Participants' evaluation of a weight-loss program

Improving Adherence to Weight-Loss Medication (Liraglutide 3.0 mg) Using Mobile Phone Text Messaging and Healthcare Professional Support

BACKGROUND

Adherence to weight-loss medication is suboptimal, leading to poor health outcomes. Short message service (SMS) can potentially improve adherence.

METHODS

A total of 3,994 participants with overweight or obesity in Australia receiving Saxenda® (liraglutide 3.0 mg) were enrolled from September 1, 2017, to February 28, 2018, through doctors, pharmacists, or websites and were randomly assigned to receive none, three, or five SMS per week. Participants were additionally offered a face-to-face consultation with a diabetes educator or a call from a dietitian. Medication adherence was measured as whether the total scripts claimed were at least as many as the total claims expected by March 31, 2018, and was modeled adjusting for age, sex, baseline BMI, residential region, enrolment channel, the total number of SMS, and additional patient support.

RESULTS

Participants receiving five SMS (OR, 6.25; 95% CI: 4.28-9.12) had greater adherence than those receiving three SMS (OR, 3.67; 95% CI: 2.67-5.03) or zero SMS per week. The effectiveness of SMS on adherence decreased as participants received more SMS over time. Moreover, the odds of adhering to liraglutide were higher for participants enrolled with pharmacists compared with those enrolled with doctors (OR, 2.28; 95% CI: 1.82-2.86) and for participants who received a face-to-face consultation (OR, 3.10; 95% CI: 1.82-5.29) or a call (OR, 1.31; 95% CI: 1.02-1.68) compared with those who received no extra support.

CONCLUSIONS

Integration of SMS into routine clinical practice should consider not only the frequency and content of reminders but also additional patient support to achieve higher and more sustained adherence to medication and health behavior changes.

The Balance protocol: a pragmatic weight gain prevention randomized controlled trial for medically vulnerable patients within primary care

BACKGROUND

For patients with obesity who are not ready for or experience barriers to weight loss, clinical practice guidelines recommend provider counseling on preventing further weight gain as a first-line treatment approach. Unfortunately, evidence-based weight gain prevention interventions are not routinely available within primary care. To address this gap, we will implement a pragmatic 12-month randomized controlled trial of a digital weight gain prevention intervention delivered to patients receiving primary care within a network of Federally Qualified Community Health Centers in central North Carolina.

METHODS

Balance (Equilibrio in Spanish) is a pragmatic effectiveness trial that will randomize adult patients who have overweight or obesity (BMI of 25-40 kg/m2) to either: 1) a weight gain prevention intervention with tailored behavior change goals and tracking, daily weighing on a network-connected electronic scale, and responsive weight and goal coaching delivered remotely by health center registered dietitians; or 2) a usual care program with automated healthy living text messages and print materials and routine primary care. The primary outcome will be weight gain prevention at 24-months, defined as ≤3% change in baseline weight. To align with its pragmatic design, trial outcome data will be pulled from the electronic health record of the community health center network.

DISCUSSION

For underserved, often rurally-located patients with obesity, digital approaches to promote a healthy lifestyle can curb further weight gain. Yet enrolling medically vulnerable patients into a weight gain prevention trial, many of whom are from racial/ethnic minorities, can be difficult. Despite these potential challenges, we plan to recruit a large, diverse sample from rural areas, and will implement a remotely-delivered weight gain prevention intervention to medically vulnerable patients. Upcoming trial results will demonstrate the effectiveness of this pragmatic approach to implement and evaluate a digital weight gain prevention intervention within primary care.

TRIALS REGISTRATION

NCT03003403 . Registered December 28, 2016.

Speech2Health: A Mobile Framework for Monitoring Dietary Composition From Spoken Data

Diet and physical activity are known as important lifestyle factors in self-management and prevention of many chronic diseases. Mobile sensors such as accelerometers have been used to measure physical activity or detect eating time. In many intervention studies, however, stringent monitoring of overall dietary composition and energy intake is needed. Currently, such a monitoring relies on self-reported data by either entering text or taking an image that represents food intake. These approaches suffer from limitations such as low adherence in technology adoption and time sensitivity to the diet intake context. In order to address these limitations, we introduce development and validation of Speech2Health, a voice-based mobile nutrition monitoring system that devises speech processing, natural language processing (NLP), and text mining techniques in a unified platform to facilitate nutrition monitoring. After converting the spoken data to text, nutrition-specific data are identified within the text using an NLP-based approach that combines standard NLP with our introduced pattern mapping technique. We then develop a tiered matching algorithm to search the food name in our nutrition database and accurately compute calorie intake values. We evaluate Speech2Health using real data collected with 30 participants. Our experimental results show that Speech2Health achieves an accuracy of 92.2% in computing calorie intake. Furthermore, our user study demonstrates that Speech2Health achieves significantly higher scores on technology adoption metrics compared to text-based and image-based nutrition monitoring. Our research demonstrates that new sensor modalities such as voice can be used either standalone or as a complementary source of information to existing modalities to improve the accuracy and acceptability of mobile health technologies for dietary composition monitoring.

Present and Future Trends in Consumer Health Informatics and Patient-Generated Health Data

Objectives: Consumer Health Informatics (CHI) and the use of Patient-Generated Health Data (PGHD) are rapidly growing focus areas in healthcare. The objective of this paper is to briefly review the literature that has been published over the past few years and to provide a sense of where the field is going. Methods: We searched PubMed and the ACM Digital Library for articles published between 2014 and 2016 on the topics of CHI and PGHD. The results of the search were screened for relevance and categorized into a set of common themes. We discuss the major topics covered in these articles. Results: We retrieved 65 articles from our PubMed query and 32 articles from our ACM Digital Library query. After a review of titles, we were left with 47 articles to conduct our full article survey of the activities in CHI and PGHD. We have summarized these articles and placed them into major categories of activity. Within the domain of consumer health informatics, articles focused on mobile health and patient-generated health data comprise the majority of the articles published in recent years. Conclusions: Current evidence indicates that technological advancements and the widespread availability of affordable consumer-grade devices are fueling research into using PGHD for better care. As we observe a growing number of (pilot) developments using various mobile health technologies to collect PGHD, major gaps still exist in how to use the data by both patients and providers. Further research is needed to understand the impact of PGHD on clinical outcomes.

S2NI: a mobile platform for nutrition monitoring from spoken data

Diet and physical activity are important lifestyle and behavioral factors in self-management and prevention of many chronic diseases. Mobile sensors such as accelerometers have been used in the past to objectively measure physical activity or detect eating time. Diet monitoring, however, still relies on self-recorded data by end users where individuals use mobile devices for recording nutrition intake by either entering text or taking images. Such approaches have shown low adherence in technology adoption and achieve only moderate accuracy. In this paper, we propose development and validation of Speech-to-Nutrient-Information (S2NI), a comprehensive nutrition monitoring system that combines speech processing, natural language processing, and text mining in a unified platform to extract nutrient information such as calorie intake from spoken data. After converting the voice data to text, we identify food name and portion size information within the text. We then develop a tiered matching algorithm to search the food name in our nutrition database and to accurately compute calorie intake. Due to its pervasive nature and ease of use, S2NI enables users to report their diet routine more frequently and at anytime through their smartphone. We evaluate S2NI using real data collected with 10 participants. Our experimental results show that S2NI achieves 80.6% accuracy in computing calorie intake.

Body Image Satisfaction Among Blacks

Satisfaction with body image is a factor related to health outcomes. The purpose of this study is to examine the relationship between body image satisfaction and body size perception in an urban, Black community sample in New Orleans, Louisiana. Only 42.2% of respondents were satisfied with their body image and 44.1% correctly perceived their body size. Most respondents chose an ideal image in the normal body mass index range with over half choosing an ideal image smaller than their actual size. Misperception was greatest among the heaviest respondents. Females, those who overestimated their size, those with an education beyond high school, and those who were active in order to lose weight were less likely to be satisfied ( p < .001). Those who were active but not trying to lose weight were more likely to be satisfied ( p < .001). This suggests that perception of and satisfaction with body size may play a role in health behavior decisions.

Perceived helpfulness of the individual components of a behavioural weight loss program: results from the Hopkins POWER Trial

Background

Behavioural weight loss programs are effective first‐line treatments for obesity and are recommended by the US Preventive Services Task Force. Gaining an understanding of intervention components that are found helpful by different demographic groups can improve tailoring of weight loss programs. This paper examined the perceived helpfulness of different weight loss program components.

Methods

Participants (n = 236) from the active intervention conditions of the Practice‐based Opportunities for Weight Reduction (POWER) Hopkins Trial rated the helpfulness of 15 different components of a multicomponent behavioural weight loss program at 24‐month follow‐up. These ratings were examined in relation to demographic variables, treatment arm and weight loss success.

Results

The components most frequently identified as helpful were individual telephone sessions (88%), tracking weight online (81%) and coach review of tracking (81%). The component least frequently rated as helpful was the primary care providers' general involvement (50%). Groups such as older adults, Blacks and those with lower education levels more frequently reported intervention components as helpful compared with their counterparts.

Discussion

Weight loss coaching delivered telephonically with web support was well received. Findings support the use of remote behavioural interventions for a wide variety of individuals.

How effective are interventions at reducing socioeconomic inequalities in obesity among children and adults? Two systematic reviews

Background

Tackling obesity is one of the major contemporary public health policy challenges and is vital in terms of addressing health inequalities.

Objectives

To systematically review the effectiveness of interventions (individual, community and societal) in reducing socioeconomic inequalities in obesity among (1) children aged 0–18 years (including prenatal) and (2) adults aged ≥18 years, in any setting, in any country, and (3) to establish how such interventions are organised, implemented and delivered.

Data sources

Nine electronic databases including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and NHS Economic Evaluation Database were searched from database start date to 10 October 2011 (child review) and to 11 October 2012 (adult review). We did not exclude papers on the basis of language, country or publication date. We supplemented these searches with website and grey literature searches.

Review methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Experimental studies and observational studies with a duration of at least 12 weeks were included. The reviews considered strategies that might reduce existing inequalities in the prevalence of obesity [i.e. effective targeted interventions or universal interventions that work more effectively in low socioeconomic status (SES) groups] as well as those interventions that might prevent the development of inequalities in obesity (i.e. universal interventions that work equally along the SES gradient). Interventions that involved drugs or surgery and laboratory-based studies were excluded from the reviews. The initial screening of titles and abstracts was conducted by one reviewer with a random 10% of the sample checked by a second reviewer. Data extraction was conducted by one reviewer and independently checked by a second reviewer. The methodological quality of the included studies was appraised independently by two reviewers. Meta-analysis and narrative synthesis were conducted focusing on the ‘best-available’ evidence for each intervention type (defined in terms of study design and quality).

Results

Of 56,967 papers of inequalities in obesity in children, 76 studies (85 papers) were included, and of 70,730 papers of inequalities in obesity in adults, 103 studies (103 papers) were included. These studies suggested that interventions that aim to prevent, reduce or manage obesity do not increase inequalities. For children, there was most evidence of effectiveness for targeted school-delivered, environmental and empowerment interventions. For adults, there was most evidence of effectiveness for primary care-delivered tailored weight loss and community-based weight loss interventions, at least in the short term among low-income women. There were few studies of appropriate design that could be included on societal-level interventions, a clear limitation of the evidence base found.

Limitations

The reviews located few evaluations of societal-level interventions and this was probably because they included only experimental study designs. The quality assessment tool, although described as a tool for public health interventions, seemed to favour those that followed a more clinical model. The implementation tool was practical but enabled only a brief summary of implementation factors to be made. Most of the studies synthesised in the reviews were from outside the UK and related to women.

Conclusions

The reviews have found some evidence of interventions with the potential to reduce SES inequalities in obesity and that obesity management interventions do not increase health inequalities. More experimental studies of the effectiveness and cost-effectiveness of interventions (particularly at the societal level) to reduce inequalities in obesity, particularly among adolescents and adult men in the UK, are needed.

Study registration

The studies are registered as PROSPERO CRD42011001740 and CRD42013003612.

Funding

The National Institute for Health Research Public Health Research programme.

Text4Diet: a randomized controlled study using text messaging for weight loss behaviors

OBJECTIVE

Text-messaging shows promise as a health intervention. This randomized controlled trial evaluated a daily text-messaging weight loss intervention.

METHODS

Overweight and obese adults (n=170) in California were randomized to receive daily interactive and personally weight-relevant text-messages or monthly e-newsletters. Participants were measured at baseline, 6 and 12 months. Group differences were assessed in weight loss. Relation of text-messaging adherence to weight loss and change in pedometer steps was examined.

RESULTS

There were no group differences in weight loss over 6 (1.53 lb vs 3.72 lb) or 12 months (2.27 lb vs 3.64 lb; control vs intervention). Text-messaging adherence was moderately strong (60-69%). Participants with greater adherence lost more weight at 6 (p=.039) and 12 months (p=.023) than those who were less adherent. Intervention participants' steps increased almost 3000 steps/day over time (p<.05), and higher step counts were associated with greater weight loss (p<.05). Text-messaging satisfaction was moderate to high, and pedometer-related satisfaction was associated with greater weight loss (p<.05).

CONCLUSIONS

Although text-messaging had no effect on weight, adherence was associated with improvement in weight-related behaviors and weight outcomes. Text-messages could be a useful adjunct to weight loss treatments.

Valuing the Benefits of Weight Loss Programs: An Application of the Discrete Choice Experiment

OBJECTIVE

Obesity is a leading health threat. Determination of optimal therapies for long-term weight loss remains a challenge. Evidence suggests that successful weight loss depends on the compliance of weight loss program participants with their weight loss efforts. Despite this, little is known regarding the attributes influencing such compliance. The purpose of this study was to assess, using a discrete choice experiment (DCE), the relative importance of weight loss program attributes to its participants and to express these preferences in terms of their willingness to pay for them.

RESEARCH METHODS

A DCE survey explored the following weight loss program attributes in a sample of 165 overweight adults enrolled in community weight loss programs: cost, travel time required to attend, extent of physician involvement (e.g., none, monthly, every 2 weeks), components (e.g., diet, exercise, behavior change) emphasized, and focus (e.g., group, individual). The rate at which participants were willing to trade among attributes and the willingness to pay for different configurations of combined attributes were estimated using regression modeling.

RESULTS

All attributes investigated appeared to be statistically significant. The most important unit change was "program components emphasized" (e.g., moving from diet only to diet and exercise).

DISCUSSION

The majority of participants were willing to pay for weight loss programs that reflected their preferences. The DCE tool was useful in quantifying and understanding individual preferences in obesity management and provided information that could help to maximize the efficiency of existing weight loss programs or the design of new programs.

The association between weight loss and engagement with a web-based food and exercise diary in a commercial weight loss programme: a retrospective analysis

BACKGROUND

The Internet provides a widely accessible platform for weight loss interventions. Automated tools can allow self-guided monitoring of food intake and other target behaviours that are established correlates of weight change. Many programmes also offer social support from the virtual community. The aim of this research was to assess associations between engagement with self-monitoring tools and social support, and weight loss in an online weight-control programme.

METHODS

This paper describes a retrospective analysis of weight change among 3621 subscribers to a commercial Internet-based weight loss programme. Participants were all subscribers (2979 women; 642 men) joining the programme between July 2005 and November 2008 with two or more recorded weights spanning at least 28 days of participation in the programme. Engagement was indexed with frequency of using online diet and exercise diaries and with use of the social support forums.

RESULTS

Programme engagement was associated with weight loss in both men and women after controlling for initial BMI and duration of participation. The three engagement variables accounted for 13% of variance in percentage weight loss in women (p < .001) and 19% in men (p < .001). In analyses including all the engagement variables, exercise diary use was an independent predictor of weight loss among men, but non-significant in women. In contrast, use of the online forums was associated with weight loss in women but not in men. Among participants who were overweight or obese, those in the highest tertile of engagement with food diaries (vs the lowest) were more likely to achieve clinically significant (> 5%) weight loss (men: OR = 3.45 p < .001; women: OR = 5.05 p < .001). Being in the highest tertile of engagement with exercise diaries was associated with clinically significant weight loss in men (OR = 3.48 p < .001) and, less strongly, in women (OR = 1.46 p < .05).

CONCLUSIONS

Use of self-monitoring tools and participation in online support are predictive of weight loss in the context of a commercial, online weight control programme.

State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change

Behavior change theories and models, validated within the field of dietetics, offer systematic explanations for nutrition-related behavior change. They are integral to the nutrition care process, guiding nutrition assessment, intervention, and outcome evaluation. The American Dietetic Association Evidence Analysis Library Nutrition Counseling Workgroup conducted a systematic review of peer-reviewed literature related to behavior change theories and strategies used in nutrition counseling. Two hundred fourteen articles were reviewed between July 2007 and March 2008, and 87 studies met the inclusion criteria. The workgroup systematically evaluated these articles and formulated conclusion statements and grades based upon the available evidence. Strong evidence exists to support the use of a combination of behavioral theory and cognitive behavioral theory, the foundation for cognitive behavioral therapy (CBT), in facilitating modification of targeted dietary habits, weight, and cardiovascular and diabetes risk factors. Evidence is particularly strong in patients with type 2 diabetes receiving intensive, intermediate-duration (6 to 12 months) CBT, and long-term (>12 months duration) CBT targeting prevention or delay in onset of type 2 diabetes and hypertension. Few studies have assessed the application of the transtheoretical model on nutrition-related behavior change. Little research was available documenting the effectiveness of nutrition counseling utilizing social cognitive theory. Motivational interviewing was shown to be a highly effective counseling strategy, particularly when combined with CBT. Strong evidence substantiates the effectiveness of self-monitoring and meal replacements and/or structured meal plans. Compelling evidence exists to demonstrate that financial reward strategies are not effective. Goal setting, problem solving, and social support are effective strategies, but additional research is needed in more diverse populations. Routine documentation and evaluation of the effectiveness of behavior change theories and models applied to nutrition care interventions are recommended.

Unannounced telephone interviews: A useful and positively received tool in the reinforcement of lifestyle intervention

OBJECTIVES

Reinforcement is critical in dietary counseling, but is also time demanding. We evaluated the acceptability of frequent telephone interviews, including a 24-hour dietary recall, as a means of reinforcement after lifestyle intervention in healthy subjects at risk of diabetes. The aim of this report is to assess the following questions: Was the chosen frequency and duration of telephone reinforcement appropriate? What were the positive and negative aspects of receiving telephone interviews?

METHODS

Seventy-seven nondiabetic relatives of patients with type 2 diabetes were included in a randomized controlled intervention study in which they received dietary education. Unannounced telephone calls were placed to follow adherence and for encouragement and support. After two years of intervention, the perceived appropriateness of the different aspects of receiving telephone interviews were evaluated by postal questionnaire.

RESULTS

Telephone reinforcement was positively received by the participants. Relatively frequent telephone calls, as many as three times per month, were not considered disturbing or time consuming. Participants became aware of their own dietary habits through the interviews, which they appreciated. They found duration of follow-up between one and five years appropriate.

CONCLUSIONS

Telephone interviews can be applied in lifestyle intervention programs in healthy at-risk individuals in which time constraints may otherwise prevent active persons from participating.

Self-monitoring predicts change in fiber intake and weight loss in adults with diabetes following an intervention regarding the glycemic index

OBJECTIVE

Self-monitoring can facilitate behavioral change by providing feedback regarding goal attainment. Glycemic index (GI) quantifies the glycemic response to carbohydrate-containing foods. Low GI diets may improve weight and glycemic control. We examined the relation between self-monitoring and changes in diet and body weight following an intervention in which consumption of low GI foods was encouraged among adults aged 40-70 years with diabetes.

METHODS

Pre/post-intervention dietary intake was assessed with 24-h dietary recalls and weight was obtained. Mean number of days participants kept self-monitoring records was determined. The impact of self-monitoring on the change in GI, fiber intake, weight and body mass index (BMI) was evaluated using regression analyses.

RESULTS

Each additional day of self-monitoring was associated with a mean reduction in weight and BMI of -0.95 kg and -0.34 kg/m(2), respectively. The mean change in fiber intake increased in men but did not significantly change in women for each additional day of monitoring.

CONCLUSION

Self-monitoring was associated with weight loss in men and women and greater fiber intake in men.

PRACTICE IMPLICATIONS

Men can self-monitor to lose weight and increase fiber intake. Self-monitoring facilitates weight loss in women but other behavioral strategies are needed to improve fiber intake.

A text message-based intervention for weight loss: randomized controlled trial

Background

To our knowledge, no studies have evaluated whether weight loss can be promoted in overweight adults through the use of an intervention that is largely based on daily SMS (Short Message Service: text) and MMS (Multimedia Message Service: small picture) messages transmitted via mobile phones.

Objective

This paper describes the development and evaluation of a text message–based intervention designed to help individuals lose or maintain weight over 4 months.

Methods

The study was a randomized controlled trial, with participants being exposed to one of the following two conditions, lasting 16 weeks: (1) receipt of monthly printed materials about weight control; (2) an intervention that included personalized SMS and MMS messages sent two to five times daily, printed materials, and brief monthly phone calls from a health counselor. The primary outcome was weight at the end of the intervention. A mixed-model repeated-measures analysis compared the effect of the intervention group to the comparison group on weight status over the 4-month intervention period. Analysis of covariance (ANCOVA) models examined weight change between baseline and 4 months after adjusting for baseline weight, sex, and age.

Results

A total of 75 overweight men and women were randomized into one of the two groups, and 65 signed the consent form, completed the baseline questionnaire, and were included in the analysis. At the end of 4 months, the intervention group (n = 33) lost more weight than the comparison group (−1.97 kg difference, 95% CI −0.34 to −3.60 kg, P = .02) after adjusting for sex and age. Intervention participants’ adjusted average weight loss was 2.88 kg (3.16%). At the end of the study, 22 of 24 (92%) intervention participants stated that they would recommend the intervention for weight control to friends and family.

Conclusions

Text messages might prove to be a productive channel of communication to promote behaviors that support weight loss in overweight adults.

Trial Registration

Clinicaltrials.gov NCT00415870; http://clinicaltrials.gov/ct2/show/NCT00415870 (Archived by WebCite at http://www.webcitation.org/5dnolbkFt)

Motivational interviewing fails to improve outcomes of a behavioral weight loss program for obese African American women: a pilot randomized trial

Compared to other racial/ethnic groups, African American (AA) women are more likely to be obese but less likely to participate in weight loss interventions or to successfully lose weight. Sustained motivation for weight loss may be especially difficult for AA women due to socioeconomic and cultural factors. The purpose of this study was to examine whether the addition of motivational interviewing (MI) to a culturally-targeted behavioral weight loss program for AA women improved adherence to the program, diet and physical activity behaviors, and weight loss outcomes. Forty-four obese (mean BMI = 39.4, SD = 7.1) AA women were randomized to receive a 16-week behavioral weight loss program plus four MI sessions, or the same behavioral weight loss program plus four health education (HE; attention control) sessions. Results showed that participants in both MI and HE conditions lost a significant amount of weight, reduced their energy intake and percent calories from fat, and increased their fruit and vegetable consumption (ps < .05). However, adherence to the behavioral weight loss program and changes in diet, physical activity, and weight did not differ across MI and HE conditions. Future research is warranted to determine the subpopulations with which MI is most effective.

Conservative treatment of obesity in an academic obesity unit. Long-term outcome and drop-out

OBJECTIVE

The aim of this study was to explore the outcome and the problems of drop-out in the treatment of obese outpatients at an academic obesity unit.

DESIGN

A two-year clinical treatment evaluation.

SUBJECTS

A total of 117 obese subjects, 83 women and 34 men, mean aged 50 (23-70) years, with an average body mass index (BMI) of 39.0 kg/m2 (28.8- 64.7).

INTERVENTION

All treatment was based on group therapy and included behaviour modification and nutrition counselling. A team of nurses, dieticians, a physiotherapist, a psychotherapist and a physician supervised the treatment. Two programmes were used. Group 1 initially received a low-calorie diet (LCD) for seven weeks combined with the behaviour treatment programme. Group 2 was treated with the behaviour treatment programme only. All subjects were offered complementary treatment according to their medical needs.

RESULTS

There was a continuous drop-out of subjects during the two-year treatment period with an overall drop-out rate of 53%. Anthropometric characteristics, medical history or reasons for drop-out had no impact on the drop-out rate. In completers the weight reduction after two years was 9.2 [+/-10.8 standard deviation (S.D.) kg. In non-completers the weight reduction of the last observed weight measurement was 4.7 (+/-7.9 S.D.) kg. After year two, the weight reduction in Group 1 was 8.8 (+/-12.2 S.D.) kg, and in Group 2 was 9.7 (+/-8.0 S.D.) kg.

CONCLUSION

This study has showed the difficulties of long-term clinical treatment of obese outpatients, even in a specialised obesity clinic. The findings demonstrate that educated and experienced staff together with an extended package of treatment options is not enough to keep patients in treatment for two years. However though the drop-out rate was high, two thirds of the included subjects reduced their weight, which is a satisfactory result in a clinical setting. The drop-out rate and the reasons for dropping out could give a clue in which direction the diagnostics and analysis of the subject's individual needs in health care should be directed.

Predictors of drop-out in overweight and obese outpatients

OBJECTIVE

To investigate the impact on drop-out rates of several baseline clinical characteristics of a sample of overweight and obese outpatients.

DESIGN

Retrospective clinical trial.

SUBJECTS

The charts of 383 patients aged 15-82 y attending an outpatient clinic for the treatment of obesity were examined from the first clinical evaluation until 1 y of diet ambulatory treatment.

MEASUREMENTS

We characterised the participants at baseline on the basis of their somatic characteristics, socioeconomic status, obesity-related diseases and dietary habits. The most significant factors resulting in univariate statistical analysis (waist, body mass index (BMI), full-time job, depressive syndrome, number of obesity-related diseases, daily frequency of fruit consumption) were then examined as independent variables in direct multiple logistic regression with the dependent variable drop-out.

RESULTS

The 1-y drop-out rate was 77.3%. A total of 87 patients completed the follow-up study. The noncompleter patients had slightly lower BMI and waist circumference mean values, and they were further regularly employed in full-time jobs, while the completer patients were principally pensioners and housewives. Drop-outs had a lower number of obesity-related diseases and as a result were less depressed. By the logistic regression, full-time job is the best predictor of premature withdrawal (odds ratio=2.40). Age, gender, anthropometric measurements, lifestyle and dietary habits did not result as significant predictors of drop-out.

CONCLUSION

The overweight and obese outpatients at higher risk of ambulatory treatment drop-out are more likely to work full hours, have less obesity-related complications and be less depressed. In our study, the full-time job condition seems to be the strongest predictor of premature withdrawal.

Industry-Sponsored Weight Loss Programs: Description, Cost, and Effectiveness

PURPOSE

To describe three commercial weight loss programs (Jenny Craig, LA Weight Loss, and Weight Watchers), including efficacy data when available, and to provide clinicians with information for patient counseling.

DATA SOURCES

Personal interviews, journal articles, and Web site information.

CONCLUSIONS

Commercial weight loss programs provide weight loss services. Benefits are experience, planned menus, and psychological support. Limitations are cost, sales promotions that encourage on-the-spot commitment to prepaid contracts, and the cost of program food and additional vitamins.

IMPLICATIONS FOR PRACTICE

Weight loss is a necessary goal for many patients. Clinicians are mandated to provide counseling regarding weight loss.

Qualitative study of spirituality in a weight loss program: contribution to self-efficacy and locus of control

OBJECTIVE

The purpose of this qualitative study was to examine how spirituality affects intrapersonal characteristics associated with a weight loss program.

DESIGN

A series of 5 focus group interviews was conducted with women who were past participants of the Weigh Down Workshop, a spiritually based weight loss program.

SETTING

Three churches in the Minneapolis/St. Paul, Minnesota, metropolitan area.

PARTICIPANTS

Focus group participants (N = 32) were white, fairly well educated, with moderate income levels. Their mean age was 50 years.

PHENOMENA OF INTEREST

Behavior changes, factors affecting self-efficacy for performing the behaviors, and locus of control.

ANALYSIS

Sessions were audiotaped and transcribed. Transcribed text was coded and analyzed using qualitative data analysis procedures.

RESULTS

Major changes in self-reported eating behaviors included eating only when experiencing true physiological hunger and stopping when sensing a feeling of fullness. Self-efficacy for these behaviors was reported to be enhanced by observing weight loss for themselves or others. Support from other group members, the simplicity of the program, and spiritual benefits through prayer and scripture reading were also reported to enhance confidence. Women indicated that they relied on an internal locus of control based on a sense of self-discipline.

CONCLUSIONS AND IMPLICATIONS

Traditional means to enhance self-efficacy were important for all women; however, for some women, spirituality was also an important aspect of adhering to program principles.

A programme of behaviour modification and nutrition counselling in the treatment of obesity: a randomised 2-y clinical trial

OBJECTIVE

To compare two group treatment programmes for obese outpatients. Both programmes included behaviour modification, nutrition counselling, very-low-calorie diet (VLCD) and a continuous measuring of metabolic and anthropometrical status, but they differed regarding the treatment intensiveness. The main aim was to study whether intensive treatment gives a larger weight reduction compared with less intensive treatment and what level of input from health care personnel is needed to reach adequate treatment results.

DESIGN

A 2-y randomised clinical trial.

SUBJECTS

A total of 43 obese subjects aged 24-60 y, BMI 35 kg/m(2) (29-48).

INTERVENTION

Two programmes were used. Both were based on group therapy and were supervised by a dietitian and a psychologist. Group 1 received a continuous intensive treatment with planned group meetings every fortnight during the first year and six group meetings the second year. Group 2 had planned group meetings every third month. Anthropometrical and metabolic data were measured every third month in both groups. The VLCD periods were the same.

RESULTS

There was no evidence that a more intensive treatment promotes a larger weight reduction. Weight reduction after 1 y: group 1, -7.6 (+/-0.97) kg, BMI -2.6 (+/-0.3) kg/m(2); group 2, -6.4 (+/-1.16) kg, BMI -2.2 (+/-0.4) kg/m(2). Weight reduction after 2 y: group 1, -6.8 (+/-1.4) kg, BMI -2.4 (+/-0.3) kg/m(2); group 2, -8.6 (+/-1.6) kg, BMI -3.0 (+/-0.3) kg/m(2). The dropout rate was 26%.

CONCLUSION

There were no significant differences in weight reduction, compliance or dropout rate between the groups and there was no evidence that a more intensive treatment promotes a larger weight reduction. This observation is of value when setting up treatment programmes. To measure the metabolic and anthropometrical status during the treatment and to give continuous feedback to the subjects seem to be important factors for compliance. Both treatment programmes gave highly significant weight reductions in the range of 5-10%, which has been referred to as a realistic goal for the treatment of obese patients.

CD-ROM nutrient analysis database assists self-monitoring behavior of active duty Air Force personnel receiving nutrition counseling for weight loss

This study observed the effect of using a computerized vs manual method of self-monitoring among Air Force personnel receiving nutrition counseling for weight loss. Subjects who enrolled during the first 2 weeks of the 4-week recruitment period completed food records for 6 weeks using a CD-ROM nutrient database (intervention group) whereas those who enrolled during the last 2 weeks used a food record booklet (comparison group). Of the 42 subjects (n = 23 intervention group and n = 19 comparison group), only 113 intervention and 11 comparison group subjects (57% of study enrollees) submitted at least 1 food record during the study and were included in the analysis, which included review of pre- and poststudy questionnaires, food records, and focus group data. There were no significant differences between the number of days per week documented or average number of items recorded daily. All 9 intervention as compared to 2 comparison group subjects who completed a poststudy questionnaire searched for lower-energy and lower-fat items and reported changing their dietary intake as a result. All intervention group subjects who participated in a focus group (n=6) had favorable comments about using the CD-ROM for monitoring and changing eating habits, indicating that it is a beneficial self-monitoring tool. Participants enjoyed the immediate dietary feedback, and computerized food records may be easier to interpret by nutrition counselors. A number of computerized nutrient databases are available to assist patients and consumers in managing nutritional concerns.

Measurement characteristics of 2 different self-monitoring tools used in a dietary intervention study

OBJECTIVE

To examine the measurement characteristics of 2 self-monitoring tools, a food diary and fat scan, used in the dietary intervention of the Women's Health Trial: Feasibility in Minority Populations study.

DESIGN

Comparison of fat intake reported on the self-monitoring tools to a criterion measure of fat intake, specifically the mean of a food frequency questionnaire and a 4-day food record. The main outcome measures were differences in fat grams and correlations between each of the self-monitoring tools and the criterion measure.

SUBJECTS/SETTING

Six-month postrandomization data from 313 women aged 50 to 79 years who participated in the intervention group of the Women's Health Trial: Feasibility in Minority Populations study.

RESULTS

Both self-monitoring tools underestimated fat intake compared to the criterion measure, the food diary by 9 g and the fat scan by 6 g. The self-monitoring instruments were better than chance at detecting a low-fat dietary pattern, however, and did not differ from each other in their ability to do so.

APPLICATIONS/CONCLUSIONS

The self-monitoring tools were modestly precise as measures of fat intake, but neither was sufficiently accurate to be reliable as a sole assessment of dietary adherence. Dietetics professionals are encouraged to assess the measurement properties of self-monitoring tools to use them appropriately in supporting dietary changes.

Motivations for exercise and weight loss among African-American women: focus group results and their contribution towards program development

OBJECTIVE

African-American women are more likely to be sedentary and maintain higher body weights compared with Caucasian women, although some are physically active and able to maintain weight loss. To develop effective intervention strategies, we need to understand why some women are successful.

DESIGN

We conducted focus groups on four distinct groups of African-American women (currently physically active; currently sedentary; successful weight loss for > or = 1 year; unsuccessful weight loss) to explore motivations and intervention strategies. Open-ended questions, probes, and visual aids were used to stimulate discussions. Transcripts of sessions were read to highlight themes and concepts.

RESULTS

Results indicated that motivators for the exercisers to start exercising were health concerns, weight control, stress reduction, and the influence of others. Motivators to continue exercising were feeling good and having energy. In contrast, the sedentary women reported that social support and enjoyment would be motivating. Both groups reported that physically active women conveyed the image of high energy and self-esteem. The successful weight loss women employed strategies that allowed them to eat a variety of foods and were less likely to 'diet'. The unsuccessful women referred to 'going on a diet' and were more likely to label foods as 'good' or 'bad'. They reported feeling tired and thought that losing weight would give them more energy.

CONCLUSION

This information was used to develop two culturally appropriate interventions for African-American women, which is presented. Conducting formative research in study design protocols can provide an important role in intervention development.

Management of obesity in patients with Type 2 diabetes

Although prevention is clearly a logical first step in the management of the obese Type 2 diabetic patient, such programmes have had little long-term success. Diet, exercise and behavioural modification still form the cornerstones of treatment and relatively small weight loss results in improvement of all major obesity-related co-morbidities, including Type 2 diabetes. The obese diabetic patient faces extra impediments to weight loss, including the adverse effects of diabetic medication, poor glycaemic control and diabetes-related complications. New drugs may offer some additional help, in general by providing the benefit associated with the weight loss as such. Bariatric surgery can produce major long-term weight loss in the severely obese.

A review of current weight management: research and recommendations

PURPOSE

To review current research and recommendations on weight loss and weight control and provide suggestions for health care providers who furnish weight management counseling.

DATA SOURCES

Scientific publications, clinical guidelines, and government sources.

CONCLUSIONS

Research reaffirms the long-held understanding that weight loss can be accomplished only through a reduction in the number of calories consumed and an increase in exercise. Weight maintenance requires life-long behavioral change combining moderate exercise, lower fat intake, increased fruit and vegetable consumption, as well as social support. Fad diets and medications are not the answer to long-term weight maintenance.

IMPLICATIONS FOR PRACTICE

The essential components of a weight loss or weight management program include: calorie reduction of 300-500 calories per day, appropriate exercise, variety in food choices, increased consumption of grains, fruits, and vegetables, and reduction of fat to no more than 30% of daily calories. Clients should be referred to dietitian and exercise consultants as needed.

A cross-sectional survey of the opinions on weight loss treatments of adult obese patients attending a dietetic clinic

OBJECTIVE

To investigate the views and opinions on weight loss treatments of adult obese patients attending a dietetic clinic.

DESIGN

Cross-sectional survey.

SUBJECTS

161 adults attending dietetic outpatients clinics in Portsmouth for obesity with a body mass index of at least 30 kg/m2.

MEASUREMENTS

Self-administered questionnaire developed from a series of focus groups with obese adults. Key topics were previous attempts to lose weight, methods used, the role of physical activity and patients' views about treatment from health professionals.

RESULTS

The preferences and usefulness of different methods to lose weight varied according to the number of attempts to lose weight, gender, age, body mass index and medical condition of the patient. Men were less likely to use special slimming products, attend slimming groups and swimming than women (odds ratios (95% confidence interval), 0.1 (0.03-0.6) for slimming groups other than Weight Watchers, 0.3 (0.1-0.80) for special slimming products and 0.3 (0.1-0.6) for swimming). Men were more likely to use physical activity (2.6 (1.1-6.2)) and in particular walking (3.7 (1.0-13.6)) and cycling (2.8 (1.0-7.6)) and were more likely to see the dietitian (3.8 (1.4-9.9)) than women. Those with more than 10 attempts to lose weight were more likely to see the dietitian (3.6(1.6-8.2)), use Weight Watchers (2.5 (1.1-5. 6)) and newspapers and magazines (4.4 (1.8-10.9)) than those with fewer attempts. The younger age group were more likely to use more vigorous forms of exercise (4.2 (1.6-11.2) for keep fit and 3.7 (1. 5-9.6) for cycling) than the older subjects. The most obese were more likely to have negative views on their treatment by health professionals (4.4 (1.9-9.8) 'chairs are never big enough' and 4.0 (1.8-8.8) 'I am regarded as a second class citizen') than those who were less obese. Those without a medical condition were more likely to exercise (2.8 (1.3-6.3)) and use books (4.8 (2.0-11.2)) than those with a medical condition.

CONCLUSION

The views of obese people should be considered when planning services for the treatment of obesity and a variety of options should be available. International Journal of Obesity (2000) 24, 164-170