Treatment of obesity: theory into practice

Facilitators and barriers to a dietitian-implemented blended care weight-loss intervention (SMARTsize): a qualitative study

BACKGROUND

Dietitians play an important role in the intervention and prevention of being overweight and obesity. More and more blended care interventions are being implemented. The present study aimed to evaluate the delivery by Dutch dietitians of a multicomponent, evidence-based weight-loss programme (SMARTsize), including counselling for relapse prevention. The aim of this qualitative study was to identify facilitators and barriers to the delivery of SMARTsize.

METHODS

Nine semi-structured interviews were conducted with 10 dietitians who participated in a larger implementation study. Each interview was recorded and transcribed verbatim. Determinants of theory of implementation, including characteristics of the user, the innovation, organisational context and setting, and innovation strategy guided interviews and analysis. Data were coded and analysed using the framework approach.

RESULTS

According to dietitians, the SMARTsize intervention had a positive influence on patients. The main implementation facilitators were the availability of implementation materials, such as a manual, training in relapse prevention and social support from other dietitians. The main barriers to implementation were organisation and financial reimbursement of cooking classes, the belief that patients need more individual counselling in the starting phase, and the unsuitability for people with low levels of health literacy.

CONCLUSIONS

Most dietitians considered that implementation of the SMARTsize intervention consisting of e-health, written information and cooking classes and face-to-face counselling is challenging but feasible. Further development of the SMARTsize intervention and implementation tools is needed to lower experienced barriers. It is also recommended that a version of the intervention to be developed that is suitable for patients with lower levels of health literacy.

An Internet-based weight loss programme -- a feasibility study with preliminary results from 4209 completers

AIMS

1. To identify characteristics of individuals seeking help for their weight problem via an internet-based programme. 2. To identify indicators of long term success in such a programme.

METHODS

An internet-based weight club (www.viktklubb.se) was used consisting of standard algorithms for calculating body mass index (BMI), food energy content and exercise energy cost. All members filled in basic data and could volunteer to fill in additional research related questions. Together with data on treatment success, attrition, and use of the various components of the programme, this information was automatically monitored and downloaded to a database.

RESULTS

Eighty-six percent of the members were female, and the age range was wide (range 18-101 years; mean 40.3 +/-11.5 years). At baseline, BMI of the entire group was 29.3 +/-5.1 kg/m(2) with 39% obese and 45% overweight. Among the completers, 16% changed from overweight or obese to normal weight. This corresponded to 29% of the members losing 5-9.9% of their initial body weight and 20% losing > or =10% of their. The strongest predictors of weight loss were activity in the weight club as judged by number of logins and diary entries, and sex.

CONCLUSIONS

A sizeable, but seemingly random, dropout rate was observed, together with significant dose-response effects between activity in the internet-based program and weight-loss among completers. Given its low cost and high accessibility at 24 hours a day, this form of programme delivery is interesting to evaluate and develop further, especially regarding attrition.

The Internet for weight control in an obese sample: results of a randomised controlled trial

BACKGROUND

Rising levels of obesity coupled with the limited success of currently available weight control methods highlight the need for investigation of novel approaches to obesity treatment. This study aims to determine the effectiveness and cost-effectiveness of an Internet-based resource for obesity management.

METHODS

A randomised controlled trial conducted in a community setting, where obese volunteers (n = 221) were randomly assigned to Internet group (n = 111) or usual care group (n = 110). Objective measures of weight and height were obtained. Questionnaires were used to collect dietary, lifestyle, physical activity and quality of life data. Data were collected at baseline, six months and 12 months.

RESULTS

Data were collected on 54 (49%) participants in the Internet group and 77 (70%) participants in the usual care group at 12 months. Based on analysis conducted on all available data, the Internet group lost 1.3 kg, compared with 1.9 kg weight loss in the usual care group at 12 months, a non-significant difference (difference = 0.6 kg; 95% CI: -1.4 to 2.5, p = 0.56). No significant differences in change in secondary outcome measures between the two groups at six or 12 months were revealed. Total costs per person per year were higher in the Internet group than the usual care group ( pound992.40 compared to pound276.12), primarily due to the fixed costs associated with setting up the website, and QALYs were similar (0.78 and 0.77) for both groups.

CONCLUSION

This trial failed to show any additional benefit of this website in terms of weight loss or secondary outcome measures compared with usual care. High attrition and low compliance limits the results of this research. The results suggest that the Internet-based weight control resource was not a cost-effective tool for weight loss in the obese sample studied.

TRIAL REGISTRATION

ISRCTN 58621669.

A randomised trial of an Internet weight control resource: the UK Weight Control Trial [ISRCTN58621669]

Background

Obesity treatment is notoriously unsuccessful and one of the barriers to successful weight loss reported by patients is a lack of social support. The Internet offers a novel and fast approach to the delivery of health information, enabling 24-hour access to help and advice. However, much of the health information available on the Internet is unregulated or not written by qualified health professionals to provide unbiased information. The proposed study aims to compare a web-based weight loss package with traditional dietary treatment of obesity in participants. The project aims to deliver high quality information to the patient and to evaluate the effectiveness of this information, both in terms of weight loss outcomes and cost-effectiveness.

Methods

This study is a randomised controlled trial of a weight loss package against usual care provided within General Practice (GP) surgeries in Leeds, UK. Participants will be recruited via posters placed in participating practices. A target recruitment figure of 220 will enable 180 people to be recruited (allowing for 22% dropout). Participants agreeing to take part in the study will be randomly allocated using minimisation to either the intervention group, receiving access to the Internet site, or the usual care group. The primary outcome of the study will be the ability of the package to promote change in BMI over 6 and 12 months compared with traditional treatment. Secondary outcomes will be the ability of the Internet package to promote change in reported lifestyle behaviours. Data will be collected on participant preferences, adherence to treatment, health care use and time off work. Difference in cost between groups in provision of the intervention and the cost of the primary outcome will also be estimated.

Conclusion

A positive result from this study would enhance the repertoire of treatment approaches available for the management of obesity. A negative result would be used to inform the research agenda and contribute to redefining future strategies for tackling obesity.

Use of folic acid supplements in the first trimester of pregnancy

Folic acid supplementation in the periconceptual period is known to reduce the risk of neural tube defects. High dose supplementation prevents a high proportion of recurrent defects, whilst low doses reduce the risk of first occurrences. The Department of Health advises all women considering pregnancy to take folate supplements for 12 weeks prior to conception and in the first trimester of pregnancy. Surveys of the British population indicate that the uptake of this advice is poor. The aim of the present study was to evaluate the uptake of advice in a group of Northampton women between January and June 2001. A total of 301 Caucasian women were recruited through an antenatal dating scan clinic. The women were aged between 16 and 42 years and completed a questionnaire concerning nutritional supplements prior to and during pregnancy and a five-day food diary, which was used to estimate dietary folate intakes. Of the women 67% consumed folate-containing supplements in the first trimester of pregnancy and 43% reported taking folate before becoming pregnant. Women under the age of 21 years were less likely to take folate supplements than women over the age of 21 years (p = 0.007), as were smokers (p < 0.001) and women from lower social classes. Mean folate intakes, including supplements, were 511 +/- 17 micrograms per day and unsupplemented dietary intakes were 237 +/- 5 micrograms per day. Of the women interviewed, 24.5% had folate intakes below the reference nutrient intake for pregnancy (300 micrograms per day). The data supports the assertion that neural tube defects are more likely to be prevented through the fortification of staple foods than through supplementation, but highlights the fact that young women from poor social backgrounds may still require close monitoring and support.