A randomised control trial comparing lifestyle groups, individual counselling and written information in the management of weight and health outcomes over 12 months

The effectiveness and usability of online, group-based interventions for people with severe obesity: a systematic review and meta-analysis

Long wait times, limited resources, and a lack of local options mean that many people with severe obesity cannot access treatment. Face-to-face group-based interventions have been found effective and can treat multiple people simultaneously, but are limited by service capacity. Digital group interventions could reduce wait times, but research on their effectiveness is limited. This systematic review aimed to examine the literature about online group-based interventions for adults with severe obesity (BMI ≥ 35 kg/m2). The review followed the PRISMA and PICOS frameworks. MEDLINE, Embase, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials were searched. Two authors independently screened articles. Data extraction, analysis, and quality assessment (using RoB2 and MMAT) was shared between two authors. A meta-analysis was conducted on eligible studies; other results were descriptively analysed. 20 papers reporting on 15 studies were included. Most studies reported some evidence of weight loss, but evidence of weight-related behaviour change was mixed. A meta-analysis on four studies indicated that online, group-based interventions had a statistically significant impact on weight loss (p = 0.001; 95% CI -0.69 to -0.17) with a small-to-moderate effect size, compared to waitlist or standard care conditions. Online interventions were considered more convenient but lack of familiarity with the group or counsellor, accessibility issues, and time constraints hindered engagement. Technical support, incentives, and interactive forums to improve group cohesion could mitigate these barriers. The findings suggested that online, group-based interventions are feasible and potentially beneficial, but barriers such as internet accessibility, digital literacy, and unfamiliarity with group members need to be mitigated. Key recommendations to improve experience and impact include providing instructions and run-throughs, building group cohesion, and providing session and additional content throughout the intervention. Future studies should focus on the influence of specific intervention characteristics and investigate the effect of these interventions compared to face-to-face interventions. Registration: National Institute for Health Research, PROSPERO CRD42021227101; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021227101 .

A controlled weight loss intervention study among women of Somali background in Norway

Background

Women of Somali background in Norway have a high prevalence of overweight and obesity, compared with women in the general Norwegian population. For lifestyle interventions to be applicable for immigrants to Norway, it is important to culturally tailor interventions in collaboration with relevant communities. The primary outcome was a difference in weight change between the intervention and control groups.

Methods

In this interventional study, Somali women living in one borough of Oslo Municipality in Norway with body mass index (BMI) ≥27.0 kg.m-2 received a co-created, culturally tailored 12-month weight loss intervention consisting of 24 interactive sessions during the first three months, and monthly sessions for the next nine months, compared to a control group. Both groups were measured at baseline and 12 months.

Results

A total of 169 participants were recruited, and 101 participants completed the follow-up. After multiple imputation, the mean difference in weight change adjusted for baseline weight, age, education, employment, marital status, number of children in the household and length of Norwegian residency was -1.6 kg (95 % CI -3.57, 0.43, p = 0.12) in the intervention compared to the control group.

Conclusion

This culturally tailored intervention study demonstrated a modest non-significant effect on weight change after 12 months, possibly due to the short intervention duration and COVID-19. Further studies of a longer duration and considering the provision of childcare are needed to understand whether this approach can be transferred to other immigrant groups and genders.Trial registration: The study was registered at clinicaltrials.gov NCT04578067, 2020-09-29.

Weight regain and mental health outcomes following behavioural weight management programmes: A systematic review with meta-analyses

Behavioural weight management programmes (BWMPs) lead to weight loss but subsequent weight regain may harm mental health outcomes. We searched for randomised trials of BWMPs in adults with overweight/obesity with follow-up ≥12 months from baseline that measured weight change both at and after programme-end. We included only studies reporting mental health at or after programme-end. We meta-analysed changes in various mental health outcomes using a random-effects model by nature of the comparator group and by time since programme end. Subgroup analysis explored heterogeneity. We used mixed models and meta-regression to analyse the association between change in weight and change in depression and/or anxiety over time, with higher scores indicating greater depression and/or anxiety. We included 47 studies. When comparing BWMPs (diet and/or exercise) to control, most estimates included the possibility of no difference, but pooled estimates for psychological wellbeing, self-esteem and mental-health composite scores at programme-end, anxiety at 1-6 months, and depression at 7-12 months after programme-end suggested improvements in intervention arms relative to control, with 95% CIs excluding no difference. Pooled estimates found no evidence that BWMPs harmed mental health at programme end or beyond. Mental health composite scores at programme-end favoured diet and exercise interventions over diet alone, with 95% CIs excluding no difference. All other measures and timepoints included the possibility of no difference or could not be meta-analysed due to high heterogeneity or a paucity of data. Mixed models and meta-regression of the association between change in depression and/or anxiety scores over time, and change in weight, were inconclusive. Despite weight regain after BWMPs, our meta-analyses found no evidence of mental health harm and some evidence that BWMPs may improve some dimensions of mental health at and after programme-end.

Systematic realist synthesis of health-related and lifestyle interventions designed to decrease overweight, obesity and unemployment in adults

Background

Obesity and unemployment are complex social and health issues with underlying causes that are interconnected. While a clear link has been established, there is lack of evidence on the underlying causal pathways and how health-related interventions could reduce obesity and unemployment using a holistic approach.

Objectives

The aim of this realist synthesis was to identify the common strategies used by health-related interventions to reduce obesity, overweight and unemployment and to determine for whom and under what circumstances these interventions were successful or unsuccessful and why.

Methods

A realist synthesis approach was used. Systematic literature searches were conducted in Cochrane library, Medline, SocIndex, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and PsychInfo. The evidence from included studies were synthesised into Context-Mechanism-Outcome configurations (CMOcs) to better understand when and how programmes work, for which participants and to refine the final programme theory.

Results

A total of 83 articles met the inclusion criteria. 8 CMOcs elucidating the contexts of the health-related interventions, underlying mechanisms and outcomes were identified. Interventions that were tailored to the target population using multiple strategies, addressing different aspects of individual and external environments led to positive outcomes for reemployment and reduction of obesity.

Conclusion

This realist synthesis presents a broad array of contexts, mechanisms underlying the success of health-related interventions to reduce obesity and unemployment. It provides novel insights and key factors that influence the success of such interventions and highlights a need for participatory and holistic approaches to maximise the effectiveness of programmes designed to reduce obesity and unemployment.

Trial registration

PROSPERO 2020 CRD42020219897.

The Validated Features of Psychological Interventions for Weight Loss: An Integration

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.

“Dietitians May Only Have One Chance”—The Realities of Treating Obesity in Private Practice in Australia

Introduction: Overweight and obesity are the leading contributors to non-fatal burden of disease in Australia. Very low energy diets (VLEDs) comprising of meal replacement products (MRP) effectively induce substantial weight loss in people with obesity, yet they are rarely used as a first line treatment. Dietitians in private practice are perfectly placed to administer treatments for obesity; however, little is known about the preferred interventions used or their attitudes to incorporating VLEDs and MRPs into their treatments for overweight and obesity. Methods: This study used descriptive qualitative methods to explore accredited practicing dietitians’ (APDs’) perspectives and practices regarding obesity and obesity interventions, including the use of VLEDs and MRPs. Qualitative in-depth semi-structured interviews were conducted with 20 dietitians who had experience in private practice and in treating obesity. Transcribed interviews were analysed thematically using the technique of template analysis. Results: In the context within which dietitians’ practice was found to be a barrier to using evidence-based practice (EBP) for obesity treatment, four overarching themes were found. These were: (1) patient-centred care is the dietitians’ preferred intervention model; (2) VLEDs promote weight loss in specific situations; (3) systemic barriers constrain effective dietetic practice and equitable access to all, and (4) successful outcomes are predicated on working outside of systemic barriers. Conclusion: Dietitians in private practice are well placed and able to provide life-enhancing and evidence-based treatments for overweight and obesity and associated chronic disease in the community. However, systemic barriers need to be addressed to provide equitable access to effective care irrespective of socio-economic status.

The impact of adult behavioural weight management interventions on mental health: A systematic review and meta-analysis

There is good evidence that behavioural weight management interventions improve physical health; however, the impact on mental health remains unclear. We evaluated the impact of behavioural weight management interventions on mental health-related outcomes in adults with overweight or obesity at intervention-end and 12 months from baseline. Eligible studies were randomized controlled trials (RCTs) or cluster RCTs of adult behavioural weight loss interventions reporting affect, anxiety, binge eating, body image, depression, emotional eating, quality of life, self-esteem and stress. We searched seven databases from inception to 7 May 2019 and included 43 articles reporting 42 RCTs. Eighteen studies were deemed to be at high risk of bias. We conducted random-effects meta-analyses, stratified analyses and meta-regression using Stata. Interventions generated greater improvements than comparators for depression, mental health-related quality of life and self-efficacy at intervention-end and 12 months from baseline. There was no difference between groups for anxiety, overall quality of life, self-esteem or stress at intervention-end. There was insufficient evidence to assess the impact on anxiety, binge eating, body image, emotional eating, affect, life satisfaction, self-esteem or stress at intervention-end and/or 12 months from baseline. Although evidence suggests that interventions benefit some aspects of mental health, high-quality, transparently reported RCTs measuring a range of mental health outcomes over longer durations are required to strengthen the evidence base.

Evaluation of a health-related intervention to reduce overweight, obesity and increase employment in France and the United Kingdom: a mixed-methods realist evaluation protocol

Background

Obesity, overweight and unemployment are interlinked, with debilitating effects on mortality, health, wellbeing and quality of life. Existing interventions to reduce overweight, obesity and unemployment have addressed these challenges independent of each other with limited success. The Adding to Social capital and individual Potential In disadvantaged REgions (ASPIRE) project will develop an innovative model using a combination of skills training and health and wellbeing interventions to improve health, wellbeing, quality of life and reduce overweight, obesity and unemployment in England and France. The aim of this paper is to outline the protocol for evaluating the ASPIRE project to examine the effectiveness of the intervention and clarify the mechanisms and contextual factors which interact to achieve outcomes.

Methods

A mixed-method realist evaluation using a single-group before-and-after design will be used. The evaluation will consist of development of an initial programme theory, theory validation and refinement using quantitative and qualitative data to understand the causal mechanisms, contexts of implementation and their interactions that result in outcomes observed in ASPIRE. Primary outcomes that will be assessed are change in body weight and body mass index, reemployment and a rise on the ASPIRE participation ladder. The ASPIRE participation ladders consists of a series of 5 steps to engage participants in the project. The first step on the ladder is joining an ASPIRE hub with paid employment as the final step on the ladder. Secondary outcomes will be physical activity, diet quality, self-efficacy and health-related quality of life. Both quantitative and qualitative approaches are appropriate in this study because the use of validated questionnaires and objective measures will demonstrate how much the intervention addressed outcomes related to weight loss and reemployment and the qualitative data (photovoice) will provide insights into the contexts and experiences that are unique to participants in the project.

Discussion

The results from this evaluation will provide an understanding of how a model of health-related interventions which improve health, wellbeing and maintenance of a healthy lifestyle could reduce overweight, obesity and unemployment. The findings will enable the adaptation of this model for effective implementation in different contexts and circumstances.

Trial registration

ISRCTN registry: Study ID: ISRCTN17609001, 24th February 2021 (Retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10523-3.

Group versus one-to-one multi-component lifestyle interventions for weight management: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Multi-component lifestyle interventions that incorporate diet, physical activity and behaviour change are effective for weight management. However, it is not clear whether delivery in a group or one-to-one format influences weight loss efficacy. The present study aimed to systematically review the evidence of the effectiveness of group compared to one-to-one multi-component lifestyle interventions for weight management.

METHODS

MEDLINE, EMBASE, CINAHL, CENTRAL and ISRCTN databases were searched from inception up to February 2020 for randomised controlled trials comparing group versus one-to-one multi-component lifestyle interventions for weight loss in adults with a body mass index ≥ 25 kg m^-2 . The primary outcome was weight loss (kg) at 12 months and the secondary outcome was attainment of ≥5% weight loss at 12 months. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Meta-analysis used random effects and estimated risk ratios and continuous inverse variance methods. Heterogeneity was investigated using I² statistics and sensitivity analyses.

RESULTS

Seven randomised controlled trials with 2576 participants were included. Group interventions were favoured over one-to-one interventions for weight loss at 12 months (-1.9 kg, 95% confidence interval = -1.3 to -2.6; I²  = 99%). Participants of group interventions were more likely to attain ≥5% weight loss at 12 months relative to one-to-one interventions (relative risk = 1.58, 95% confidence interval = 1.25-2.00; I²  = 60%).

CONCLUSIONS

Group multi-component lifestyle interventions are superior for weight loss compared to one-to-one interventions with respect to adult weight management. Further research is required to determine whether specific components of group interventions can explain the superiority of weight loss outcomes in group interventions.

Group-based intervention in a primary healthcare setting was more effective for weight loss than usual care

BACKGROUND

Literature and practice recommendations for lifestyle interventions to treat the increasing number of obese patients with non-communicable diseases (NCDs) or risk factors for NCDs attending resource-constrained public healthcare facilities in South Africa are scarce.

AIM

To compare the impact of a facility-based therapeutic group (FBTG) intervention with usual care on weight in obese participants, with NCDs or risk factors for NCDs.

SETTING

Public healthcare facility providing primary healthcare services in Cape Town, South Africa.

METHODS

A quasi-experimental study design was used where participants chose to receive weight loss treatment with either the FBTG or usual care interventions. Both interventions involved a one-on-one medical and dietetic consultation, while FBTG participants had six additional group sessions. Follow-up assessments took place 6 months after baseline. Socio-demographic variables, blood pressure, smoking status, weight, height, waist circumference, dietary intake, physical activity and stage of change were measured.

RESULTS

Of the 193 obese adults enrolled, 96 selected the FBTG and 97 selected usual care. There were no significant differences at baseline between the two groups. Weight loss over 6 months was greater (p < 0.001) in FBTG (median [IQR] of -2.9 [-5.1; -0.3] kg) than usual care (-0.9 [-0.9; 0.6] kg) participants. At 6 months, more FBTG completers reached the weekly target of 150 min (p = 0.009), while both groups showed improvements in dietary intake. More FBTG (74%) than usual care (49%) participants were in the action stage of change by 6 months (p = 0.010).

CONCLUSIONS

The group-based intervention was more effective than usual care in weight reduction as well as improvements in physical activity and stage of change.

Effects of cognitive behavioral therapy on weight maintenance after successful weight loss in women; a randomized clinical trial

BACKGROUND/OBJECTIVES

Weight regain after weight loss is a main challenge in obesity management. Cognitive behavioral therapy (CBT) has been introduced as an option for achieving weight loss but not tested for weight maintenance. The aim of this study was to evaluate the effects of CBT on weight maintenance after successful weight loss.

SUBJECTS/METHODS

Female adults [n = 113, BMI = 23-30 kg/m²; age = 18-45 years], who had lost at least 10% of their body weight by using a weight loss program, were randomly allocated to either CBT or control group for a further 24-week weight-maintenance period.

RESULTS

Compared with control group, CBT treatment improved weight loss maintenance (mean difference, -2.2 kg [95% CI, -3.50, -0.94]; P = 0.001), BMI (mean difference, -0.77 kg/m²; [95% CI, -1.25, -0.28]; P = 0.002), and waist circumference (mean difference, -2.08 cm; [95% CI, -3.31, -0.844]; P = 0.001) at the end of the 24-week period intervention. Estimated energy intake showed a significant reduction over time in CBT group, while it increased in control group (P < 0.001). There was also a significant group × time interaction for mean daily steps over the 24-week period with CBT having a higher level (P < 0.001). However, changes in lipid profiles and carbohydrate metabolism were not significantly different between the groups.

CONCLUSION

Cognitive behavioral therapy is an effective tool for weight maintenance over a 24-week period in successful weight losers, with corresponding maintenance of a reduced energy intake and doing more physical activity which may helpful for weight maintenance in the long term.

Health, not weight loss, focused programmes versus conventional weight loss programmes for cardiovascular risk factors: a systematic review and meta-analysis

BACKGROUND

Obesity is a cardiovascular disease risk factor. Conventional weight loss (CWL) programmes focus on weight loss, however 'health, not weight loss, focused' (HNWL) programmes concentrate on improved health and well-being, irrespective of weight loss. What are the differences in CVD risk outcomes between these programmes?

AIM

To conduct a systematic review and meta-analysis to compare the effects of HNWL with CWL programmes on cardiovascular disease risk factors.

METHODS

We searched CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, ASSIA, clinical trial registers, commercial websites and reference lists for randomised controlled trials comparing the two programmes (initially searched up to August 2015 and searched updated to 5 April 2019). We used the Mantel-Haneszel fixed-effect model to pool results. Sub-group and sensitivity analyses that accounted for variations in length of follow-up, enhanced programmes and risk of bias dealt with heterogeneity.

RESULTS

Eight randomised controlled trials of 20,242 potential studies were included. Improvements in total cholesterol-HDL ratio (mean difference - 0.21 mmol/L, 95% confidence interval [- 3.91, 3.50]) and weight loss (- 0.28 kg [- 2.00, 1.44]) favoured HNWL compared to CWL programmes in the long term (53-104 week follow-up), whereas improvements in systolic (- 1.14 mmHg, [- 5.84, 3.56]) and diastolic (- 0.15 mmHg, [- 3.64, 3.34]) blood pressure favoured CWL programmes. These differences did not reach statistical significance. Statistically significant improvements in body satisfaction (- 4.30 [- 8.32, - 0.28]) and restrained eating behaviour (- 4.30 [- 6.77, - 1.83]) favoured HNWL over CWL programmes.

CONCLUSIONS

We found no long-term significant differences in improved CVD risk factors; however, body satisfaction and restrained eating behaviour improved more with HNWL compared to CWL programmes. Yet firm conclusions cannot be drawn from small studies with high losses to follow-up and data sometimes arising from a single small study.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015019505.

A Scoping Review of Positive Lifestyle and Wellness Interventions to Inform the Development of a Comprehensive Health Promotion Program: "HealthPro"

Background. Lifestyle medicine has emerged as a transformational force in mainstream health care. Numerous health promotion and wellness programs have been created to facilitate the adoption of increased positive, modifiable health behaviors to prevent and lessen the effects of chronic disease. This article provides a scoping review of available health promotion interventions that focus on healthy adult populations in the past 10 years. Methods. We conducted a scoping review of the literature searching for health promotion interventions in the past 10 years. Interventions were limited to those conducted among healthy adults that offered a face-to-face, group-based format, with positive results on one or more health outcomes. We then developed a new health promotion intervention that draws on multiple components of included interventions. Results. Fifty-eight articles met our inclusion criteria. Physical activity was the primary focus of a majority (N = 47) of articles, followed by diet/nutrition (N = 40) and coping/social support (N = 40). Conclusions. Efficacious health promotion interventions are critical to address the prevention of chronic disease by addressing modifiable risk factors such as exercise, nutrition, stress, and coping. A new intervention, discussed is this article, provides a comprehensive approaches to health behavior change and may be adapted for future research.

Effectiveness and Feasibility of a Remote Lifestyle Intervention by Dietitians for Overweight and Obese Adults: Pilot Study

Background

To tackle the problem of obesity and related diseases in Switzerland, cost-efficient, effective, and innovative primary health care interventions for weight management are required. In this context, Oviva has developed a scalable technology for registered dietitians to counsel overweight and obese patients via a mobile phone app.

Objective

The aim of this study was to evaluate the effectiveness and feasibility of weight loss counseling by dietitians using a mobile phone app for patients with overweight and obesity.

Methods

In this pre- and posttest pilot study, overweight and obese adults participated in a 1-year behavioral intervention to lose weight through remote counseling by dietitians in the German-speaking part of Switzerland. The study started in April 2016 and finished in May 2018. Participants received individual counseling through the app and the exchange with the dietitian focused on regular feedback on photo-based food log, motivation, and education. The contents were tailored to the individual lifestyle goal set. The predefined intensity of remote counseling decreased during the year. Group chat could be used. The outcomes examined were changes in weight (primary outcome), hemoglobin A_1c, fasting glucose, fasting insulin, triglyceride, high-density lipoprotein cholesterol, blood pressure (BP), body mass index (BMI), waist circumference, body fat, and responses to a self-administered questionnaire with questions regarding participants’ physical activity, dietary assessment, and health-related quality of life. Changes were tested at baseline, after 3 months, and after 12 months, as well as between the third and the 12th month.

Results

In total, 36 women and 7 men, with a mean age of 40.6 years, participated and 36 participants completed the study. Median weight change after the first 12 weeks was −3.8 kg (range: −15 to 2.4 and P<.001), between week 12 and week 52 it was −1.1 kg (range: −9.7 to 7 and P=.08), and the median change during the entire period of intervention was −4.9 kg (range: −21.9 to 7.5 and P<.001). Furthermore, changes in BMI, waist circumference, body fat, and BP between baseline and 12 weeks and between baseline and 52 weeks were also significant. Significant changes in certain eating habits were also demonstrated (higher frequency of vegetable, fruit, and breakfast consumption and lower frequency of alcohol, sweet, and fat consumption).

Conclusions

In addition to the professional skills of a dietitian, a profession-specific app such as Oviva can provide effective support that meets the needs of dietitians and clients on the long path of behavioral change and sustainable weight reduction.

Trial Registration

ClinicalTrials.gov NCT02694614; https://clinicaltrials.gov/ct2/show/NCT02694614 (Archived by WebCite at http://www.webcitation.org/76gYkGOIc)

How Effective Are Dietitians in Weight Management? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Effective, evidence-based strategies to prevent and treat obesity are urgently required. Dietitians have provided individualized weight management counselling for decades, yet evidence of the effectiveness of this intervention has never been synthesized. The aim of this study was to examine the effectiveness of individualized nutrition care for weight management provided by dietitians to adults in comparison to minimal or no intervention. Databases (Cochrane, CINAHL plus, MedLine ovid, ProQuest family health, PubMed, Scopus) were searched for terms analogous with patient, dietetics and consultation with no date restrictions. The search yielded 5796 unique articles, with 14 randomized controlled trials meeting inclusion criteria. The risk of bias for the included studies ranged from unclear to high. Six studies found a significant intervention effect for the dietitian consultation, and a further four found significant positive change for both the intervention and control groups. Data were synthesized through random effects meta-analysis from five studies (n = 1598) with weight loss as the outcome, and from four studies (n = 1224) with Body Mass Index (BMI) decrease as the outcome. Groups receiving the dietitian intervention lost an additional 1.03 kg (95% CI:−1.40; −0.66, p < 0.0001) of weight and 0.43 kg/m² (95% CI:−0.59, −0.26; p < 0.0001) of BMI than those receiving usual care. Heterogeneity was low for both weight loss and BMI, with the pooled means varying from 1.26 to −0.93 kg and −0.4 kg/m² for weight and BMI, respectively, with the removal of single studies. This study is the first to synthesize evidence on the effectiveness of individualized nutrition care delivered by a dietitian. Well-controlled studies that include cost-effectiveness measures are needed to strengthen the evidence base.

Feasibility, effectiveness and cost-effectiveness of a telephone-based weight loss program delivered via a hospital outpatient setting

Engaging patients in a group-based weight loss program is a challenge for the acute-care hospital outpatient setting. To evaluate the feasibility, effectiveness and cost-effectiveness of a telephone-based weight loss service and an existing face-to-face, group-based service a non-randomised, two-arm feasibility trial was used. Patients who declined a two-month existing outpatient group-based program were offered a six-month research-based telephone program. Outcomes were assessed at baseline, two months (both groups) and six months (telephone program only) using paired t tests and linear regression models. Cost per healthy life year gained was calculated for both programs. The telephone program achieved significant weight loss (-4.1 ± 5.0 %; p = 0.001) for completers (n = 35; 57 % of enrolees) at six months. Compared to the group-based program (n = 33 completers; 66 %), the telephone program was associated with greater weight loss (mean difference [95%CI] -2.0 % [-3.4, -0.6]; p = 0.007) at two months. The cost per healthy life year gained was $33,000 and $85,000, for the telephone and group program, respectively. Telephone-delivered weight management services may be effective and cost-effective within an acute-care hospital setting, likely more so than usual (group-based) care.

Effectiveness of Dietetic Consultations in Primary Health Care: A Systematic Review of Randomized Controlled Trials

BACKGROUND

A dietetic consultation is a structured process aimed at supporting individual patients to modify their dietary behaviors to improve health outcomes. The body of evidence on the effectiveness of nutrition care provided by dietitians in primary health care settings has not previously been synthesized. This information is important to inform the role of dietitians in primary health care service delivery.

OBJECTIVE

The aim of this systematic review was to evaluate the evidence of the effectiveness of individual consultations provided exclusively by dietitians in primary care to support adult patients to modify dietary intake and improve health outcomes.

STUDY DESIGN

ProQuest Family Health, Scopus, PubMed Central, Medline, the Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for English language systematic reviews or randomized controlled trials published before October 2016. The key terms used identified the provision of nutrition care exclusively by a dietitian in a primary health care setting aimed at supporting adult patients to modify dietary behaviors and/or improve biomarkers of health. Interventions delivered to patients aged younger than 18 years, in hospital, via telephone only, in a group or lecture setting, or by a multidisciplinary team were excluded. The methodologic quality of each study was appraised using the Cochrane Risk of Bias tool and the body of evidence was assessed using the Academy of Nutrition and Dietetics Evidence Analysis Manual.

MAIN OUTCOME MEASURES

Outcomes included the effectiveness of dietetic interventions in terms of anthropometry, clinical indicators, and dietary intake. A statistically significant between-group difference was used to indicate intervention effectiveness (P<0.05).

RESULTS

Twenty-six randomized controlled studies met eligibility criteria, representing 5,500 adults receiving dietetic consultations in a primary care setting. Eighteen of 26 included studies showed statistically significant differences in dietary, anthropometric, or clinical indicators between intervention and comparator groups. When focusing specifically on each study's stated aim, significant improvements favoring the intervention compared with control were found for the following management areas: glycemic control (four out of four studies), dietary change (four out of four studies), anthropometry (four out of seven studies), cholesterol (two out of eight studies), triglycerides (one out of five), and blood pressure (zero out of three) studies.

CONCLUSIONS

Dietetic consultations for adults in primary care settings appear to be effective for improvement in diet quality, diabetes outcomes (including blood glucose and glycated haemoglobin values), and weight loss outcomes (eg, changes in weight and waist circumference) and to limit gestational weight gain (Grade II: Fair evidence). Research evaluated in this review does not provide consistent support for the effectiveness of direct dietetic counseling alone in achieving outcomes relating to plasma lipid levels and blood pressure (Grade III: Limited evidence). Therefore, to more effectively control these cardiovascular disease risk factors, future research might explore novel nutrition counseling approaches as well as dietitians functioning as part of multidisciplinary teams.

Non-communicable disease risk factors and treatment preference of obese patients in Cape Town

BACKGROUND

Insights into the characteristics of treatment seekers for lifestyle changes and treatment preferences are necessary for intervention planning.

AIM

To compile a profile of treatment-seeking obese patients with non-communicable diseases (NCDs) or NCD risk factors and to compare patients who choose group-based (facility-based therapeutic group [FBTG]) versus usual care (individual consultations) treatment.

SETTING

A primary healthcare facility in Cape Town, South Africa.

METHODS

One hundred and ninety-three patients were recruited in this cross-sectional study. Ninety six chose FBTG while 97 chose usual care. A questionnaire, the hospital database and patients' folders were used to collect data. Weight, height and waist circumference were measured. STATA 11.0 was used for descriptive statistics and to compare the two groups.

RESULTS

The subjects' mean age was 50.4 years, 78% were women and of low education levels and income, and 41.5% had type 2 diabetes, 83.4% hypertension and 69.5% high cholesterol. Mean (s.d.) HbA1c was 9.1 (2.0)%, systolic BP 145.6 (21.0) mmHg, diastolic BP 84.5 (12.0) mmHg, cholesterol 5.4 (1.2) mmol/L), body mass indicator (BMI) 39.3 (7.3) kg/m2 and waist circumference 117 (12.6) cm). These figures were undesirable although pharmacological treatment for diabetes and hypertension was in place. Only 14% were physically active, while TV viewing was > 2h/day. Mean daily intake of fruit and vegetables (2.2 portions/day) was low while added sugar (5 teaspoons) and sugar-sweetened beverages (1.3 glasses) were high. Usual care patients had a higher smoking prevalence, HbA1c, number of NCD risk factors and refined carbohydrate intake, and a lower fruit and vegetable intake.

CONCLUSION

Treatment seekers were typically middle-aged, low income women with various modifiable and intermediate risk factors for NCDs. Patients choosing usual care could have more NCD risks.

Telephone-delivered weight management services in the hospital outpatient setting: Decision-makers' perceptions of their use in routine practice

AIM

Providing effective weight management services to the growing number of overweight or obese hospital patients necessitates long-term service provision; however, it is arguably not within the acute-care hospital remit to provide such extended services. Referral to community-based programs is required to provide continuing weight management services. The Get Healthy Service is a free six-month, telephone-delivered lifestyle program, now offered in several states of Australia with potential for wide population reach. However, health practitioner referral into the service has been low. The study aimed to examine awareness and suitability of the Get Healthy Service for referral of hospital outpatients for weight management, among key health-care decision-makers.

METHODS

Nine key decision-makers from metropolitan and rural Queensland Health hospitals took part in semi-structured telephone interviews that were audio-recorded (January-July 2014), transcribed verbatim and thematically analysed.

RESULTS

Interviews revealed that most decision-makers had limited awareness of the Get Healthy Service but perceived the telephone service to be suitable for patient referrals. Incorporating Get Healthy Service referrals into patient care was seen to be potentially valuable and relatively easy to implement, with most interviewees suggesting that they would provide a Get Healthy Service brochure to patients who could then self-refer into the service.

CONCLUSIONS

The Get Healthy Service provides a referral model for weight management service provision that appears feasible for use in Queensland hospital settings. Increased awareness and a more integrated approach to referrals would likely result in improved enrolment to the service, with future research needed to demonstrate this.

Changes in the degree of patient expectations for patient-centered care in a primary care setting

BACKGROUND

To date, the medical environment has been undergoing continual changes. It is therefore imperative that clinicians recognize the changing trends in the degree of patient expectations for patient-centered care. We conducted this study to examine changes in the degree of patient expectations for patient-centered care and the related socio-demographic factors in a primary care setting over a 5-year period.

METHODS

We evaluated patients' attitudes toward patient-centered care using the Patient-Practitioner Orientation Scale, which provides 'sharing' and 'caring' scores. The study included 359 and 468 patients in phase I (March-July, 2005) and II (March-July, 2010). We also examined the relationship of their changes to their socio-demographic factors.

RESULTS

In phase II, as compared with phase I, the 'sharing' score was higher (3.67 ± 0.68 vs. 3.82 ± 0.44; P < 0.001) and 'caring' one was lower (4.01 ± 0.57 vs. 3.67 ± 0.58; P = 0.001). Further, 'sharing' and 'caring' scores were associated with age, monthly income, education level, marital status, and the functional health status of patients.

CONCLUSION

These results would be of help for providing patient-centered care for patients because it makes clinicians are aware of the degree to which patients' expect it.

Physical activity and quality of life in severely obese adults during a two-year lifestyle intervention programme

It is unknown how changes in physical activity may affect changes in quality of life (QoL) outcomes during lifestyle interventions for severely obese adults. The purpose of this study was to examine associations in the patterns of change between objectively assessed physical activity as the independent variable and physical, mental, and obesity-specific QoL and life satisfaction as the dependent variables during a two-year lifestyle intervention. Forty-nine severely obese adults (37 women; 43.6 ± 9.4 years; body mass index 42.1 ± 6.0 kg/m(2)) participated in the study. Assessments were conducted four times using Medical Outcomes Study Short-Form 36 Health Survey (SF-36), Obesity-Related Problems (OP) scale, a single item on life satisfaction, and accelerometers. The physical component summary (PCS) score and the mental component summary (MCS) score were used as SF-36 outcomes. Associations were determined using linear regression analyses and reported as standardized coefficients (stand. coeff.). Change in physical activity was independently associated with change in PCS (stand. coeff. = 0.35, P = .033), MCS (stand. coeff. = 0.51, P = .001), OP (stand. coeff. = -0.31,  P = .018), and life satisfaction (stand. coeff. = 0.39, P = .004) after adjustment for gender, age, and change in body mass index.

Patient experiences of a theory-based lifestyle-focused group treatment in the prevention of cardiovascular diseases and type 2 diabetes

Background

Cardiovascular disease and type 2 diabetes are two of the most common public health diseases, and up to 80 % of the cases may be prevented by lifestyle modification. The physiological effects of lifestyle-focused treatment are relatively well studied, but how patients actually experience such treatments is still rather unclear.

Purpose

The aim of this study was to explore how patients experience lifestyle-focused group treatment in primary and secondary prevention of cardiovascular disease and type 2 diabetes.

Method

Qualitative interviews were conducted with 19 patients attending lifestyle-focused group treatment based on social cognitive theory at a behavioral medicine clinic in northern Sweden. The interviews were transcribed verbatim and analyzed according to Malterud’s systematic text condensation.

Results

The study shows that patients participating in this kind of group-based lifestyle treatment went through a process of self-development which deepened their understanding of own responsibility for health and improved their skills in finding support in others. The process could be tracked through three different themes (the holistic view, personal responsibility, and group treatment) which together reflected the most essential parts of the informants’ experience and showed the patient as an active decision maker struggling to adopt the principles of behavioral change.

Conclusion

Lifestyle-focused group treatment, based on social cognitive theory, was shown to stimulate different components that strengthen patients’ self-efficacy for long-term behavioral change.

The muscle mass, omega-3, diet, exercise and lifestyle (MODEL) study - a randomised controlled trial for women who have completed breast cancer treatment

Background

Loss of lean body mass (LBM) is a common occurrence after treatment for breast cancer and is related to deleterious metabolic health outcomes [Clin Oncol, 22(4):281–288, 2010; Appl Physiol Nutr Metab, 34(5):950–956, 2009]. The aim of this research is to determine the effectiveness of long chain omega-3 fatty acids (LCn-3s) and exercise training alone, or in combination, in addressing LBM loss in breast cancer survivors.

Methods/design

A total of 153 women who have completed treatment for breast cancer in the last 12 months, with a Body Mass Index (BMI) of 20 to 35 kg/m², will be randomly assigned to one of 3 groups: 3g/d LCn-3s (N-3), a 12-week nutrition and exercise education program plus olive oil (P-LC) or the education program plus LCn-3s (EX+N-3). Participants randomised to the education groups will be blinded to treatment, and will receive either olive oil placebo (OO+N-3) or LCn-3 provision, while the N-3 group will be open label. The education program includes nine 60-75min sessions over 12 weeks that will involve breast cancer specific healthy eating advice, plus a supervised exercise session run as a resistance exercise circuit. They will also be advised to conduct the resistance training and aerobic training 5 to 7 days per week collectively. Outcome measures will be taken at baseline, 12-weeks and 24-weeks. The primary outcome is % change in LBM as measured by the air displacement plethysmograhy. Secondary outcomes include quality of life (FACT-B + 4) and inflammation (C-Reactive protein: CRP). Additional measures taken will be erythrocyte fatty acid analysis, fatigue, physical activity, menopausal symptoms, dietary intake, joint pain and function indices.

Discussion

This research will provide the first insight into the efficacy of LCn-3s alone or in combination with exercise in breast cancer survivors with regards to LBM and quality of life. In addition, this study is designed to improve evidence-based dietetic practice, and how specific dietary prescription may link with appropriate exercise interventions.

Trials registration

ACTRN12610001005044; and World Health Organisation Universal trial number: U1111-1116-8520.

The effect of weight loss on health-related quality of life: systematic review and meta-analysis of randomized trials

The aim of this study was to examine the effect of weight loss on health-related quality of life (HRQL) in randomized controlled intervention trials (RCTs). MEDLINE, HealthStar and PsycINFO were searched. RCTs of any weight loss intervention and 20 HRQL instruments were examined. Contingency tables were constructed to examine the association between statistically significant weight loss and statistically significant HRQL improvement within five HRQL categories. In addition, Short Form-36 (SF-36) outcomes were pooled using random-effects models. Fifty-three trials were included. Seventeen studies reported statistically significant weight loss and HRQL improvement. No statistically significant associations between weight loss and HRQL improvement were found in any contingency table. Because of suboptimal endpoint reporting, quantitative data pooling could only be performed using 25% of SF-36 trials in any one model. Significant improvements in physical health were found: mean difference 2.83 points, 95% CI 0.55-5.1, for the physical component score, and mean difference 6.81 points, 95% CI 2.99-10.63, for the physical functioning domain score. Conversely, no significant improvements in mental health were found. No significant association was found between weight loss and overall HRQL improvement. Weight loss may be associated with modest improvements in physical, but not mental, health.

Benefits of repeated individual dietary counselling in long-term weight control in women after delivery

As pregnancy may trigger overweight in women, new means for its prevention are being sought. The aim here was to investigate the effect of individual dietary counselling during and after pregnancy on post-partum weight and waist circumference up to 4 years post-partum. A cohort of women (n = 256) were randomized to receive repeated individual dietary counselling by a nutritionist during and after pregnancy, or as controls not receiving dietary counselling, from the first trimester of pregnancy until 6 months after delivery. Counselling aimed to bring dietary intake into line with recommendations, with particular focus on the increase in the intake of unsaturated fatty acids instead of saturated. Pre-pregnancy weight was taken from welfare clinic records. Weight and waist circumference were measured at 4 years after delivery. The proportion of overweight women increased from 26% prior to pregnancy to 30% at 4 years after delivery among women receiving dietary counselling, as against considerably more, from 32% to 57%, among controls. The prevalence of central adiposity was 31% in women receiving dietary counselling, 64% in controls. Likewise, both the risk of overweight (odds ratio: 0.23, 0.08-0.63, P = 0.005) and central adiposity (odds ratio: 0.18, 0.06-0.52, P = 0.002) were lower in women receiving dietary counselling compared with controls. Repeated dietary counselling initiated in early pregnancy can be beneficial in long-term weight control after delivery.

A randomized, double-blind, placebo-controlled trial of the effect of dried purple carrot on body mass, lipids, blood pressure, body composition, and inflammatory markers in overweight and obese adults: The QUENCH Trial

Obesity is a significant health issue worldwide and is associated with chronic, low-grade inflammation predisposing the individual to cardiovascular disease and impaired blood glucose homeostasis. Anthocyanins and phenolic acids from purple carrots are effective at reversing inflammation and metabolic alterations in animal models, potentially through inhibition of inflammatory pathways. The effects of dried purple carrot on body mass, body composition, blood pressure, lipids, inflammatory markers, liver function tests, and appetite were investigated in 16 males (aged 53.1 ± 7.6 years and with a mean BMI of 32.8 ± 4.6 kg/m2) with normal lipid and inflammatory markers. There was no evidence that 118.5 mg/day of anthocyanins and 259.2 mg/day of phenolic acids for 4 weeks resulted in statistically significant changes in body mass, body composition, appetite, dietary intake, low density lipoprotein, total cholesterol, blood pressure, or C-reactive protein in these obese participants at the dose and length of intervention used in this trial. High density lipoprotein cholesterol was lower in the intervention group (p < 0.05). Aspartate amino transferase and alanine amino transferase did not change, indicating that the intervention was safe. More studies are required to establish the bioavailability and pharmacokinetic effects of purple carrot anthocyanins and phenolic acids prior to further trials of efficacy with respect to treating inflammation and metabolic alterations.

Weight change in control group participants in behavioural weight loss interventions: a systematic review and meta-regression study

Background

Unanticipated control group improvements have been observed in intervention trials targeting various health behaviours. This phenomenon has not been studied in the context of behavioural weight loss intervention trials. The purpose of this study is to conduct a systematic review and meta-regression of behavioural weight loss interventions to quantify control group weight change, and relate the size of this effect to specific trial and sample characteristics.

Methods

Database searches identified reports of intervention trials meeting the inclusion criteria. Data on control group weight change and possible explanatory factors were abstracted and analysed descriptively and quantitatively.

Results

85 trials were reviewed and 72 were included in the meta-regression. While there was no change in control group weight, control groups receiving usual care lost 1 kg more than control groups that received no intervention, beyond measurement.

Conclusions

There are several possible explanations why control group changes occur in intervention trials targeting other behaviours, but not for weight loss. Control group participation may prevent weight gain, although more research is needed to confirm this hypothesis.

Effects of lifestyle intervention in persons at risk for type 2 diabetes mellitus - results from a randomised, controlled trial

BACKGROUND

Lifestyle change is probably the most important single action to prevent type 2 diabetes mellitus. The purpose of this study was to assess the effects of a low-intensity individual lifestyle intervention by a physician and compare this to the same physician intervention combined with an interdisciplinary, group-based approach in a real-life setting.

METHODS

The "Finnish Diabetes Risk score" (FINDRISC) was used by GPs to identify individuals at high risk. A randomised, controlled design and an 18 month follow-up was used to assess the effect of individual lifestyle counselling by a physician (individual physician group, (IG)) every six months, with emphasis on diet and exercise, and compare this to the same individual lifestyle counselling combined with a group-based interdisciplinary program (individual and interdisciplinary group, (IIG)) provided over 16 weeks. Primary outcomes were changes in lifestyle indicated by weight reduction ≥ 5%, improvement in exercise capacity as assessed by VO2 max and diet improvements according to the Smart Diet Score (SDS).

RESULTS

213 participants (104 in the IG and 109 in the IIG group, 50% women), with a mean age of 46 and mean body mass index 37, were included (inclusion rate > 91%) of whom 182 returned at follow-up (drop-out rate 15%). There were no significant differences in changes in lifestyle behaviours between the two groups. At baseline 57% (IG) and 53% (IIG) of participants had poor aerobic capacity and after intervention 35% and 33%, respectively, improved their aerobic capacity at least one metabolic equivalent. Unhealthy diets according to SDS were common in both groups at baseline, 61% (IG) and 60% (IIG), but uncommon at follow-up, 17% and 10%, respectively. At least 5% weight loss was achieved by 35% (IG) and 28% (IIG). In the combined IG and IIG group, at least one primary outcome was achieved by 93% while all primary outcomes were achieved by 6%. Most successful was the 78% reduction in the proportion of participants with unhealthy diet (almost 50% absolute reduction).

CONCLUSION

It is possible to achieve important lifestyle changes in persons at risk for type 2 diabetes with modest clinical efforts. Group intervention yields no additional effects. The design of the study, with high inclusion and low dropout rates, should make the results applicable to ordinary clinical settings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00202748.

The effect of theory-based interventions on physical activity participation among overweight/obese individuals: a systematic review

Little attention has been paid to the evaluation of the long-term impact of theory-based interventions on physical activity participation among overweight/obese individuals after the interventions have ended. The primary aim of this systematic review was to investigate the long-term effectiveness of theory-based interventions increasing physical activity and identify the most effective techniques for behaviour change among overweight/obese individuals. The secondary aim was to investigate the effect of these interventions on theoretical variables. Eighteen studies were reviewed. Among these studies, three reported significant short-term and two long-term effects of interventions on physical activity participation. Most of the studies observed a significant short- or long-term effect of time on this behaviour. Theoretical frameworks most often applied included the Behavioural Model and the Social Learning/Cognitive Theory. However, few of the studies reported any impact on theoretical variables. The most prevalent techniques consisted of providing opportunities for social comparison and instruction as well as self-monitoring. Leading techniques differentiating the experimental group from the control group included prompting practice and intentions formation and barriers identification. Although the combination of these three techniques appears successful, the long-term impact of theory-based interventions remains ambiguous.

Using a technology-based intervention to promote weight loss in sedentary overweight or obese adults: a randomized controlled trial study design

PURPOSE

The SenseWear™ Armband is an activity monitor developed to improve lifestyle self-monitoring. Currently, few studies assess electronic self-monitoring and weight loss with a lifestyle intervention program. To our knowledge, only one study has used the SenseWear Armband in combination with a lifestyle intervention to improve weight loss, and no studies have evaluated whether a self-monitoring intervention based solely on the armband can promote weight loss. Consequently, the aims of the study were to assess weight loss from electronic self-monitoring, to compare these values to the lifestyle intervention and standard care groups, and to compare weight loss with lifestyle intervention with and without the armband.

PATIENTS AND METHODS

We recruited 197 sedentary overweight or obese adults (age, 46.8 ± 10.8 years; BMI, 33.3 ± 5.2 kg/m(2)) to participate in the 9-month study. Participants were randomized into one of four weight loss groups: 1) the standard care group received a self-directed weight loss program, complete with an evidence-based weight loss manual (standard care, n = 50); 2) a 14-week group-based behavioral weight loss program followed by weekly, biweekly, and monthly telephone counseling calls (GWL, n = 49); 3) the use of the armband to help improve lifestyle self-monitoring (SWA alone, n = 49); or (4) the group-based behavioral weight loss program and follow-up telephone counseling calls plus the armband (GWL + SWA, n = 49). All participants received the evidence-based weight loss manual at baseline. All measures were performed at baseline and months 4 and 9. The primary outcomes were weight loss and waist circumference reduction.

RESULTS

This study is a well-designed randomized controlled study powered to detect a 0.5-kg weight loss and 0.6-cm waist circumference reduction in overweight and obese sedentary adults.

CONCLUSION

Innovative technologies are providing lifestyle self-monitoring and weight loss tools. Utilizing these technologies may be an important step in improving the current obesity epidemic.

Cardiometabolic results from an armband-based weight loss trial

PURPOSE

This report examines the blood chemistry and blood pressure (BP) results from the Lifestyle Education for Activity and Nutrition (LEAN) study, a randomized weight loss trial. A primary purpose of the study was to evaluate the effects of real-time self-monitoring of energy balance (using the SenseWear(™) Armband, BodyMedia, Inc Pittsburgh, PA) on these health factors.

METHODS

164 sedentary overweight or obese adults (46.8 ± 10.8 years; BMI 33.3 ± 5.2 kg/m(2); 80% women) took part in the 9-month study. Participants were randomized into 4 conditions: a standard care condition with an evidence-based weight loss manual (n = 40), a group-based behavioral weight loss program (n = 44), an armband alone condition (n = 41), and a group plus armband (n = 39) condition. BP, fasting blood lipids and glucose were measured at baseline and 9 months.

RESULTS

99 participants (60%) completed both baseline and follow-up measurements for BP and blood chemistry analysis. Missing data were handled by baseline carried forward. None of the intervention groups had significant changes in blood lipids or BP when compared to standard care after adjustment for covariates, though within-group lowering was found for systolic BP in group and group + armband conditions, a rise in total cholesterol and LDL were found in standard care and group conditions, and a lowering of triglycerides was found in the two armband conditions. Compared with the standard care condition, fasting glucose decreased significantly for participants in the group, armband, and group + armband conditions (all P < 0.05), respectively.

CONCLUSION

Our results suggest that using an armband program is an effective strategy to decrease fasting blood glucose. This indicates that devices, such as the armband, can be a successful way to disseminate programs that can improve health risk factors. This can be accomplished without group-based behavioral programs, thereby potentially reducing costs.

A Comparison of the Effectiveness of a Telephone Coaching Program and a Mail-Based Program

Many health promotion interventions have been developed and tested in recent years. Practitioners and researchers must continue to explore how various program delivery modalities can be used effectively and efficiently to optimize program outcomes. A sample of 6,055 participants was drawn from 10 large employers. Participants self-selected into a mail or telephone intervention. This study compared the demographics of those who selected each modality and assessed differences in program success relative to the modalities chosen. Telephone participants were more likely to be older, female, and salaried. Telephone participants were also more ready, confident, and motivated to make a behavior change, when compared to those in the mail program. Researchers found both the telephone and mail programs to be effective in reducing participants’ health risk status, though the telephone program was slightly more effective. These findings demonstrate the importance of offering a variety of interventions when promoting healthy changes. More research is needed to investigate the role of participant choice and the combinations of learning experiences that best facilitate sustainable behavior change.

Gender differences in satisfaction with life in patients with coronary heart disease: physical activity as a possible mediating factor

The objective of the present study was to examine if time varying, mediating effect of physical activity plays an important role in the gender-satisfaction with life relationship. Six hundred four male and 197 female patients were included. Principal outcomes of interest were self-report satisfaction with life and physical activity at baseline, 6, 12 and 24 months. The Krull and MacKinnon procedure for hierarchical linear modeling showed that the change in physical activity mediated the gender-satisfaction with life over a 2 year period. Results from the current study suggest that increased physical activity partially explains why males report having increased well-being than females after hospitalization. This suggests that future interventions need to focus on reducing the gender disparity in physical activity to improve differences noted in satisfaction with life. If higher physical activity levels impact satisfaction with life positively, the importance of physical activity for female patients is warranted.

Insulin resistance, obesity, inflammation, and depression in polycystic ovary syndrome: biobehavioral mechanisms and interventions

OBJECTIVE

To summarize physiological and psychological characteristics that are common among women diagnosed with polycystic ovary syndrome (PCOS) and provide evidence suggesting that addressing psychological disturbances can reduce or alleviate physical symptoms of PCOS through behavioral pathways and physiological pathways.

METHOD(S)

Empirical studies and expert consensuses pertaining to physiological, psychological, and medical management aspects of PCOS were identified and presented in this review. Articles were identified by searching Pubmed, PsycInfo, Medline ISI, CINAHL, or a Web browser (i.e., Google) using numerous combinations of terms pertaining to physiological, psychological, and medical management aspects of PCOS. An article was chosen to be included in this review if it reported findings and/or provided information that related to and helped support the main purpose(s) of this review article.

RESULT(S)

Available literature on the physiological (i.e., hyperandrogenism, central obesity, inflammation, insulin resistance) and psychological (i.e., depression, anxiety, eating disorders) factors among women with PCOS provides evidence that these various aspects of PCOS are strongly interrelated.

CONCLUSION(S)

The existence of these relationships among physiological and psychological factors strongly suggests that medical management of PCOS would greatly benefit from inclusion of psychological and behavioral approaches.

Living Well with Diabetes: a randomized controlled trial of a telephone-delivered intervention for maintenance of weight loss, physical activity and glycaemic control in adults with type 2 diabetes

BACKGROUND

By 2025, it is estimated that approximately 1.8 million Australian adults (approximately 8.4% of the adult population) will have diabetes, with the majority having type 2 diabetes. Weight management via improved physical activity and diet is the cornerstone of type 2 diabetes management. However, the majority of weight loss trials in diabetes have evaluated short-term, intensive clinic-based interventions that, while producing short-term outcomes, have failed to address issues of maintenance and broad population reach. Telephone-delivered interventions have the potential to address these gaps.

METHODS/DESIGN

Using a two-arm randomised controlled design, this study will evaluate an 18-month, telephone-delivered, behavioural weight loss intervention focussing on physical activity, diet and behavioural therapy, versus usual care, with follow-up at 24 months. Three-hundred adult participants, aged 20-75 years, with type 2 diabetes, will be recruited from 10 general practices via electronic medical records search. The Social-Cognitive Theory driven intervention involves a six-month intensive phase (4 weekly calls and 11 fortnightly calls) and a 12-month maintenance phase (one call per month). Primary outcomes, assessed at 6, 18 and 24 months, are: weight loss, physical activity, and glycaemic control (HbA1c), with weight loss and physical activity also measured at 12 months. Incremental cost-effectiveness will also be examined. Study recruitment began in February 2009, with final data collection expected by February 2013.

DISCUSSION

This is the first study to evaluate the telephone as the primary method of delivering a behavioural weight loss intervention in type 2 diabetes. The evaluation of maintenance outcomes (6 months following the end of intervention), the use of accelerometers to objectively measure physical activity, and the inclusion of a cost-effectiveness analysis will advance the science of broad reach approaches to weight control and health behaviour change, and will build the evidence base needed to advocate for the translation of this work into population health practice.

TRIAL REGISTRATION

ACTRN12608000203358.

Using group support to complement a task-based weight management programme in multi-ethnic localities of high deprivation

OBJECTIVE

Two pilot studies were undertaken to assess the efficacy and potential reach of a weight management programme in two inner-city areas of East London.

METHODS

The programme provides a 6 weekly group sessions combining a task-based cognitive-behavioural intervention with interactive group support to increase client engagement and retention. Treatment outcome was assessed at end of treatment and at 2 and 3 months by objective markers including pedometer readings, improvements in knowledge of healthy eating, and weight change.

RESULTS

A total of 162 people (mean BMI 35 kg/m(2)) participated. Forty-one started the first pilot and 21 (51%) completed it, losing on average 3.0 kg. In the second pilot 121 participants started the course and 75 (62%) completed it, losing on average 2.6 kg. A total of 62 and 39 participants completed 2- and 3-month follow-up, with average weight loss of 3.8 and 4.5 kg. There were significant increases in mean daily pedometer readings and improvements in objectively assessed knowledge of caloric intake.

CONCLUSIONS

A task-based lifestyle-modification programme complemented by social support proved attractive to inner-city residents and generated significant short-term effects comparable to those achieved by intensive interventions with more traditional target groups.

The cumulative effect of small dietary changes may significantly improve nutritional intakes in free-living children and adults

BACKGROUND/OBJECTIVES

The ELPAS (Etude Longitudinale Prospective Alimentation et Santé) study was an 8-month randomized controlled dietary modification trial designed to test the hypothesis that family dietary coaching would improve nutritional intakes and weight control in 2026 free-living children and parents. It resulted in significant nutritional changes, with beneficial effects on body mass index in adults. In these ancillary analyses, we investigated dietary changes throughout the intervention.

SUBJECTS/METHODS

Before the study, modeling analyses were carried out on the French Association Sucre Produits Sucrés Consommation et Communication (ASPCC) food-consumption database to identify the most efficient dietary intervention strategy. During the study, all participants performed monthly three nonconsecutive 24-h dietary recalls: this allowed for measuring changes in the number of servings per day and serving size for each targeted food category throughout the intervention.

RESULTS

Modeling analyses showed that targeting only the 10 main foods contributing to fat and carbohydrate intakes did not allow for reaching the ELPAS nutritional goals. As a result, it was decided to target more foods and to propose several types of dietary advice (such as change in serving size, change in cooking method, food substitution). This strategy led to many appropriate dietary changes during the intervention, but only a few of them reached significance. The mean number of servings per day was indeed significantly modified for only 7% of the targeted food categories in children and 17% in parents. The mean serving size was modified for only 12% of targeted food categories in children and 9% in parents.

CONCLUSIONS

The cumulative effect of small dietary changes may induce significant nutritional improvements, with limited burden for populations.

Mediators of physical activity behaviour change among adult non-clinical populations: a review update

BACKGROUND

An understanding of the determinants of physical activity through mediators of behaviour change is important in order to evaluate the efficacy of interventions. Prior reviews on this topic noted that few studies employed mediator analyses in experimental physical activity trials; the purpose of this review is to update these prior reviews in order to evaluate the state of our present understanding of interventions that include proposed mediators of behaviour change.

METHODS

Literature was identified through electronic database (e.g., MEDLINE, psychINFO) searching. Studies were eligible if they described a published experimental or quasi-experimental trial examining the effect of an intervention on physical activity behaviour and mediator change in non-clinical adult populations. Quality of included studies was assessed and the analyses examined the symmetry between mediators and behaviour change.

RESULTS

Twenty seven unique trials passed the eligibility criteria and 22 were included in the analysis with scores of moderate or higher quality. Half of the studies reviewed failed to show an intervention effect on PA. The remaining studies showed evidence that the intervention affected changes in the proposed mediators, but tests of mediated effect were performed in only six of these 11 cases and demonstrated mixed outcomes. Differences by theory were not discernable at this time, but self-regulation constructs had the most evidence for mediation.

CONCLUSION

Published literature employing mediators of change analyses in experimental designs is still relatively elusive since the time of prior reviews; however, the general null findings of changes in mediating constructs from these interventions are a more timely concern. Changes in self-regulation constructs may have the most effect on changes in PA while self-efficacy and outcome expectation type constructs have negligible but limited findings. Innovation and increased fidelity of interventions is needed and should be a priority for future research.

Mediators of physical activity behaviour change among adult non-clinical populations: a review update

BACKGROUND

An understanding of the determinants of physical activity through mediators of behaviour change is important in order to evaluate the efficacy of interventions. Prior reviews on this topic noted that few studies employed mediator analyses in experimental physical activity trials; the purpose of this review is to update these prior reviews in order to evaluate the state of our present understanding of interventions that include proposed mediators of behaviour change.

METHODS

Literature was identified through electronic database (e.g., MEDLINE, psychINFO) searching. Studies were eligible if they described a published experimental or quasi-experimental trial examining the effect of an intervention on physical activity behaviour and mediator change in non-clinical adult populations. Quality of included studies was assessed and the analyses examined the symmetry between mediators and behaviour change.

RESULTS

Twenty seven unique trials passed the eligibility criteria and 22 were included in the analysis with scores of moderate or higher quality. Half of the studies reviewed failed to show an intervention effect on PA. The remaining studies showed evidence that the intervention affected changes in the proposed mediators, but tests of mediated effect were performed in only six of these 11 cases and demonstrated mixed outcomes. Differences by theory were not discernable at this time, but self-regulation constructs had the most evidence for mediation.

CONCLUSION

Published literature employing mediators of change analyses in experimental designs is still relatively elusive since the time of prior reviews; however, the general null findings of changes in mediating constructs from these interventions are a more timely concern. Changes in self-regulation constructs may have the most effect on changes in PA while self-efficacy and outcome expectation type constructs have negligible but limited findings. Innovation and increased fidelity of interventions is needed and should be a priority for future research.

Relationship between costs of lifestyle interventions and weight loss in overweight adults

Lifestyle interventions in a healthcare setting are effective for weight loss, but it is unclear whether more expensive interventions result in more weight loss. Our objective was to explore the relationship between intervention costs and effectiveness in a systematic review of randomized trials. Intervention studies were selected from 14 reviews and from a systematic MEDLINE-search. Studies had to contain a dietary and a physical activity component and report data on measured weight loss in healthy Caucasian overweight adults. Intervention costs were calculated in a standardized way. The association between costs and percentage weight loss after 1 year was assessed using regression analysis. Nineteen original studies describing 31 interventions were selected. The relationship between weight loss and intervention costs was best described by an asymptotic regression model, which explained 47% of the variance in weight loss. A clinically relevant weight loss of 5% was already observed in interventions of approximately euro110. Results were similar in an intention-to-treat analysis. In conclusion, lifestyle interventions in health care for overweight adults are relatively cheap and higher intervention costs are associated with more weight loss, although the effect of costs on weight loss levels off with growing costs.

Exploring the mechanisms of weight loss in the SHED-IT intervention for overweight men: a mediation analysis

BACKGROUND

Statistical mediation analysis can be used to improve the design of obesity prevention and treatment programs by identifying the possible mechanisms through which an intervention achieved its effects. The aim of this study was to identify mediators of weight loss in an Internet-based weight-loss program specifically designed for overweight men.

METHODS

The Self-Help, Exercise and Diet using Information Technology (SHED-IT) program was a 3-month randomized controlled trial (Internet-based intervention group vs information only control group) that was implemented in 2007 with baseline and 6-month follow-up assessment of weight, physical activity and dietary behaviors. Intention-to-treat and per-protocol mediation analyses were conducted using a product-of-coefficients test.

RESULTS

Participants (N = 65) were overweight and obese male academic (n = 10) and non-academic (n = 27) staff and students (n = 28) from the University of Newcastle, Australia. Mean (SD) age = 35.9 (11.1) years and mean (SD) BMI = 30.6 (2.8). In the intention-to-treat analysis, both groups lost weight, but relative to the control group, the intervention did not have a statistically significant 'total effect' on weight, tau = -.507, p = .716 (95% CI = -3.277 to 2.263). In the per-protocol analysis, the intervention had a statistically significant 'total effect' on weight, tau = -4.487, p < .05 (95% CI = -8.208 to -.765). The intervention did not have a statistically significant effect on any of the hypothesized mediators and none of the behavioral variables mediated weight loss in the SHED-IT program. Although participants in the intervention group reduced their fat intake over the study period, the changes did not satisfy the criteria for mediation.

CONCLUSION

Few studies have examined the mediators of weight loss in obesity treatment interventions. While none of the hypothesized mediators satisfied the criteria for mediation in the current study, there was some evidence to suggest that overweight men in the SHED-IT intervention reduced their fat intake over the study period. Future obesity treatment and prevention programs should explore behavioral mediators of weight loss using appropriate statistical methods.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry No: ANZCTRN12607000481471.

Exploring the mechanisms of weight loss in the SHED-IT intervention for overweight men: a mediation analysis

BACKGROUND

Statistical mediation analysis can be used to improve the design of obesity prevention and treatment programs by identifying the possible mechanisms through which an intervention achieved its effects. The aim of this study was to identify mediators of weight loss in an Internet-based weight-loss program specifically designed for overweight men.

METHODS

The Self-Help, Exercise and Diet using Information Technology (SHED-IT) program was a 3-month randomized controlled trial (Internet-based intervention group vs information only control group) that was implemented in 2007 with baseline and 6-month follow-up assessment of weight, physical activity and dietary behaviors. Intention-to-treat and per-protocol mediation analyses were conducted using a product-of-coefficients test.

RESULTS

Participants (N = 65) were overweight and obese male academic (n = 10) and non-academic (n = 27) staff and students (n = 28) from the University of Newcastle, Australia. Mean (SD) age = 35.9 (11.1) years and mean (SD) BMI = 30.6 (2.8). In the intention-to-treat analysis, both groups lost weight, but relative to the control group, the intervention did not have a statistically significant 'total effect' on weight, tau = -.507, p = .716 (95% CI = -3.277 to 2.263). In the per-protocol analysis, the intervention had a statistically significant 'total effect' on weight, tau = -4.487, p < .05 (95% CI = -8.208 to -.765). The intervention did not have a statistically significant effect on any of the hypothesized mediators and none of the behavioral variables mediated weight loss in the SHED-IT program. Although participants in the intervention group reduced their fat intake over the study period, the changes did not satisfy the criteria for mediation.

CONCLUSION

Few studies have examined the mediators of weight loss in obesity treatment interventions. While none of the hypothesized mediators satisfied the criteria for mediation in the current study, there was some evidence to suggest that overweight men in the SHED-IT intervention reduced their fat intake over the study period. Future obesity treatment and prevention programs should explore behavioral mediators of weight loss using appropriate statistical methods.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry No: ANZCTRN12607000481471.

A systematic review of the effectiveness of group versus individual treatments for adult obesity

BACKGROUND

Both group and individual modes of delivery are employed for obesity treatments. Commercial weight loss groups commonly employ group-based delivery, while many clinical based settings employ one-to-one delivery. We systematically reviewed randomised controlled trials of treatments for adult obesity to compare the effectiveness of group-based to individual-based modes of treatment delivery.

METHODS

We searched 7 electronic databases and 2 journals and reviewed secondary references, based on a priori criteria to systematically review: randomised controlled trials of obesity treatments, participants with BMI >or=28 kg/m(2), age >or=18 years, comparison groups including at least 1 group-based and 1 individual-based treatment group, and follow-up >or=1 year. We extracted data and conducted meta-analysis of weight change.

RESULTS

Eleven comparison groups from 5 qualifying trials were obtained, representing a total participant pool of 336. Significantly greater (p = 0.03) weight change at 12 months was found in group-based over individualbased treatment, and sub-analyses showed that increased effectiveness was associated with the use of financial reward and psychologist-led interventions.

CONCLUSION

Group-based interventions were more effective than individual-based interventions among a predominantly female participant pool receiving psychologist-led interventions. Future studies to explore differences by professional group and interventions among men, which are accompanied by economic evaluation, are recommended.

Self-management for obesity and cardio-metabolic fitness: description and evaluation of the lifestyle modification program of a randomised controlled trial

Background

Sustainable lifestyle modification strategies are needed to address obesity and cardiovascular risk factors. Intensive, individualised programs have been successful, but are limited by time and resources. We have formulated a group-based lifestyle education program based upon national diet and physical activity (PA) recommendations to manage obesity and cardio-metabolic risk factors. This article describes the content and delivery of this program, with information on compliance and acceptability.

Methods

Overweight/obese adults (n = 153) with metabolic syndrome were recruited from the community and randomly allocated to intervention (INT) or control (CON). Written copies of Australian national dietary and PA guidelines were provided to all participants. INT took part in a 16-week lifestyle program which provided a curriculum and practical strategies on 1) dietary and PA information based on national guidelines, 2) behavioural self-management tools, 3) food-label reading, supermarkets tour and cooking, 4) exercise sessions, and 5) peer-group support. Compliance was assessed using attendance records and weekly food/PA logs. Participants' motivations, perceived benefits and goals were assessed through facilitated discussion. Program acceptability feedback was collected through structured focus groups.

Results

Although completion of weekly food/PA records was poor, attendance at information/education sessions (77% overall) and exercise participation (66% overall) was high, and compared with CON, multiple markers of body composition and cardio-metabolic health improved in INT. Participants reported that the most useful program components included food-label reading, cooking sessions, and learning new and different physical exercises, including home-based options. Participants also reported finding self-management techniques helpful, namely problem solving and short-term goal setting. The use of a group setting and supportive 'peer' leaders were found to be supportive. More frequent clinical assessment was suggested for future programs.

Conclusion

This group-based lifestyle program achieved improvements in body composition and cardio-metabolic and physical fitness similar to individualised interventions which are more resource intensive to deliver. It confirmed that active training in lifestyle modification is more effective than passive provision of guidelines. Such programs should include social support and self-management techniques. Continued clinical follow up may be required for long-term maintenance in individuals attempting lifestyle behaviour change. Program facilitation by peers may help and should be further investigated in a community-based model.