Rationale, design, and sample characteristics of a practical randomized trial to assess a weight loss intervention for low-income women: the Weight-Wise II Program

Successful long-term weight loss among participants with diabetes receiving an intervention promoting an adapted Mediterranean-style dietary pattern: the Heart Healthy Lenoir Project

OBJECTIVE

To examine weight change by diabetes status among participants receiving a Mediterranean-style diet, physical activity, and weight loss intervention adapted for delivery in the southeastern USA, where rates of cardiovascular disease (CVD) are disproportionately high.

RESEARCH DESIGN AND METHODS

The intervention included: Phase I (months 1-6), an individually tailored intervention promoting a Mediterranean-style dietary pattern and increased walking; Phase II (months 7-12), option of a 16-week weight loss intervention for those with BMI≥25 kg/m² offered as 16 weekly group sessions or 5 group sessions and 10 phone calls, or a lifestyle maintenance intervention; and Phase III (months 13-24), weight loss maintenance intervention for those losing ≥8 pounds with all others receiving a lifestyle maintenance intervention. Weight change was assessed at 6, 12, and 24-month follow-up.

RESULTS

Baseline characteristics (n=339): mean age 56, 77% female, 65% African-American, 124 (37%) with diabetes; mean weight 103 kg for those with diabetes and 95 kg for those without. Among participants with diabetes, average weight change was -1.2 kg (95% CI -2.1 to -0.4) at 6 months (n=92), -1.5 kg (95% CI -2.9 to -0.2) at 12 months (n=96), and -3.7 kg (95% CI -5.2 to -2.1) at 24 months (n=93). Among those without diabetes, weight change was -0.4 kg (95% CI -1.4 to 0.6) at 24 months (n=154).

CONCLUSIONS

Participants with diabetes experienced sustained weight loss at 24-month follow-up. High-risk US populations with diabetes may experience clinically important weight loss from this type of lifestyle intervention.

TRIAL REGISTRATION NUMBER

NCT01433484.

A community-based lifestyle and weight loss intervention promoting a Mediterranean-style diet pattern evaluated in the stroke belt of North Carolina: the Heart Healthy Lenoir Project

BACKGROUND

Because residents of the southeastern United States experience disproportionally high rates of cardiovascular disease (CVD), it is important to develop effective lifestyle interventions for this population.

METHODS

The primary objective was to develop and evaluate a dietary, physical activity (PA) and weight loss intervention for residents of the southeastern US. The intervention, given in eastern North Carolina, was evaluated in a 2 year prospective cohort study with an embedded randomized controlled trial (RCT) of a weight loss maintenance intervention. The intervention included: Phase I (months 1-6), individually-tailored intervention promoting a Mediterranean-style dietary pattern and increased walking; Phase II (months 7-12), option of a 16-week weight loss intervention for those with BMI ≥ 25 kg/m(2) offered in 2 formats (16 weekly group sessions or 5 group sessions and 10 phone calls) or a lifestyle maintenance intervention; and Phase III (months 13-24), weight loss maintenance RCT for those losing ≥ 8 lb with all other participants receiving a lifestyle maintenance intervention. Change in diet and PA behaviors, CVD risk factors, and weight were assessed at 6, 12, and 24 month follow-up.

RESULTS

Baseline characteristics (N = 339) were: 260 (77 %) females, 219 (65 %) African Americans, mean age 56 years, and mean body mass index 36 kg/m(2). In Phase I, among 251 (74 %) that returned for 6 month follow-up, there were substantial improvements in diet score (4.3 units [95 % CI 3.7 to 5.0]), walking (64 min/week [19 to 109]), and systolic blood pressure (-6.4 mmHg [-8.7 to -4.1]) that were generally maintained through 24 month follow-up. In Phase II, 138 (57 group only, 81 group/phone) chose the weight loss intervention and at 12 months, weight change was: -3.1 kg (-4.9 to -1.3) for group (N = 50) and -2.1 kg (-3.2 to -1.0) for group/phone combination (N = 75). In Phase III, 27 participants took part in the RCT. At 24 months, weight loss was -2.1 kg (-4.3 to 0.0) for group (N = 51) and -1.1 kg (-2.7 to 0.4) for combination (N = 72). Outcomes for African American and whites were similar.

CONCLUSIONS

The intervention yielded substantial improvement in diet, PA, and blood pressure, but weight loss was modest.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01433484.

Assessing the Feasibility of a Web-Based Weight Loss Intervention for Low-Income Women of Reproductive Age: A Pilot Study

Background

Low-income women of reproductive age are at increased risk for obesity and resulting increases in the risk of maternal/fetal complications and mortality and morbidity. Very few weight-loss interventions, however, have been targeted to this high-risk group. Based on the high prevalence of social media use among young and low-income individuals and previous successes using group formats for weight-loss interventions, the use of social media as a platform for weight-loss intervention delivery may benefit low-income women of reproductive age.

Objective

Examine the feasibility of delivering group-based weight-loss interventions to low-income women of reproductive age using face-to-face meetings and Web-based modalities including social media.

Methods

Participants attended a family planning clinic in eastern North Carolina and received a 5-month, group- and Web-based, face-to-face weight-loss intervention. Measures were assessed at baseline and 20 weeks.

Results

Forty participants enrolled, including 29 (73%) African American women. The mean body mass index of enrollees was 39 kg/m². Among the 12 women who completed follow-up, mean weight change was -1.3 kg. Participation in the intervention was modest and retention at 5 months was 30%. Returnees suggested sending reminders to improve participation and adding activities to increase familiarity among participants.

Conclusions

Engagement with the intervention was limited and attrition was high. Additional formative work on the barriers and facilitators to participation may improve the intervention’s feasibility with low-income women of reproductive age.

Personalized Weight Management Interventions for Cardiovascular Risk Reduction: A Viable Option for African-American Women

Obesity is an independent contributor to cardiovascular disease (CVD) and a major driving force behind racial/ethnic and gender disparities in risk. Due to a multitude of interrelating factors (i.e., personal, social, cultural, economic and environmental), African-American (AA) women are disproportionately obese and twice as likely to succumb to CVD, yet they are significantly underrepresented in behavioral weight management interventions. In this selective review we highlight components of the limited interventions shown to enhance weight loss outcomes in this population and make a case for leveraging Web-based technology and artificial intelligence techniques to deliver personalized programs aimed at obesity treatment and CVD risk reduction. Although many of the approaches discussed are generally applicable across populations burdened by disparate rates of obesity and CVD, we specifically focus on AA women due to the disproportionate impact of these non-communicable diseases and the general paucity of interventions targeted to this high-risk group.

Fidelity to and comparative results across behavioral interventions evaluated through the RE-AIM framework: a systematic review

BACKGROUND

The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was developed to determine potential public health impact of interventions (i.e., programs, policy, and practice). The purpose of this systematic review was to determine (1) comparative results across accurately reported RE-AIM indicators, (2) relevant information when there remains under-reporting or misclassification of data across each dimension, (3) the degree to which authors intervened to improve outcomes related to each dimension, and (4) the number of articles reporting RE-AIM dimensions for a given study.

METHODS

In April 2013, a systematic search of the RE-AIM framework was completed in PubMed, PSYCHInfo, EbscoHost, Web of Science, and Scopus. Evidence was analyzed until January 2015.

RESULTS

Eighty-two interventions that included empirical data related to at least one of the RE-AIM dimensions were included in the review. Across these interventions, they reached a median sample size of 320 participants (M = 4894 ± 28,256). Summarizing the effectiveness indicators, we found that: the average participation rate was 45 % (±28 %), 89 % of the interventions reported positive changes in the primary outcome and 11 interventions reported broader outcomes (e.g., quality of life). As for individual-level maintenance, 11 % of studies showed effects ≥6 months post-program. Average setting and staff adoption rates were 75 % (±32 %) and 79 % (±28 %), respectively. Interventions reported being delivered as intended (82 % (±16 %)) and 22 % intervention reported adaptations to delivery. There were insufficient data to determine average maintenance at the organizational level. Data on costs associated with each dimension were infrequent and disparate: four studies reported costs of recruitment, two reported intervention costs per participant, and two reported adoption costs.

CONCLUSIONS

The RE-AIM framework has been employed in a variety of populations and settings for the planning, delivery, and evaluation of behavioral interventions. This review highlights inconsistencies in the degree to which authors reported each dimension in its entirety as well as inaccuracies in reporting indicators within each dimension. Further, there are few interventions that aim to improve outcomes related to reach, adoption, implementation, and maintenance.

Psychometric properties of the modified RESIDE physical activity questionnaire among low-income overweight women

OBJECTIVES

This study explored the criterion-related validity and test-retest reliability of the modified RESIDential Environment physical activity questionnaire and whether the instrument's validity varied by body mass index, education, race/ethnicity, or employment status.

DESIGN

Validation study using baseline data collected for randomized trial of a weight loss intervention.

METHODS

Participants recruited from health departments wore an ActiGraph accelerometer and self-reported non-occupational walking, moderate and vigorous physical activity on the modified RESIDential Environment questionnaire. We assessed validity (n=152) using Spearman correlation coefficients, and reliability (n=57) using intraclass correlation coefficients.

RESULTS

When compared to steps, moderate physical activity, and bouts of moderate/vigorous physical activity measured by accelerometer, these questionnaire measures showed fair evidence for validity: recreational walking (Spearman correlation coefficients 0.23-0.36), total walking (Spearman correlation coefficients 0.24-0.37), and total moderate physical activity (Spearman correlation coefficients 0.18-0.36). Correlations for self-reported walking and moderate physical activity were higher among unemployed participants and women with lower body mass indices. Generally no other variability in the validity of the instrument was found. Evidence for reliability of RESIDential Environment measures of recreational walking, total walking, and total moderate physical activity was substantial (intraclass correlation coefficients 0.56-0.68).

CONCLUSIONS

Evidence for questionnaire validity and reliability varied by activity domain and was strongest for walking measures. The questionnaire may capture physical activity less accurately among women with higher body mass indices and employed participants. Capturing occupational activity, specifically walking at work, may improve questionnaire validity.

Effectiveness of Diabetes Prevention Program translations among African Americans

The Diabetes Prevention Program (DPP) demonstrated risk reduction for incident diabetes through weight loss among all participants, including African Americans. Several DPP translations have been conducted in less controlled settings, including primary care practices and communities; however, there is no detailed compilation of how effective these translations have been for African Americans. This systematic literature review evaluated DPP translations from 2003 to 2012. Eligible records were retrieved using a search strategy of relevant databases and gray literature. Retrieved records (n=1,272) were screened using a priori criteria, which resulted in 21 full-text studies for review. Seventeen studies were included in the full-text qualitative synthesis. Seven studies had 100% African American samples and 10 studies had mixed samples with African American subgroups. African American participants' average weight loss was roughly half of that achieved in the DPP intervention. However, with few higher-quality studies, small sample sizes and differences in intervention designs and implementation, comparisons across interventions were difficult. The suboptimal effectiveness of DPP translations among African American adults, particularly women, signals the need for enhancements to existing evidence-based interventions and more high-quality research that includes other at-risk African American subgroups such as men and younger adults of lower socioeconomic status.

Operationalizing the RE-AIM framework to evaluate the impact of multi-sector partnerships

Background

The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework is a reliable tool for the translation of research to practice. This framework has been widely applied to assess the impact of individual interventions. However, RE-AIM has rarely been used to evaluate implementation interventions, especially from multi-sector partnerships. The primary purpose of this paper is to operationalize the RE-AIM approach to evaluate large, multi-sector partnerships. SCI Action Canada, a community-university partnership aimed to promote physical activity among adults with spinal cord injury, is used as an example. A secondary purpose is to provide initial data from SCI Action Canada by using this conceptualization of RE-AIM.

Methods

Each RE-AIM element is operationalized for multi-sector partnerships. Specific to SCI Action Canada, seven reach calculations, four adoption rates, four effectiveness outcomes, one implementation, one organizational maintenance, and two individual maintenance outcomes are defined. The specific numerators based on SCI Action Canada activities are also listed for each of these calculations.

Results

The results are derived from SCI Action Canada activities. SCI Action Canada’s reach ranged from 3% (end-user direct national reach) to 37% (total regional reach). Adoption rates were 15% (provincial level adoption) to 76% (regional level adoption). Implementation and organizational maintenance rates were 92% and 100%, respectively.

Conclusions

We have operationalized the RE-AIM framework for larger multi-sectoral partnerships and demonstrated its applicability to such partnerships with SCI Action Canada. Future partnerships could use RE-AIM to assess their public health impact.

Translation of a behavioral weight loss intervention for mid-life, low-income women in local health departments

OBJECTIVE

To translate a behavioral weight loss intervention for mid-life, low-income women in real world settings.

DESIGN AND METHODS

In this pragmatic clinical trial, we randomly selected six North Carolina county health departments and trained their current staff to deliver a 16-session evidence-based behavioral weight loss intervention (special intervention, SI). SI weight loss outcomes were compared to a delayed intervention (DI) control group.

RESULTS

Of 432 women expressing interest, 189 completed baseline measures and were randomized within health departments to SI (N = 126) or DI (N = 63). At baseline, average age was 51 years, 53% were African American, mean weight was 100 kg, and BMI averaged 37 kg/m2 . A total of 96 (76%) SI and 55 (87%) DI participants returned for 5-month follow-up measures. The crude weight change was -3.1 kg in the SI and -0.4 kg in the DI group, for a difference of 2.8 kg (95% CI 1.4 to 4.1, p = 0.0001). Diet quality and physical activity improved significantly more in the SI group, and estimated intervention costs were $327 per participant.

CONCLUSION

This pragmatic short-term weight loss intervention targeted to low-income mid-life women yielded meaningful weight loss when translated to the county health department setting.

Development and evaluation of a brief questionnaire to assess dietary fat quality in low-income overweight women in the southern United States

OBJECTIVE

To develop a brief questionnaire to assess dietary fat quality, the Dietary Fat Quality Assessment (DFQA), for use in dietary counseling to reduce heart disease risk.

METHODS

A subsample of 120 underserved, midlife women enrolled in a randomized, controlled weight loss trial completed baseline and follow-up telephone surveys. Main outcome measures included dietary fat components (total fat, saturated fat, polyunsaturated fat, monounsaturated fat, omega-3 fatty acids, and cholesterol).

RESULTS

Assessments of major dietary fat components using the DFQA and a food frequency questionnaire were significantly correlated, with correlation coefficients of 0.54-0.66 (P < .001). Intra-class correlation coefficients to assess reliability ranged from 0.48 to 0.59 for each of the fat components studied.

CONCLUSIONS AND IMPLICATIONS

The DFQA provides a reasonable assessment of dietary fat quality associated with coronary heart disease risk and may prove useful as a brief assessment tool to guide dietary counseling given to reduce heart disease risk.

Use of RE-AIM to Address Health Inequities: Application in a low-income community health center based weight loss and hypertension self-management program

BACKGROUND

While health inequities are well documented, and there are helpful frameworks to understand health disparities, implementation frameworks are also needed to focus the design, evaluation and reporting on interventions targeting populations at increased risk.

PURPOSE

Describe how the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) can be used for these purposes and illustrate its application in the context of a randomized, pragmatic weight-loss and hypertension self-management intervention.

METHODS

RE-AIM was used to both plan and evaluate the Be Fit Be Well program for urban community health center patients.

RESULTS

The RE-AIM framework helped to focus attention on and produce high rates of adoption and reach. Implementation rates varied across components. Weight losses were statistically significant, but not clinically significant. They were robust across a variety of patient characteristics, and the program was relatively low cost. Individual weight losses and blood pressure reductions were maintained throughout the 24-month period, but the program was not sustained at any of the three settings.

CONCLUSION

Implementation frameworks such as RE-AIM can help design pragmatic interventions that focus on both the context for disparities reduction and the ultimate goal of public health impact.

Promoting fruit and vegetable consumption among members of black churches, Michigan and North Carolina, 2008-2010

INTRODUCTION

Evidence-based health promotion programs that are disseminated in community settings can improve population health. However, little is known about how effective such programs are when they are implemented in communities. We examined community implementation of an evidence-based program, Body and Soul, to promote consumption of fruits and vegetables.

METHODS

We randomly assigned 19 churches to 1 of 2 arms, a colon cancer screening intervention or Body and Soul. We conducted our study from 2008 through 2010. We used the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to evaluate the program and collected data via participant surveys, on-site observations, and interviews with church coordinators and pastors.

RESULTS

Members of 8 churches in Michigan and North Carolina participated in the Body and Soul program. Mean fruit and vegetable consumption increased from baseline (3.9 servings/d) to follow-up (+0.35, P = .04). The program reached 41.4% of the eligible congregation. Six of the 8 churches partially or fully completed at least 3 of the 4 program components. Six churches expressed intention to maintain the program. Church coordinators reported limited time and help to plan and implement activities, competing church events, and lack of motivation among congregation members as barriers to implementation.

CONCLUSIONS

The RE-AIM framework provided an effective approach to evaluating the dissemination of an evidence-based program to promote health. Stronger emphasis should be placed on providing technical assistance as a way to improve other community-based translational efforts.

Baseline reach and adoption characteristics in a randomized controlled trial of two weight loss interventions translated into primary care: a structured report of real-world applicability

BACKGROUND

Although the Diabetes Prevention Program (DPP) lifestyle intervention reduced type 2 diabetes incidence by 58% among high-risk adults at academic centers, it requires translation into typical primary care settings. Using baseline data from the Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care (E-LITE) randomized controlled trial, we evaluated the potential of its two DPP-based interventions to reach their target populations and be adopted into routine use.

METHODS

Overweight/obese adults with increased cardiometabolic risk enrolled from one primary care clinic. Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model, we assessed reach with data on patient identification, participation, and representativeness, and adoption with data on intervention feasibility and potential for organizational diffusion.

RESULTS

The target population was identified by searching electronic health records. Contact was attempted for 2391 patients who completed initial screening by phone (56% uptake) or online (44%). Most (88%) of those screened ineligible were not within the target population; 12% were excluded because of research requirements. Conservatively estimated participation rate was 44%. Participants (n=241) included 54% men and had a mean (SD) age of 52.9 years (10.6) and body mass index of 32 kg/m(2) (5.4). Regarding adoption, all clinic physicians agreed to participate. The feasibility of intervention implementation and dissemination was enhanced by leveraging existing intervention, training, and primary care resources.

CONCLUSIONS

E-LITE's lifestyle interventions had fair-to-good potential for primary care reach and adoption. Our trial evidence and structured reporting may inform real-world implementation of translational trials by health networks, physicians, and payers.

Food Store Environment Modifies Intervention Effect on Fruit and Vegetable Intake among Low-Income Women in North Carolina

Background. The aim of the study is to determine how the food store environment modifies the effects of an intervention on diet among low-income women. Study Design. A 16-week face-to-face behavioral weight loss intervention was delivered among low income midlife women. Methods. The retail food environment for all women was characterized by (1) the number and type of food stores within census tracts; (2) availability of healthy foods in stores where participants shop; (3) an aggregate score of self-reported availability of healthy foods in neighborhood and food stores. Statistical Analyses. Multivariable linear regression was used to model the food store environment as an effect modifier between the intervention effect of fruit and vegetable serving change. Results. Among intervention participants with a low perception of availability of healthy foods in stores, the intervention effect on fruit and vegetable serving change was greater [1.89, 95% CI (0.48, 3.31)] compared to controls. Among intervention participants residing in neighborhoods with few super markets, the intervention effect on fruit and vegetable serving change was greater [1.62, 95% CI (1.27, 1.96)] compared to controls. Conclusion. Results point to how the food store environment may modify the success of an intervention on diet change among low-income women.