningful weight loss, but only 30-60% achieve this goal. Developing adaptive interventions that change based on individual progress could increase the number of people who benefit. PURPOSE Conduct a Sequential Multiple Assignment Randomized Trial (SMART) to determine the optimal time to identify SBT suboptimal responders and whether it is better to switch to portion-controlled meals (PCM) or acceptance-based treatment (ABT). METHOD The BestFIT trial enrolled 468 adults with obesity who started SBT and were randomized to treatment response assessment at Session 3 (Early TRA) or 7 (Late TRA). Suboptimal responders were re-randomized to PCM or ABT. Responders continued SBT. Primary outcomes were weight change at 6 and 18 months. RESULTS PCM participants lost more weight at 6 months (-18.4 lbs, 95% CI -20.5, -16.2) than ABT participants (-15.7 lbs, 95% CI: -18.0, -13.4), but this difference was not statistically significant (-2.7 lbs, 95% CI: -5.8, 0.5, p = .09). PCM and ABT participant 18 month weight loss did not differ. Early and Late TRA participants had similar weight losses (p = .96), however, Early TRA PCM participants lost more weight than Late TRA PCM participants (p = .03). CONCLUSIONS Results suggest adaptive intervention sequences that warrant further research (e.g., identify suboptimal responders at Session 3, use PCMs as second-stage treatment). Utilizing the SMART methodology to develop an adaptive weight loss intervention that would outperform gold standard SBT in a randomized controlled trial is an important next step, but may require additional optimization work. CLINICAL TRIAL INFORMATION ClinicalTrials.gov identifier; NCT02368002.
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Affiliation(s)
- Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Meghan L Butryn
- Department of Psychology, Drexel University, Philadelphia, PA, USA
| | - Evan M Forman
- Department of Psychology, Drexel University, Philadelphia, PA, USA
| | - Melissa M Crane
- Department of Preventive Medicine, Rush University, Chicago, IL, USA
| | - Rona L Levy
- School of Social Work, University of Washington, Seattle, WA, USA
| | | | - Robert W Jeffery
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Griauzde DH, Standafer Lopez K, Saslow LR, Richardson CR. A Pragmatic Approach to Translating Low- and Very Low-Carbohydrate Diets Into Clinical Practice for Patients With Obesity and Type 2 Diabetes. Front Nutr 2021; 8:682137. [PMID: 34350205 PMCID: PMC8326333 DOI: 10.3389/fnut.2021.682137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/14/2021] [Indexed: 12/26/2022] Open
Abstract
Across all eating patterns, individuals demonstrate marked differences in treatment response; some individuals gain weight and others lose weight with the same approach. Policy makers and research institutions now call for the development and use of personalized nutrition counseling strategies rather than one-size-fits-all dietary recommendations. However, challenges persist in translating some evidence-based eating patterns into the clinical practice due to the persistent notion that certain dietary approaches-regardless of individuals' preferences and health outcomes-are less healthy than others. For example, low- and very low-carbohydrate ketogenic diets (VLCKDs)-commonly defined as 10-26% and <10% total daily energy from carbohydrate, respectively-are recognized as viable lifestyle change options to support weight loss, glycemic control, and reduced medication use. Yet, critics contend that such eating patterns are less healthy and encourage general avoidance rather than patient-centered use. As with all medical treatments, the potential benefits and risks must be considered in the context of patient-centered, outcome-driven care; this is the cornerstone of evidence-based medicine. Thus, the critical challenge is to identify and safely support patients who may prefer and benefit from dietary carbohydrate restriction. In this Perspective, we propose a pragmatic, 4-stepped, outcome-driven approach to help health professionals use carbohydrate-restricted diets as one potential tool for supporting individual patients' weight loss and metabolic health.
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Affiliation(s)
- Dina Hafez Griauzde
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
- University of Michigan Medical School, Ann Arbor, MI, United States
| | | | - Laura R. Saslow
- University of Michigan School of Nursing, Ann Arbor, MI, United States
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Tronieri JS, Wadden TA, Chao AM, Pearl RL, Alamuddin N, Berkowitz RI. Early Weight Loss in Behavioral Treatment Predicts Later Rate of Weight Loss and Response to Pharmacotherapy. Ann Behav Med 2020; 53:290-295. [PMID: 29800080 DOI: 10.1093/abm/kay036] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early weight loss (EWL) in the first 1-2 months of behavioral treatment is a strong predictor of later total weight loss. It is not clear whether participants with lower early losses lose less in ongoing treatment or simply fail to overcome the smaller initial loss. Furthermore, no study has tested whether EWL in behavioral treatment predicts response to a different treatment modality, such as pharmacotherapy. METHODS Data were from 170 participants with obesity (baseline BMI = 40.8 ± 5.8 kg/m2, 87.6% female; 71.3% Black) enrolled in a two-phase trial. Data from the weight loss phase, which provided weekly lifestyle counseling and a meal replacement diet, were used to examine the relationship between 4-week EWL and subsequent rate of weight loss in behavioral treatment. Data from the maintenance phase, in which 137 participants who had lost ≥5% of initial weight were randomized to 52 weeks of maintenance counseling with lorcaserin or placebo, were used to determine whether EWL with behavioral treatment affects the benefit of pharmacotherapy. RESULTS EWL in the first 4 weeks of behavioral treatment (3.6 ± 1.7%) predicted greater total losses at Week 14 (r2 = 0.61, p < .001) and a faster rate of weight loss in the subsequent 9 weeks of the program (p < .001). During the maintenance phase, lower EWL in behavioral treatment predicted a greater benefit of lorcaserin, in comparison with placebo, for the maintenance of a ≥5% loss at Weeks 24 and 52. CONCLUSIONS These findings support recommendations to modify treatment for individuals with low EWL.
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Affiliation(s)
- Jena Shaw Tronieri
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Suite, Philadelphia, PA, USA
| | - Thomas A Wadden
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Suite, Philadelphia, PA, USA
| | - Ariana M Chao
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Suite, Philadelphia, PA, USA.,Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA,USA
| | - Rebecca L Pearl
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Suite, Philadelphia, PA, USA.,Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Naji Alamuddin
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Suite, Philadelphia, PA, USA.,Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert I Berkowitz
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Suite, Philadelphia, PA, USA.,Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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8
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Unick JL, Pellegrini CA, Dunsiger SI, Demos KE, Thomas JG, Bond DS, Webster J, Wing RR. DIAL now protocol: A randomized trial examining the provision of phone coaching to those with sub-optimal early weight loss during an Internet weight management program. Contemp Clin Trials 2020; 90:105953. [PMID: 32017994 PMCID: PMC7071958 DOI: 10.1016/j.cct.2020.105953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/22/2020] [Accepted: 01/30/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND While low-intensity Internet-delivered weight loss (IDWL) programs are efficacious, many patients fail to achieve clinically significant weight loss (WL). Given the positive association between 4-week and post-treatment WL, providing a more intensive intervention for those with sub-optimal 4-week WL may improve outcomes for a greater proportion of individuals. This stepped-care approach would minimize cost by reserving more aggressive treatment for those with sub-optimal early WL. OBJECTIVE This randomized trial examines whether the provision of brief or extended phone coaching for those with sub-optimal early WL improves 4- and 12-month WL when compared to no coaching. Secondary aims include examination of cost/kg WL and intervention engagement. METHODS 450 individuals (age 18-70 years, BMI: 25-45 kg/m2) will be randomized to: 1) IDWL+3 weeks of coaching ('Brief'), 2) IDWL+12 weeks of coaching ('Extended'), or 3) IDWL only ('Control'). All individuals will receive a 4-month IDWL program followed by an 8-month IDWL maintenance program. At week 4, individuals will be classified as early sub-optimal responders (<4% WL) or initial responders (≥4% WL). Individuals with sub-optimal early WL randomized to 'Brief' or 'Extended' will receive 3 and 12 weeks of phone coaching respectively, starting at week 5. Those with sub-optimal early WL randomized to 'Control', and initial responders will not receive any coaching. Assessments will occur at 4 and 12 months. DISCUSSION Study findings can inform the development of more effective IDWL programs. This model which provides additional support to those with sub-optimal early WL can easily be translated into healthcare and community settings.
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Affiliation(s)
- Jessica L Unick
- Warren Alpert Medical School at Brown University and The Miriam Hospital's Weight Control and Diabetes Research Center, Providence, RI, USA.
| | - Christine A Pellegrini
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Shira I Dunsiger
- Department of Behavioral and Social Sciences, Brown University School of Public Health, USA
| | - Kathryn E Demos
- Warren Alpert Medical School at Brown University and The Miriam Hospital's Weight Control and Diabetes Research Center, Providence, RI, USA
| | - J Graham Thomas
- Warren Alpert Medical School at Brown University and The Miriam Hospital's Weight Control and Diabetes Research Center, Providence, RI, USA
| | - Dale S Bond
- Warren Alpert Medical School at Brown University and The Miriam Hospital's Weight Control and Diabetes Research Center, Providence, RI, USA
| | - Jennifer Webster
- Warren Alpert Medical School at Brown University and The Miriam Hospital's Weight Control and Diabetes Research Center, Providence, RI, USA
| | - Rena R Wing
- Warren Alpert Medical School at Brown University and The Miriam Hospital's Weight Control and Diabetes Research Center, Providence, RI, USA
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Pfammatter AF, Nahum-Shani I, DeZelar M, Scanlan L, McFadden HG, Siddique J, Hedeker D, Spring B. SMART: Study protocol for a sequential multiple assignment randomized controlled trial to optimize weight loss management. Contemp Clin Trials 2019; 82:36-45. [PMID: 31129369 PMCID: PMC6624080 DOI: 10.1016/j.cct.2019.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 05/14/2019] [Accepted: 05/22/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Stepped care is a rational resource allocation approach to reduce population obesity. Evidence is lacking to guide decisions on use of low cost treatment components such as mobile health (mHealth) tools without compromising weight loss of those needing more expensive traditional treatment components (e.g., coaching, meal replacement). A sequential multiple assignment randomization trial (SMART) will be conducted to inform the development of an empirically based stepped care intervention that incorporates mHealth and traditional treatment components. OBJECTIVE The primary aim tests the non-inferiority of app alone, compared to app plus coaching, as first line obesity treatment, measured by weight change from baseline to 6 months. Secondary aims are to identify the best tactic to address early treatment non-response and the optimal treatment sequence for resource efficient weight loss. STUDY DESIGN Four hundred participants, 18-60 years old with Body Mass Index between 27 and 45 kg/m2 will be randomized to receive a weight loss smartphone app (APP) or the app plus weekly coaching (APP + C) for a 12 week period. Those achieving <0.5 lb. weight loss on average per week, assessed by wireless scale at 2, 4, and 8 weeks, will be classified as non-responders and re-randomized once to step-up modestly (adding another mHealth component) or vigorously (adding mHealth and traditional treatment components) for the remaining treatment period. Weight will be assessed in person at baseline, 3, 6, and 12 months. SIGNIFICANCE Results will inform construction of an obesity treatment algorithm that balances weight loss outcomes with resource consumption.
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Affiliation(s)
- Angela Fidler Pfammatter
- Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, IL, United States.
| | - Inbal Nahum-Shani
- Survey Research Center, Institute for Social Research, University of Michigan Ann Arbor, Ann Arbor, MI, United States
| | - Margaret DeZelar
- Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, IL, United States
| | - Laura Scanlan
- Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, IL, United States
| | - H Gene McFadden
- Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, IL, United States
| | - Juned Siddique
- Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, IL, United States
| | - Donald Hedeker
- University of Chicago, Department of Public Health Sciences, Chicago, IL, United States
| | - Bonnie Spring
- Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, IL, United States
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10
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LaRose JG, Fava JL, Lanoye A, Caccavale LJ. Early Engagement is Associated with Better Weight Loss in Emerging Adults. Am J Health Behav 2019; 43:795-801. [PMID: 31239021 DOI: 10.5993/ajhb.43.4.12] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Predictors of success among emerging adults (EAs; ages 18-25) within behavioral weight loss (BWL) trials are largely unknown. We examined whether early program engagement predicted overall engagement and weight loss in EAs. Methods: Data were pooled from 2 randomized controlled pilot trials in EAs. Participants (N = 99, 80% female, BMI = 33.7±5.1 kg/m²) received a 3-month BWL intervention. Weight was objectively assessed at 0 and 3 months; engagement was tracked weekly; retention was assessed at 3 months. Results: Greater engagement during the initial 4 weeks of treatment predicted greater weight loss (p = .001). Compared to those who did not engage in all 4 initial weeks, participants meeting this threshold experienced greater overall engagement (9.6 vs 4.2 weeks, p < .001), weight losses (intent-to-treat = -3.8% vs -1.3%, p = .004), and retention (78% vs 53%, p = .012). Conclusions: Early engagement in BWL is associated with better outcomes among EAs. Monitoring engagement in real-time during the initial 4 weeks of treatment may be necessary to intervene effectively. Early engagement did not vary by sex or race; future work should identify characteristics associated with poor early engagement.
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Affiliation(s)
- Jessica Gokee LaRose
- Associate Professor, Virginia Commonwealth University School of Medicine, Department of Health Behavior and Policy, Richmond, VA;,
| | - Joseph L. Fava
- Research Associate, The Miriam Hospital Weight Control and Diabetes Research Center, Providence, RI
| | - Autumn Lanoye
- Postdoctoral Fellow, Virginia Commonwealth University School of Medicine, Department of Health Behavior and Policy, Richmond, VA
| | - Laura J. Caccavale
- Postdoctoral Fellow, Children's Hospital of Richmond at Virginia Commonwealth University, Healthy Lifestyles Center, Richmond, VA
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Carels RA, Caroline Miller J, Selensky JC, Hlavka R, Solar C, Rossi J, Ellis J. Using an acceptance-based behavioral approach as a supplement to obesity treatment: A stepped-care approach. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2019. [DOI: 10.1016/j.jcbs.2019.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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12
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Liu J, Godino JG, Norman GJ, Hill L, Calfas K, Sallis JF, Arredondo E, Rock CL, Criqui M, Zhu SH, Griffiths K, Covin J, Dillon L, Patrick K. Planned care for obesity and cardiovascular risk reduction using a stepped-down approach: A randomized-controlled trial. Prev Med 2018; 114:223-231. [PMID: 30055199 PMCID: PMC6130909 DOI: 10.1016/j.ypmed.2018.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 07/21/2018] [Accepted: 07/24/2018] [Indexed: 11/29/2022]
Abstract
UNLABELLED Primary care-based approaches to address concurrent obesity and cardiovascular disease risk factors (CVDRFs) that begin with a high intensity intervention that is subsequently decreased (i.e., stepped-down) if weight loss is achieved have not been rigorously examined. Our study is a 20-month, single-blind randomized controlled trial at five primary care clinics in San Diego, CA, in 2013, where 262 obese adults (aged 25-70 years; 32.1% male; 59.2% white) with at least one CVDRF were enrolled into planned care for obesity and risk reduction (PCORR) using a stepped-down approach or enhanced usual care (EUC). All patients received physician recommendations for weight loss and CVDRFs. EUC patients (n = 132) received an individual session with a health educator every 4 months. PCORR patients (n = 130) received individual and group sessions (in-person, mail, telephone, and email) in three steps, characterized by less contact if success was achieved. At 20 months, 40.7%, 23.8%, and 15.4% of PCORR patients were in steps 1, 2, and 3, respectively (25.2% were lost to follow-up). PCORR resulted in a between-group difference in reduction in body weight of 6.1% [95% CI, 5.3 to 6.9] compared to EUC 2.8% [95% CI, 2.0 to 3.6] p = 0.007, with a greater reduction in BMI (35.2 [95% CI, 34.4 to 35.9] to 33.7 [95% CI, 32.9 to 34.5] kg/m2) than EUC (36.0 [95% CI, 35.3 to 36.8] to 35.1 [95% CI, 34.3 to 35.9] kg/m2), as indicated by a significant treatment by time interaction (p = 0.009). PCORR resulted in greater weight loss over 20 months than EUC. TRIAL REGISTRATION ClinicalTrials.gov, NCT01134029.
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Affiliation(s)
- Jie Liu
- School of Medicine, University of California, San Diego, La Jolla, CA, United States of America
| | - Job G Godino
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America; Center for Wireless and Population Health Systems, University of California, San Diego, La Jolla, CA, United States of America
| | - Gregory J Norman
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America; Center for Wireless and Population Health Systems, University of California, San Diego, La Jolla, CA, United States of America
| | - Linda Hill
- School of Medicine, University of California, San Diego, La Jolla, CA, United States of America; Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America
| | - Karen Calfas
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America
| | - James F Sallis
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America
| | - Elva Arredondo
- Graduate School of Public Health, San Diego State University, San Diego, CA, United States of America
| | - Cheryl L Rock
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America
| | - Michael Criqui
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America
| | - Shu-Hong Zhu
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America
| | - Kenneth Griffiths
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America
| | - Jennifer Covin
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America
| | - Lindsay Dillon
- Center for Wireless and Population Health Systems, University of California, San Diego, La Jolla, CA, United States of America
| | - Kevin Patrick
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, United States of America; Center for Wireless and Population Health Systems, University of California, San Diego, La Jolla, CA, United States of America.
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Unick JL, Pellegrini CA, Demos KE, Dorfman L. Initial Weight Loss Response as an Indicator for Providing Early Rescue Efforts to Improve Long-term Treatment Outcomes. Curr Diab Rep 2017; 17:69. [PMID: 28726155 PMCID: PMC5789799 DOI: 10.1007/s11892-017-0904-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW There is a large variability in response to behavioral weight loss (WL) programs. Reducing rates of obesity and diabetes may require more individuals to achieve clinically significant WL post-treatment. Given that WL within the first 1-2 months of a WL program is associated with long-term WL, it may be possible to improve treatment outcomes by identifying and providing additional intervention to those with poor initial success (i.e., "early non-responders"). We review the current literature regarding early non-response to WL programs and discuss how adaptive interventions can be leveraged as a strategy to "rescue" early non-responders. RECENT FINDINGS Preliminary findings suggest that adaptive interventions, specifically stepped care approaches, offer promise for improving outcomes among early non-responders. Future studies need to determine the optimal time point and threshold for intervening and the type of early intervention to employ. Clinicians and researchers should consider the discussed factors when making treatment decisions.
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Affiliation(s)
- Jessica L Unick
- The Miriam Hospital's Weight Control and Diabetes Research Center, Warren Alpert Medical School at Brown University, 196 Richmond Street, Providence, RI, 02903, USA.
| | - Christine A Pellegrini
- Technology Center to Promote Healthy Lifestyles, Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Kathryn E Demos
- The Miriam Hospital's Weight Control and Diabetes Research Center, Warren Alpert Medical School at Brown University, 196 Richmond Street, Providence, RI, 02903, USA
| | - Leah Dorfman
- The Miriam Hospital's Weight Control and Diabetes Research Center, Warren Alpert Medical School at Brown University, 196 Richmond Street, Providence, RI, 02903, USA
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Carels RA, Selensky JC, Rossi J, Solar C, Hlavka R. A novel stepped-care approach to weight loss: The role of self-monitoring and health literacy in treatment outcomes. Eat Behav 2017; 26:76-82. [PMID: 28189945 DOI: 10.1016/j.eatbeh.2017.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/28/2017] [Accepted: 01/30/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The aims of the current study were twofold: 1) examine the effectiveness of an innovative three-step, stepped-care behavioral weight loss treatment, and 2) examine factors that contribute to poor weight loss outcomes and the need for more intensive treatment. METHODS The total sample for the study consisted of 53 individuals (87% female) with MBMI=35.6, SDBMI=6.4. A three-step, stepped-care treatment approach was implemented over six months. Step 1 included the Diabetes Prevention Program manual adapted for self-administration augmented with monitoring technology shown to facilitate weight loss and participant accountability and engagement. Participants who were unsuccessful at achieving established weight loss goals received stepped-up treatments in 2-month increments beginning at month 2. The stepped progression included the addition of meal replacement at Step 2 and individual counseling concurrent with meal replacement at Step 3. RESULTS Un-stepped and once stepped participants lost a clinically significant amount of weight (i.e., >5%), while twice stepped participants lost an insignificant amount of weight. Twice stepped participants were significantly lower in health literacy and self-monitoring frequency. CONCLUSIONS In this investigation, approximately 60% of the participants were able to lose a clinically significant amount of weight utilizing a minimally intensive intervention with little additional support. Regular self-monitoring and high health literacy proved to be significant correlates of success.
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Jakicic JM, Rickman AD, Lang W, Davis KK, Gibbs BB, Neiberg R, Marcus MD. Time-based physical activity interventions for weight loss: a randomized trial. Med Sci Sports Exerc 2016; 47:1061-9. [PMID: 25160843 DOI: 10.1249/mss.0000000000000482] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE This study aims to examine whether enhancing standard behavioral weight loss interventions (standard behavioral weight loss program (SBWP)) with additional strategies at the initiation of intervention (ADOPT) or providing the additional strategies at predetermined times over the intervention period (MAINTAIN) enhances 18-month weight loss. METHODS This was a clinical trial of participants (N = 195; mean ± SEM: age, 43.2 ± 8.6 yr; body mass index, 33.0 ± 3.4 kg·m) randomized to SBWP, ADOPT, or MAINTAIN. All participants were prescribed an energy-restricted diet and physical activity, with group intervention sessions delivered over 18 months. ADOPT participants received additional phone contact (months 1-3), supervised exercise (months 1-6), and behavior campaigns (months 4-9). MAINTAIN participants received additional phone contact (months 4-6), supervised exercise (months 7-12), and behavior campaigns (months 13-18). RESULTS There was a significant group-time interaction for weight loss (P = 0.0032). SBWP participants lost 9.3 ± 0.9, 7.8 ± 1.1, and 5.9 ± 1.2 kg at 6, 12, and 18 months, respectively. ADOPT participants lost 8.9 ± 0.9, 7.6 ± 1.2, and 5.8 ± 1.2 kg, whereas MAINTAIN participants lost 9.7 ± 0.9, 11.0 ± 1.2, and 9.0 ± 1.2 kg at 6, 12, and 18 months, respectively. The group-time interactions for SBWP versus MAINTAIN (P = 0.0033) and for ADOPT versus MAINTAIN (P = 0.0075) were significant. There was a significant group-time interaction for change in fitness (P = 0.0060). The group-time interaction for MAINTAIN versus ADOPT (P = 0.0018) was significant, with a trend for MAINTAIN versus SBWP (P = 0.0525). CONCLUSIONS MAINTAIN improves 18-month weight loss compared with SBWP and ADOPT, with statistical trends indicating that MAINTAIN results in greater improvements in fitness. These results suggest that time-based strategies emphasizing physical activity confer greater benefits when delivered later and over the full course of intervention. This provides valuable information for the implementation of time-based strategies for improving long-term weight loss and fitness in overweight and obese adults.
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Affiliation(s)
- John M Jakicic
- 1Department of Health and Physical Activity, Physical Activity and Weight Management Research Center, University of Pittsburgh, Pittsburgh, PA; 2Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC; and 3Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Nordgreen T, Haug T, Öst LG, Andersson G, Carlbring P, Kvale G, Tangen T, Heiervang E, Havik OE. Stepped Care Versus Direct Face-to-Face Cognitive Behavior Therapy for Social Anxiety Disorder and Panic Disorder: A Randomized Effectiveness Trial. Behav Ther 2016; 47:166-83. [PMID: 26956650 DOI: 10.1016/j.beth.2015.10.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/07/2015] [Accepted: 10/08/2015] [Indexed: 11/15/2022]
Abstract
The aim of this study was to assess the effectiveness of a cognitive behavioral therapy (CBT) stepped care model (psychoeducation, guided Internet treatment, and face-to-face CBT) compared with direct face-to-face (FtF) CBT. Patients with panic disorder or social anxiety disorder were randomized to either stepped care (n=85) or direct FtF CBT (n=88). Recovery was defined as meeting two of the following three criteria: loss of diagnosis, below cut-off for self-reported symptoms, and functional improvement. No significant differences in intention-to-treat recovery rates were identified between stepped care (40.0%) and direct FtF CBT (43.2%). The majority of the patients who recovered in the stepped care did so at the less therapist-demanding steps (26/34, 76.5%). Moderate to large within-groups effect sizes were identified at posttreatment and 1-year follow-up. The attrition rates were high: 41.2% in the stepped care condition and 27.3% in the direct FtF CBT condition. These findings indicate that the outcome of a stepped care model for anxiety disorders is comparable to that of direct FtF CBT. The rates of improvement at the two less therapist-demanding steps indicate that stepped care models might be useful for increasing patients' access to evidence-based psychological treatments for anxiety disorders. However, attrition in the stepped care condition was high, and research regarding the factors that can improve adherence should be prioritized.
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Affiliation(s)
- Tine Nordgreen
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen.
| | - Thomas Haug
- Anxiety Disorders Research Network, Haukeland University Hospital
| | - Lars-Göran Öst
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen; Stockholm University; Karolinska Institutet
| | | | | | - Gerd Kvale
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen
| | - Tone Tangen
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen
| | - Einar Heiervang
- Anxiety Disorders Research Network, Haukeland University Hospital; Institute of Clinical Medicine, University of Oslo
| | - Odd E Havik
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen
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17
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Szabo-Reed AN, Lee J, Ptomey L, Willis E, Schubert M, Washburn R, Donnelly JE. Longitudinal Weight Loss Patterns and their Behavioral and Demographic Associations. Ann Behav Med 2016; 50:147-56. [PMID: 26423446 PMCID: PMC4744131 DOI: 10.1007/s12160-015-9740-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
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.
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Affiliation(s)
- Amanda N Szabo-Reed
- Cardiovascular Research Institute, Division of Internal Medicine, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
| | - Jaehoon Lee
- Institute for Measurement, Methodology, Analysis and Policy, Texas Tech University, Box 43150, Lubbock, TX, 79409, USA.
| | - Lauren Ptomey
- Cardiovascular Research Institute, Division of Internal Medicine, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
| | - Erik Willis
- Cardiovascular Research Institute, Division of Internal Medicine, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
| | - Matt Schubert
- Cardiovascular Research Institute, Division of Internal Medicine, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
| | - Richard Washburn
- Cardiovascular Research Institute, Division of Internal Medicine, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
| | - Joseph E Donnelly
- Cardiovascular Research Institute, Division of Internal Medicine, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
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The BestFIT trial: A SMART approach to developing individualized weight loss treatments. Contemp Clin Trials 2016; 47:209-16. [PMID: 26825020 DOI: 10.1016/j.cct.2016.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/22/2016] [Accepted: 01/25/2016] [Indexed: 11/23/2022]
Abstract
Behavioral weight loss programs help people achieve clinically meaningful weight losses (8-10% of starting body weight). Despite data showing that only half of participants achieve this goal, a "one size fits all" approach is normative. This weight loss intervention science gap calls for adaptive interventions that provide the "right treatment at the right time for the right person." Sequential Multiple Assignment Randomized Trials (SMART), use experimental design principles to answer questions for building adaptive interventions including whether, how, or when to alter treatment intensity, type, or delivery. This paper describes the rationale and design of the BestFIT study, a SMART designed to evaluate the optimal timing for intervening with sub-optimal responders to weight loss treatment and relative efficacy of two treatments that address self-regulation challenges which impede weight loss: 1) augmenting treatment with portion-controlled meals (PCM) which decrease the need for self-regulation; and 2) switching to acceptance-based behavior treatment (ABT) which boosts capacity for self-regulation. The primary aim is to evaluate the benefit of changing treatment with PCM versus ABT. The secondary aim is to evaluate the best time to intervene with sub-optimal responders. BestFIT results will lead to the empirically-supported construction of an adaptive intervention that will optimize weight loss outcomes and associated health benefits.
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19
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Unick JL, Dorfman L, Leahey TM, Wing RR. A preliminary investigation into whether early intervention can improve weight loss among those initially non-responsive to an internet-based behavioral program. J Behav Med 2015; 39:254-61. [DOI: 10.1007/s10865-015-9691-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 10/15/2015] [Indexed: 01/22/2023]
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20
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Examination of whether early weight loss predicts 1-year weight loss among those enrolled in an Internet-based weight loss program. Int J Obes (Lond) 2015; 39:1558-60. [PMID: 25982792 PMCID: PMC4596751 DOI: 10.1038/ijo.2015.89] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/01/2015] [Accepted: 05/06/2015] [Indexed: 12/25/2022]
Abstract
One-month weight loss (WL) predicts post-treatment WL in face-to-face interventions; however whether this holds true within Internet programs is unknown. This study examined whether 4-week WL predicts WL following a 12-week Internet program and at 6 and 12 months follow-up. 181 participants (BMI=33.4±5.5kg/m2; 83.1% female) received a 12-week behaviorally-based Internet WL program consisting of weekly video lessons. Participants were given a daily WL, calorie, and physical activity goal and asked to enter these data on the study website weekly. Personalized feedback was provided. Using 4-week WL, individuals were categorized as ‘early non-responders’ (<2.0% WL) or ‘early responders’ (≥2.0% WL). Early non-responders had significantly lower WL than early responders at 3 (-1.3±3.8% vs. -6.3±4.3%), 6 (-1.7±5.1% vs. -5.8±5.2%), and 12 months (-0.05±6.8% vs. -2.7±6.3%, p's<0.05). The odds of achieving a ≥5% WL were 8.5 (95% CI:3.3–22.1), 3.4 (95% CI:1.4-8.3), and 2.6 (95% CI:0.93-7.4) times lower in early non-responders, compared to early responders at 3, 6, and 12 months respectively. Compared to early responders, early non-responders viewed fewer video lessons and self-monitored less often across the 12-week intervention (p's<0.05). This study provides initial evidence that a 4-week WL of <2.0% places an individual at an increased risk of failing to achieve clinically significant WL following an Internet program.
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Almirall D, Nahum-Shani I, Sherwood NE, Murphy SA. Introduction to SMART designs for the development of adaptive interventions: with application to weight loss research. Transl Behav Med 2014; 4:260-74. [PMID: 25264466 DOI: 10.1007/s13142-014-0265-0] [Citation(s) in RCA: 252] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The management of many health disorders often entails a sequential, individualized approach whereby treatment is adapted and readapted over time in response to the specific needs and evolving status of the individual. Adaptive interventions provide one way to operationalize the strategies (e.g., continue, augment, switch, step-down) leading to individualized sequences of treatment. Often, a wide variety of critical questions must be answered when developing a high-quality adaptive intervention. Yet, there is often insufficient empirical evidence or theoretical basis to address these questions. The Sequential Multiple Assignment Randomized Trial (SMART)-a type of research design-was developed explicitly for the purpose of building optimal adaptive interventions by providing answers to such questions. Despite increasing popularity, SMARTs remain relatively new to intervention scientists. This manuscript provides an introduction to adaptive interventions and SMARTs. We discuss SMART design considerations, including common primary and secondary aims. For illustration, we discuss the development of an adaptive intervention for optimizing weight loss among adult individuals who are overweight.
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Affiliation(s)
- Daniel Almirall
- 214NU Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48104-2321 USA
| | - Inbal Nahum-Shani
- 214NU Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48104-2321 USA
| | - Nancy E Sherwood
- HealthPartners Institute for Education and Research, Minneapolis, USA
| | - Susan A Murphy
- Department of Statistics and Institute for Social Research, University of Michigan, Ann Arbor, USA
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22
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Unick JL, Hogan PE, Neiberg RH, Cheskin LJ, Dutton GR, Evans-Hudnall G, Jeffery R, Kitabchi AE, Nelson JA, Pi-Sunyer FX, West DS, Wing RR. Evaluation of early weight loss thresholds for identifying nonresponders to an intensive lifestyle intervention. Obesity (Silver Spring) 2014; 22:1608-16. [PMID: 24771618 PMCID: PMC4077939 DOI: 10.1002/oby.20777] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 04/13/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Weight losses in lifestyle interventions are variable, yet prediction of long-term success is difficult. The utility of using various weight loss thresholds in the first 2 months of treatment for predicting 1-year outcomes was examined. METHODS Participants included 2327 adults with type 2 diabetes (BMI:35.8 ± 6.0) randomized to the intensive lifestyle intervention (ILI) of the Look AHEAD trial. ILI included weekly behavioral sessions designed to increase physical activity and reduce caloric intake. 1-month, 2-month, and 1-year weight changes were calculated. RESULTS Participants failing to achieve a ≥2% weight loss at Month 1 were 5.6 (95% CI:4.5, 7.0) times more likely to also not achieve a ≥10% weight loss at Year 1, compared to those losing ≥2% initially. These odds were increased to 11.6 (95% CI:8.6, 15.6) when using a 3% weight loss threshold at Month 2. Only 15.2% and 8.2% of individuals failing to achieve the ≥2% and ≥3% thresholds at Months 1 and 2, respectively, go on to achieve a ≥10% weight loss at Year 1. CONCLUSIONS Given the association between initial and 1-year weight loss, the first few months of treatment may be an opportune time to identify those who are unsuccessful and utilize rescue efforts. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00017953.
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Affiliation(s)
- Jessica L Unick
- Weight Control and Diabetes Research Center, The Miriam Hospital and Brown Medical School, Providence, Rhode Island, USA
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Durant NH, Joseph RP, Affuso OH, Dutton GR, Robertson HT, Allison DB. Empirical evidence does not support an association between less ambitious pre-treatment goals and better treatment outcomes: a meta-analysis. Obes Rev 2013; 14:532-40. [PMID: 23601605 PMCID: PMC4366879 DOI: 10.1111/obr.12038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 02/13/2013] [Accepted: 03/06/2013] [Indexed: 01/01/2023]
Abstract
Setting realistic weight loss goals may play a role in weight loss. We abstracted data from randomized controlled trials and observational studies conducted between 1998 and 2012 concerning the association of weight loss goals with weight loss. Studies included those that (i) were conducted in humans; (ii) delivered a weight loss intervention; (iii) lasted ≥6 weeks; (iv) assessed baseline weight loss goals; (vi) assessed pre- and post-weight either in the form of body mass index or some other measure that could be converted to weight loss based on information included in the original study or later provided by the author(s); and (vii) assessed the correlation between weight loss goals and final weight loss or provided data to calculate the correlation. Studies that included interventions to modify weight loss goals were excluded. Eleven studies met inclusion criteria. The overall correlation between goal weight and weight at intervention completion was small and statistically insignificant (ρ=0.0 5 ; P = 0.20). The current evidence does not demonstrate that setting realistic goals leads to more favourable weight loss outcomes. Thus, our field may wish to reconsider the value of setting realistic goals in successful weight loss.
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Affiliation(s)
- N H Durant
- School of Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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Abstract
This article provides an overview of research regarding adult behavioral lifestyle intervention for obesity treatment. We first describe two trials using a behavioral lifestyle intervention to induce weight loss in adults, the Diabetes Prevention Program (DPP) and the Look AHEAD (Action for Health in Diabetes) trial. We then review the three main components of a behavioral lifestyle intervention program: behavior therapy, an energy- and fat-restricted diet, and a moderate- to vigorous-intensity physical activity prescription. Research regarding the influence of dietary prescriptions focusing on macronutrient composition, meal replacements, and more novel dietary approaches (such as reducing dietary variety and energy density) on weight loss is examined. Methods to assist with meeting physical activity goals, such as shortening exercise bouts, using a pedometer, and having access to exercise equipment within the home, are reviewed. To assist with improving weight loss outcomes, broadening activity goals to include resistance training and a reduction in sedentary behavior are considered. To increase the accessibility of behavioral lifestyle interventions to treat obesity in the broader population, translation of efficacious interventions such as the DPP, must be undertaken. Translational studies have successfully altered the DPP to reduce treatment intensity and/or used alternative modalities to implement the DPP in primary care, worksite, and church settings; several examples are provided. The use of new methodologies or technologies that provide individualized treatment and real-time feedback, and which may further enhance weight loss in behavioral lifestyle interventions, is also discussed.
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Affiliation(s)
- Shannon M Looney
- Department of Nutrition, University of Tennessee, Knoxville, TN, United States
| | - Hollie A Raynor
- Department of Nutrition, University of Tennessee, Knoxville, TN, United States
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Carels RA, Hoffmann DA, Hinman N, Burmeister JM, Koball A, Ashrafioun L, Oehlhof MW, Bannon E, Leroy M, Darby L. Step-down approach to behavioural weight loss treatment: a pilot of a randomised clinical trial. Psychol Health 2013; 28:1121-34. [PMID: 23607537 DOI: 10.1080/08870446.2013.789875] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND In a stepped-down approach, patients begin with a more intensive treatment and are stepped down to a less intensive treatment based on achieving treatment goals. This study compared a standard behavioural weight loss programme (BWLP) to a stepped-down approach to treatment. METHODS Fifty-two overweight/obese adults (Age: M = 47 years, SD = 13.5; female = 67%) participated in an 18-week BWLP. Half of them were randomly assigned to be stepped down from weekly group meetings based on completion of weight loss goals (3%) every 6 weeks, while the other half remained in their groups regardless of weight loss. RESULTS There was a significant difference favouring the BWLP in the proportion of participants who met or exceeded their 3% weight loss goal during the first six weeks. While not statistically significant by the end of treatment, the BWLP participants lost nearly 3% more body weight than stepped-down participants (SC = 4.9% vs. BWLP = 7.8%; p = .10). Greater self-monitoring was associated with increased likelihood of stepped-care eligibility and higher percent weight loss at the end of treatment (p < .01). CONCLUSION There was little evidence to support the efficacy of the stepped-down approach for behavioural weight loss treatment employed in this investigation.
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Affiliation(s)
- Robert A Carels
- a Department of Psychology , Bowling Green State University , Bowling Green , OH , USA
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26
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Jakicic JM, Tate DF, Lang W, Davis KK, Polzien K, Rickman AD, Erickson K, Neiberg RH, Finkelstein EA. Effect of a stepped-care intervention approach on weight loss in adults: a randomized clinical trial. JAMA 2012; 307:2617-26. [PMID: 22735431 PMCID: PMC4132634 DOI: 10.1001/jama.2012.6866] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
CONTEXT Given the obesity epidemic, effective but resource-efficient weight loss treatments are needed. Stepped-treatment approaches customize interventions based on milestone completion and can be more effective while costing less to administer than conventional treatment approaches. OBJECTIVE To determine whether a stepped-care weight loss intervention (STEP) compared with a standard behavioral weight loss intervention (SBWI) would result in greater weight loss. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial of 363 overweight and obese adults (body mass index: 25-<40; age: 18-55 years, 33% nonwhite, and 83% female) who were randomized to SBWI (n = 165) or STEP (n = 198) at 2 universities affiliated with academic medical centers in the United States (Step-Up Study). Participants were enrolled between May 2008 and February 2010 and data collection was completed by September 2011. INTERVENTIONS All participants were placed on a low-calorie diet, prescribed increases in physical activity, and attended group counseling sessions ranging from weekly to monthly during an 18-month period. The SBWI group was assigned to a fixed program. Counseling frequency, type, and weight loss strategies could be modified every 3 months for the STEP group in response to observed weight loss as it related to weight loss goals. MAIN OUTCOME MEASURE Mean change in weight over 18 months. Additional outcomes included resting heart rate and blood pressure, waist circumference, body composition, fitness, physical activity, dietary intake, and cost of the program. RESULTS Of the 363 participants randomized, 260 (71.6%) provided a measure of mean change in weight over 18 months. The 18-month intervention resulted in weight decreasing from 93.1 kg (95% CI, 91.0 to 95.2 kg) to 85.6 kg (95% CI, 83.4 to 87.7 kg) (P < .001) in the SBWI group and from 92.7 kg (95% CI, 90.8 to 94.6 kg) to 86.4 kg (95% CI, 84.5 to 88.4 kg) in the STEP group (P < .001). The percentage change in weight from baseline to 18 months was -8.1% (95% CI, -9.4% to -6.9%) in the SBWI group (P < .001) compared with -6.9% (95% CI, -8.0% to -5.8%) in the STEP group (P < .001). Although the between-group difference in 18-month weight loss was not statistically different (-1.3 kg [95% CI, -2.8 to 0.2 kg]; P = .09), there was a significant group × time interaction effect (P = .03). The cost per participant was $1357 (95% CI, $1272 to $1442) for the SBWI group vs $785 (95% CI, $739 to $830) for the STEP group (P < .001). Both groups had significant and comparable improvements in resting heart rate, blood pressure level, and fitness. CONCLUSIONS Among overweight and obese adults, the use of SBWI resulted in a greater mean weight loss than STEP over 18 months. Compared with SBWI, STEP resulted in clinically meaningful weight loss that cost less to implement. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00714168.
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Affiliation(s)
- John M Jakicic
- Department of Health and Physical Activity, Physical Activity and Weight Management Research Center, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Carels RA, Young KM, Hinman N, Gumble A, Koball A, Oehlhof MW, Darby L. Stepped-care in obesity treatment: matching treatment intensity to participant performance. Eat Behav 2012; 13:112-8. [PMID: 22365792 PMCID: PMC3510656 DOI: 10.1016/j.eatbeh.2012.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 12/06/2011] [Accepted: 01/10/2012] [Indexed: 01/22/2023]
Abstract
This investigation examined the effectiveness of a self-help (SH), stepped-care (SC) weight loss program. Based on a failure to achieve pre-assigned weight loss goals, participants were eligible to be stepped-up from a SH program to two levels of treatment intensity (weight loss group [WLG]; individual counseling [IC]) beyond SH. The primary outcome was change in body weight. Fifty-three overweight/obese adults (BMI≥27 kg/m(2); mean BMI of 37.3, SD=6.6, 89% Caucasian, and 77% female) participated in an 18-week weight loss intervention. During several phases of the investigation, those stepped-up to more intensive treatment lost comparable weight to those who were not stepped-up. Nevertheless, by the end of treatment, individuals who remained in SH (M=8.6%) lost a significantly greater percentage of weight than individuals who received SH+IC (M=4.7%; p<.05) and individuals in SH+IC lost a significantly greater percentage of weight than individuals who received SH+WLG+IC (M=1.6%; p<.05). While some individuals benefited from being stepped-up to greater intensity treatment, other individuals experienced little benefit. The application of SC principles to the treatment of obesity needs further study.
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Affiliation(s)
- Robert A. Carels
- Corresponding author at: Bowling Green State University, Department of Psychology, Bowling Green, OH 43403, United States. Tel.: +1 419 372 9405; fax: +1 419 372 6013, (R.A. Carels)
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Hall KS, Pieper CF, Edelman DE, Yancy WS, Green JB, Lum H, Peterson MJ, Sloane R, Cowper PA, Bosworth HB, Huffman KM, PhD JTC, Chapman JG, Pearson MP, Howard TA, Ekelund CC, McCraw BL, Burrell JB, Taylor GA, Morey MC. Lessons learned when innovations go awry: a baseline description of a behavioral trial-the Enhancing Fitness in Older Overweight Veterans with Impaired Fasting Glucose study. Transl Behav Med 2011; 1:573-587. [PMID: 22866170 PMCID: PMC3411119 DOI: 10.1007/s13142-011-0075-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Individuals diagnosed with impaired glucose tolerance (i.e., prediabetes) are at increased risk for developing diabetes. We proposed a clinical trial with a novel adaptive randomization designed to examine the impact of a home-based physical activity (PA) counseling intervention on metabolic risk in prediabetic elders. This manuscript details the lessons learned relative to recruitment, study design, and implementation of a 12-month randomized controlled PA counseling trial. A detailed discussion on how we responded to unforeseen challenges is provided. A total of 302 older patients with prediabetes were randomly assigned to either PA counseling or usual care. A novel adaptive design that reallocated counseling intensity based on self-report of adherence to PA was initiated but revised when rates of non-response were lower than projected. This study presents baseline participant characteristics and discusses unwelcome adaptations to a highly innovative study design to increase PA and enhance glucose metabolism when the best-laid plans went awry.
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Affiliation(s)
| | | | - David E Edelman
- />Veterans Affairs Medical Center, Durham, NC USA
- />Department of Medicine, Duke University, Durham, NC USA
| | - William S Yancy
- />Veterans Affairs Medical Center, Durham, NC USA
- />Department of Medicine, Duke University, Durham, NC USA
| | - Jennifer B. Green
- />Veterans Affairs Medical Center, Durham, NC USA
- />Department of Medicine, Duke University, Durham, NC USA
- />Clinical Research Institute, Duke University, Durham, NC USA
| | - Helen Lum
- />Barshop Institute for Longevity and Aging Studies, University of Texas Health Science Center, San Antonio, TX USA
| | - Matthew J Peterson
- />Veterans Affairs Medical Center, Durham, NC USA
- />Department of Medicine, Duke University, Durham, NC USA
- />Aging Center, Duke University, Durham, NC UK
| | - Richard Sloane
- />Veterans Affairs Medical Center, Durham, NC USA
- />Aging Center, Duke University, Durham, NC UK
| | | | - Hayden B Bosworth
- />Veterans Affairs Medical Center, Durham, NC USA
- />Department of Medicine, Duke University, Durham, NC USA
- />Aging Center, Duke University, Durham, NC UK
| | - Kim M Huffman
- />Veterans Affairs Medical Center, Durham, NC USA
- />Department of Medicine, Duke University, Durham, NC USA
| | | | | | - Megan P Pearson
- />Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, NC USA
- />Center for Health Services Research and Development, Veterans Affairs Medical Center, Durham, NC USA
| | - Teresa A Howard
- />Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, NC USA
- />Center for Health Services Research and Development, Veterans Affairs Medical Center, Durham, NC USA
| | - Carola C Ekelund
- />Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, NC USA
- />Center for Health Services Research and Development, Veterans Affairs Medical Center, Durham, NC USA
| | | | | | - Gregory A Taylor
- />Veterans Affairs Medical Center, Durham, NC USA
- />Department of Medicine, Duke University, Durham, NC USA
- />Aging Center, Duke University, Durham, NC UK
- />Department of Genetics and Microbiology, Duke University, Durham, NC USA
| | - Miriam C Morey
- />Department of Medicine, Duke University, Durham, NC USA
- />Aging Center, Duke University, Durham, NC UK
- />Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, NC USA
- />Center for Health Services Research and Development, Veterans Affairs Medical Center, Durham, NC USA
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Li J, Linnan L, Finkelstein EA, Tate DF, Naseer C, Evenson KR. Knowledge and perceptions among overweight and obese employees about lifestyle-related health benefit changes. N C Med J 2011; 72:183-90. [PMID: 21901911 PMCID: PMC5082972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND We investigated perceptions among overweight and obese state employees about changes to health insurance that were designed to reduce the scope of health benefits for employees who are obese or who smoke. METHODS Before implementation of health benefit plan changes, 658 state employees who were overweight (ie, those with a body mass index [BMI] of 25-29.9) or obese (ie, those with a BMI of > or = 30) enrolled in a weight-loss intervention study were asked about their attitudes and beliefs concerning the new benefit plan changes. RESULTS Thirty-one percent of employees with a measured BMI of 40 or greater self-reported a BMI of less than 40, suggesting they were unaware that their current BMI would place them in a higher-risk benefit plan. More than half of all respondents reported that the new benefit changes would motivate them to make behavioral changes, but fewer than half felt confident in their ability to make changes. Respondents with a BMI of 40 or greater were more likely than respondents in lower BMI categories to oppose the new changes focused on obesity (P < .001). Current smokers were more likely than former smokers and nonsmokers to oppose the new benefit changes focused on tobacco use (P < .01). LIMITATIONS Participants represented a sample of employees enrolled in a weight-loss study, limiting generalizability to the larger population of state employees. CONCLUSIONS Benefit plan changes that require employees who are obese and smoke to pay more for health care may motivate some, but not all, individuals to change their behaviors. Since confidence to lose weight was lowest among individuals in the highest BMI categories, more-intense intervention options may be needed to achieve desired health behavior changes.
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Affiliation(s)
- Jiang Li
- Department of Health Behavior and Health Education, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, CB 7440, Chapel Hill, NC 27599-7440, USA.
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Carels RA, Young KM, Koball A, Gumble A, Darby LA, Wagner Oehlhof M, Wott CB, Hinman N. Transforming your life: an environmental modification approach to weight loss. J Health Psychol 2011; 16:430-8. [PMID: 20929947 PMCID: PMC3165028 DOI: 10.1177/1359105310380986] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This investigation compared a traditional behavioral weight loss program with a weight loss intervention emphasizing environmental modification and habit formation and disruption. Fifty-four overweight and obese adults (BMI ≥ 27 kg/m² were randomly assigned to either a 14-week LEARN or TYL intervention. Forty-two participants completed the six-month follow-up assessment. Treatment outcomes between LEARN and TYL participants were equivalent. During the six-month no-treatment follow-up period, participants evidenced a 3.3 lb (SD = 9.2) weight gain. The TYL intervention appears to represent an attractive option for individuals seeking an alternative to the traditional behavioral approach to weight loss.
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