Persistence of Depressive Symptoms and Risk of Incident Cardiovascular Disease With and Without Diabetes: Results from the REGARDS Study

BACKGROUND

Baseline depressive symptoms are associated with subsequent adverse cardiovascular (CV) events in subjects with and without diabetes but the impact of persistent symptoms vs. improvement remains controversial.

OBJECTIVE

Examine long-term changes in depressive symptoms in individuals with and without diabetes and the associated risk for adverse CV events.

DESIGN

REGARDS is a prospective cohort study of CV risk factors in 30,000 participants aged 45 years and older.

PARTICIPANTS

N = 16,368 (16.5% with diabetes mellitus) who remained in the cohort an average of 11.1 years later and who had complete data.

MAIN MEASURES

Depressive symptoms were measured using the 4-item Centers for Epidemiologic Study of Depression (CES-D) questionnaire at baseline and again at a mean follow-up of 5.07 (SD = 1.66) years. Adjudicated incident stroke, coronary heart disease (CHD), CV mortality, and a composite outcome were assessed in a subsequent follow-up period of 6.1 (SD = 2.6) years.

METHODS

The association of changes in depressive symptoms (CES-D scores) across 5 years with incident CV events was assessed using Cox proportional hazards modeling.

KEY RESULTS

Compared to participants with no depressive symptoms at either time point, participants without diabetes but with persistently elevated depressive symptoms at both baseline and follow-up demonstrated a significantly increased risk of incident stroke (HR (95% CI) = 1.84 (1.03, 3.30)), a pattern which was substantially more prevalent in blacks (HR (95% CI) = 2.64 (1.48, 4.72)) compared to whites (HR (95% CI) = 1.06 (0.50, 2.25)) and in those not taking anti-depressants (HR (95% CI) = 2.01 (1.21, 3.35)) in fully adjusted models.

CONCLUSIONS

The persistence of depressive symptoms across 5 years of follow-up in participants without diabetes identifies individuals at increased risk for incident stroke. This was particularly evident in black participants and among those not taking anti-depressants.

Efficacy of a Commercial Weight Management Program Compared With a Do-It-Yourself Approach: A Randomized Clinical Trial

IMPORTANCE

Given the prevalence of obesity, accessible and effective treatment options are needed to manage obesity and its comorbid conditions. Commercial weight management programs are a potential solution to the lack of available treatment, providing greater access at lower cost than clinic-based approaches, but few commercial programs have been rigorously evaluated.

OBJECTIVE

To compare the differences in weight change between individuals randomly assigned to a commercial weight management program and those randomly assigned to a do-it-yourself (DIY) approach.

DESIGN, SETTING, AND PARTICIPANTS

This 1-year, randomized clinical trial conducted in the United States, Canada, and United Kingdom between June 19, 2018, and November 30, 2019, enrolled 373 adults aged 18 to 75 years with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 25 to 45. Assessors were blinded to treatment conditions.

INTERVENTIONS

A widely available commercial weight management program that included reduced requirements for dietary self-monitoring and recommendations for a variety of DIY approaches to weight loss.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the difference in weight change between the 2 groups at 3 and 12 months. The a priori hypothesis was that the commercial program would result in greater weight loss than the DIY approach at 3 and 12 months. Analyses were performed on an intention-to-treat basis.

RESULTS

The study include 373 participants (272 women [72.9%]; mean [SD] BMI, 33.8 [5.2]; 77 [20.6%] aged 18-34 years, 74 [19.8%] aged 35-43 years, 82 [22.0%] aged 44-52 years, and 140 [37.5%] aged 53-75 years). At 12 months, retention rates were 88.8% (166 of 187) for the commercial weight management program group and 95.7% (178 of 186) for the DIY group. At 3 months, participants in the commercial program had a mean (SD) weight loss of -3.8 (4.1) kg vs -1.8 (3.7) kg among those in the DIY group. At 12 months, participants in the commercial program had a mean (SD) weight loss of -4.4 (7.3) kg vs -1.7 (7.3) kg among those in the DIY group. The mean difference between groups was -2.0 kg (97.5% CI, -2.9 to -1.1 kg) at 3 months (P < .001) and -2.6 kg (97.5% CI, -4.3 to -0.8 kg) at 12 months (P < .001). A greater percentage of participants in the commercial program group than participants in the DIY group achieved loss of 5% of body weight at both 3 months (40.7% [72 of 177] vs 18.6% [34 of 183]) and 12 months (42.8% [71 of 166] vs 24.7% [44 of 178]).

CONCLUSIONS AND RELEVANCE

Adults randomly assigned to a commercial weight management program with reduced requirements for dietary self-monitoring lost more weight and were more likely to achieve weight loss of 5% at 3 and 12 months than adults following a DIY approach. This study contributes data on the efficacy of commercial weight management programs and DIY weight management approaches.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03571893.

The influence of sex and maturation on carotid and vertebral artery hemodynamics and associations with free-living (in)activity in 6-17-year-olds

We explored the influence of sex and maturation on resting cervical artery hemodynamics (common carotid artery, CCA; internal carotid artery, ICA; and vertebral artery, VA), free-living physical activity, and sedentary behavior in children 6-17 yr of age. In addition, we investigated the relationship between physical activity, sedentary behavior, and cervical artery hemodynamics. Seventy-eight children and adolescents, girls (n = 42; mean age, 11.4 ± 2.5 yr) and boys (n = 36; mean age, 11.0 ± 2.6 yr), completed anthropometric measures, duplex ultrasound assessment of the cervical arteries, and wore an activPAL accelerometer to assess physical activity (indexed by steps/day) and sedentary behavior for 7 days. The ICA and VA diameters were similar between prepubertal and pubertal groups, as was volumetric blood flow (Q); however, the CCA diameter was significantly larger in the pubertal group (P < 0.05). Boys were found to have larger diameters in all cervical arteries than girls, as well as higher Q_CCA, Q_ICA, and global cerebral blood flow (P < 0.05). The pubertal group was more sedentary (100 min/day more; P < 0.05) and took 3,500 fewer steps/day than the prepubertal group (P < 0.05). Shear rate (SR) and Q of the cervical arteries showed no relationship to physical activity or prolonged bouts of sedentary behavior; however, a significant negative relationship was apparent between total sedentary time and internal carotid artery shear rate (ICA_SR) after covarying for steps/day and maturation (P < 0.05). These findings provide novel insight into the potential influence sedentary behavior may have on cerebrovascular blood flow in healthy girls and boys.NEW & NOTEWORTHY Cerebral blood flow is known to change with age; however, assessing these age-related changes is complex and requires consideration of pubertal status. This, to our knowledge, is the first study to investigate the influence of sex and maturation on resting cervical artery hemodynamics and subsequently explore associations with physical activity and sedentary behavior in healthy children and adolescents. Our findings suggest that habitual sedentary behavior may influence cervical artery hemodynamics in youth, independent of physical activity, maturation, and sex.

The Effect of Aerobic Training and Increasing Nonexercise Physical Activity on Cardiometabolic Risk Factors

PURPOSE

Epidemiological studies suggest that sedentary behavior is an independent risk factor for cardiovascular mortality independent of meeting physical activity guidelines. However, limited evidence of this relationship is available from prospective interventions. The purpose of the present study is to evaluate the combined effect of aerobic training and increasing non-exercise physical activity on body composition and cardiometabolic risk factors.

METHODS

Obese adults (N=45) were randomized to 6-months of aerobic training (AERO), aerobic training and increasing non-exercise physical activity (~3,000 steps above baseline levels) (AERO-PA), or a control group (CON). The AERO and AERO-PA groups performed supervised aerobic training (3-4 times per week). The AERO-PA group wore Fitbit One accelerometers and received behavioral coaching to increase non-exercise physical activity.

RESULTS

There was a larger increase in fitness in the AERO-PA group (0.27 L/min, 0.16 to 0.40) compared to the AERO group (0.09 L/min, CI: -0.04 to 0.22) and the CON (0.01, CI: -0.11 to 0.12) groups. While significant findings were not observed in the entire study sample, when the analysis was restricted to participants compliant to the intervention (N=33), we observed significant reductions in waist circumference, percent weight loss, body fat, 2-hr glucose and 2-hr insulin in comparison to the CON group (p<0.05), but not the AERO group. Further, linear regression models showed that change in steps was associated with 21% and 26% of the variation in percent weight loss and percent fat loss, respectively.

CONCLUSION

Increasing non-exercise physical activity with aerobic training may represent a viable strategy to augment the fitness response in comparison to aerobic training alone and has promise for other health indicators.

Does Happiness Improve Health? Evidence From a Randomized Controlled Trial

Happier people are healthier, but does becoming happier lead to better health? In the current study, we deployed a comprehensive, 3-month positive psychological intervention as an experimental tool to examine the effects of increasing subjective well-being on physical health in a nonclinical population. In a 6-month randomized controlled trial with 155 community adults, we found effects of treatment on self-reported physical health—the number of days in the previous month that participants felt healthy or sick, as assessed by questions from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System Questionnaire. In a subsample of 100 participants, we also found evidence that improvements in subjective well-being over the course of the program predicted subsequent decreases in the number of sick days. Combining experimental and longitudinal methodologies, this work provides some evidence for a causal effect of subjective well-being on self-reported physical health.

ENHANCE: Evidence for the efficacy of a comprehensive intervention program to promote subjective well-being

Building from the growing empirical science of happiness, or subjective well-being (SWB), we have developed a 12-week comprehensive intervention program-Enduring Happiness and Continued Self-Enhancement (ENHANCE)-to increase SWB and enable a thorough examination of the mechanistic processes of program content and administrative structure for SWB change over time. In a randomized controlled trial, participants (N = 155; 55 using the in-person format, 100 online format) were randomly assigned to participate in ENHANCE or to a waitlist control condition. All participants completed assessments of SWB, including non-self-report measures, and process variables at baseline, posttest, and follow-up (3 months). We found evidence supporting the efficacy of ENHANCE for increasing SWB, whether administered in-person or online. Furthermore, development of the skills targeted in the program (e.g., gratitude, mindfulness) accounted for SWB improvements. This study provides initial evidence that ENHANCE can promote SWB and offers insights regarding the processes involved in these changes. To bolster these findings, we present additional data (n = 74) from a fourth assessment showing within-person maintenance of SWB gains over 6 months in the original treatment condition (n = 39) and a replication of the immediate ENHANCE treatment effects in the waitlist condition (n = 36). We discuss potential avenues for the utilization of ENHANCE in basic research and applied disseminations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Randomized Trial of a Tailored Cognitive Behavioral Intervention in Type 2 Diabetes With Comorbid Depressive and/or Regimen-Related Distress Symptoms: 12-Month Outcomes From COMRADE

OBJECTIVE

This study evaluated the effect of cognitive behavioral therapy (CBT) plus lifestyle counseling in primary care on hemoglobin A_1c (HbA_1c) in rural adult patients with type 2 diabetes (T2D) and comorbid depressive or regimen-related distress (RRD) symptoms.

RESEARCH DESIGN AND METHODS

This study was a randomized controlled trial of a 16-session severity-tailored CBT plus lifestyle counseling intervention compared with usual care. Outcomes included changes in HbA_1c, RRD, depressive symptoms, self-care behaviors, and medication adherence across 12 months.

RESULTS

Patients included 139 diverse, rural adults (mean age 52.6 ± 9.5 years; 72% black; BMI 37.0 ± 9.0 kg/m²) with T2D (mean HbA_1c 9.6% [81 mmol/mol] ± 2.0%) and comorbid depressive or distress symptoms. Using intent-to-treat analyses, patients in the intervention experienced marginally significant improvements in HbA_1c (-0.92 ± 1.81 vs. -0.31 ± 2.04; P = 0.06) compared with usual care. However, intervention patients experienced significantly greater improvements in RRD (-1.12 ± 1.05 vs. -0.31 ± 1.22; P = 0.001), depressive symptoms (-3.39 ± 5.00 vs. -0.90 ± 6.17; P = 0.01), self-care behaviors (1.10 ± 1.30 vs. 0.58 ± 1.45; P = 0.03), and medication adherence (1.00 ± 2.0 vs. 0.17 ± 1.0; P = 0.02) versus usual care. Improvement in HbA_1c correlated with improvement in RRD (r = 0.3; P = 0.0001) and adherence (r = -0.23; P = 0.007).

CONCLUSIONS

Tailored CBT with lifestyle counseling improves behavioral outcomes and may improve HbA_1c in rural patients with T2D and comorbid depressive and/or RRD symptoms.

COMRADE: A randomized trial of an individually tailored integrated care intervention for uncontrolled type 2 diabetes with depression and/or distress in the rural southeastern US

BACKGROUND

Emerging evidence suggests that people living with Type 2 diabetes mellitus (T2D) are also at greater risk for depression and distress. If left untreated, these comorbid mental health concerns can have long-lasting impacts on medical and physical health outcomes.

DESIGN

This prospective trial randomized rural men and women with uncontrolled T2D (HbA1c ≥ 7.0) who screened positive for co-morbid depressive (PHQ-2 > 3) or distress (DDS-2 > 3) symptoms in a primary medical care setting to receive either: 1) 16 sessions of cognitive and/or behavioral intervention tailored to symptom severity across 12 months along with routine medical care, or 2) usual primary care. Outcomes included change from baseline to 12-months in HbA1c, diabetes related distress, depressive symptoms, and diabetes self-care activities.

BASELINE RESULTS

139 patients (Mean age = 52.6 ± 9.6 years) with T2D from impoverished rural communities were enrolled (almost half reporting annual income of <$10,000 per year). Baseline data indicated that patients were experiencing profoundly uncontrolled T2D of a long duration (Mean HbA1c = 9.61 ± 2.0; Mean BMI = 37.0 ± 9.1; Mean duration = 11.2 ± 8.9 years) along with high levels of distress (Mean DDS-17 Scale Score = 2.5 ± 1.0) and/or depressive symptoms (Mean PHQ-9 Scale Score = 9.3 ± 6.1).

CONCLUSION

Patients with uncontrolled T2D of long duration manifest complex co-morbidities including associated obesity, depressive symptoms and/or diabetes related distress. A behavioral intervention for T2D that concurrently targets symptoms of depression and distress may lead to more effective outcomes in this high-risk population.

CLINICAL TRIAL REGISTRATION

NCT02863523.

Weight Loss Strategies Utilized in a Men's Weight Loss Intervention

Men are underrepresented in weight loss programs and little is currently known about the weight loss strategies men prefer. This study describes the weight loss strategies used by men during a men-only weight loss program. At baseline, 3 months, and 6 months, participants reported how frequently they used 45 weight loss strategies including strategies frequently recommended by the program (i.e., mentioned during every intervention contact; e.g., daily self-weighing), strategies occasionally recommended by the program (i.e., mentioned at least once during the program; e.g., reduce calories from beverages), and strategies not included in the program (e.g., increase daily steps). At baseline participants ( N = 107, 44.2 years, body mass index = 31.4 kg/m², 76.6% White) reported regularly using 7.3 ± 6.6 ( M ± SD) strategies. The intervention group increased the number of strategies used to 19.1 ± 8.3 at 3 months and 17.1 ± 8.4 at 6 months with no changes in the waitlist group. The intervention group reported increased use of most of the strategies frequently recommended by the program (4 of 5), nearly half of the strategies occasionally recommended by the program (10 of 24), and one strategy not included in the program (of 16) at 6 months. The intervention effect at 6 months was significantly mediated by the number of strategies used at 3 months. This study adds to what is known about men's use of weight loss strategies prior to and during a formal weight loss program and will help future program developers create programs that are tailored to men.

A Community Health Worker-Delivered Intervention in African American Women with Type 2 Diabetes: A 12-Month Randomized Trial

OBJECTIVE

To evaluate the effectiveness of a community health worker (CHW)-delivered lifestyle intervention for African American women with type 2 diabetes.

METHODS

Participants were randomized to either 16 phone-based lifestyle intervention sessions aimed at making small changes in their diet and activity or 16 educational mailings sent across 12 months. Main outcomes included glycosylated hemoglobin (HbA1c), blood pressure (BP), and weight (kg) changes.

RESULTS

Two hundred middle-aged (mean = 53 ± 10.24 years), rural, African American women with moderate obesity (mean BMI = 37.7 ± 8.02) and type 2 diabetes (mean HbA1c = 9.1 ± 1.83) were enrolled. At 12 months, the intervention group exhibited no significant differences in HbA1c (-0.29 ± 1.84 vs. + 0.005 ± 1.61; P = 0.789) or BP (-1.01 ± 20.46/+0.66 ± 13.24 vs. + 0.22 ± 25.33/-2.87 ± 1.52; P = 0.100) but did exhibit greater weight loss (-1.35 ± 6.22  vs. -0.39 ± 4.57 kg, respectively; P = 0.046) compared with controls. Exploratory post hoc analyses revealed that participants not using insulin had significantly greater reductions in HbA1c (-0.70 ± 1.86 vs. + 0.07 ± 2.01; P = 0.000), diastolic BP (-5.17 ± 14.16 vs. -3.40 ± 14.72 mmHg; P = 0.035), and weight (-2.36 ± 6.59 vs. -1.64 ± 4.36 kg; P = 0.003) compared to controls not on insulin.

CONCLUSIONS

A phone-based CHW intervention resulted in no significant improvements in HbA1c or BP but did demonstrate modest improvements in weight. Women not using insulin showed significant improvements in all primary outcomes.

Mental health and behavioral weight loss: 24-month outcomes in Veterans

BACKGROUND

Individuals with mental health (MH) disorders have an increased risk of being overweight/obese; however research on behavioral weight loss interventions has been limited. A priori hypothesis was that Veterans with serious mental illness (SMI) and/or affective disorders (AD) would lose significantly less weight and have a different pattern of weight loss than Veterans without these diagnoses.

METHODS

Secondary data analysis of ASPIRE-VA study, three-arm randomized, effectiveness weight loss trial among Veterans (n=409) categorized by MH diagnoses: 1) SMI, 2) AD without SMI, or 3) No SMI/No AD. Linear mixed-effects model analyzed weight changes from baseline thru 24 months.

RESULTS

SMI and AD were diagnosed in 10% (n=41) and 31% (n=125). Participants attended approximately 15 sessions from baseline to 24 months. On average, participants lost a modest amount of weight over 24 months regardless of MH diagnosis. Longitudinally, no statistically significant differences were found in weight loss patterns by MH diagnosis. Unadjusted average weight loss (kg) was 1.6±4.0 at 3 months (n=373), 1.9±6.5 at 12 months (n=361), 1.5±7.8 at 18 months (n=289), and 1.4±8.0 at 24 months (n=279).

LIMITATIONS

ASPIRE-VA study was not designed or powered to detect weight loss differences among MH diagnostic groups.

CONCLUSIONS

Veterans achieved and maintained modest weight loss, through 24 months, with the three behavioral weight loss interventions. Contrary to our hypotheses, the amount and pattern of weight loss did not differ by MH diagnosis. Greater inclusion of individuals with MH diagnoses may be warranted in behavioral weight loss interventions not specifically tailored for them.

The effects of a low-dose physical activity intervention on physical activity and body mass index in severely obese adolescents

Background While severe obesity in childhood poses the greatest long-term health risks, access to treatment is a common barrier. The present pilot study examined the effect of a 7-week low-dose physical activity (PA) intervention on PA and body mass index (BMI) in severe obese adolescents delivered via telephone and mail. Methods Adolescents (n = 64) receiving care from a pediatric obesity medical clinic were randomized to a control (n = 30) or intervention (n = 34) group. Height and weight were measured and BMI z-scores were calculated. PA was assessed by a pedometer. All measurements were completed pre- and post-intervention. The intervention group received weekly newsletters and telephone calls discussing various PA topics based on motivational interviewing for 7 weeks. The control group received no contact. A series of 2 × 2 (group by time) repeated measures analysis of covariances (ANCOVAs) adjusting for length of time between visits were performed to examine the effect of the intervention on PA and BMI z-scores. Results The majority of adolescents were severely obese (77%, BMI: > 99th percentile). Intention-to-treat analysis revealed intervention effects were not observed for either pedometer steps or BMI z-score (p > 0.05). Among those with complete data, adolescents who successfully changed their BMI z-score had larger BMI z-score changes than those who did not change their BMI z-score (p = 0.0001). This improvement was due to something other than PA as the change in BMI z-score was similar among those who did and did not successfully increase PA levels (p > 0.05). Conclusions More intensive, comprehensive, and longer-term treatment is needed in this high risk population.

Impact of Distress Reduction on Behavioral Correlates and A1C in African American Women with Uncontrolled Type 2 Diabetes: Results from EMPOWER

OBJECTIVE

Symptoms of emotional distress related to diabetes have been associated with inadequate self-care behaviors, medication non-adherence, and poor glycemic control that may predispose patients to premature death. African American women, in whom diabetes is more common and social support is often insufficient, may be at particularly high risk. The objective of this study was to examine the impact of lowering diabetes-related emotional distress on glycemic control and associated behavioral correlates in rural African American women with uncontrolled type 2 diabetes (T2D).

DESIGN

Post-hoc analysis of prospective, randomized, controlled trial.

SETTING

Rural communities in the southeastern United States.

PATIENTS

129 rural middle-aged African American women with uncontrolled type 2 diabetes (T2D)(A1C ≥ 7.0).

PRIMARY INDEPENDENT VARIABLE

Diabetes-related distress.

MAIN OUTCOME MEASURES

Changes from baseline to 12-month follow-up in diabetes-related distress, and associated changes in medication adherence, self-care activities, self-efficacy, and glycemic control (A1C).

RESULTS

Patients with a reduction in diabetes-related distress (n=79) had significantly greater improvement in A1C, medication adherence, self-care activities, and self-efficacy compared with those in whom diabetes distress worsened or was unchanged (n=50). Changes in distress were also significantly and inversely correlated with improvements in medication adherence, self-care activities, and self-efficacy.

CONCLUSIONS

Among rural African American women, reductions in diabetes-related distress may be associated with lower A1C and improvements in self-efficacy, self-care behaviors, and medication adherence.

ENHANCE: Design and rationale of a randomized controlled trial for promoting enduring happiness & well-being

Individuals who are higher in subjective well-being not only feel happier, they are more likely have fulfilling relationships, increased work performance and income, better physical health, and longer lives. Over the past several decades, the science of subjective well-being has produced insights into these benefits of happiness, and-recognizing their importance-has begun to examine the factors that lead to greater well-being, from cultivating strong relationships to pursuing meaningful goals. However, studies to date have typically focused on improving subjective well-being by intervening with singular constructs, using primarily college student populations, and were short-term in nature. Moreover, little is understood about the impact of a well-being treatment delivered online vs. in-person. In the present article, we describe a comprehensive intervention program including 3-month initial treatment followed by a 3-month follow-up, ENHANCE: Enduring Happiness and Continued Self-Enhancement. One-hundred and sixty participants will be recruited from two different sites to participate in one of two versions of ENHANCE: in-person (n=30) vs. wait-list control (n=30); or online (n=50) vs. wait-list control (n=50). Assessments will be completed at baseline, three months and six months. Our primary outcome is change in subjective well-being across treatment (3months) and follow-up (6months). Secondary outcomes include self-report and objective measures of health, as well as a psychological mediators (e.g., psychological needs) and moderators (e.g., personality) of treatment outcomes. We hope to provide researchers, practitioners, and individuals with an evidence-based treatment to improve happiness and subjective well-being.

A randomized trial testing the efficacy of a novel approach to weight loss among men with overweight and obesity

OBJECTIVE

To test the efficacy of a weight loss intervention designed to appeal to men.

METHODS

A randomized trial tested the efficacy of the Rethinking Eating and FITness (REFIT) weight loss program compared to a wait-list control. The 6-month intervention was delivered via two face-to-face sessions followed by Internet contacts. REFIT encouraged participants to create calorie deficits by making six 100-calorie changes to their eating daily while increasing physical activity, and the program encouraged customization through selection of specific diet strategies evaluated each week.

RESULTS

Participants (N = 107, 44.2 years, 31.4 kg/m(2) , 76.6% white) were randomized into the study, and 90.6% provided data at 6 months. REFIT participants lost -5.0 kg (95% CI: -6.1, -3.9) at 3 months, which was maintained through 6 months (-5.3 kg, 95% CI: -6.5, -4.2); this was greater than the control group (p < 0.001; 6 months: -0.6, 95% CI: -1.8, 0.5). More REFIT participants (49%) achieved a 5% weight loss than control participants (19%; OR 9.4; 95% CI: 3.2, 27.4). An average of 11.2 (±2.7) of 13 of the online intervention contacts were completed.

CONCLUSIONS

The novel REFIT intervention produced clinically significant weight losses. This approach holds promise as an alternative to traditional behavioral therapy for men.

Weight loss outcomes in patients with pain

OBJECTIVE

To determine whether the presence or severity of pain is predictive of suboptimal weight loss outcomes in behavioral weight management programs.

METHODS

This is a secondary data analysis comparing weight loss among participants with overweight/obesity who participated in a 12-month randomized controlled trial. Of the 481 participants randomized, 394 (81.9%) had available pain data and were categorized by Pain Type (back pain, arthritis pain, both, or neither) and Pain Severity (no pain, moderate pain, or severe pain). Dietary and physical activity outcomes were also explored.

RESULTS

High rates of moderate and severe (80.2%), and back and arthritis (72.6%), pain were observed. Linear mixed models showed significant differences in % weight loss among Pain Severity, but not Pain Type, groups. Patients with severe pain lost significantly less weight (-0.1 kg, 95% CI = -1.5, -1.2) compared to those with either moderate or no pain (-1.9 kg, 95% CI = -2.5, -1.3; -2.1 kg, 95% CI = -3.3, -1.0, respectively). Patients with arthritis pain lost a significant amount of weight despite only minor improvements in walking distance.

CONCLUSIONS

Pain severity, but not pain type, is predictive of suboptimal weight loss outcomes.

Relationship of sleep quality, baseline weight status, and weight-loss responsiveness in obese adolescents in an immersion treatment program

OBJECTIVE

The objective of this study was to investigate the effect of baseline sleep on baseline weight status and weight-loss responsiveness in obese adolescents.

METHODS

Twenty-five obese adolescents who participated in a 19-day summer camp-based immersion treatment (IT) program completed pre-intervention measures of sleep duration and quality, and pre- and post-intervention body mass index z-scores (zBMI) and waist circumference (WC) assessments. Objective measures of sleep were obtained by actigraphy for a random subset of six participants for 1 week pre- and post-intervention.

RESULTS

Shorter weekday sleep durations and more sleep debt were related to higher pre-intervention WCs (r = -0.54, p = 0.01 and r = -0.56, p = 0.01), and lower subjective sleep quality was related to higher pre-intervention zBMIs (r = -0.49, p = 0.02). Longer weekend sleep durations and more sleep debt were related to smaller reductions in pre- to post-intervention zBMIs (r = -0.47, p = 0.04 and r = -0.51, p = 0.03). For the subgroup of adolescents who wore actigraphs pre- and post-intervention, an increase in their sleep durations (d = -0.25) and a reduction in their sleep latencies (d = 0.52), zBMIs (d = 0.31), and WCs (d = 0.20) were observed.

CONCLUSIONS

These results provide further evidence linking poor sleep patterns and obesity in adolescence, and suggest that sleep patterns may impact the effectiveness of pediatric obesity interventions and that IT programs may improve sleep in obese adolescents. Overall, they provide support for addressing sleep problems as part of obesity interventions.

High-frequency binge eating predicts weight gain among veterans receiving behavioral weight loss treatments

OBJECTIVE

To assess for the frequency of binge eating behavior and its association with weight loss in an overweight/obese sample of veterans.

METHODS

This study is a secondary analysis of data from the ASPIRE study, a randomized effectiveness trial of weight loss among veterans. Of the 481 enrolled veterans with overweight/obesity, binge eating frequency was obtained by survey for 392 (82%).

RESULTS

The majority (77.6%) reported binge eating, and 6.1% reported high-frequency binge eating. Those reporting any binge eating lost 1.4% of body weight, decreased waist circumference by 2.0 cm, and had significantly worse outcomes than those reporting never binge eating who lost about double the weight (2.7%) and reduced waist circumference by twice as much (4.2 cm). The high-frequency binge group gained 1.4% of body weight and increased waist circumference by 0.3 cm.

CONCLUSIONS

High rates of binge eating were observed in an overweight/obese sample of veterans enrolled in weight loss treatment. The presence of binge eating predicted poorer weight loss outcomes. Furthermore, high-frequency binge eating was associated with weight gain. These findings have operational and policy implications for developing effective strategies to address binge eating in the context of behavioral weight loss programs for veterans.

Small-changes obesity treatment among veterans: 12-month outcomes

BACKGROUND

Weight-loss trials tend to recruit highly selective, non-representative samples. Effective weight-loss approaches are needed for real-world challenging populations.

PURPOSE

To test whether a small-changes intervention, delivered in groups or via telephone, promotes greater weight loss than standard obesity treatment in a predominantly male, high-risk Veteran population. Data were collected in 2010-2012 and analyzed in 2013.

DESIGN

A three-arm, 12-month randomized pragmatic effectiveness trial.

SETTING/PARTICIPANTS

Four-hundred eighty-one overweight/obese participants from two Midwestern Veterans Affairs (VA) Medical Centers were randomly assigned to one of three programs: the 12-month Aspiring to Lifelong Health (ASPIRE) weight-loss program delivered (1) individually over the phone (ASPIRE-Phone) or (2) in-person group sessions (ASPIRE-Group); compared to (3) VA's standard weight-loss program (MOVE!).

INTERVENTION

Twenty-eight sessions with a non-clinician coach via telephone or in-person groups using a small-changes obesity treatment approach compared to a 15-30-session standard VA program.

MAIN OUTCOME MEASURES

Twelve-month change in weight (kilograms).

RESULTS

Participants in all three arms lost significant (p<0.01) weight at 12 months. Participants in the ASPIRE-Group arm lost significantly more weight at 12 months than those in the other two treatment arms (-2.8 kg, 95% CI=-3.8, -1.9, in ASPIRE-Group vs -1.4 kg, 95% CI=-2.4, -0.5, in ASPIRE-Phone and -1.4 kg, 95% CI=-2.3, -0.4) in MOVE!(®). ASPIRE-Group resulted in greater improvements in all other anthropometric measures compared to MOVE! at 12 months (p<0.05) and for all (p<0.05) but waist circumference (p=0.23) compared to ASPIRE-Phone.

CONCLUSIONS

Group-based delivery of the ASPIRE weight management program is more effective than MOVE! and the phone-based version of ASPIRE at promoting sustained weight loss in a predominantly male population with multiple comorbidities. The incremental benefits of group-based ASPIRE over the current MOVE! program could yield significant population-level benefits if implemented on a large scale.

Should providers encourage realistic weight expectations and satisfaction with lost weight in commercial weight loss programs? a preliminary study

Background

Attrition is a problem among patients who participate in commercial weight loss programs. One possible explanation is that if patients are unable to reach a weight that they expect to achieve, they may be more likely to drop out of treatment. This study investigated variables associated with attrition among 30 obese patients who completed a liquid meal replacement program (LMR) and enrolled in a 52-week Small Changes Maintenance intervention (SCM). Patients lost a median 18% of body weight during LMR and completed assessments about weight expectations and weight satisfaction pre- and post-SCM.

Findings

Of the 30 patients who started SCM, 8 (27%) were lost to attrition. Odds of SCM attrition were higher in patients who lost ≤ 18.2% of pre-LMR weight (OR: 12.25, P = 0.035), had lower satisfaction (≤7) pre-SCM (OR: 10.11, P = 0.040), and who expected further weight loss of 9.1 kg or more pre-SCM (OR: 10.11, P = 0.040). SCM completers significantly increased weight loss expectations by a median of 2.3 kg from pre-SCM to post-SCM (WSR P = 0.049) that paralleled weight regained post-SCM (2.7 kg).

Conclusions

After completion of a medically-supervised commercial weight loss program, patients with the greatest expectations for further weight loss and the lowest weight satisfaction were more likely to drop out of SCM. Failure to participate in maintenance treatment may lead to regain of greater than half of lost weight over the next year. Among SCM completers, lower expectations for further weight loss and greater weight satisfaction appeared to be associated with continued engagement in maintenance treatment.

Camp-based immersion treatment for obese, low socioeconomic status, multi-ethnic adolescents

BACKGROUND

Immersion treatment (IT) provided in a camp setting has been shown to promote short-term improvements in weight and health status in obese adolescents. However, evidence of IT's long-term efficacy and efficacy for multi-ethnic and lower socioeconomic status (SES) adolescents is limited.

METHODS

This was a cohort study with a pre/post design and longitudinal follow-up. The intervention was a 19-day camp-based IT program comprising (1) a nutrition curriculum and ad-lib access to a nutritious diet, (2) several hours of physical activity daily, (3) group therapy, and (4) cognitive-behavioral therapy (CBT). This analysis included 52 low-SES adolescents that participated in 2009 and 2010. A subgroup of 33 campers and their families was offered follow-up monthly for 10 months. Primary outcome measures were change in weight-related parameters immediately postcamp and after 10 months of follow-up.

RESULTS

Campers had significant short-term improvements in mean waist circumference (mean [M], 2.6; standard deviation [SD], 3.2 cm), weight (M, 2.6; SD, 1.9 kg), BMI (M, 1.1; SD, 0.9 kg/m2), BMI z-score (M, 0.06; SD, 0.07), and percent overweight (M, 6.1; SD, 4.7). Campers offered follow-up had a modest increase in mean percent overweight (M, 2.0; SD, 8.4) during 10 months of follow-up. However, 33% experienced continuing decline in percent overweight during follow-up, and long-term follow-up was associated with significant overall (precamp vs. end of follow-up) improvements in percent overweight (M, 4.9; SD, 7.2).

CONCLUSIONS

Camp-based IT with CBT is a promising intervention for improving short- and long-term weight status of low-SES adolescents. Additional research is needed to increase long-term efficacy.

Developing a new treatment paradigm for disease prevention and healthy aging

An increasingly prevalent pattern of risk factors has emerged in middle-aged and older adults that includes the presence of type 2 diabetes or prediabetes, overweight or obese weight status with central obesity and very high body fat, low cardiorespiratory fitness (CRF), low strength, and a low lean-body-mass-to-body-fat ratio. Traditionally, these problems have been approached with a low-fat and low-calorie diet and with lower to moderate intensity activity such as walking. While the treatment has some clear benefits, this approach may no longer be optimal because it does not reflect more recent findings from nutrition and exercise sciences. Specifically, these fields have gained a greater understanding of the metabolic and functional importance of focusing on reducing body fat and central obesity while maintaining or even increasing lean body mass, a quality weight loss, and how to efficiently and effectively increase CRF and strength. Evidence is presented for shifting the treatment paradigm for disease prevention and healthy aging to include the DASH nutrition pattern but with additional protein, higher intensity, brief aerobic training, effort-based, brief resistance training, and structured physical activity. Recent interventions based on social cognitive theory for initiating and then maintaining health behavior changes show the feasibility and efficacy of the approach we are advocating especially within a multiple health behavior change format and the potential for translating the new treatment paradigm into practice.

EMPOWER: a randomized trial using community health workers to deliver a lifestyle intervention program in African American women with Type 2 diabetes: design, rationale, and baseline characteristics

BACKGROUND

African American (AA) women with Type 2 diabetes mellitus (T2DM) in the rural south experience less weight loss and poorer glycemic control in traditional diabetes management programs compared to Caucasians. This paper describes the design, rationale, and baseline characteristics from an innovative community health worker (CHW) delivered intervention program in this population.

METHODS/DESIGN

This prospective trial randomized rural AA women with uncontrolled T2DM (HbA1c ≥ 7.0) to receive a behaviorally-centered, culturally-tailored lifestyle intervention during 16 contacts from a trained AA CHW or 16 approved diabetes educational mailings. Changes from baseline in glycosylated hemoglobin levels (HbA1c), blood pressure (BP), weight, body mass index (BMI), self-reported dietary and physical activity patterns, and psychosocial measures including diabetes distress, empowerment, depression, self-care, medication adherence, and life satisfaction will be assessed at 6- and 12-months.

BASELINE RESULTS

Two hundred AA women (mean age = 53.09 ± 10.89 years) with T2DM from impoverished rural communities were enrolled. Baseline data demonstrated profoundly uncontrolled diabetes of long term duration (mean HbA1c = 9.11 ± 1.82; mean BMI = 37.68 ± 8.20; mean BP = 134.51 ± 20.39/84.19 ± 11.68; 10.5 ± 0.7 years). Self-care behavior assessment revealed poor dietary and medication adherence and sedentary lifestyle. Most psychosocial measures ranged within normal limits.

CONCLUSION

The present sample of AA women from impoverished rural communities exhibited significantly uncontrolled T2DM of long duration with associated obesity and poor lifestyle behaviors. An innovative CHW led lifestyle intervention may lead to more effective strategies for T2DM management in this population.

Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings

BACKGROUND

A major challenge after successful weight loss is continuing the behaviors required for long-term weight maintenance. This challenge can be exacerbated in rural areas with limited local support resources.

OBJECTIVE

This study describes and compares program costs and cost effectiveness for 12-month extended-care lifestyle maintenance programs after an initial 6-month weight-loss program.

DESIGN

We conducted a 1-year prospective randomized controlled clinical trial.

PARTICIPANTS/SETTING

The study included 215 female participants age 50 years or older from rural areas who completed an initial 6-month lifestyle program for weight loss. The study was conducted from June 1, 2003 to May 31, 2007.

INTERVENTION

The intervention was delivered through local Cooperative Extension Service offices in rural Florida. Participants were randomly assigned to a 12-month extended-care program using either individual telephone counseling (n=67), group face-to-face counseling (n=74), or a mail/control group (n=74).

MAIN OUTCOME MEASURES

Program delivery costs, weight loss, and self-reported health status were directly assessed through questionnaires and program activity logs. Costs were estimated across a range of enrollment sizes to allow inferences beyond the study sample.

STATISTICAL ANALYSES PERFORMED

Nonparametric and parametric tests of differences across groups for program outcomes were combined with direct program cost estimates and expected value calculations to determine which scales of operation favored alternative formats for lifestyle maintenance.

RESULTS

Median weight regain during the intervention year was 1.7 kg for participants in the face-to-face format, 2.1 kg for the telephone format, and 3.1 kg for the mail/control format. For a typical group size of 13 participants, the face-to-face format had higher fixed costs, which translated into higher overall program costs ($420 per participant) when compared with individual telephone counseling ($268 per participant) and control ($226 per participant) programs. Although the net weight lost after the 12-month maintenance program was higher for the face-to-face and telephone programs compared with the control group, the average cost per expected kilogram of weight lost was higher for the face-to-face program ($47/kg) compared with the other two programs (approximately $33/kg for telephone and control).

CONCLUSIONS

Both the scale of operations and local demand for programs are important considerations in selecting a delivery format for lifestyle maintenance. In this study, the telephone format had a lower cost but similar outcomes compared with the face-to-face format.

Small changes approach promotes initial and continued weight loss with a phone-based follow-up: nine-month outcomes from ASPIRES II

PURPOSE

To examine the impact of a small-changes weight loss program across a 3-month intervention followed by a 6-month follow-up program.

DESIGN

A one-group pre-post intervention study.

SETTING

Medium-sized Southwestern university.

PARTICIPANTS

Twenty-five obese adult women (mean body mass index [BMI]  =  31.8 kg/m(2), standard deviation [SD]  =  4.9).

INTERVENTION

Participants were asked to choose and adopt small changes in their diet and physical activity relative to baseline during weekly group-based meetings over 3 months. Participants then received bi-weekly phone calls across a 6-month follow-up period.

MEASURES

Weight change was the primary outcome. Secondary outcomes included waist circumference, daily step count, and caloric intake.

ANALYSES

Intention-to-treat analysis of change from baseline and completers-only analysis (n  =  22) for secondary outcomes.

RESULTS

Participants achieved clinically significant weight loss (mean [M]  =  -3.2 kg, standard error [SE]  =  .47 kg, p < .001) across the initial small changes treatment program. Moreover, participants continued to lose weight across the 6-month phone-based follow-up program (M  =  -2.1 kg, SE  =  .83 kg, p < .017), totaling >5% weight loss across the 9-month program (M  =  5.3 kg, SE  =  1.1 kg, p < .001).

CONCLUSION

Using a small changes approach, participants achieved weight loss in an initial group-based program, which continued with minimal phone-based follow-up. Larger randomized studies comparing a small changes approach to traditional obesity treatment are warranted.

How many steps/day are enough? For older adults and special populations

Older adults and special populations (living with disability and/or chronic illness that may limit mobility and/or physical endurance) can benefit from practicing a more physically active lifestyle, typically by increasing ambulatory activity. Step counting devices (accelerometers and pedometers) offer an opportunity to monitor daily ambulatory activity; however, an appropriate translation of public health guidelines in terms of steps/day is unknown. Therefore this review was conducted to translate public health recommendations in terms of steps/day. Normative data indicates that 1) healthy older adults average 2,000-9,000 steps/day, and 2) special populations average 1,200-8,800 steps/day. Pedometer-based interventions in older adults and special populations elicit a weighted increase of approximately 775 steps/day (or an effect size of 0.26) and 2,215 steps/day (or an effect size of 0.67), respectively. There is no evidence to inform a moderate intensity cadence (i.e., steps/minute) in older adults at this time. However, using the adult cadence of 100 steps/minute to demark the lower end of an absolutely-defined moderate intensity (i.e., 3 METs), and multiplying this by 30 minutes produces a reasonable heuristic (i.e., guiding) value of 3,000 steps. However, this cadence may be unattainable in some frail/diseased populations. Regardless, to truly translate public health guidelines, these steps should be taken over and above activities performed in the course of daily living, be of at least moderate intensity accumulated in minimally 10 minute bouts, and add up to at least 150 minutes over the week. Considering a daily background of 5,000 steps/day (which may actually be too high for some older adults and/or special populations), a computed translation approximates 8,000 steps on days that include a target of achieving 30 minutes of moderate-to-vigorous physical activity (MVPA), and approximately 7,100 steps/day if averaged over a week. Measured directly and including these background activities, the evidence suggests that 30 minutes of daily MVPA accumulated in addition to habitual daily activities in healthy older adults is equivalent to taking approximately 7,000-10,000 steps/day. Those living with disability and/or chronic illness (that limits mobility and or/physical endurance) display lower levels of background daily activity, and this will affect whole-day estimates of recommended physical activity.

A small-change approach delivered via telephone promotes weight loss in veterans: results from the ASPIRE-VA pilot study

OBJECTIVE

High rates of overweight and obesity (70%) among US veterans pose a significant threat of obesity-related chronic disease and disability. The purpose of this pilot study was to demonstrate feasibility and impact of a phone-based small-change weight loss intervention (ASPIRE-VA) with veterans.

METHODS

Participants received a pedometer, food log book, and treatment manual outlining the small change program. Participants then scheduled weekly phone calls with a lifestyle coach, during which they reviewed the prior week's goals and developed new goals for the following week. Primary outcome was weight loss measured at 12 weeks, compared to baseline.

RESULTS

Fourteen sedentary (4471+/-2315 steps per day), obese (37.0+/-4.2 BMI), middle aged (53.8+/-12.5) male (64%) and female (36%) participants were enrolled. At 12 weeks participants exhibited significant weight loss (-3.8+/-3.6 kg; p=.002) and increased intake of fruits and vegetables (+2.2+/-3.1 daily servings; p=.03); though no change in walking (+786+/-2288 daily steps; p=.24).

CONCLUSION

Results suggest that a phone-based small change program is feasible and beneficial for promoting weight loss in overweight/obese veterans.

PRACTICE IMPLICATIONS

This telephone-based program has the potential to reduce rates of overweight and obesity among veterans and thus prevent and improve prognosis of associated chronic conditions.

Comparison of program costs for parent-only and family-based interventions for pediatric obesity in medically underserved rural settings

PURPOSE

To compare the costs of parent-only and family-based group interventions for childhood obesity delivered through Cooperative Extension Services in rural communities.

METHODS

Ninety-three overweight or obese children (aged 8 to 14 years) and their parent(s) participated in this randomized controlled trial, which included a 4-month intervention and 6-month follow-up. Families were randomized to either a behavioral family-based intervention (n = 33), a behavioral parent-only intervention (n = 34), or a waitlist control condition (n = 26). Only program costs data for the parent-only and family-based programs are reported here (n = 67). Assessments were completed at baseline, post-treatment (month 4) and follow-up (month 10). The primary outcome measures were total program costs and cost per child for the parent-only and family interventions.

FINDINGS

Twenty-six families in the parent-only intervention and 24 families in the family intervention completed all 3 assessments. As reported previously, both intervention programs led to significantly greater decreases in weight status relative to the control condition at month 10 follow-up. There was no significant difference in weight status change between the parent-only and family interventions. Total program costs for the parent-only and family interventions were 13,546 US dollars and 20,928, US dollars respectively. Total cost per child for the parent-only and family interventions were 521 US dollars and 872 US dollars, respectively.

CONCLUSIONS

Parent-only interventions may be a cost-effective alternative treatment for pediatric obesity, especially for families in medically underserved settings.

Comparison of parent-only vs family-based interventions for overweight children in underserved rural settings: outcomes from project STORY

OBJECTIVE

To assess the effectiveness of parent-only vs family-based interventions for pediatric weight management in underserved rural settings.

DESIGN

A 3-arm randomized controlled clinical trial.

SETTING

All sessions were conducted at Cooperative Extension Service offices in underserved rural counties.

PARTICIPANTS

Ninety-three overweight or obese children (8-14 years old) and their parent(s).

INTERVENTION

Families were randomized to (1) a behavioral family-based intervention, (2) a behavioral parent-only intervention, or (3) a wait-list control group.

OUTCOME MEASURE

The primary outcome measure was change in children's standardized body mass index (BMI).

RESULTS

Seventy-one children completed posttreatment (month 4) and follow-up (month 10) assessments. At the month 4 assessment, children in the parent-only intervention demonstrated a greater decrease in BMI z score (mean difference [MD], 0.127; 95% confidence interval [CI], 0.027 to 0.226) than children in the control condition. No significant difference was found between the family-based intervention and the control condition (MD, 0.065; 95% CI, -0.027 to 0.158). At month 10 follow-up, children in the parent-only and family-based intervention groups demonstrated greater decreases in BMI z score from before treatment compared with those in the control group (MD, 0.115; 95% CI, 0.003 to 0.220; and MD, 0.136; 95% CI, 0.018 to 0.254, respectively). No difference was found in weight status change between the parent-only and family-based interventions at either assessment.

CONCLUSIONS

A parent-only intervention may be a viable and effective alternative to family-based treatment of childhood overweight. Cooperative Extension Service offices have the potential to serve as effective venues for the dissemination of obesity-related health promotion programs.

Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial

BACKGROUND

Rural counties in the United States have higher rates of obesity, sedentary lifestyle, and associated chronic diseases than nonrural areas, yet the management of obesity in rural communities has received little attention from researchers.

METHODS

Obese women from rural communities who completed an initial 6-month weight-loss program at Cooperative Extension Service offices in 6 medically underserved rural counties (n = 234) were randomized to extended care or to an education control group. The extended-care programs entailed problem-solving counseling delivered in 26 biweekly sessions via telephone or face to face. Control group participants received 26 biweekly newsletters containing weight-control advice.

RESULTS

Mean weight at study entry was 96.4 kg. Mean weight loss during the initial 6-month intervention was 10.0 kg. One year after randomization, participants in the telephone and face-to-face extended-care programs regained less weight (mean [SE], 1.2 [0.7] and 1.2 [0.6] kg, respectively) than those in the education control group (3.7 [0.7] kg; P = .03 and .02, respectively). The beneficial effects of extended-care counseling were mediated by greater adherence to behavioral weight-management strategies, and cost analyses indicated that telephone counseling was less expensive than face-to-face intervention.

CONCLUSIONS

Extended care delivered either by telephone or in face-to-face sessions improved the 1-year maintenance of lost weight compared with education alone. Telephone counseling constitutes an effective and cost-efficient option for long-term weight management. Delivering lifestyle interventions via the existing infrastructure of the Cooperative Extension Service represents a viable means of adapting research for rural communities with limited access to preventive health services. Trial Registration clinicaltrials.gov Identifier: NCT00201006.

Sensible treatment of obesity in rural youth (STORY): design and methods

Project STORY is a 3-arm, randomized, planning and feasibility study assessing the effectiveness of two behavioral weight management interventions in an important and at-risk population, overweight children and their parents in medically underserved rural counties. Participants will include 90 parent-child dyads from rural counties in north central Florida. Families will be randomized to one of three conditions: (a) a Family-Based Behavioral Group Intervention, (b) a Parent-Only Behavioral Group Intervention, and (c) a waitlist control condition. Child and parent participants will be assessed at baseline (month 0), post-treatment (month 4) and follow-up (month 10). Assessment and intervention sessions will be held at Cooperative Extension offices within each local participating county. The primary outcome measure is change in child body mass index (BMI) z-score. Additional key outcome measures include child dietary intake, physical activity, self-esteem, body image, and parent BMI. The goals of the study are to (a) assess the feasibility of recruitment in rural settings, (b) develop and evaluate training protocol for group leaders, (c) determine strategies to increase adherence to monitoring and goal setting protocol, (d) evaluate strategies for participant retention, (e) assess the relative cost-effectiveness of the interventions, (f) assess the acceptability of the intervention to families and Cooperative Extension administrators and personnel, and (g) if successful, estimate the sample size needed for a full-scale trial. This research has potential implications for medically underserved rural communities with limited resources and preventive health care services. If successful, a Parent-Only intervention program may provide a cost-effective and practical intervention for families in underserved rural communities.