Socio-demographic, anthropometric, and psychosocial predictors of attrition across behavioral weight-loss trials

Factors affecting continuous participation in follow-up evaluations during a lifestyle intervention programme for type 2 diabetes prevention: The Feel4Diabetes-study

AIMS

Community- and school-based lifestyle interventions are an efficient method of preventing type 2 diabetes in vulnerable populations. Many participants, however, fail to complete the necessary follow-ups. We investigated factors affecting the continuous participation in follow-up evaluations during the Feel4Diabetes-study, a multilevel intervention programme implemented across Europe.

METHODS

Socioeconomic, sociodemographic and clinical factors were assessed for 2702 participants within six participating countries: Bulgaria and Hungary (low-to-middle-income countries, LMIC), Belgium and Finland (high-income countries, HIC) and Greece and Spain (high-income countries under austerity measures, HICAM).

RESULTS

Statistically significant differences were detected with respect to sex, control group, education level, employment status, BMI and blood pressure measurements (systolic and diastolic blood pressure). Post hoc analysis revealed significant differences within socioeconomic regions. Higher levels of education were associated with significantly lower attrition in HIC (p < 0.05) and HICAM (p < 0.001), higher employment status was associated with lower attrition in HICAM (p < 0.001) and being female was associated with lower attrition in LMIC (p < 0.001). Surprisingly, the intervention group exhibited higher-than-expected attrition in HIC (p < 0.001) and HICAM (p = 0.003), and lower attrition in LMIC (p = 0.007). When tested together in the same multivariable predictive model, all sociodemographic and socioeconomic variables along with higher BMI retained their statistical significance, while systolic and diastolic blood pressure failed to remain significant.

CONCLUSIONS

Key socioeconomic and sociodemographic factors along with BMI play a significant role in determining continuous participation in follow-up evaluations during school- and community-based intervention programmes.

Socio-economic factors, mood, primary care utilization, and quality of life as predictors of intervention cessation and chronic stress in a type 2 diabetes prevention intervention (PREVIEW Study)

BACKGROUND

Sedentary lifestyle and unhealthy diet combined with overweight are risk factors for type 2 diabetes (T2D). Lifestyle interventions with weight-loss are effective in T2D-prevention, but unsuccessful completion and chronic stress may hinder efficacy. Determinants of chronic stress and premature cessation at the start of the 3-year PREVIEW study were examined.

METHODS

Baseline Quality of Life (QoL), social support, primary care utilization, and mood were examined as predictors of intervention cessation and chronic stress for participants aged 25 to 70 with prediabetes (n = 2,220). Moderating effects of sex and socio-economic status (SES) and independence of predictor variables of BMI were tested.

RESULTS

Participants with children, women, and higher SES quitted intervention earlier than those without children, lower SES, and men. Lower QoL, lack of family support, and primary care utilization were associated with cessation. Lower QoL and higher mood disturbances were associated with chronic stress. Predictor variables were independent (p ≤ .001) from BMI, but moderated by sex and SES.

CONCLUSIONS

Policy-based strategy in public health should consider how preventive interventions may better accommodate different individual states and life situations, which could influence intervention completion. Intervention designs should enable in-built flexibility in delivery enabling response to individual needs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01777893.

The impact of stress and lifestyle factors on short-term sickness absence in a large Danish industrial company

Objectives: Work-related stress and certain lifestyles have been associated with sickness absence among employees. We analysed relations between stress and lifestyles (as risk factors) and short-term sickness absence among employees of a large Danish industrial company. Moreover, we analysed the impact of risk factors on short-term sickness absence. Methods: A self-administered questionnaire was completed by 7753 employees (67% response rate). Relations between risk factors (dyssomnia, low physical activity, alcohol, smoking, unhealthy food habits, overweight and stress) and short-term sickness absence were analysed by calculating etiologic fractions and binary logistic regression. Relations between the number of risk factors and short-term sickness absence were also analysed. Finally, the cost of short-term sickness absence from risk factors was estimated to illustrate the potential savings in avoided loss of productivity that could be gained from intervention programmes. Results: Stress, overweight, smoking and dyssomnia are significantly related to short-term sickness absence. Etiologic fractions revealed that these factors were associated with between 29.8% and 37.8% of short-term sickness absence. The number of risk factors was also related to the risk and length of sickness absence. Conclusions: This study identified risk factors that could be addressed by intervention programmes to reduce short-term sickness absence. Based on the results, focus on the risk factors that account for most short-term sickness absence and reduction of the number of risk factors could potentially reduce short-term sickness absence. A 30% reduction is equivalent to an avoidance of a loss of productivity of 4.5%, corresponding to €9.4 million per year.

Factors influencing adults to drop out of intensive lifestyle interventions for weight loss

Reducing ≥5% of body weight can decrease the risk of developing chronic diseases in adults with excess weight. Although Intensive Lifestyle Interventions (ILIs) that include cognitive-behavioral techniques to improve physical activity and eating habits are the best approach for losing weight, the failure to retain participants is a barrier to their successful implementation. We aimed to investigate the factors influencing adults to drop out of ILIs for weight loss at six months. We conducted retrospective multiple logistic regression analysis of 268 participants with excess weight (body mass index ≥ 25 kg/m2) from a multicenter study (n = 237, in-person ILI in five clinics, delivered by nutrition interns), and a randomized controlled trial (n = 31, one online ILI, delivered by a master's degree student). The same research team conducted both studies in Northern Mexico, using the same intervention components, and identical instruments and techniques to collect the data. We found that older participants (≥50 years) were less likely to drop out of the ILI for weight loss compared to participants <35 years old (OR = 0.34, 95% CI = 0.16-0.70). For each unit increase in the bodily pain scale of the SF-36 (less perceived pain), the risk of dropping out decreased by 2% (OR = 0.98, 95% CI = 0.97, 0.996), while a change in the interventionist during the 6-month intervention more than doubled the risk of dropping out (OR 2.25, 95% CI = 1.23-4.14). Retention in ILIs may be improved by ensuring that the same interventionist remains during the six-month intervention. In addition, ILIs may need further tailoring for younger ages and for participants with higher perceived pain.

Identifying Personality Characteristics and Indicators of Psychological Well-Being Associated With Attrition in the Motivation Makes the Move! Physical Activity Intervention: Randomized Technology-Supported Trial

BACKGROUND

Data attrition has been a common problem in longitudinal lifestyle interventions. The contributors to attrition in technology-supported physical activity interventions have not been thoroughly studied.

OBJECTIVE

The present study examined the roles of personality characteristics and indicators of psychological well-being in data attrition within a technology-supported, longitudinal intervention study with overweight adults.

METHODS

Participants (N=89) were adults from the Motivation Makes the Move! intervention study. Data attrition was studied after a 3-month follow-up. Participants' personality characteristics were studied using the Short Five self-report questionnaire. Psychological well-being indicators were assessed with the RAND 36-item health survey, Positive and Negative Affect Schedule, and Beck Depression Inventory. Logistic regression analyses were conducted to assess the risk of discontinuing the study. The analyses were adjusted for sex, age, study group, and educational status.

RESULTS

At the 3-month follow-up, 65 of 89 participants (73% of the initial sample) had continued in the study. Participants' personality characteristics and indicators of psychological well-being were not associated with the risk of dropping out of the study (all P values >.05). The results remained the same after covariate controls.

CONCLUSIONS

Participant attrition was not attributable to personality characteristics or psychological well-being in the Motivation Makes the Move! study conducted with overweight adults. As attrition remains a challenge within longitudinal, technology-supported lifestyle interventions, attention should be paid to the potentially dynamic natures of personality and psychological well-being, as well as other elements beyond these.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02686502; https://clinicaltrials.gov/ct2/show/NCT02686502.

Accept Yourself! A Pilot Randomized Controlled Trial of a Self-Acceptance-Based Treatment for Large-Bodied Women With Depression

A pilot parallel randomized controlled trial compared a self-acceptance, non-weight-loss intervention, Accept Yourself! (AY), to a weight loss program, Weight Watchers (WW), in order to provide preliminary safety, feasibility, and efficacy data in preparation for a definitive RCT of AY as an intervention to enhance the mental and physical health of larger-bodied women with Major Depressive Disorder (MDD). Adult women with MDD and a Body Mass Index ≥30 were eligible. Nineteen women were randomized by random number table into AY (n = 9) or WW (n = 10). Intake, pretreatment, posttreatment, 3-, 6-, 9-, and 12-month follow-up assessments occurred at a rural academic medical center. Primary outcomes included depression severity and cardiovascular fitness. Chi-square and t-tests assessed attrition and participant preferences for treatment; other analyses used intention-to-treat, linear mixed-effects models for repeated measures, including all participants' available data. Both groups improved in self-reported, F(5, 43.81) = 7.45, p < .001, partial η² = .38, and blinded-clinician-rated depression, F(6, 62.03) = 10.41, p < .001, partial η² = .5. AY was superior to WW in self-reported depression, F(5, 43.81) = 2.72, p = .03, partial η² = .11. Neither group improved in fitness. Eating disorder symptoms and weight gain worsened in WW. AY appeared safe, feasible, and offered initial evidence of efficacy for depression; it should be investigated in a definitive RCT, with modifications to increase potency. WW may not be suitable as a comparator intervention for AY because of risk to participants.

Integrated collaborative care intervention for depression and obesity in primary care: translation from research to practice

The objective of this study was to present lessons learned about engagement, delivery modality and pandemic impact while delivering a collaborative care intervention with a socioeconomically, racially and ethnically diverse sample. Participants completed a post-intervention survey (n = 41) on experiences and preferred intervention delivery modality, coronavirus 2019 (COVID-19) Impact Survey (n = 50) and provided open-ended feedback about the intervention (n = 27). Intervention process data included attendance, modality, and withdrawals. Data were analyzed using descriptive statistics and inductive content analyses. Of 71 intervention participants, 6 (8%) withdrew before session 1. Completers adhered to intervention timeline better than withdrawals. Participants liked the in-person interaction, efficient coach support, accountability of in-person and Zoom vs. phone sessions and the flexibility and convenience of phone and Zoom vs. in-person sessions. A majority of participants reported experiencing pandemic impacts such as heightened emotional distress, decreased activity engagement, poorer eating behaviors and being unable to meet basic needs. Participants deviating from intervention timelines may be re-engaged by targeted outreach attempts. Videoconference has the potential for providing as-needed coaching. Future interventions may be optimized to account for and address areas impacted by the pandemic. Findings revealed specific strategies that can be implemented in future interventions to improve emotional and physical health among diverse populations.

Weight Maintenance after Dietary Weight Loss: Systematic Review and Meta-Analysis on the Effectiveness of Behavioural Intensive Intervention

After a low-calorie diet, only 25% of patients succeed in maintaining the result of weight loss for a long time. This systematic review and meta-analysis aims to explore whether patients undergoing intensive intervention during the maintenance phase have a greater preservation of the weight achieved during the previous slimming phase than controls. A bibliographic search was conducted using PubMed, Scopus, and Cochrane databases for clinical trials and randomised, controlled trials investigating the role of choice in weight-loss-maintenance strategies. Only studies with a follow-up of at least 12 months were considered. A total of eight studies, for a total of 1454 patients, was identified, each comparing a group that followed a more intensive protocol to a control group. Our metanalysis highlighted that an intensive approach even in the maintenance phase could be important to ensure greater success in the phase following the weight-loss period. However, it should be pointed out that the improvement was not so different from the trend of the respective controls, with a non-statistically significant mean difference of the effect size (0.087; 95% CI −0.016 to 0.190 p = 0.098). This finding, along with the observation of a weight regain in half of the selected studies, suggests this is a long work that has to be started within the weight-loss phase and reinforced during the maintenance phase. The problem of weight control in patients with obesity should be understood as a process of education to a healthy lifestyle and a balanced diet to be integrated in the context of a multidisciplinary approach.

Perceptions of body weight that vary by body mass index: Clear associations with perceptions based on personal control and responsibility

This project aimed to identify the perceptions of body weight that vary by body mass index. First, a qualitative study explored body weight perceptions in 17 individuals with overweight. Second, a questionnaire was developed and completed by a UK sample with body mass index from 16.6 to 59.7 kg/m2 (N = 328). A higher body mass index was associated with perceptions of less personal control and responsibility. Body mass index in females was also associated with three other questionnaire factors and body mass index in males with illness/medication. Thus, body mass index was associated with different perceptions of body weight. Focussing on personal control and responsibility may be useful for treatment and prevention.

Conservative Treatment for Childhood and Adolescent Obesity: Real World Follow-Up Profiling and Clinical Evolution in 1300 Patients

Background: Limited therapeutic tools and an overwhelming clinical demand are the major limiting factors in pediatric obesity management. The optimal protocol, environment, body mass index (BMI) change targets and duration of obesity-oriented interventions remain to be elucidated. Aims: We aimed to characterize the singularities of follow-up, anthropometric and metabolic evolution of a large cohort of pediatric patients with obesity in a specialized university hospital outpatient obesity unit. Patients and methods: Follow-up duration (up to seven years), attrition rate and anthropometric and metabolic evolution of 1300 children and adolescents with obesity were studied. An individualized analysis was conducted in patients attaining a high level of weight loss (over 1.5 BMI-SDS (standard deviation score) and/or 10% of initial weight; n = 252; 19.4%) as well as in "metabolically healthy" patients (n = 505; 38.8%). Results: Attrition rate was high during the early stages (11.2% prior to and 32.5% right after their initial metabolic evaluation). Mean follow-up time was 1.59 ± 1.60 years (7% of patients fulfilled 7 years). The highest BMI reduction occurred in the first year (-1.11 ± 0.89 SDS, p < 0.001 in 72.5% of patients). At the end of the follow-up, improvements in glucose and lipid metabolism parameters were observed (both p < 0.05), that were highest in patients with the greatest weight reduction (all p < 0.01), independent of the time spent to achieve weight loss. The pubertal growth spurt negatively correlated with obesity severity (r = -0.38; p < 0.01) but patients attaining adult height exceeded their predicted adult height (n = 308, +1.6 ± 5.4 cm; p < 0.001). "Metabolically healthy" patients, but with insulin resistance, had higher blood pressure, glucose, uric acid and triglyceride levels than those without insulin resistance (all p < 0.05). Preservation of the "metabolically healthy" status was associated with BMI improvement. Conclusions: Behavioral management of children with obesity can be effective and does not impair growth but is highly conditioned by high attrition. The best results regarding BMI reduction and metabolic improvement are achieved in the first year of intervention and can be preserved if follow-up is retained.

Predictors of attrition from a weight loss program. A study of adult patients with obesity in a community setting

PURPOSE

Obesity unit attrition is frequent and contributes to treatment failure. Many studies evaluating attrition predictors were part of randomized trials, and different terminology and criteria were used in the engagement field. We aimed to investigate the factors potentially implicated in early (< 12 weeks) and late (> 12 weeks) attrition from an obesity unit in a community setting METHODS: This was a retrospective cohort study of 250 patients with obesity who were followed-up at our obesity unit. Our program included at least 6 meetings in 12 months. Sociodemographic and anthropometric data, and psychometric questionnaires were collected from all participants.

RESULTS

One-hundred thirty-four (53.6%) participants dropped out. Those individuals showed lower BMI, lower overall health status, and increased depression scores. In a multiple regression model, BMI (inversely; OR = 0.90; 95%CI 0.84-0.96) and depression score (directly, OR = 1.05; 1.00-1.10) were associated with attrition risk. Early dropouts (n = 47) had lower weights, smaller waist circumferences and worse mental health scores than late dropouts (n = 87) and more frequently lived alone. When compared to completers, early dropouts had lower weights, BMIs, waist circumferences, overall health and mental status scores, increased depression scores and percentage of individuals living alone. In a multiple regression, lower BMI (OR = 0.83; 0.75-0.92), lower mental status score (OR = 3.17; 1.17-8.59) and living alone (OR = 2.25; 1.02-4.97) were associated with early attrition risk.

CONCLUSION

Lower BMI and increased depression score were associated with attrition. Early attrition was associated with lower weight, decreased mental well-being, and living alone. Individuals with these characteristics might need tailored approaches to enhance their engagement.

LEVEL OF EVIDENCE

Level V, retrospective descriptive study.

Exploratory Analysis of Racial/Ethnic and Educational Differences in a Randomized Controlled Trial of a Mindfulness-Based Weight Loss Intervention

OBJECTIVE

People of color and lower socioeconomic groups have higher obesity prevalence, lose less weight compared with Whites and higher socioeconomic groups, and are underrepresented in randomized controlled trials of mindfulness-based interventions. We examined whether mindfulness approaches reduce disparities in weight loss interventions.

METHODS

We analyzed data from a randomized controlled trial of 194 participants with obesity (41% participants of color, 36% without college degree) comparing a 5.5-month mindfulness-based weight loss intervention to an active-control with identical diet-exercise guidelines. We assessed attendance, 18-month attrition, and weight change at 6, 12, and 18 months by race/ethnicity and education level using linear mixed models, adjusting for baseline body mass index, age, and education or race/ethnicity, respectively.

RESULTS

Participants without versus with a college degree attended fewer sessions and had higher attrition across interventions. Participants of color attended fewer intervention sessions in the mindfulness compared with the control intervention. Overall, participants of color lost significantly less weight at 12 and 18 months compared with Whites. However, during the 6- to 18-month maintenance period, we found an interaction of intervention arm, race/ethnicity, and time (p = .035), indicating that participants of color compared with Whites regained more weight in the control (0.33 kg/mo; p = .005) but not mindfulness intervention (0.06 kg/mo; p = .62). Participants without a college degree had greater initial weight loss in the mindfulness compared to control intervention from 0 to 6 months (-0.46 kg/mo; p = .039).

CONCLUSIONS

Although disparities persist, mindfulness approaches may mitigate some racial/ethnic and socioeconomic differences in weight loss compared with conventional diet-exercise programs.Trial Registration: Clinicaltrials.gov registration: NCT00960414.

Understanding mechanisms of integrated behavioral therapy for co-occurring obesity and depression in primary care: a mediation analysis in the RAINBOW trial

The RAINBOW trial demonstrated that an integrated collaborative care intervention was effective for improving weight and depression. This study examined mediation of the treatment effect by a priori specified lifestyle behaviors and cognitive functioning. Participants were randomized to a 12-month integrated intervention (n = 204) or usual care (n = 205). Body mass index (BMI) and 20-item Depression Symptom Check List (SCL-20) were co-primary outcomes (Y). To examine mediation, we assessed (a) the effect of the integrated intervention (X) on lifestyle behaviors (diet and physical activity) and cognitive functioning (problem-solving; M, X→M path a) and (b) the association of these behaviors with BMI and SCL-20 (M→Y path b). Mediation existed if paths a and b were significant or if path a and the product of coefficients test (paths a and b) were significant. Compared with usual care, the intervention led to significant improvements in leisure time physical activity (201.3 MET minutes/week [SD, 1,457.6]) and total calorie intake (337.4 kcal/day [818.3]) at 6 months but not 12 months (path a). These improvements were not significantly associated with improvements in BMI or SCL-20 (path b). However, avoidant problem-solving style score and increased fruit and vegetable intake significantly correlated with improvements in BMI at 6 and 12 months, respectively. Also, increased fruit and vegetable intake, higher dietary quality, and better problem-solving abilities significantly correlated with improvements in SCL-20 at 6 and 12 months. These findings did not support the hypothesized mediation, but suggest lifestyle behaviors and cognitive functioning to target in future intervention optimization.

Self-Pay Payer Status Predicts Long-Term Loss to Follow-Up After Bariatric Surgery

PURPOSE

In spite of widespread recommendations for lifelong patient follow-up with a bariatric provider after bariatric surgery, attrition to follow-up is common. Over the past two decades, many programs have sought to expand access to care for patients lacking insurance coverage for bariatric surgery by offering "self-pay" packages; however, the impact of this financing on long-term follow-up is unclear. We sought to determine whether payer status impacts loss to follow-up within 1 year after bariatric surgery.

MATERIALS AND METHODS

Records of 554 consecutive patients undergoing bariatric surgery who were eligible for 1-year post-surgical follow-up between 2014 and 2019 were retrospectively reviewed. Multiple logistic regression examined the relationship between demographics, psychological variables, payer status, and loss to follow-up.

RESULTS

Self-pay status more than tripled the odds of loss to follow-up (OR = 3.44, p < 0.01) at 1 year following surgery. Males had more than double the odds of attrition (OR = 2.43, p < 0.01), and members of racial and ethnic minority groups (OR = 2.51, p < 0.05) were more likely to experience loss.

CONCLUSIONS

Self-pay patients, males and members of racial and ethnic minority groups, may face additional barriers to long-term access to postoperative bariatric care. Further investigation is greatly needed to develop strategies to overcome barriers to and disparities in long-term post-surgical care for more frequently lost groups.

Retention Among Participants in the National Diabetes Prevention Program Lifestyle Change Program, 2012-2017

OBJECTIVE

To assess retention in the National Diabetes Prevention Program (DPP) lifestyle change program, which seeks to prevent type 2 diabetes in adults at high risk.

RESEARCH DESIGN AND METHODS

We analyzed retention among 41,203 individuals who enrolled in Centers for Disease Control and Prevention (CDC)-recognized in-person lifestyle change programs at organizations that submitted data to CDC's Diabetes Prevention Recognition Program during January 2012-February 2017.

RESULTS

Weekly attrition rates were typically <1-2% but were between 3.5% and 5% at week 2 and at weeks 17 and 18, where session frequency typically transitions from weekly to monthly. The percentage of participants retained through 18 weeks varied by age (45.9% for 18-29 year olds, 53.4% for 30-44 year olds, 60.2% for 45-54 year olds, 66.7% for 55-64 year olds, and 67.6% for ≥65 year olds), race/ethnicity (70.5% for non-Hispanic whites, 60.5% for non-Hispanic blacks, 52.6% for Hispanics, and 50.6% for other), mean weekly percentage of body weight lost (41.0% for ≤0% lost, 66.2% for >0% to <0.25% lost, 72.9% for 0.25% to <0.5% lost, and 73.9% for ≥0.5% lost), and mean weekly physical activity minutes (12.8% for 0 min, 56.1% for >0 to <60 min, 74.8% for 60 to <150 min, and 82.8% for ≥150 min) but not by sex (63.0% for men and 63.1% for women).

CONCLUSIONS

Our results demonstrate the need to identify strategies to improve retention, especially among individuals who are younger or are members of racial/ethnic minority populations and among those who report less physical activity or less early weight loss. Strategies that address retention after the first session and during the transition from weekly to monthly sessions offer the greatest opportunity for impact.

Greater Attendance at a Community Weight Loss Programme over the First 12 Weeks Predicts Weight Loss at 2 Years

BACKGROUND

There is considerable heterogeneity in long-term weight loss among people referred to obesity treatment programmes. It is unclear whether attendance at face-to-face sessions in the early weeks of the programme is an independent predictor of long-term success.

OBJECTIVE

To investigate whether frequency of attendance at a community weight loss programme over the first 12 weeks is associated with long-term weight change.

METHODS

Participants were randomised to receive brief support only (control, n = 211), or a weight loss programme for 12 weeks (n = 530) or 52 weeks (n = 528). This study included participants with data on session attendance over the first 12 weeks (n = 889) compared to the control group. The association between attendance (continuously) and weight loss was explored using a linear model. A multi-level mixed-effects linear model was used to investigate whether attendance (categorised as 0, 1, 2-5, 6-9, and 10-12 sessions) was associated with weight loss at 3, 12, and 24 months compared to the control.

RESULTS

For every session attended in the first 12 weeks, the average weight loss was -0.259 kg/session at 24 months (p = 0.005). Analysis by attendance group found only those attending 10-12 sessions had significantly greater weight loss (-7.5 kg [95% CI -8.1 to -6.9] at 12 months; -4.7 kg [95% CI -5.3 to -4.1] at 24 months) compared to the control group (-3.4 [95% CI -4.5 to -2.4] at 12 months, -2.5 [95% CI -3.5 to -1.5] at 24 months). Early attendance was higher for people ≥70 years, but there was no evidence of a difference by gender, ethnicity, education, or income.

CONCLUSIONS

Greater attendance at a community weight loss programme in the first 12 weeks is associated with enhanced weight loss up to 24 months. Regular attendance at a programme could be used as a criterion for continued provision of weight loss services to maximise the cost-effectiveness of interventions.

Goal achievement and adaptive goal adjustment in a behavioral intervention for participants with prediabetes

Participants with prediabetes were supported to achieve and maintain weight loss with a stage-based behavior change group program named PREview behavior Modification Intervention Toolbox (PREMIT). The tendency to engage in a process of goal adjustment was examined in relation to PREMIT attendance. Analyses were based on 1857 participants who had achieved ⩾8percent weight loss. Tendency to engage in a process of goal adjustment appeared not to be influenced by PREMIT attendance. Instead, results suggested that when unsure about reaching an intervention goal, participants were more likely to engage in a process of goal adjustment, possibly lessening distress due to potentially unachievable goals, either weight loss or maintenance.

Sociocognitive factors associated with lifestyle intervention attrition after successful weight loss among participants with prediabetes-The PREVIEW study

INTRODUCTION

Major risk factors for type 2 diabetes are lifestyle choices such as lack of physical activity (PA) and poor diet. Many individuals either do not take part or struggle to complete interventions supporting lifestyle changes. Demographic and theory-based sociocognitive factors associated with PREVIEW intervention attrition after successful weight loss were examined.

METHODS

Participants (1,856) who started the weight maintenance phase after completion of low-energy diet were retrospectively divided into three clusters depending on the point they left the trial. Discriminant analysis examined which demographic and theory-based sociocognitive variables were associated with cluster membership.

RESULTS

Most of the participants were women and well-educated. Two discriminant functions were calculated (χ² (24) = 247.0, p ≥ .05, d = 0.78). The demographic variables, such as age and ethnicity, and the social cognitive variable outcome expectancies on the other side were associated with cluster membership. Older age, Caucasian ethnicity, and fewer expected disadvantages of PA were associated with high success.

DISCUSSION

The discriminant model gave insight into some factors associated with early attrition. For practitioners planning interventions it underlines the necessity to take extra attention to younger participants and to those being afraid that being physically active causes unpleasant ramifications.

Depressive symptom severity as a predictor of attendance in the HOME behavioral weight loss trial

OBJECTIVE

We examined whether total depressive symptoms and symptom clusters predicted behavioral weight loss attendance among economically disadvantaged adults in a randomized controlled trial.

METHODS

150 adults with obesity were randomized to 12 months of in-person, video conference, or enhanced usual care weight loss groups. We categorized percent session attendance in the intervention arms into three levels: no attendance, poorer attendance, and better attendance.

RESULTS

Higher baseline Patient Health Questionnaire-8 (PHQ-8) score was associated with a greater odds of being in the poorer versus better attendance group (OR = 1.94, 95% CI: 1.02-3.69, p = .04). A similar relationship between PHQ-8 score and odds of being in the no attendance versus better attendance group was observed but was not statistically significant (OR = 1.63, 95% CI: 0.94-2.81, p = .08). Both cognitive/affective and somatic clusters contributed to the depressive symptoms-attendance relationships.

CONCLUSION

Greater depressive symptoms at the start of a behavioral weight loss program may predict poorer subsequent session attendance. Screening for and addressing depression may improve intervention uptake. ClinicalTrials.gov Identifier: NCT02057952.

Perceived barriers to physical activity during and after a behavioural weight loss programme

BACKGROUND

Most adults with overweight/obesity participating in behavioural weight loss (BWL) programmes never achieve prescribed physical activity (PA) levels. This study examined changes in PA barriers, their relationships with accelerometer-measured PA during and after a 12-month BWL programme, and associations between PA barriers and participant characteristics.

METHODS

Adults (N = 283) in a BWL programme completed the Barriers to Being Active Quiz, a 21-item self-report measure that assesses seven perceived PA barriers, and they wore an accelerometer for seven consecutive days at baseline and at 6 (midtreatment), 12 (end of treatment), 18 (6-mo follow-up), and 24 months (12-mo follow-up). Weight and height were measured, and demographic information was collected at baseline.

RESULTS

Repeated-measures analyses of variance (ANOVAs) revealed a significant quadratic effect of time on total PA barriers, P < .001, such that PA barriers decreased by midtreatment, remained below baseline levels by end of treatment, but increased to near-baseline levels by follow-up. Perceived PA barriers were negatively associated with baseline moderate-to-vigorous PA (MVPA), P < .001, and decreases in perceived PA barriers were related to greater MVPA at 6 (P = .004), 12 (P < .001), and 24 months (P = .007). Participants who were younger, P = .02, and white, P = .009, reported more baseline barriers.

CONCLUSIONS

Perceived PA barriers meaningfully decreased during BWL treatment, which in turn was associated with greater MVPA. This pattern suggests that, on average, BWL effectively addresses perceived PA barriers, which contributes to increased PA. Future research should identify interventions to maintain decreases in barriers after end of treatment.

Baseline Psychosocial and Demographic Factors Associated with Study Attrition and 12-Month Weight Gain in the DIETFITS Trial

OBJECTIVE

The purpose of this study was to examine correlates of failure-trial attrition and weight gain-in a randomized clinical weight-loss trial.

METHODS

The Diet Intervention Examining The Factors Interacting with Treatment Success (DIETFITS) trial included 609 adults (18-50 years; BMI 28-40). Participants were randomized to a 12-month healthy low-fat or healthy low-carbohydrate diet for weight loss. At baseline, participants completed psychosocial, demographic, and anthropometric measures. Stepwise logistic regressions identified baseline factors associated with (1) study attrition and (2) among trial completers, weight gain at 12 months.

RESULTS

Having higher baseline food addiction and self-efficacy was linked to treatment failure. Being younger, not having a college education, having higher outcome expectations and quality of life, and having lower social functioning and self-control increased the odds of trial attrition. Identifying as other than non-Hispanic white; not being married or cohabitating; having higher cognitive restraint and self-control; and having lower amotivation, family encouragement, and physical limitations increased the odds of gaining weight by treatment's end.

CONCLUSIONS

Participants' baseline psychosocial and demographic factors may support or impede successful weight loss. Trialists should attend to these factors when designing treatments in order to promote participants' likelihood of completing the trial and achieving their weight-loss goals.

Recruitment and retention of WIC participants in a longitudinal dietary intervention trial

BACKGROUND

This paper describes strategies and outcomes of techniques to recruit and retain low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in a longitudinal dietary intervention trial.

METHODS

Community engagement strategies, methods to recruit and retain participants, and recruitment and retention rates are reported. Demographic and lifestyle predictors of loss to follow-up, contacts required to reach participants at each data collection point, participant reactions to the recruitment and retention strategies used, and reasons for drop out (assessed among those who discontinued their study involvement) also were examined.

RESULTS

Of 1281 eligible women, 744 were enrolled (58% recruitment rate); retention rates were 87%, 70%, and 55%, respectively, 2 weeks and 3 and 6 months post-intervention. Being unmarried, younger, and having low baseline vegetable intake predicted loss to follow-up. Between 4 and 5 contact attempts and 1 and 2 completed contacts were required to reach participants at each data collection point. Participants endorsed recruiting women while waiting for WIC appointments (as they were accessible, perceived the information provided as informative, and wanted to pass the time) and by word of mouth. Lacking time and loss of interest were commonly reported reasons for not completing assessments and dropout. To improve retention, shortening telephone assessments, conducting the assessments in person, and increasing the amount of incentives were recommended.

CONCLUSION

Despite using recommended strategies, recruitment and retention rates were modest. Research is needed to identify and test approaches to effectively engage WIC-enrolled adults in health intervention trials.

The PREVIEW Study

Abstract. Individuals at risk of Type 2 Diabetes are advised to change health habits. This study investigated how the PREMIT behavior modification intervention and its association with socio-economic variables influenced weight maintenance and habit strength in the PREVIEW study. Overweight adults with pre-diabetes were enrolled ( n = 2,224) in a multi-center RCT including a 2-month weight-loss phase and a 34-month weight-maintenance phase for those who lost ≥ 8% body weight. Initial stages of the PREMIT covered the end of weight-loss and the beginning of weight-maintenance phase (18 weeks). Cross-sectional and longitudinal data were explored. Frequent PREMIT sessions attendance, being female, and lower habit strength for poor diet were associated with lower weight re-gain. Being older and not in employment were associated with lower habit strength for physical inactivity. The PREMIT appeared to support weight loss maintenance. Younger participants, males, and those in employment appeared to struggle more with inactivity habit change and weight maintenance.

Patient, Family, and Center-Based Factors Associated with Attrition in Neonatal Clinical Research: A Prospective Study

BACKGROUND

Attrition, or loss to follow-up, presents a significant threat to the integrity and validity of longitudinal clinical research. Little is known about predictors of attrition in neonatal clinical research, and no prior studies have examined how families' experiences participating in research with their infants influences study compliance.

OBJECTIVE

To identify novel factors that were associated with attrition over 1 year of study follow-up among preterm infants enrolled in the multicenter Prematurity and Respiratory Outcomes Program (PROP) observational study.

METHODS

At discharge, research coordinators estimated the likelihood of attrition. The parents completed questionnaires about their experience with the study at discharge and at 1 year corrected age. The primary endpoint was completion of 4 PROP interviews during the first year. Logistic models were used to evaluate the associations between infant, family, and center-based characteristics and attrition.

RESULTS

Among 318 children, 283 (89%) met the primary endpoint. In bivariate analyses, lower maternal education, more people in the household, public insurance, and site were associated with attrition (p < 0.05). Parent survey responses, infant characteristics, and site characteristics were unrelated to attrition. Coordinators' prediction of attrition was associated with completion of early study interviews; this effect waned over time. In multivariable analyses, lower maternal education and more people in the household were the factors most strongly associated with attrition.

CONCLUSION

Future neonatal research should evaluate novel strategies to decrease the burden associated with study participation and reinforcement of study goals with families who have lower educational levels to facilitate participation and decrease attrition bias.

Perceived barriers and facilitators of initiation of behavioral weight loss interventions among adults with obesity: a qualitative study

Background

Evidence-based behavioral weight loss interventions are under-utilized. To inform efforts to increase uptake of these interventions, it is important to understand the perspectives of adults with obesity regarding barriers and facilitators of weight loss intervention initiation.

Methods

We conducted a qualitative study in adults with obesity who had recently attempted weight loss either with assistance from an evidence-based behavioral intervention (intervention initiators) or without use of a formal intervention (intervention non-initiators). We recruited primary care patients, members of a commercial weight loss program, and members of a Veterans Affairs weight loss program. Intervention initiators and non-initiators were interviewed separately using a semi-structured interview guide that asked participants about barriers and facilitators of weight loss intervention initiation. Conversations were audio-recorded and transcribed. Data were analyzed with qualitative content analysis. Two researchers used open coding to generate the code book on a subset of transcripts and a single researcher coded remaining transcripts. Codes were combined into subthemes, which were combined in to higher order themes. Intervention initiators and non-initiators were compared.

Results

We conducted three focus groups with participants who had initiated interventions (n = 26) and three focus groups (n = 24) and 8 individual interviews with participants who had not initiated interventions. Intervention initiators and non-initiators were, respectively, 65% and 37.5% white, 62% and 63% female, mean age of 55 and 54 years old, and mean BMI of 34 kg/m². Three themes were identified. One theme was practical factors, with subthemes of reasonable cost and scheduling compatibility. A second theme was anticipated effectiveness of intervention, with subthemes of intervention content addressing individual needs; social aspects influencing effectiveness; and evaluating evidence of effectiveness. A third theme was anticipated pleasantness of intervention, with subthemes of social aspects influencing enjoyment; anticipated dietary and tracking prescriptions; and identity and self-reliance factors. Different perspectives were identified from intervention initiators and non-initiators.

Conclusions

Strategies to engage individuals in evidence-based weight loss interventions can be developed using these results. Strategies could target individuals’ perceived barriers and benefits to initiating interventions, or could focus on refining interventions to appeal to more individuals.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5795-9) contains supplementary material, which is available to authorized users.

Expected benefits and motivation to weight loss in relation to treatment outcomes in group-based cognitive-behavior therapy of obesity

PURPOSE

We aimed to determine cognitive drivers, expected to play a role in target reach and/or attrition in obesity programs.

METHODS

We recorded the expected benefits of weight loss, weight targets, primary motivation for weight loss, perceived treatment needs, readiness and self-confidence to be successful and a battery of psychopathology questionnaires in 793 subjects with obesity (68% women; mean age 48.7; 46% obesity class III) enrolled into a group-based cognitive-behavioral treatment program. Their relevance on attrition and successful weight loss outcome were tested by logistic regression analysis.

RESULTS

The expected benefits of weight loss scored very high in all physical, psychological and social areas, with differences between genders. Attrition rate was 24, 41 and 65% at 6-, 12-, and 24-month follow-up. Average weight loss was 5.8 ± 7.1 kg (- 4.8%) at 6 months, with 17% of cases (32% of continuers) maintaining weight loss > 10% at 24 months. After adjustment for confounders, attrition was reduced by concern for present health, motivation/consciousness of the importance of physical activity and need for support; treatment discontinuation was favored by concern for body image, by expectations for drug treatment or bariatric surgery, and by high-challenging weight loss targets. Male gender, higher BMI and concern for present health predicted weight loss > 10%, whereas concern for body appearance was associated with lower probability of attaining the desired weight loss targets.

CONCLUSION

A more precise definition of needs and expectations might help tailor treatment to individual patients, but attrition rates and target reach remain difficult to predict.

LEVEL OF EVIDENCE

Level V, descriptive studies.

Supervised vs. self-selected physical activity for individuals with diabetes and obesity: the Lifestyle Gym program

The effectiveness of different programs of physical activity outside randomized studies is difficult to determine. We carried out an audit in two different units where either a supervised physical activity (PA) program or a self-selected PA program was in use in individuals with type 2 diabetes or obesity. The supervised PA cohort (n = 101) received progressive gym training (120 min, twice a week for 13 weeks) by a dedicated team, with nutritional counseling during resting periods. The self-selected PA cohort (n = 69) was enrolled in a 13-week cognitive-behavioral program (120 min/week, in groups of 12-15 individuals), chaired by an expert team. Body weight and physical fitness (6-min walk test) were measured at baseline and after 6 and 12 months. Outcome measures were attrition, weight loss ≥10 % initial body weight, 10 % increase in 6-min walk test; their association with a PA program was tested by logistic regression analysis. Attrition rate was lower in the supervised PA group (28 vs. 45 % than in the self-selected cohort, P = 0.023). After adjustment for confounders, the supervised PA program was associated with a lower risk of attrition at 1 year (odds ratio 0.45; 95 % confidence interval, 0.21-0.98) at logistic regression analysis. Body weight similarly decreased in both groups (more rapidly in the supervised PA cohort); also physical fitness improved in a similar way, and no differences in achieved targets of body weight (supervised, 31 %; self-selected, 18 %; P = 0.118) or fitness (supervised, 62 %; self-selected, 49 %; P = 0.312) were demonstrated. Different PA programs produce very similar health benefits, but an initially supervised program has lower attrition rates, which might translate into better outcomes in the long term.

Effect of dose of behavioral treatment for obesity on binge eating severity

OBJECTIVES

We evaluated the effects of three doses of a behavioral intervention for obesity (High dose=24 sessions, Moderate=16 sessions, Low=8 sessions) compared with a nutrition education control group (Control) on binge eating. We also examined whether participants with clinically significant improvements in binge eating had better treatment adherence and weight-loss outcomes than those who did not experience clinically significant improvements in binge eating. Finally, we examined the relation of pretreatment binge eating severity to changes at six months.

METHODS

Participants included 572 adults (female=78.7%; baseline mean±SD: age=52.7±11.2years, BMI=36.4±3.9kg/m(2)) who provided binge eating data at baseline. We evaluated binge eating severity (assessed via the Binge Eating Scale) and weight status at baseline and six months, as well as treatment adherence over six months.

RESULTS

At six months, participants in the Moderate and High treatment conditions reported greater reductions in binge eating severity than participants in the Low and Control conditions, ps<.02. Participants who demonstrated improvements in binge eating severity reported greater dietary self-monitoring adherence and attained larger weight losses than those who did not experience clinically significant reductions, ps<.001. Pretreatment binge eating severity predicted less improvement in binge eating severity over six months and fewer days with dietary self-monitoring records completed, ps≤.002.

CONCLUSION

A moderate or high dose of behavioral weight-loss treatment may be required to produce clinically significant reductions in binge eating severity in adults with obesity.

Assisting the Novice in Lifestyle Change

The beginning of a lifestyle intervention is a sensitive time, as doing “too much too quickly” may stress the immune system, resulting in an increase in upper respiratory symptoms and, consequently, attrition. However, “too little too slowly” may not align with patients’ motivation to change and may also result in attrition. There is also evidence that early weight loss is predictive of long-term maintenance of goal weight. Health care providers are frequently presented with contradictory information on the best model to promote enduring lifestyle change. Best practice dictates that health care provider acknowledge their patients’ motivation to change and incorporate each individual’s goals in designing the lifestyle change intervention. Additional support and advice may be warranted at the beginning of an intervention to promote the patient’s health and avoid attrition.