A randomized trial of a small changes approach for weight loss in veterans: design, rationale, and baseline characteristics of the ASPIRE-VA trial

A randomized controlled trial of a "Small Changes" behavioral weight loss treatment delivered in cardiac rehabilitation for patients with atrial fibrillation and obesity: study protocol for the BE-WEL in CR-AF study

BACKGROUND

Atrial fibrillation (AF) represents a global epidemic. Although international AF practice guidelines indicate weight loss for patients with AF and comorbid obesity (BMI ≥ 30 kg/m2) to alleviate symptom burden and improve prognosis, few cardiac rehabilitation (CR) programs include targeted weight loss treatment.

AIMS

This RCT protocol will evaluate the efficacy of a "Small Changes" behavioral weight loss treatment (BWLT) to produce clinically relevant (≥ 10%) weight loss among patients with AF and obesity undergoing CR, relative to CR alone. Secondary aims are to establish efficacy of CR + BWLT for improving AF symptoms, AF risk factors, and health-related quality of life.

METHODS

Adults (18 +) with AF and obesity will be recruited and randomized to receive CR + BWLT (intervention) or CR-only (control). Controls will receive CR consisting of supervised exercise and risk factor self-management for 12 weeks. The intervention group will receive CR plus BWLT (12 weekly, group-based virtual sessions, followed by 12 weeks of follow-up support). Weight and AF-risk factors will be assessed at pre-randomization, 12 weeks, 24 weeks, and 52 weeks. AF burden will be assessed using 30-s ECGs recorded bidaily and with AF symptoms. The primary endpoint of weight loss will be calculated from baseline to 52 weeks as a percentage of starting weight. Intention-to-treat analyses will compare the proportion in each group achieving ≥ 10% weight loss. Assuming success rates of 5% and 30% among controls and intervention groups, respectively, and a 30% loss to follow-up, 120 patients (60 per group) will provide 80% power to detect a difference using a two-sided independent test of proportions (alpha = 5%).

IMPACT

This clinical trial will be the first to demonstrate that adding BWLT to CR promotes clinically meaningful weight loss among patients with AF and comorbid obesity. Findings will inform design and execution of a large efficacy trial of long-term (e.g., 5-year) clinical endpoints (e.g., AF severity, mortality). Implementing weight control interventions designed to target the AF substrate in CR could dramatically reduce morbidity and enhance quality of life among patients living with AF in Canada.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT05600829. Registered October 31, 2022.

Continuous quality improvement at the frontline: One interdisciplinary clinical team's four-year journey after completing a virtual learning program

Background

The Veterans Health Administration (VHA) is the largest integrated health system in the U.S. and has identified the learning health system as a strategic priority. Clinicians and staff engaging in active learning through continuous quality improvement (QI) is a key pillar for learning system maturity. An interdisciplinary frontline team at a VHA medical center participated in the Learn. Engage. Act. Process. (LEAP) virtual coaching program to learn how to conduct multidisciplinary team-based QI cycles of change. These clinicians lead and deliver the MOVE! weight management program, an evidence-based comprehensive lifestyle intervention. The team worked to continuously improve patient weight loss by engaging in incremental learning cycles of change. The aim of this study is to tell the story of this team's learning experience and the resulting positive reinforcing loop with patient outcomes.

Methods

This is a mixed methods case study description of one team that participated in the LEAP Program that provides hands-on QI learning for frontline teams with virtual coaching and a structured curriculum. Autoethnographic qualitative descriptions of team experiences over time illustrate this team's continued engagement in learning loops. Multilevel linear modeling was used to assess patient outcomes before vs after the team's participation in LEAP.

Results

The team's participation in LEAP provided a set of fundamental QI skills and established a commitment to continual learning. Incremental improvements led to significant weight loss for patients who participated in MOVE! after the team completed LEAP (mean = 9.80 pounds; SD 10.43) compared to the pre-LEAP time period (mean = -6.83 pounds; SD 9.63).

Conclusions

Despite competing priorities and time limitations, this team's experiences provide a positive vision of how team engagement in data-driven continuous learning is feasible at the frontline and can lead to higher job satisfaction and stronger teams. These types of team activities provide much-needed backbone to being a mature learning health system.

An Acceptance Based Lifestyle Intervention in Black Breast Cancer Survivors with Obesity

To assess the feasibility and early efficacy of a combined lifestyle and acceptance-based therapy (ABT) intervention on weight loss at 16 weeks among Black breast cancer (BC) survivors with obesity. Thirty black breast cancer survivors with a BMI ≥ 30 kg/m2 at least 6 months post-treatment were enrolled. Outcomes included feasibility process measures, physical well-being assessed using the subscale of QOL-Breast Cancer (QOL-BC), physical activity assessed by Global Physical Activity Questionnaire (GPAQ), and weight. Fisher's Exact/Chi-Squared tests and Wilcoxon rank-sum tests were used to explore differences between responders and non-responders, as well as within-group changes during the intervention. Within the first 4 weeks, responders (participants who lost any weight) lost a median of 2.6 lbs. compared to non-responders (no weight loss) who gained a median of 2.6 lbs. At 16 weeks, participants reported greater physical well-being (p < 0.0001), increased time in recreational activities (p = 0.03), and a median weight loss of 5.6 pounds in responders vs. 0.7 pounds in non-responders (p ≤ 0.001). Non-responders were more likely to have developed a new health condition compared to responders (44% vs. 0%; p = 0.014). In this study, weight loss at 4 weeks and new-onset health conditions were significant factors associated with non-response to the combined intervention. Black BC with obesity are at high risk for recurrent cancer and secondary health conditions. ABT may be a suitable adjunct therapeutic option to lifestyle interventions implemented soon after a cancer diagnosis to improve physical well-being, increase physical activity, and promote weight loss.

Conceptualizing outcomes for use with the Consolidated Framework for Implementation Research (CFIR): the CFIR Outcomes Addendum

BACKGROUND

The challenges of implementing evidence-based innovations (EBIs) are widely recognized among practitioners and researchers. Context, broadly defined as everything outside the EBI, includes the dynamic and diverse array of forces working for or against implementation efforts. The Consolidated Framework for Implementation Research (CFIR) is one of the most widely used frameworks to guide assessment of contextual determinants of implementation. The original 2009 article invited critique in recognition for the need for the framework to evolve. As implementation science has matured, gaps in the CFIR have been identified and updates are needed. Our team is developing the CFIR 2.0 based on a literature review and follow-up survey with authors. We propose an Outcomes Addendum to the CFIR to address recommendations from these sources to include outcomes in the framework.

MAIN TEXT

We conducted a literature review and surveyed corresponding authors of included articles to identify recommendations for the CFIR. There were recommendations to add both implementation and innovation outcomes from these sources. Based on these recommendations, we make conceptual distinctions between (1) anticipated implementation outcomes and actual implementation outcomes, (2) implementation outcomes and innovation outcomes, and (3) CFIR-based implementation determinants and innovation determinants.

CONCLUSION

An Outcomes Addendum to the CFIR is proposed. Our goal is to offer clear conceptual distinctions between types of outcomes for use with the CFIR, and perhaps other determinant implementation frameworks as well. These distinctions can help bring clarity as researchers consider which outcomes are most appropriate to evaluate in their research. We hope that sharing this in advance will generate feedback and debate about the merits of our proposed addendum.

Weight management for adults with mobility related disabilities: Rationale and design for an 18-month randomized trial

Adults with mobility related disabilities (MRDs) represent an underserved group with a high prevalence of overweight/obesity and limited options for weight management. We previously demonstrated clinically meaningful 12-month weight loss in adults with MRDs (-6.2%, 36% ≥5% of baseline weight) using an enhanced Stop Light Diet (eSLD) delivered using at home face-to-face behavioral sessions and optional physical activity. However, the costs/logistics associated with intervention delivery by individual home visits limits the potential for scaling and implementation of this approach. Thus, we will conduct a two-arm randomized trial in 128 overweight/obese adults with MRDs to compare weight loss (6 mos.) and maintenance (12 mos.) between interventions utilizing the eSLD, behavioral counseling, and increased physical activity delivered to individual participants in their homes or delivered to groups of participants in their homes remotely via video conferencing. The primary aim will compare weight loss between interventions arms across 6 months. Secondarily, we will compare weight loss (0-18 mos.), the proportion of participants who achieve clinically meaningful weight loss (≥5%) from 0 to 6 and 0 to18 months, and changes in quality of life from 0 to 6 and 0 to 18 months between interventions arms. We will also conduct cost, cost-effectiveness and contingent valuation comparisons and explore the influence of behavioral session attendance, compliance with the recommendations for diet and physical activity, self-monitoring of diet and physical activity, barriers to physical activity, sleep quality, and medications on weight change across 6 and 18 months. NCT REGISTRATION: NCT04046471.

Comparing the Recommended Eating Patterns of the EAT-Lancet Commission and Dietary Guidelines for Americans: Implications for Sustainable Nutrition

The purpose of this research was to compare the global reference diet from the EAT-Lancet Commission on Healthy Diets from Sustainable Food Systems (EAT-Lancet) with the healthy eating patterns from the 2015-2020 Dietary Guidelines for Americans (DGA). Conversion factors were developed to quantitatively compare the patterns. These factors are provided to enable investigators to incorporate the EAT-Lancet diet into analyses while maintaining relevance to US-based dietary guidance. Our findings show several areas of agreement between EAT-Lancet and the DGA but key differences in the amounts of whole grains, fruit, starchy vegetables, red meat, nuts and seeds, and discretionary calories. Many of the differences between the patterns reflect divergent approaches to developing dietary recommendations, not only methodologically but also regarding whether current food consumption patterns are considered as constraints on recommendations. Continued interdisciplinary collaboration is needed to advance dietary guidance that promotes sustainable nutrition.

Food Price Elasticity by Status of Participation in Federal Food Assistance Programs: A Laboratory-Based Grocery Store Study

Background

Federal food assistance programs target low-income and nutritionally vulnerable Americans, with the dual goals of reducing food insecurity and improving diet quality. Individuals on limited food budgets may face constraints on their ability to purchase healthy foods when their prices increase, which could mitigate the intended impact of federal feeding programs. To better understand the effect of food price changes on healthy food purchases, we focus on eggs, which are rich in many important nutrients and can be a healthy part of a wide range of cultural food menus.

Objective

We use a laboratory-based grocery store experiment (n = 80) to examine the difference in price elasticity of eggs between individuals participating in food assistance programs and those not participating in these programs. This trial was registered at clinicaltrials.gov as NCT03296878.

Methods

Subjects completed several food purchasing trials, as well as questionnaires that assessed demographic, psychosocial, and other factors. Mixed linear regression models were used to assess the relationship between food price changes and food purchases (price elasticity).

Results

No difference in price elasticity was observed between groups, but subjects in both groups decreased their egg purchases by 6.9–8.6% for every 10% increase in egg price. For every 10% increase in the price of all nonegg foods, egg purchases increased by 3.3% among federal food assistance program participants but not nonparticipants, and purchases for foods such as lean meats, low-fat dairy, fruits, vegetables, and whole grains decreased by up to 14% among both groups.

Conclusions

Efforts to emphasize healthy eating strategies for individuals on limited budgets will be especially important during times of food price increases. Additional research is needed to estimate the price elasticities of other food groups among individuals participating in federal food assistance programs.

Study design for a clinical trial to examine food price elasticity among participants in federal food assistance programs: A laboratory-based grocery store study

We present a protocol for a study investigating the effect of food price changes on purchasing decisions among individuals participating in federal food assistance programs and among those not participating in these programs. We use a laboratory-based grocery store design, which provides greater control over factors influencing food purchasing than in situ experiments in actual grocery stores. We focus primarily, but not exclusively, on eggs because they are highly nutritious, easy to prepare, can be included in many different dishes, and are a part of a wide range of cultural food menus. The primary aim of this study is to compare the own-and cross-price elasticity of eggs between individuals participating in federal food assistance programs and those not participating in these programs. Our secondary aims are to 1) compare the own- and cross-price elasticity of eggs between overweight/obese individuals and non-overweight/obese individuals, 2) examine whether delay discounting moderates the effect of income on own- and cross-price elasticity, 3) examine whether subjective social status moderates the effect of participation in federal food assistance programs on the purchase of high nutrient-dense foods, and 4) examine whether usual psychological stress level moderates the effect of subjective social status on the purchase of high-nutrient dense foods. The results of this study will provide information about the drivers of food demand among low-income adults. A better understanding of these drivers is needed to develop effective nutrition interventions for this large population.

Nutrient intake disparities in the US: modeling the effect of food substitutions

Background

Diet quality among federal food assistance program participants remains low, and little research has assessed the diet quality of food insecure non-participants. Further research is needed to assess the extent to which food substitutions can improve the nutritional status of these vulnerable populations. Substituting egg dishes for other commonly consumed dishes at certain eating occasions may be an effective strategy for improving the daily nutrient intake among these groups. Eggs are rich in many important nutrients, and are low-cost and part of a wide range of cultural food menus, which are important considerations for low-income and ethnically diverse populations. To help guide the focus of targeted nutrition interventions and education campaigns for vulnerable populations, the present work begins by 1) estimating the prevalence of nutrient inadequacy among these groups, and then models the effect of consuming egg dishes instead of commonly consumed dishes at each eating occasion on 2) the prevalence of nutrient inadequacy, and 3) the mean intake of nutrients.

Methods

Dietary data from 34,741 adults ≥ 20 y were acquired from the National Health and Nutrition Examination Survey, 2001–2014. Diet pattern modeling was used to substitute commonly consumed egg dishes for commonly consumed main dishes at breakfast, lunch, and dinner. National Cancer Institute usual intake methods were used to estimate the prevalence of inadequate intake of 31 nutrients pre- and post-substitution, and a novel index was used to estimate change in intake of all nutrients collectively.

Results

Substituting eggs for commonly consumed main dishes at lunch or dinner did not change total daily nutrient intake for each group (P > 0.05), but decreased the prevalence of vitamin D inadequacy by 1–4 percentage points (P < 0.01). Substituting eggs for commonly consumed foods at breakfast increased the prevalence of folate inadequacy by 8–12 percentage points among each group (P < 0.01).

Conclusions

When making food substitutions to increase nutrient intake, eating occasion should be an important consideration. Further research is needed to better understand how food substitutions affect diet costs, which may be an important driver of food purchasing decisions among low income individuals with limited food budgets.

Electronic supplementary material

The online version of this article (10.1186/s12937-018-0360-z) contains supplementary material, which is available to authorized users.

Development and validation of the ASPIRE-VA coaching fidelity checklist (ACFC): a tool to help ensure delivery of high-quality weight management interventions

Practical and valid instruments are needed to assess fidelity of coaching for weight loss. The purpose of this study was to develop and validate the ASPIRE Coaching Fidelity Checklist (ACFC). Classical test theory guided ACFC development. Principal component analyses were used to determine item groupings. Psychometric properties, internal consistency, and inter-rater reliability were evaluated for each subscale. Criterion validity was tested by predicting weight loss as a function of coaching fidelity. The final 19-item ACFC consists of two domains (session process and session structure) and five subscales (sets goals and monitor progress, assess and personalize self-regulatory content, manages the session, creates a supportive and empathetic climate, and stays on track). Four of five subscales showed high internal consistency (Cronbach alphas > 0.70) for group-based coaching; only two of five subscales had high internal reliability for phone-based coaching. All five sub-scales were positively and significantly associated with weight loss for group- but not for phone-based coaching. The ACFC is a reliable and valid instrument that can be used to assess fidelity and guide skill-building for weight management interventionists.

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.

Innovative approaches to weight loss in a high-risk population: The small changes and lasting effects (SCALE) trial

OBJECTIVE

To evaluate the efficacy of a small change behavioral weight loss intervention with or without a positive affect/self-affirmation (PA/SA) component on weight loss at 12 months.

METHODS

Black and Hispanic adults (N = 405) with body mass index 25-50 kg/m² selected one of ten small change eating strategies and a physical activity goal, randomly with/without PA/SA. Participants were followed by community health workers at set intervals (weekly in months 1-3; biweekly in months 4-9; once monthly in months 10-12).

RESULTS

There was no difference in weight loss at 12 months between participants in the small change approach alone (1.1%) versus the small change PA/SA intervention (1.2%). During treatment, 9% of participants lost at least 7% of their initial body weight. Participants who reported more interval life events had a lower likelihood of losing weight (P < 0.0001). However, those randomized to the small change PA/SA intervention gained less weight (+0.3% vs. 2.3% gain; P < 0.0001).

CONCLUSIONS

The small change PA/SA intervention did not lead to a significant difference in weight loss in comparison to the small change approach alone. It did, however, decrease the negative impact of psychosocial stressors on weight gain among participants with more interval life events.

ForgIng New paths in DIabetes PrevenTion (FINDIT): Study Protocol for a Randomized Controlled Trial

BACKGROUND

Prediabetes is an asymptomatic condition in which patients' blood glucose levels are higher than normal but do not meet diagnostic criteria for type 2 diabetes mellitus (T2DM). A key window of opportunity to increase engagement of patients with prediabetes in strategies to prevent T2DM is when they are screened for T2DM and found to have prediabetes, yet the effects of this screening and brief counseling are unknown.

METHODS

In this parallel-design randomized controlled trial we will recruit 315 non-diabetic patients from the Ann Arbor VA Medical Center (AAVA) who have one or major risk factors for T2DM and an upcoming primary care appointment at the AAVA, but have not had a hemoglobin A1c (HbA1c) test to screen for T2DM in the previous 12 months. After informed consent, participants will complete a baseline survey and be randomly assigned to, at the time of their next primary care appointment, one of two arms: (1) to have a hemoglobin A1c (HbA1c) test to screen for T2DM and receive brief, standardized counseling about these results or (2) to review a brochure about clinical preventive services. Participants will complete surveys 2 weeks, 3 months, and 12 months after their primary care appointment, and a weight measurement 12 months after their primary care appointment. The primary outcome is weight change after 12 months. The secondary outcomes are changes in perception of risk for T2DM; knowledge of T2DM prevention; self-efficacy and motivation to prevent T2DM; use of pharmacotherapy for T2DM prevention; physical activity; participation in weight management programs; and mental health. Quantitative analyses will compare outcomes among participants in the HbA1c test arm found to have prediabetes with participants in the brochure arm. Among participants in the HbA1c test arm found to have prediabetes we will conduct semi-structured interviews about their understanding of and reactions to receiving a prediabetes diagnosis.

DISCUSSION

This trial will generate foundational data on the effects of a prediabetes diagnosis and brief counseling on patients' preventive behaviors and mediators of these behaviors that will enable the development of novel strategies to improve patient engagement in T2DM prevention.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02747108 . Registered on 18 April 2016.

Behavioral Treatment for Veterans with Obesity: 24-Month Weight Outcomes from the ASPIRE-VA Small Changes Randomized Trial

BACKGROUND

Small Changes (SC) is a weight management approach that demonstrated superior 12-month outcomes compared to the existing MOVE!^® Weight Management Program at two Veterans Affairs (VA) sites. However, approaches are needed to help graduates of treatment continue to lose or maintain their weight over the longer term.

OBJECTIVE

The purpose of the present study was to examine the effectiveness of a second year of low-intensity SC support compared to support offered by the usual care MOVE! programs.

DESIGN

Following participation in the year-long Aspiring to Lifelong Health in VA (ASPIRE-VA) randomized controlled trial, participants were invited to extend their participation in their assigned program for another year. Three programs were extended to include six SC sessions delivered via telephone (ASPIRE-Phone) or an in-person group (ASPIRE-Group), or 12 sessions offered by the MOVE! programs.

PARTICIPANTS

Three hundred thirty-two overweight/obese veterans who consented to extend their participation in the ASPIRE-VA trial by an additional year.

MAIN MEASURES

Twenty-four-month weight change (kg).

KEY RESULTS

Twenty-four months after baseline, participants in all three groups had modest weight loss (-1.40 kg [-2.61 to -0.18] in the ASPIRE-Group, -2.13 kg [-3.43 to -0.83] in ASPIRE-Phone, and -1.78 kg [-3.07 to -0.49] in MOVE!), with no significant differences among the three groups. Exploratory post hoc analyses revealed that participants diagnosed with diabetes initially benefited from the ASPIRE-Group program (-2.6 kg [-4.37 to 0.83]), but experienced significant weight regain during the second year (+2.8 kg [0.92-4.69]) compared to those without diabetes.

CONCLUSIONS

Participants in all three programs lost weight and maintained a statistically significant, though clinically modest, amount of weight loss over a 24-month period. Although participants in the ASPIRE-Group initially had greater weight loss, treatment was not sufficient to sustain weight loss through the second year, particularly in veterans with diabetes. Consistent, continuous-care treatment is needed to address obesity in the VA.

Weight loss among women and men in the ASPIRE-VA behavioral weight loss intervention trial

OBJECTIVE

Weight loss was examined among women and men veterans in a clinical trial comparing Aspiring for Lifelong Health (ASPIRE), a "small changes" weight loss program using either mixed-sex group-visit or telephone-based coaching, to MOVE!(®) , the usual mixed-sex group-based program.

METHODS

Linear mixed-effects models were used to calculate adjusted percent weight change at 12 months by sex and compare outcomes across arms within sex.

RESULTS

Analyses included 72 women (ASPIRE-Phone = 26; ASPIRE-Group = 26; MOVE! = 20) and 409 men (ASPIRE-Phone = 136; ASPIRE-Group = 134; MOVE! = 139). At 12 months, women displayed significant weight loss from baseline in ASPIRE-Group (-2.6%) and MOVE! (-2.7%), but not ASPIRE-Phone (+0.2%). Between-arm differences in weight change among women were: ASPIRE-Group versus ASPIRE-Phone, -2.8% (P = 0.15); MOVE! versus ASPIRE-Phone, -2.8% (P = 0.20); and ASPIRE-Group versus MOVE!, 0.0% (P = 1.0). At 12 months, men lost significant weight from baseline across arms (ASPIRE-Phone, -1.5%; ASPIRE-Group, -2.5%; MOVE!, -1.0%). Between-arm differences in weight change among men were: ASPIRE-Group versus ASPIRE-Phone, -0.9% (P = 0.23); MOVE! versus ASPIRE-Phone, +0.5% (P = 0.76); ASPIRE-Group versus MOVE!, -1.5% (P = 0.03).

CONCLUSIONS

Mixed-sex, group-based programs can result in weight loss for both women and men veterans.

Military service and other socioecological factors influencing weight and health behavior change in overweight and obese Veterans: a qualitative study to inform intervention development within primary care at the United States Veterans Health Administration

BACKGROUND

Obesity affects 37 % of patients at Veterans Health Administration (VHA) medical centers. The VHA offers an intensive weight management program (MOVE!) but less than 10 % of eligible patients ever attend. However, VHA patients see their primary care provider about 3.6 times per year, supporting the development of primary care-based weight management interventions. To address gaps in the literature regarding Veterans' experiences with weight management and determine whether and how to develop a primary care-based weight management intervention to both improve obesity counseling and increase attendance to MOVE!, we conducted a qualitative study to assess: 1) Veterans' personal experiences with healthy weight-related behavior change (including barriers and facilitators to behavior change and experiences with primary care providers, staff, and the MOVE! program), and 2) potential new approaches to improve weight management within primary care at the VHA including goal setting and technology.

METHODS

Overweight/obese VHA patients (aged 18-75, BMI greater than 30 or greater than 25 with at least 1 co-morbidity) were recruited for focus group sessions stratified by gender, MOVE! referral, and attendance. Each session was facilitated by a trained moderator, audio-recorded, and professionally transcribed. Using an iterative coding approach, two coders separately reviewed and coded transcripts, and met frequently to negotiate codes and synthesize emerging themes.

RESULTS

Of 161 eligible patients, 54 attended one of 6 focus groups (2 female, 4 male, 9-11 participants per session): 63 % were male, 46 % identified as African-American, 32 % White/Caucasian, 74 % were college-educated or higher, and 61 % reported having attended MOVE!. We identified two major themes: Impact of Military Service and Promotion and Sustainability of Healthy Behaviors. After service in a highly structured military environment, Veterans had difficulty maintaining weight on their own. They perceived physical activity as having more impact than diet, but chronic pain was a barrier. We identified individual/interpersonal-, community/environment-, and healthcare system-related factors affecting healthy behaviors. We also received input about Veteran's preferences and experiences with technology and setting health goals.

CONCLUSIONS

Unique factors influence weight management in Veterans. Findings will inform development of a technology-assisted weight management intervention with tailored counseling and goal-setting within primary care at the VHA.

Using synchronous distance education to deliver a weight loss intervention: A randomized trial

OBJECTIVE

To implement a randomized trial to evaluate the effectiveness of a weight loss program delivered using synchronous distance education compared with a wait-list control group with 6-month follow-up.

METHODS

Adults with a body mass index (BMI) ≥25 were randomized to the intervention (n = 42) or wait-list control group (n = 38). The intervention group participated in a synchronous, online, 15-week weight loss program; weight loss was the primary outcome. Secondary measures included height, BMI, and confidence in ability to be physically active and eat healthy. Assessments occurred at three and four time points in the intervention and control group, respectively.

RESULTS

Participants who completed the program lost significantly more weight (1.8 kg) than those in the wait-list control group (0.25 kg) at week 15 [F(1,61) = 6.19, P = 0.02] and had a greater reduction in BMI (0.71 vs. 0.14 kg/m(2) ), [F(1,61) = 7.45, P = 0.01]. There were no significant differences between the intervention and the wait-list control groups for change in confidence in ability to be physically active or eat healthy. Weight loss was maintained at 6 months.

CONCLUSIONS

Use of synchronous distance education is a promising approach for weight loss. The results of this study will help to inform future research that employs Web-based interventions.

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.

Social network characteristics associated with weight loss among black and hispanic adults

OBJECTIVE

To examine social network member characteristics associated with weight loss.

METHODS

A cross-sectional examination included egocentric network data from 245 Black and Hispanic adults with BMI ≥ 25 kg/m(2) enrolled in a small change weight loss study. The relationships between weight loss at 12 months and characteristics of helpful and harmful network members (relationship, contact frequency, living proximity, and body size) were examined.

RESULTS

There were 2,571 network members identified. Mean weight loss was -4.8 (±11.3) lbs. among participants with network help and no harm with eating goals vs. +3.4 (±7.8) lbs. among participants with network harm alone. In a multivariable regression model, greater weight loss was associated with help from a child with eating goals (P = 0.0002) and coworker help with physical activity (P = 0.01). Weight gain was associated with having network members with obesity living in the home (P = 0.048) and increased network size (P = 0.002).

CONCLUSIONS

There was greater weight loss among participants with support from children and coworkers. Weight gain was associated with harmful network behaviors and having network members with obesity in the home. Incorporating child and coworker support and evaluating network harm and the body size of network members should be considered in future weight loss interventions.

Small Changes and Lasting Effects (SCALE) Trial: the formation of a weight loss behavioral intervention using EVOLVE

Background

Obesity is a major health problem that disproportionately affects Black and Hispanic adults. This paper presents the rationale and innovative design of a small change eating and physical activity intervention (SC) combined with a positive affect and self-affirmation (PA/SA) intervention versus the SC intervention alone for weight loss.

Methods

Using a mixed methods translational model (EVOLVE), we designed and tested a SC approach intervention in overweight and/ or obese African American and Hispanic adults. In Phase I, we explored participant’s values and beliefs about the small change approach. In Phase II, we tested and refined the intervention and then, in Phase III we conducted a RCT. Participants were randomized to the SC approach with PA/SA intervention vs. a SC approach alone for 12 months. The primary outcome was clinically significant weight loss at 12 months.

Results

Over 4.5 years a total of 574 participants (67 in Phase I, 102 in Phase II and 405 in Phase III) were enrolled. Phase I findings were used to create a workbook based on real life experiences about weight loss and to refine the small change eating strategies. Phase II results shaped the recruitment and retention strategy for the RCT, as well as the final intervention. The RCT results are currently under analysis.

Conclusion

The present study seeks to determine if a SC approach combined with a PA/SA intervention will result in greater weight loss at 12 months in Black and Hispanic adults compared to a SC approach alone.

The Relationship between Social Network Body Size and the Body Size Norms of Black and Hispanic Adults

Objective

To examine the relationship between the body size norms of Black and Hispanic adults and the body sizes of their social network members.

Methods

Egocentric network data were examined for 245 adults recruited from 2012–2013 in New York City. A multivariable regression model was used to examine the relationship between participants' perception of normal body size and the body sizes of their network members adjusted for participant age, education, race/ethnicity and network size. Participants' body size norms were also examined stratified by the following characteristics of obese network members: frequency of contact, living proximity, relationship, and importance of relationship.

Results

Index participants were 89% female with mean body mass index 33.5 kg/m². There were 2571 network members identified (31% overweight, 10% obese). In the fully adjusted multivariable model, perception of normal body size increased as the number of network members with obesity increased (p < 0.01). Larger body size norms were associated with increased frequency of contact with obese network members (p = 0.04), and obese members living in the home (p = 0.049).

Conclusions

These findings support a relationship between the body size norms of Black and Hispanic adults and their social network body size.

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Participants reported a larger body size as normal as the number of social network members with obesity increased.

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Participants' perception of normal body size increased as frequency of contact with obese members increased.

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Participants with obese network members living in the home perceived a larger body size as normal.

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.

Improving maintenance of lost weight following a commercial liquid meal replacement program: a preliminary study

Clinic-based liquid meal replacement (800kcals/day) programs produce substantial weight loss. Nevertheless, long-term maintenance remains a challenge. A limitation of maintenance programs is that they continue to promote large behavior changes that are initially required to induce weight loss which may be unsustainable long-term. The study aims were to conduct a preliminary assessment of the feasibility, acceptability, and effectiveness of a small changes maintenance intervention (SCM) for 30 patients who completed liquid meal replacement program (LMR). The 20-session SCM delivered over 52 weeks offered no preset goals for maintenance behaviors and all changes in behavior were self-selected. Participants had a median BMI of 40.9 kg/m(2) and weight of 111 kg at the start of LMR. At LMR completion, they lost 18% (21 kg) of body weight. The SCM was completed by 22 patients (73%); 19 completers (86%) attended ≥ 17 of 20 sessions with a median satisfaction rating of 9 (on a scale of 1 to 9). Completers were asked to record self-selected maintenance behaviors daily (median 351 days recorded). The most commonly reported daily behaviors were self-weighing, use of meal replacements and step counting. Median percent regain at week 52 was 14% (2.8 kg) of lost weight (range, -42 to 74%), significantly less than a median of 56% (11 kg) percent regain of lost weight (range, -78 to 110%) in a demographically similar historical control group with no maintenance intervention after LMR completion (P<0.001). Thus, SCM holds promise for improving weight maintenance. Future research should compare SCM to standard maintenance programs that promote large program-directed changes.

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.