Perceptions of an acceptance-based weight management treatment among adults living in rural areas

Obesity and obesity-related comorbidities disproportionately affect rural communities. Research has emerged in support of a novel acceptance-based behavioural weight management treatment (ABT) that integrates the principles and procedures of acceptance-commitment therapy (ACT) with traditional components of standard behavioural treatment (SBT). The current study assessed the perceptions of community stakeholders in rural areas to session materials of a commercially available ABT program. Surveys and focus groups were used to solicit feedback from three former interventionists with experience delivering SBTs in rural counties and from 17 former participants in these programs. Qualitative responses encompassed four overarching themes: (1) recommendations to support participant engagement, (2) comments about preferences for specific ABT and SBT strategies, (3) concerns about specific aspects of treatment delivery, and (4) requests for aesthetic changes to session materials to enhance clarity and engagement. Overall, participants viewed ABT materials and concepts favourably but believed it would be important to begin the intervention with rapport building and training in traditional SBT strategies prior to delving into ACT strategies. Future studies should investigate the efficacy of ABT for weight loss in adults with obesity living in rural communities and continue to solicit feedback from rural community stakeholders.

Predicting high-risk periods for weight regain following initial weight loss

OBJECTIVE

The aim of this study was to develop a predictive algorithm of "high-risk" periods for weight regain after weight loss.

METHODS

Longitudinal mixed-effects models and random forest regression were used to select predictors and develop an algorithm to predict weight regain on a week-to-week basis, using weekly questionnaire and self-monitoring data (including daily e-scale data) collected over 40 weeks from 46 adults who lost ≥5% of baseline weight during an initial 12-week intervention (Study 1). The algorithm was evaluated in 22 adults who completed the same Study 1 intervention but lost <5% of baseline weight and in 30 adults recruited for a separate 30-week study (Study 2).

RESULTS

The final algorithm retained the frequency of self-monitoring caloric intake and weight plus self-report ratings of hunger and the importance of weight-management goals compared with competing life demands. In the initial training data set, the algorithm predicted weight regain the following week with a sensitivity of 75.6% and a specificity of 45.8%; performance was similar (sensitivity: 81%-82%, specificity: 30%-33%) in testing data sets.

CONCLUSIONS

Weight regain can be predicted on a proximal, week-to-week level. Future work should investigate the clinical utility of adaptive interventions for weight-loss maintenance and develop more sophisticated predictive models of weight regain.

Change in parent and child psychopathology following obesity treatment and maintenance: A secondary data analysis

BACKGROUND

General and eating disorder (ED) psychopathology are common among children and adults with overweight/obesity; few studies have examined their course of change throughout family-based behavioural obesity treatment (FBT) and maintenance.

OBJECTIVES

Examine: (1) the changes in the parent and child general and ED psychopathology during FBT and maintenance interventions; (2) the associations between change in psychopathology and change in weight among children or parents; (3) the associations between change in psychopathology within parent-child dyads.

METHODS

172 parent-child dyads participated in 4-month FBT and were subsequently randomized to one of three 8-month maintenance interventions. General psychopathology (child anxiety/depressive symptoms, parent severity of global psychological distress), ED psychopathology (shape/weight concern), and percent overweight were assessed at baseline, post-FBT, and post-maintenance. Separate linear mixed-effects models evaluated change in general and ED psychopathology, including an interaction between maintenance condition and time. Partial correlations examined associations between change in psychopathology and percent overweight among children or parents, and associations between change in psychopathology within parent-child dyads.

RESULTS

Among children, significant reductions were observed from baseline to post-FBT in all forms of psychopathology and from post-FBT to post-maintenance in general psychopathology. Among parents, significant reductions were observed from baseline to post-FBT in all forms of psychopathology; reductions were maintained from post-FBT to post-maintenance. There was no significant interaction between maintenance condition and time. Correlations between change in most forms of parent or child psychopathology and percent overweight were observed.

CONCLUSIONS

Participation in FBT and maintenance was associated with improvements in general and ED psychopathology in both parents and children.

Parents of minor children lose less weight during a behavioral weight loss intervention: Findings from the Rural LEAP trial

Objective

The transition to parenthood is associated with worsening health behaviors, yet the impact of parental status on successful weight loss has rarely been examined. The purpose of this study was to examine the effect of parental status of minor children on weight loss and behavioral adherence in a rural community-based weight loss intervention.

Methods

Five hundred and twenty-eight adults (age 21-75 years, body mass index [BMI] 30-45 kg/m2) were enrolled in a group-based weight loss intervention consisting of 16 weekly sessions delivered in face-to-face group sessions at Cooperative Extension Service (CES) offices. Participants who were parents with at least one minor child (≤18 years old) in the home were compared to participants with no minor children in the home. Measures included percent weight loss, session attendance, adherence to self-monitoring, and achieving calorie and physical activity goals.

Results

Compared to participants without minor children, parents with minor children lost significantly less weight (7.5% vs. 6.2%, respectively; p = 0.01), and were less likely to lose ≥5% of baseline weight (59.2% vs. 70.2%, respectively; p = 0.02). In addition, parents with minor children attended significantly fewer sessions, had lower adherence to self-monitoring, and met calorie and step goals less often (all ps < 0.001). The association between parental status and percent weight loss was not significantly moderated by gender of the parent.

Conclusions

Parents of minor children had greater difficulty adhering to intervention goals and lost less weight than participants without minor children. Future research should investigate whether tailoring intervention to meet the unique needs of parents can enhance outcomes, especially given the large segment of the population represented by this group.

Relation of social network support to child health behaviors among children in treatment for overweight/obesity

PURPOSE

Little is known about the influence of social network support on child health behaviors in the context of weight-loss interventions. This study examined the associations between a child's co-participation (i.e., network support) in weight-related health behaviors (i.e., physical and sedentary activity, eating behavior) and the child's own health behaviors during family-based behavioral treatment (FBT).

METHODS

Children (n = 241) with overweight/obesity (mean age = 9.4 ± 1.3y; 63% female) completed semi-structured interviews assessing network support for healthy/unhealthy eating and physical/sedentary activity, and a 3-day dietary recall. Physical activity was assessed with accelerometry, and sedentary activity was measured via parent-reported child screen time use. All assessments were taken at baseline and after 4 months of FBT. Hierarchical linear regressions examined changes in network support as they related to changes in health behaviors from baseline to the end of FBT.

RESULTS

Changes in network support for healthy eating were related to changes in vegetable, but not fruit, intake across FBT, while changes in network support for unhealthy eating were negatively related to changes in diet quality. Changes in network support for sedentary activity were negatively related to changes in minutes of physical activity and positively related to changes in screen time.

CONCLUSION

The present findings suggest that a child's network support for health behaviors may relate to behavior change among children during FBT and provide opportunities for targeted intervention.

LEVEL OF EVIDENCE

III. cohort study.

Impact of transition from face-to-face to telehealth on behavioral obesity treatment during the COVID-19 pandemic

OBJECTIVE

This study evaluated whether the transition of a face-to-face behavioral intervention to videoconferencing-based telehealth delivery during the COVID-19 pandemic resulted in significantly smaller weight losses than those typically observed in gold-standard, face-to-face programs.

METHODS

Participants were 160 adults with obesity (mean [SD] age = 49.2 [11.9] years, BMI = 36.1 [4.2] kg/m² ) enrolled in two cohorts of a 16-week comprehensive weight-management program. Cohort 1 began in person and transitioned to telehealth (Zoom) delivery during week 11 of the intervention because of COVID-19; Cohort 2 was conducted completely remotely. A noninferiority approach (using a clinically relevant noninferiority margin of 2.5%) was used to assess whether the weight losses observed were inferior to the 8% losses from baseline typically produced by gold-standard, face-to-face lifestyle interventions.

RESULTS

From baseline to postintervention, participants lost an average of 7.4 [4.9] kg, representing a reduction of 7.2% [4.6%]. This magnitude of weight change was significantly greater than 5.5% (t[159] = 4.7, p < 0.001), and, thus, was within the proposed noninferiority margin.

CONCLUSIONS

These findings demonstrate that the results of behavioral weight-management interventions are robust, whether delivered in person or remotely, and that individuals can achieve clinically meaningful benefits from behavioral treatment even during a global pandemic. Pragmatic "lessons learned," including modified trial recruitment techniques, are discussed.

Weight loss in primary care: A pooled analysis of two pragmatic cluster-randomized trials

OBJECTIVE

The aim of this study was to report the results of five weight-loss interventions in primary care settings in underserved patients and to compare the level of pragmatism across the interventions using the Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) tool.

METHODS

Data from 54 primary care clinics (2,210 patients) were pooled from the Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL) and Rural Engagement in Primary Care for Optimizing Weight Reduction (REPOWER) cluster-randomized trials. Clinics were randomized to one of five comparators: PROPEL usual care, PROPEL combination of in-clinic and telephone visits, REPOWER in-clinic individual visits, REPOWER in-clinic group visits, or REPOWER telephone group visits.

RESULTS

At 24 months, weight loss (kilograms) was -0.50 (95% CI: -1.77 to 0.76), -3.05 (-4.10 to -2.01), -4.30 (-5.35 to -3.26), -4.79 (-5.83 to -3.75), and -4.80 (-5.96 to -3.64) in the PROPEL usual care, REPOWER in-clinic individual visits, REPOWER telephone group visits, REPOWER in-clinic group visits, and PROPEL in-clinic and telephone visits arms, respectively. At 24 months, percentage of weight loss was -0.360 (-1.60 to 0.88), -3.00 (-4.02 to -1.98), -4.23 (-5.25 to -3.20), -4.67 (-5.69 to -3.65), and -4.69 (-5.82 to -3.56), respectively, in the five arms. The REPOWER in-clinic individual visits intervention was the most pragmatic and reflects the current Centers for Medicare and Medicaid Services funding model, although this intervention produced the least weight loss.

CONCLUSIONS

Clinically significant weight loss over 6 months in primary care settings is achievable using a variety of lifestyle-based treatment approaches. Longer-term weight-loss maintenance is more difficult to achieve.

Racial and socioeconomic disparities in the efficacy of a family-based treatment programme for paediatric obesity

BACKGROUND

Family-based behavioural weight loss treatment (FBT) is an evidence-based intervention for paediatric overweight/obesity (OV/OB), but little research has examined the relative efficacy of FBT across socioeconomic status (SES), and racial groups.

METHOD

A total of 172 youth (7-11 years; 61.6% female; 70.1% White, 15.7% Black; child percent OV = 64.2 ± 25.2; 14.5% low-income) completed 4 months of FBT and 8 months of additional intervention (either active social facilitation-based weight management or an education control condition). Parents reported family income, social status (Barratt simplified measure of social status) and child race at baseline. Household income was dichotomized into < or >50% of the area median family income. Race was classified into White, Black or other/multi-race. Treatment efficacy was assessed by change in child % OV (BMI % above median BMI for age and sex) and change in child BMI % of 95th percentile (BMI % of the 95th percentile of weight for age and sex). Latent change score models examined differences in weight change between 0 and 4 months, 4 and 12 months and 0 and 12 months by income, social status and race.

RESULTS

Black children had, on average, less weight loss by 4 months compared to White children. Low-income was associated with less weight loss at 4 months when assessed independent of race. No differences by race, social status or income were detected from 4 to 12-months or from 0 to 12 months.

CONCLUSIONS

FBT is effective at producing child weight loss across different SES and racial groups, but more work is needed to understand observed differences in initial efficacy and optimize treatment across all groups.

Rural/urban disparities in access to the National Diabetes Prevention Program

Residents of rural communities generally have limited access to preventive health services such as lifestyle programs for weight management. In 2009, the U.S. Congress authorized the Centers for Disease Control and Prevention (CDC) to partner with local community organizations to disseminate the Diabetes Prevention Program (DPP), an evidence-based lifestyle intervention for weight management. Given that the National DPP (NDPP) was designed to broaden nationwide access to weight-loss treatment for adults at high risk for developing diabetes, the present study examined the implementation of the NDPP in rural and urban counties across the USA. The names and locations of NDPP community partnership sites were collected from the CDC website and cross-referenced with the U.S. Census Bureau's classification of counties as rural versus urban. Results showed that overall 27.9% of the 3,142 counties in the USA contained one or more NDPP partnership sites. However, significantly fewer rural counties had access to a NDPP site compared with urban counties (14.6% vs. 48.4%, respectively, p < .001). This disparity was evident across all types of partnership sites (ps < .001). These findings indicate that implementation of the NDPP has expanded the overall availability of evidence-based weight-management programs across the USA. However, this increase has been disproportionately greater for urban counties versus rural counties, thereby widening the rural/urban disparity in access to preventive health services. Alternative dissemination strategies that address the special barriers to implementation faced by rural communities are needed to increase access to the NDPP.

General and Eating Disorder Psychopathology in Relation to Short- and Long-Term Weight Change in Treatment-Seeking Children: A Latent Profile Analysis

BACKGROUND

Concurrent general psychopathology (GP) and eating disorder psychopathology (EDP) are commonly reported among youth with overweight/obesity and may impact weight change.

PURPOSE

We identified patterns of GP and EDP in children with overweight/obesity and examined the impact on weight change following family-based behavioral obesity treatment (FBT) and maintenance interventions.

METHODS

Children (N = 172) participated in 4 month FBT and subsequent 8 month weight maintenance interventions. GP and EDP were assessed prior to FBT (baseline). Child percentage overweight was assessed at baseline, post-FBT (4 months), and post-maintenance (12 months). Latent profile analysis identified patterns of baseline GP and EDP. Linear mixed-effects models examined if profiles predicted 4- and 12-month change in percentage overweight and if there were two-way and three-way interactions among these variables, adjusting for relevant covariates.

RESULTS

Results indicated a three-profile structure: lower GP and EDP (LOWER); subclinically elevated GP and EDP without loss of control (LOC; HIGHER); and subclinically elevated GP and EDP with LOC (HIGHER + LOC). Across profiles, children on average achieved clinically meaningful weight loss (i.e., ≥9 unit change in percentage overweight) from baseline to 4 month FBT and sustained these improvements at 12 month maintenance. There was no evidence that latent profiles were related to percentage overweight change from baseline to FBT (p > .05) or baseline to maintenance (p > .05). There was no evidence for two-way or three-way interactions (p > .05).

CONCLUSION

Concurrent GP and EDP do not portend differential short- or long-term weight change following FBT and maintenance. Future research is warranted on the durability of weight change among youth with GP and EDP.

TRIAL REGISTRATION

NCT00759746.

Children with Severe Obesity in Family-Based Obesity Treatment Compared with Other Participants: Conclusions Depend on Metrics

OBJECTIVE

This study compares children with severe obesity and children with mild obesity/overweight participating in family-based obesity treatment (FBT) on change in (1) relative weight and adiposity and (2) psychosocial distress.

METHODS

Children 7 to 11 years old (N = 241) and their parents participated in 12 months of behavioral treatment (FBT + maintenance treatment) and completed anthropometric, adiposity, and psychosocial assessments (psychiatric disorder symptomology, quality of life). Severe obesity was defined as a baseline BMI ≥ 120% of the 95th percentile (N = 105).

RESULTS

At 12 months, 40% of children with baseline severe obesity no longer had severe obesity. Percent overweight and fat mass index measurements showed similar magnitudes of change among children with severe obesity and children with mild obesity/overweight, whereas BMI z score and percent body fat change was lower in the group with severe obesity. Youth with severe obesity were higher on some measures of psychosocial distress at baseline but generally experienced improvements similar to children with mild obesity/overweight.

CONCLUSIONS

FBT with maintenance treatment is beneficial for children with severe obesity and is recommended for use prior to more invasive treatments in severe pediatric obesity. Future studies should assess the necessity of additional treatment, as children with severe obesity still have high relative weights post intervention.

Effect of Behavioral Therapy With In-Clinic or Telephone Group Visits vs In-Clinic Individual Visits on Weight Loss Among Patients With Obesity in Rural Clinical Practice: A Randomized Clinical Trial

IMPORTANCE

Rural populations have a higher prevalence of obesity and poor access to weight loss programs. Effective models for treating obesity in rural clinical practice are needed.

OBJECTIVE

To compare the Medicare Intensive Behavioral Therapy for Obesity fee-for-service model with 2 alternatives: in-clinic group visits based on a patient-centered medical home model and telephone-based group visits based on a disease management model.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial conducted in 36 primary care practices in the rural Midwestern US. Inclusion criteria included age 20 to 75 years and body mass index of 30 to 45. Participants were enrolled from February 2016 to October 2017. Final follow-up occurred in December 2019.

INTERVENTIONS

All participants received a lifestyle intervention focused on diet, physical activity, and behavior change strategies. In the fee-for-service intervention (n = 473), practice-employed clinicians provided 15-minute in-clinic individual visits at a frequency similar to that reimbursed by Medicare (weekly for 1 month, biweekly for 5 months, and monthly thereafter). In the in-clinic group intervention (n = 468), practice-employed clinicians delivered group visits that were weekly for 3 months, biweekly for 3 months, and monthly thereafter. In the telephone group intervention (n = 466), patients received the same intervention as the in-clinic group intervention, but sessions were delivered remotely via conference calls by centralized staff.

MAIN OUTCOMES AND MEASURES

The primary outcome was weight change at 24 months. A minimum clinically important difference was defined as 2.75 kg.

RESULTS

Among 1407 participants (mean age, 54.7 [SD, 11.8] years; baseline body mass index, 36.7 [SD, 4.0]; 1081 [77%] women), 1220 (87%) completed the trial. Mean weight loss at 24 months was -4.4 kg (95% CI, -5.5 to -3.4 kg) in the in-clinic group intervention, -3.9 kg (95% CI, -5.0 to -2.9 kg) in the telephone group intervention, and -2.6 kg (95% CI, -3.6 to -1.5 kg) in the in-clinic individual intervention. Compared with the in-clinic individual intervention, the mean difference in weight change was -1.9 kg (97.5% CI, -3.5 to -0.2 kg; P = .01) for the in-clinic group intervention and -1.4 kg (97.5% CI, -3.0 to 0.3 kg; P = .06) for the telephone group intervention.

CONCLUSIONS AND RELEVANCE

Among patients with obesity in rural primary care clinics, in-clinic group visits but not telephone-based group visits, compared with in-clinic individual visits, resulted in statistically significantly greater weight loss at 24 months. However, the differences were small in magnitude and of uncertain clinical importance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02456636.

Examining the interdependence of parent-child dyads: Effects on weight loss and maintenance

BACKGROUND

This study aimed to further elucidate correlated weight changes in parent-child dyads enrolled in family-based treatment (FBT) by modeling the interdependence of weight changes during treatment.

METHODS

Parent-child dyads (n = 172) with overweight/obesity (child mean zBMI = 2.16 ± 0.39; parent mean BMI = 37.9 ± 9.4 kg/m2 ) completed 4 months of FBT and were randomized to one of three 8-month maintenance interventions (Social Facilitation Maintenance [SFM]-high dose, SFM-low dose or control). Weight/height was measured at 0, 4 and 12 months. Structural equation models simultaneously estimated the effect that an individual had on their own (actor effect) and on one another's (partner effect) weight-status across time using the actor-partner interdependence model.

RESULTS

Actor paths were significant over time for parent and child. Partner paths were significant for child zBMI predicting parent BMI at 4 and 12 months. Maintenance condition moderated actor/partner paths in the model.

CONCLUSIONS

Child weight change may motivate parents to make environmental and behavioural changes that impact their own weight.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00759746.

Analysis of the impact of sub-acute care activities on consumption of hospital resources in Milan

Background

In 2011, a new health service called 'sub-acute care activities' (SA) has been provided by Lombardy. It is a protected hospitalization of patients, especially elderlies, suffering for clinical issues following an acute disease or for non-complex clinical failures due to a chronic pathology. This is a hospitalization area between the hospital and home, created to reduce the number of post-acute hospitalized patients who can't be discharged. The goal of this study is the analysis of the hospitalizations in the SA setting within medical structures located in the Metropolitan area of Milan.

Methods

The data extracted from the hospital discharge card database, is focused on hospitalizations in SA that occurred from 2016 to 2019. The analysis describes yearly production, the characteristics of hospitalizations and patients, finally some trends.

Results

16,395 hospitalizations in SA were analyzed (0.7% of the total). Some data are constant in time: hospitalizations (1%), age (average 79), days of hospitalization (average 26). Patients coming from public hospitals (from 28% to 22%) are decreasing while those coming from other in-patient admission typologies within the same organization (from 44% to 54%) are increasing. The major diagnostic categories are related to cardiovascular and respiratory diseases. Over the 85% of hospitalizations are paid with the highest daily rate among those allowed by law. Talking about discharge typologies, 57% of patients return home, 20% are re-transferred to the acute ward, 16% are sent to rehabilitation/long-term care while 7% have died.

Conclusions

The use of the highest daily tariff and the high number of patients who need to be re-transferred to the acute ward place, gives many doubts on how appropriate is allocation of resources and about the accuracy of admissions in the SA unit during the patient care path. We're planning to return to these issues with further targeted studies.

Key messages

The analysis showed constant characteristics of SA activities during the four years. Data showed that there may be management issues in the appropriate use of resources in SA assistence.

Featured Article: Behavior Interventions Addressing Obesity in Rural Settings: The E-FLIP for Kids Trial

OBJECTIVE

To assess the effectiveness of behavioral parent-only (PO) and family-based (FB) interventions on child weight, dietary intake, glycated hemoglobin, and quality of life in rural settings.

METHODS

This study was a three-armed, randomized controlled trial. Participants were children (age 8-12 years) with overweight or obesity and their parents. A FB (n = 88), a PO (n = 78) and a health education condition (HEC) (n = 83) each included 20 group contacts over 1 year. Assessment and treatment contacts occurred at Cooperative Extension Service offices. The main outcome was change in child body mass index z-score (BMIz) from baseline to year 2.

RESULTS

Parents in all conditions reported high treatment satisfaction (mean of 3.5 or higher on a 4-point scale). A linear mixed model analysis of change in child BMIz from baseline to year 1 and year 2 found that there were no significant group by time differences in child BMIz (year 2 change in BMIz for FB = -0.03 [-0.1, 0.04], PO = -0.01 [-0.08, 0.06], and HEC = -0.09 [-0.15, -0.02]). While mean attendance across conditions was satisfactory during months 1-4 (69%), it dropped during the maintenance phase (42%). High attendance for the PO intervention was related to greater changes in child BMIz (p < .02). Numerous barriers to participation were reported.

CONCLUSION

Many barriers exist that inhibit regular attendance at in-person contacts for many families. Innovative delivery strategies are needed that balance treatment intensity with feasibility and acceptability to families and providers to facilitate broad dissemination in underserved rural settings.ClinicalTrials.gov Identifier: NCT01820338.

Effect of Telehealth Extended Care for Maintenance of Weight Loss in Rural US Communities: A Randomized Clinical Trial

IMPORTANCE

Lifestyle interventions for obesity produce reductions in body weight that can decrease risk for diabetes and cardiovascular disease but are limited by suboptimal maintenance of lost weight and inadequate dissemination in low-resource communities.

OBJECTIVE

To evaluate the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted from October 21, 2013, to December 21, 2018, in Cooperative Extension Service offices of 14 counties in Florida. A total of 851 individuals were screened for participation; 220 individuals did not meet eligibility criteria, and 103 individuals declined to participate. Of 528 individuals who initiated a 4-month lifestyle intervention, 445 qualified for randomization. Data were analyzed from August 22 to October 21, 2019.

INTERVENTIONS

Participants were randomly assigned to extended care delivered via individual or group telephone counseling or an education control program delivered via email. All participants received 18 modules with posttreatment recommendations for maintaining lost weight. In the telephone-based interventions, health coaches provided participants with 18 individual or group sessions focused on problem solving for obstacles to the maintenance of weight loss.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in body weight from the conclusion of initial intervention (month 4) to final follow-up (month 22). An additional outcome was the proportion of participants achieving at least 10% body weight reduction at follow-up.

RESULTS

Among 445 participants (mean [SD] age, 55.4 [10.2] years; 368 [82.7%] women; 329 [73.9%] white), 149 participants (33.5%) were randomized to individual telephone counseling, 143 participants (32.1%) were randomized to group telephone counseling, and 153 participants (34.4%) were randomized to the email education control. Mean (SD) baseline weight was 99.9 (14.6) kg, and mean (SD) weight loss after the initial intervention was 8.3 (4.9) kg. Mean weight regains at follow-up were 2.3 (95% credible interval [CrI], 1.2-3.4) kg in the individual telephone counseling group, 2.8 (95% CrI, 1.4-4.2) kg for the group telephone counseling group, and 4.1 (95% CrI, 3.1-5.0) kg for the education control group, with a significantly smaller weight regain observed in the individual telephone counseling group vs control group (posterior probability >.99). A larger proportion of participants in the individual telephone counseling group achieved at least 10% weight reductions (31.5% [95% CrI, 24.1%-40.0%]) than in the control group (19.1% [95% CrI, 14.1%-24.9%]) (posterior probability >.99).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that providing extended care for obesity management in rural communities via individual telephone counseling decreased weight regain and increased the proportion of participants who sustained clinically meaningful weight losses.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02054624.

Family Encouragement of Healthy Eating Predicts Child Dietary Intake and Weight Loss in Family-Based Behavioral Weight-Loss Treatment

Introduction: Social support for healthy eating can influence child eating behaviors; however, little is known about the impact of social support during family-based behavioral weight-loss treatment (FBT). This study aimed to determine the impacts of both baseline and change in family support on change in child diet and weight during FBT. Methods: Children (n = 175; BMI percentile ≥85th; ages 7-11; 61.1% female; 70.9% white) and a participating parent completed 4 months of FBT. Parents were active participants and learned social support-related strategies (i.e., praise and modeling of healthy eating). Child perceived family encouragement and discouragement for healthy eating, child diet quality (via 24-hour recalls), and child weight were assessed pre- and post-FBT. Results: Family encouragement for healthy eating increased during FBT, and this increase was related to increases in child healthy vegetable intake and overall diet quality, as well as decreases in refined grains consumed. Low pre-FBT family encouragement predicted greater increases in healthy vegetable intake, greater weight reduction, and greater increases in family encouragement for healthy eating. Family discouragement for healthy eating did not change during treatment nor did it predict dietary or weight outcomes. Conclusions: FBT successfully improves family encouragement, which is associated with improvements in child diet. Furthermore, even children who began treatment with low family encouragement for healthy eating show great improvements in dietary intake and weight during treatment. Results suggest that changes in child eating behavior during treatment is influenced by active, positive parenting techniques such as praise of healthy eating rather than negative family support.

Effects of Intervention Characteristics on Willingness to Initiate a Weight Gain Prevention Program

PURPOSE

To determine characteristics of weight gain prevention programs that facilitate engagement.

DESIGN

Randomized factorial experiment (5 × 2).

SETTING

Recruited nationally online.

PARTICIPANTS

Adults aged 18 to 75 with body mass index ≥25 who decline a behavioral weight loss intervention (n = 498).

MEASURES

Participants were randomly presented with one of 10 possible descriptions of hypothetical, free weight gain prevention programs that were all low dose and technology-based but differed in regard to 5 behavior change targets (self-weighing only; diet only; physical activity only; combined diet, physical activity, and self-weighing; or choice between diet, physical activity, and self-weighing targets) crossed with 2 financial incentive conditions (presence or absence of incentives for self-monitoring). Participants reported willingness to join the programs, perceived program effectiveness, and reasons for declining enrollment.

ANALYSIS

Logistic regression and linear regression to test effects of program characteristics offered on willingness to initiate programs and programs' perceived effectiveness, respectively. Content analyses for open-ended text responses.

RESULTS

Participants offered the self-weighing-only programs were more willing to initiate than those offered the programs targeting all 3 behaviors combined (50% vs 36%; odds ratio [OR] = 1.79; 95% confidence interval [CI], 1.01-3.13). Participants offered the programs with financial incentives were more willing to initiate (50% vs 33%; OR = 2.08; 95% CI, 1.44-2.99) and anticipated greater intervention effectiveness (β = .34, P = .02) than those offered no financial incentives. Reasons for declining to initiate included specific program features, behavior targets, social aspects, and benefits.

CONCLUSION

Targeting self-weighing and providing financial incentives for self-monitoring may result in greater uptake of weight gain prevention programs.

STUDY PREREGISTRATION

https://osf.io/b9zfh, June 19, 2018.

Cost-Effectiveness of Three Doses of a Behavioral Intervention to Prevent or Delay Type 2 Diabetes in Rural Areas

BACKGROUND

Rural Americans have higher prevalence of obesity and type 2 diabetes (T2D) than urban populations and more limited access to behavioral programs to promote healthy lifestyle habits. Descriptive evidence from the Rural Lifestyle Intervention Treatment Effectiveness trial delivered through local cooperative extension service offices in rural areas previously identified that behavioral modification with both nutrition education and coaching resulted in a lower program delivery cost per kilogram of weight loss maintained at 2-years compared with an education-only comparator intervention.

OBJECTIVE

This analysis extended earlier Rural Lifestyle Intervention Treatment Effectiveness trial research regarding weight loss outcomes to assess whether nutrition education with behavioral coaching delivered through cooperative extension service offices is cost-effective relative to nutrition education only in reducing T2D cases in rural areas.

DESIGN

A cost-utility analysis was conducted.

PARTICIPANTS/SETTING

Trial participants (n=317) from June 2008 through June 2014 were adults residing in rural Florida counties with a baseline body mass index between 30 and 45, but otherwise identified as healthy.

INTERVENTION

Trial participants were randomly assigned to low, moderate, or high doses of behavioral coaching with nutrition education (ie, 16, 32, or 48 sessions over 24 months) or a comparator intervention that included 16 sessions of nutrition education without coaching. Participant glycated hemoglobin level was measured at baseline and the end of the trial to assess T2D status.

MAIN OUTCOME MEASURES

T2D categories by treatment arm were used to estimate participants' expected annual health care expenditures and expected health-related utility measured as quality adjusted life years (ie, QALYs) over a 5-year time horizon. Discounted incremental costs and QALYs were used to calculate incremental cost-effectiveness ratios for each behavioral coaching intervention dose relative to the education-only comparator.

STATISTICAL ANALYSES PERFORMED

Using a third-party payer perspective, Markov transition matrices were used to model participant transitions between T2D states. Replications of the individual participant behavior were conducted using Monte Carlo simulation.

RESULTS

All three doses of the behavioral coaching intervention had lower expected total costs and higher estimated QALYs than the education-only comparator. The moderate dose behavioral coaching intervention was associated with higher estimated QALYs but was costlier than the low dose; the moderate dose was favored over the low dose with willingness to pay thresholds over $107,895/QALY. The low dose behavioral coaching intervention was otherwise favored.

CONCLUSIONS

Because most rural Americans live in counties with cooperative extension service offices, nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and efficient in preventing or delaying T2D-associated consequences of obesity for rural adults.

Factors associated with depression and anxiety symptoms among children seeking treatment for obesity: A social-ecological approach

BACKGROUND

Children with overweight/obesity are more likely to exhibit symptoms of depression and anxiety than are their peers without overweight/obesity; however, the rates and correlates of depression and anxiety symptoms among children seeking obesity treatment remain unclear.

OBJECTIVES

Examine the prevalence and associated factors of depression and anxiety symptoms among treatment-seeking children with overweight/obesity.

METHODS

Children 7 to 11 years old (N = 241) and their parents completed assessments before beginning family-based behavioral weight-loss treatment. Disorder-specific self-report questionnaires assessed child depression and anxiety. The social-ecological model served as a framework for examining factors associated with depression and anxiety symptoms.

RESULTS

Among our sample, 39.8% (96/241) met clinical cutoffs for depression and/or anxiety symptomatology. Specifically, of these 96, 48 met criteria for both depression and anxiety, 24 for depression only, and 24 for anxiety only. Child eating disorder pathology, parents' use of psychological control (ie, a parenting style characterized by emotional manipulation), and lower child subjective social status were significantly associated with greater child depression symptomatology. Child eating disorder pathology and parent psychological control were significantly associated with greater child anxiety symptomatology.

CONCLUSION

Nearly 40% of children exhibited psychopathology symptoms, and a variety of correlates were found. Thus, pediatric weight-loss providers may consider screening for and addressing mental health concerns (and associated factors) prior to and during treatment.

Child and parent reports of children's depressive symptoms in relation to children's weight loss response in family-based obesity treatment

BACKGROUND

Studies of the association between children's depressive symptoms and obesity treatment response show mixed results. Different measurement may contribute to the inconsistent findings, as children's depressive symptoms are often based on parent-report about their child rather than child self-report.

OBJECTIVES

We assessed both child- and parent-report of child depressive symptoms as predictors of children's obesity treatment response.

METHODS

Children with overweight/obesity (body mass index [BMI] ≥ 85th percentile; N = 181) and their parents reported on children's depressive symptoms prior to family-based behavioral weight loss treatment.

RESULTS

Child percent overweight reduction from baseline to post-treatment was not predicted by child self-reported depressive symptoms or parent-report of child symptoms (P > 0.80), but was significantly predicted by the interaction between child self-report and parent-report on child (β = 0.14, P = 0.05). In analyses using clinical cutoffs, amongst children with high self-reported symptoms, those whose parents reported low child depressive symptoms had greater reduction in percent overweight (t = 2.67, P = 0.008), whereas amongst children with low self-reported symptoms, parent ratings were not associated with treatment outcome.

CONCLUSIONS

Including both child self-report and parent-report of child depressive symptoms may inform obesity care. Research is needed to examine differences amongst child and parent depressive symptom reports and strategies to address symptoms and optimize pediatric obesity treatment.

Home and neighbourhood built environment features in family-based treatment for childhood obesity

BACKGROUND

Family-based behavioural weight loss treatment (FBT) for childhood obesity helps families develop strategies to facilitate healthy choices in their home and other environments (e.g. home neighbourhood). The current study examines how the home food environment, both pre-FBT and post-FBT, and the neighbourhoods in which families live are associated with child weight and weight-related outcomes in FBT.

METHODS

Parent-child dyads (n = 181) completed a 16-session FBT programme and completed home environment, anthropometric and child dietary/activity assessments at pre-FBT and post-FBT. Parents reported on availability of food, electronics and physical activity equipment in the home. The neighbourhood food and recreation environments around each dyad's residence was characterized using existing data within a geographic information system.

RESULTS

Families successfully made healthy home environment modifications during FBT. Regression models showed reducing RED (e.g. high-energy-dense and low-nutrient-dense) foods and electronics in the home during FBT had positive effects on child weight and weight-related outcomes. No neighbourhood food or recreation environment variables were significantly related to outcomes, although having a larger density of public recreation spaces was associated with increases in physical activity at the trend-level.

CONCLUSIONS

Modifying the home environment, specifically reducing RED foods and electronics, may be particularly important for FBT success.

Effect of dose of behavioral weight loss treatment on glycemic control in adults with prediabetes

OBJECTIVE

This study examined the effects of three doses of behavioral weight loss treatment, compared with a nutrition education control group, on changes in glycemic control in individuals with obesity and prediabetes.

RESEARCH DESIGN AND METHODS

The study included 287 adults (77% female, 81% White; mean (SD) age=54.1 (10.5) years, body mass index=36.3 (3.9) kg/m², and hemoglobin A1c (HbA1c)=5.9 (0.2%)). Participants were randomized to one of three behavioral treatment doses (high=24 sessions, moderate=16 sessions, or low=8 sessions) or to an education group (control=8 sessions). Changes in HbA1c, fasting glucose, and body weight were assessed from baseline to 6 months.

RESULTS

Mean (99.2% credible interval (CI)) reductions in HbA1c were 0.11% (0.07% to 0.16%), 0.08% (0.03% to 0.13%), 0.03% (-0.01% to 0.07%), and 0.02% (-0.02% to 0.07%), for the high, moderate, low, and control conditions, respectively. Mean (CI) reductions in fasting blood glucose were 0.26 mmol/L (0.14 to 0.39), 0.09 mmol/L (0 to 0.19), 0.01 mmol/L (-0.07 to 0.09), and 0.04 mmol/L (-0.03 to 0.12) for the high, moderate, low, and control conditions, respectively. The high-dose treatment produced significantly greater reductions in HbA1c and fasting blood glucose than the low-dose and control conditions (posterior probabilities (pp)<0.001); no other significant between-group differences were observed. Mean (CI) reductions in body weight were 10.91 kg (9.30 to 12.64), 10.08 kg (8.38 to 11.72), 6.35 kg (5.19 to 7.69), and 3.82 kg (3.04 to 4.54) for the high, moderate, low, and control conditions, respectively. All between-group differences in 6-month weight change were significant (pps<0.001) except for the high-dose versus moderate-dose comparison.

CONCLUSION

For adults with obesity and prediabetes a high dose of behavioral treatment involving 24 sessions over 6 months may be needed to optimize improvements in glycemic control.

TRIAL REGISTRATION NUMBER

NCT00912652.

Dose, Content, and Mediators of Family-Based Treatment for Childhood Obesity: A Multisite Randomized Clinical Trial

IMPORTANCE

Elucidation of optimal dosing and treatment content is critical for health care providers, payers, and policy makers, as well as mechanisms of change to inform intervention delivery and training initiatives for childhood obesity.

OBJECTIVES

To evaluate effects, following a 4-month family-based behavioral weight loss treatment (FBT), of 2 doses (HIGH or LOW) of a weight-control intervention (enhanced social facilitation maintenance [SFM+]) vs a weight-control education condition (CONTROL; matched for dose with LOW), on child anthropometrics, and to explore putative mediators of weight loss outcomes.

DESIGN, SETTING, AND PARTICIPANTS

For this parallel-group randomized clinical trial conducted at 2 US academic medical centers from December 2009 to March 2013, 172 parent-child dyads completed FBT and were then randomized to 8 months of SFM+ (HIGH, n = 59; LOW, n = 56) or CONTROL (n = 57). Children (aged 7-11 years) with overweight and obesity (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared] ≥85th percentile) with at least 1 parent with overweight and obesity (BMI ≥25) were recruited.

INTERVENTIONS

HIGH SFM+ vs LOW SFM+ (CONTROL matched the dose of LOW).

MAIN OUTCOMES AND MEASURES

Intention-to-treat analysis using mixed-effects models estimated change in child percentage overweight (percentage above the median BMI for a child's age and sex) for the FBT period (0-4 months) and the SFM+ period (4-12 months), and proportion of children achieving a clinically significant change in percentage overweight (≥9-unit decrease; months 0-12). Theory-based outcome mediators were also evaluated.

RESULTS

This study recruited 172 parent-child dyads (mean [SD] age: parents 42.3 [6.4] years; children, 9.4 [1.3] years). The omnibus treatment × time interaction for child percentage overweight was significant (F8, 618.9 = 2.89; P = .004). Planned pairwise comparisons revealed that from months 4 to 12, LOW had better outcomes than CONTROL (difference, -3.34; 95% CI, -6.21 to -0.47; d = -0.40; P = .02). HIGH had better outcomes than LOW (difference, -3.37; 95% CI, -6.15 to -0.59; d = -0.38; P = .02) and CONTROL (difference, -6.71; 95% CI, -9.57 to -3.84; d = -0.77; P < .001). A greater proportion of children in HIGH (45 [82%]) vs LOW (34 [64%]) (difference, 18.00; 95% CI, 1.00-34.00; P = .03; number needed to treat = 5.56) and CONTROL (25 [48%]) (difference, 34.00; 95% CI, 16.00-51.00; P < .001; number needed to treat = 2.94) had clinically significant percentage overweight reductions. Food and activity monitoring and goal setting mediated the effect of LOW vs CONTROL (50%). Monitoring and goal setting, family and home environment, and healthy behaviors with peers mediated the effect of HIGH vs CONTROL (25%-42%).

CONCLUSIONS AND RELEVANCE

Following FBT, specialized intervention content (SFM+) enhanced children's weight outcomes and outperformed a credible control condition, with high dose delivery yielding the best outcomes. Sustained monitoring and goal setting, support from the family and home environment, and healthy peer interactions explained outcome differences, highlighting key treatment targets.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00759746.

Patterns of Eating Disorder Pathology are Associated with Weight Change in Family-Based Behavioral Obesity Treatment

OBJECTIVE

Children with overweight or obesity have elevated eating disorder (ED) pathology, which may increase their risk for clinical EDs. The current study identified patterns of ED pathology in children with overweight or obesity entering family-based behavioral weight loss treatment (FBT) and examined whether children with distinct patterns differed in their ED pathology and BMI z score (zBMI) change across FBT.

METHODS

Before participating in a 16-session FBT, children (N = 241) completed surveys or interviews assessing ED pathology (emotional eating, shape/weight/eating concerns, restraint, and loss of control [LOC]). Shape and weight concerns (SWC) and LOC were also assessed post treatment. Child height and weight were measured at baseline and post treatment. Latent class analysis identified patterns of ED pathology. Repeated-measures ANOVA examined changes in zBMI and ED pathology.

RESULTS

Four patterns of ED pathology were identified: low ED pathology, SWC, only loss of control, and high ED pathology. SWC decreased across treatment, with the highest decreases in patterns characterized by high SWC. All groups experienced significant decreases in zBMI; however, children with the highest ED pathology did not achieve clinically significant weight loss.

CONCLUSIONS

ED pathology decreased after FBT, decreasing ED risk. While all children achieved zBMI reductions, further research is needed to enhance outcomes for children with high ED pathology.

Comparison of an alternative schedule of extended care contacts to a self-directed control: a randomized trial of weight loss maintenance

BACKGROUND

Behavioral interventions for obesity produce clinically meaningful weight loss, but weight regain following treatment is common. Extended care programs attenuate weight regain and improve weight loss maintenance. However, less is known about the most effective ways to deliver extended care, including contact schedules.

METHODS

We compared the 12-month weight regain of an extended care program utilizing a non-conventional, clustered campaign treatment schedule and a self-directed program among individuals who previously achieved ≥5% weight reductions. Participants (N = 108; mean age = 51.6 years; mean weight = 92.6 kg; 52% African American; 95% female) who achieved ≥5% weight loss during an initial 16-week behavioral obesity treatment were randomized into a 2-arm, 12-month extended care trial. A clustered campaign condition included 12 group-based visits delivered in three, 4-week clusters. A self-directed condition included provision of the same printed intervention materials but no additional treatment visits. The study was conducted in a U.S. academic medical center from 2011 to 2015.

RESULTS

Prior to randomization, participants lost an average of -7.55 ± 3.04 kg. Participants randomized to the 12-month clustered campaign program regained significantly less weight (0.35 ± 4.62 kg) than self-directed participants (2.40 ± 3.99 kg), which represented a significant between-group difference of 2.28 kg (p = 0.0154) after covariate adjustments. This corresponded to maintaining 87% and 64% of lost weight in the clustered campaign and self-directed conditions, respectively, which was a significant between-group difference of 29% maintenance of lost weight after covariate adjustments, p = 0.0396.

CONCLUSIONS

In this initial test of a clustered campaign treatment schedule, this novel approach effectively promoted 12-month maintenance of lost weight. Future trials should directly compare the clustered campaigns with conventional (e.g., monthly) extended care schedules.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02487121 . Registered 06/26/2015 (retrospectively registered).

Psychometric evaluation of the youth eating disorder examination questionnaire in children with overweight or obesity

This study evaluated the psychometric properties of the Youth Eating Disorder Examination Questionnaire (YEDE-Q) and its utility for detecting loss of control (LOC) eating (i.e., eating episodes, regardless of size, involving a perceived inability to control what or how much one is eating) among school-age children with overweight or obesity. Identifying eating pathology, particularly LOC eating, in this population may facilitate treatment that improves weight outcomes and reduces eating disorder risk. Children with overweight or obesity (N = 241; 7-11 years) completed the YEDE-Q and abbreviated Child EDE (ChEDE) to assess LOC eating, prior to entering a weight management treatment trial. Confirmatory factor analyses (CFA) were conducted on children's YEDE-Q responses and compared to the standard adult EDE-Q factor structure and newer, alternate factor structures. CFA supported a three-factor structure, which distinguished youth with versus without LOC. The YEDE-Q showed low accuracy for detecting LOC eating as measured by the ChEDE, which served as the gold-standard benchmark (AUC = 0.69). Among children who endorsed LOC eating, more episodes per month were reported on the YEDE-Q than ChEDE (p < .001). The YEDE-Q may not have utility as a screener for identifying true cases of LOC eating among school-age children with overweight or obesity. Further evaluation of the YEDE-Q and the alternate three-factor structure is warranted.

Decreasing food fussiness in children with obesity leads to greater weight loss in family-based treatment

OBJECTIVE

Food fussiness (FF), or the frequent rejection of both familiar and unfamiliar foods, is common among children and, given its link to poor diet quality, may contribute to the onset and/or maintenance of childhood obesity. This study examined child FF in association with anthropometric variables and diet in children with overweight/obesity participating in family-based behavioral weight loss treatment (FBT). Change in FF was assessed in relation to FBT outcome, including whether change in diet quality mediated the relation between change in FF and change in child weight.

METHODS

Child (N = 170; age = 9.41 ± 1.23) height and weight were measured, and parents completed FF questionnaires and three 24-h recalls of child diet at baseline and post-treatment. Healthy Eating Index-2005 scores were calculated.

RESULTS

At baseline, child FF was related to lower vegetable intake. Average child FF decreased from start to end of FBT. Greater decreases in FF were associated with greater reductions in child body mass index and improved overall diet quality. Overall, diet quality change through FBT mediated the relation between child FF change and child body mass index change.

CONCLUSIONS

Children with high FF can benefit from FBT, and addressing FF may be important in childhood obesity treatment to maximize weight outcomes.

Weight loss maintenance strategies among rural breast cancer survivors: The rural women connecting for better health trial

OBJECTIVE

Obesity is a risk factor for breast cancer recurrence. Rural women have higher obesity rates compared with urban women and are in need of distance-based interventions that promote long-term weight loss.

METHODS

In this two-phase trial, rural breast cancer survivors who lost >5% of their starting weight during a 6-month lifestyle intervention (delivered through weekly group conference calls) were randomized to one of two 12-month interventions for weight loss maintenance: continued biweekly phone-based group counseling or mailed newsletters. The primary outcome was weight regain from 6 to 18 months. Secondary outcomes included dichotomous measures of weight change and costs.

RESULTS

Mean weight loss at 6 months was 14.0 ± 5.1%. Participants in the group phone condition regained less weight (3.3 ± 4.8 kg) compared with participants in the newsletter condition (4.9 ± 4.8 kg; P = 0.03). At 18 months, 75.3% of participants in the group phone condition remained ≥5% below baseline weight compared with 57.8% in the newsletter condition (P = 0.02). Incremental cost-effectiveness ratios were $882 to keep one more person ≥5% below baseline weight.

CONCLUSIONS

A lifestyle intervention incorporating group phone-based support improved the magnitude of weight loss maintained and increased the proportion of survivors who maintained clinically significant reductions.

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.

Assessment of Heterosocial Skills in Male College Students

Deficiencies in heterosocial skills constitute significant psychological concerns for many young adults; yet, no adequate assessment procedure has been available for the behavioral measurement of heterosocial difficulties. In the present investigation, an empirical research strategy was employed to develop such an instrument. Construction and evaluation of the instrument was carried out following the five-stage test development strategy suggested by Goldfried and D'Zurilla's (1969) behavioral-analytic assessment model. Samples of potential responses to hetero-social situations were obtained, and five male and five female students were carefully selected to judge the effectiveness of potential responses. Psychometric evaluation of the final set of 22 test items revealed good interrater reliability (r =.85) and excellent criterion-related validity, as evidenced by the instrument's ability to discriminate between groups of heterosocially adequate and inadequate males (p<.OOOI). It was concluded that the scale is a reliable, valid, and useful tool for assessing heterosocial effectiveness.

Abstract P3-08-02: Comparison of strategies for weight loss maintenance among rural breast cancer survivors: The rural women connecting for better health randomized controlled trial

Background: Breast cancer survivors who reside in rural areas represent one of the largest medically underserved populations of breast cancer survivors in the nation and have higher obesity prevalence compared to their urban counterparts. Given the evidence linking obesity with poor breast cancer prognosis, trials are needed to demonstrate ability to produce long-term weight loss maintenance in this hard-to-reach group. Group phone-based counseling via conference calls is a low-technology approach with excellent reach to rural areas. This treatment delivery approach capitalizes on the support benefits of in-person groups by allowing participants to interact in real time while also diminishing costs.

Methods: In this 2 phase trial, overweight and obese (BMI 27 to 45 kg/m2) rural breast cancer survivors (with initial stage 0-III disease) were randomized to one of two extended care interventions for weight loss maintenance (Phase 2) subsequent to an initial 6-month weekly group phone-based behavioral weight loss intervention (Phase 1). To be eligible for randomization for maintenance, participants must have lost ≥ 5% of their baseline weight during Phase 1. In Phase 2, participants were randomized to continued group phone-based counseling reduced in frequency to every other week during maintenance vs every other week mailed newsletters that followed the same content.

Results: 210 breast cancer survivors with a mean time since treatment of 3.5 years ± 2.4 years, mean age of 58.1 ± 9.9 years, and mean BMI of 33.9 ± 4.4 kg/m2 residing in a three state region of the rural Midwest were entered in the 6-month weight loss phase. Retention from baseline to 6 months (Phase 1) was 91%. Mean percent weight loss at 6 months for the total sample was 12.9% with 82% of enrolled participants ≥ 5% below baseline weight. 172 participants with a mean initial loss of 14.0% of baseline weight (12.8 ± 4.9 kg) were randomized to a maintenance intervention. Retention from 6 to 18 months (Phase 2) was 92%. Intent-to-treat analyses with imputation of missing data revealed participants in the group phone condition regained less weight (3.3 ± 4.8 kg) compared to participants in the newsletter condition (4.9 ± 4.8 kg; p = 0.03). Mean percent weight loss from baseline to 18 months did not significantly differ between the group phone condition (10.2 ± 7.5%) and the newsletter condition (9.2 ± 7.9%). However, at 18 months 75.3% of participants in the group phone condition remained ≥ 5% below baseline weight compared to 57.8% in the newsletter condition (p = .02).

Discussion: The initial group phone-based weight loss intervention exceeded typical weight losses reported in the literature with over 80% of enrolled participants achieving clinically meaningful weight loss. Continued group phone counseling was modestly better in sustaining weight loss at 18 months than a mailed newsletter. However, for both maintenance approaches, the majority of participants maintained a weight at 18 months that was 5% or more below baseline.

Citation Format: Befort CA, Klemp JR, Sullivan DK, Diaz FJ, Schmitz KH, Perri MG, Fabian CJ. Comparison of strategies for weight loss maintenance among rural breast cancer survivors: The rural women connecting for better health randomized controlled trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-08-02.

Successful aging: Advancing the science of physical independence in older adults

The concept of 'successful aging' has long intrigued the scientific community. Despite this long-standing interest, a consensus definition has proven to be a difficult task, due to the inherent challenge involved in defining such a complex, multi-dimensional phenomenon. The lack of a clear set of defining characteristics for the construct of successful aging has made comparison of findings across studies difficult and has limited advances in aging research. A consensus on markers of successful aging is furthest developed is the domain of physical functioning. For example, walking speed appears to be an excellent surrogate marker of overall health and predicts the maintenance of physical independence, a cornerstone of successful aging. The purpose of the present article is to provide an overview and discussion of specific health conditions, behavioral factors, and biological mechanisms that mark declining mobility and physical function and promising interventions to counter these effects. With life expectancy continuing to increase in the United States and developed countries throughout the world, there is an increasing public health focus on the maintenance of physical independence among all older adults.

Group dynamics are associated with weight loss in the behavioral treatment of obesity

OBJECTIVE

To assess whether group dynamics are associated with weight loss, session attendance, and self-monitoring adherence after 6 months of lifestyle intervention for obesity.

METHODS

Women with obesity (N = 125; mean ± SD BMI = 37.84 ± 3.94 kg/m(2) ; age =  51.99 ± 10.81 years) participated in a 24-week group-based lifestyle weight loss intervention and achieved a weight loss of 9.13 ± 7.15 kg after 6 months. Participants reported their perceptions of group conflict, avoidance, engagement, social support, and attraction at the end of treatment. Multiple regression with forward selection assessed which group dynamic variables were associated with weight loss, attendance, and adherence.

RESULTS

Greater perceived group conflict was associated with smaller weight losses (β = 1.833, P = 0.044) and lower attendance (β = -2.313, P = 0.002) and adherence rates (β = -2.261, P = 0.030). Higher group attraction was associated with higher attendance rates (β = 0.051, P = 0.039). The association between perceived conflict and weight change was mediated by attendance and adherence (P = 0.019).

CONCLUSIONS

Findings demonstrate that group dynamics associate with weight loss outcomes, attendance, and adherence. Addressing conflicts and fostering acceptance among group members may promote success in group-based lifestyle interventions for obesity.

Quantile regression in the presence of monotone missingness with sensitivity analysis

In this paper, we develop methods for longitudinal quantile regression when there is monotone missingness. In particular, we propose pattern mixture models with a constraint that provides a straightforward interpretation of the marginal quantile regression parameters. Our approach allows sensitivity analysis which is an essential component in inference for incomplete data. To facilitate computation of the likelihood, we propose a novel way to obtain analytic forms for the required integrals. We conduct simulations to examine the robustness of our approach to modeling assumptions and compare its performance to competing approaches. The model is applied to data from a recent clinical trial on weight management.

Reduction in food away from home is associated with improved child relative weight and body composition outcomes and this relation is mediated by changes in diet quality

BACKGROUND

Reducing consumption of food away from home is often targeted during pediatric obesity treatment, given the associations with weight status and gain. However, the effects of this dietary change on weight loss are unknown.

OBJECTIVE

Our aim was to evaluate associations between changes in dietary factors and child anthropometric outcomes after treatment. It is hypothesized that reduced consumption of food away from home will be associated with improved dietary intake and greater reductions in anthropometric outcomes (standardized body mass index [BMI] and percent body fat), and the relationship between food away from home and anthropometric outcomes will be mediated by improved child dietary intake.

DESIGN

We conducted a longitudinal evaluation of associations between dietary changes and child anthropometric outcomes. Child diet (three 24-hour recalls) and anthropometric data were collected at baseline and 16 weeks.

PARTICIPANTS/SETTING

Participants were 170 overweight and obese children ages 7 to 11 years who completed a 16-week family-based behavioral weight-loss treatment as part of a larger multi-site randomized controlled trial conducted in two cohorts between 2010 and 2011 (clinical research trial).

INTERVENTION

Dietary treatment targets during family-based behavioral weight-loss treatment included improving diet quality and reducing food away from home.

MAIN OUTCOME MEASURES

The main outcome measures in this study were child relative weight (standardized BMI) and body composition (percent body fat).

STATISTICAL ANALYSES

We performed t tests and bootstrapped single-mediation analyses adjusting for relevant covariates.

RESULTS

As hypothesized, decreased food away from home was associated with improved diet quality and greater reductions in standardized BMI (P<0.05) and percent body fat (P<0.01). Associations between food away from home and anthropometric outcomes were mediated by changes in diet quality. Specifically, change in total energy intake and added sugars mediated the association between change in food away from home and standardized BMI, and change in overall diet quality, fiber, added sugars, and added fats mediated the association between change in food away from home and percent body fat. Including physical activity as a covariate did not significantly impact these findings.

CONCLUSIONS

These results suggest that reducing food away from home can be an important behavioral target for affecting positive changes in both diet quality and anthropometric outcomes during treatment.

Public health education at the University of Florida: synergism and educational innovation

The College of Public Health and Health Professions at the University of Florida is composed of five public health departments and four clinical health professions departments, and the college is one of six that make up the university's Health Science Center. These organizational resources, along with the university's explicit emphasis on collaboration across professions, colleges, institutes, and centers and the strong leadership and full support of deans and other academic leaders, provide a strong foundation for educational innovations. Three key areas in which the college has built upon these opportunities are interprofessional education, development of One Health instructional programs, and application of cutting-edge technology to students' educational experiences. These innovations represent the types of creative approaches to preparing the 21st-century workforce that can be developed through collaboration among multiple disciplines in a major university.

NIH working group report: Innovative research to improve maintenance of weight loss

OBJECTIVES

The National Institutes of Health, led by the National Heart, Lung, and Blood Institute, organized a working group of experts to discuss the problem of weight regain after weight loss. A number of experts in integrative physiology and behavioral psychology were convened with the goal of merging their perspectives regarding the barriers to scientific progress and the development of novel ways to improve long-term outcomes in obesity therapeutics. The specific objectives of this working group were to: (1) identify the challenges that make maintaining a reduced weight so difficult; (2) review strategies that have been used to improve success in previous studies; and (3) recommend novel solutions that could be examined in future studies of long-term weight control.

RESULTS

Specific barriers to successful weight loss maintenance include poor adherence to behavioral regimens and physiological adaptations that promote weight regain. A better understanding of how these behavioral and physiological barriers are related, how they vary between individuals, and how they can be overcome will lead to the development of novel strategies with improved outcomes.

CONCLUSIONS

Greater collaboration and cross-talk between physiological and behavioral researchers is needed to advance the science and develop better strategies for weight loss maintenance.

Comparative effectiveness of three doses of weight-loss counseling: two-year findings from the rural LITE trial

OBJECTIVE

To evaluate the effects and costs of three doses of behavioral weight-loss treatment delivered via Cooperative Extension Offices in rural communities.

METHODS

Obese adults (N = 612) were randomly assigned to low, moderate, or high doses of behavioral treatment (i.e., 16, 32, or 48 sessions over two years) or to a control condition that received nutrition education without instruction in behavior modification strategies.

RESULTS

Two-year mean reductions in initial body weight were 2.9% (95% Credible Interval = 1.7-4.3), 3.5% (2.0-4.8), 6.7% (5.3-7.9), and 6.8% (5.5-8.1) for the control, low-, moderate-, and high-dose conditions, respectively. The moderate-dose treatment produced weight losses similar to the high-dose condition and significantly larger than the low-dose and control conditions (posterior probability > 0.996). The percentages of participants who achieved weight reductions ≥ 5% at two years were significantly higher in the moderate-dose (58%) and high-dose (58%) conditions compared with low-dose (43%) and control (40%) conditions (posterior probability > 0.996). Cost-effectiveness analyses favored the moderate-dose treatment over all other conditions.

CONCLUSIONS

A moderate dose of behavioral treatment produced two-year weight reductions comparable to high-dose treatment but at a lower cost. These findings have important policy implications for the dissemination of weight-loss interventions into communities with limited resources.

Lifestyle interventions for cardiovascular disease risk reduction: a systematic review of the effects of diet composition, food provision, and treatment modality on weight loss

The purpose of this systematic review was to evaluate, synthesize, and interpret findings from recent randomized controlled trials (RCTs) of dietary and lifestyle weight loss interventions examining the effects of (1) diet composition, (2) use of food provision, and (3) modality of treatment delivery on weight loss. Trials comparing different dietary approaches indicated that reducing carbohydrate intake promoted greater initial weight loss than other approaches but did not appear to significantly improve long-term outcomes. Food provision appears to enhance adherence to reduction in energy intake and produce greater initial weight losses. The long-term benefits of food provision are less clear. Trials comparing alternative treatment modalities suggest that phone-based treatment produce short- and long-term weight reductions equivalent to face-to-face interventions. The use of Internet and mobile technologies are associated with smaller reductions in body weight than face-to-face interventions. Based on this review, clinical implications and future research directions are provided.

A randomized trial comparing weight loss treatment delivered in large versus small groups

Background

Behavioral interventions for obesity are commonly delivered in groups, although the effect of group size on weight loss has not been empirically evaluated. This behavioral weight loss trial compared the 6- and 12-month weight changes associated with interventions delivered in a large group (LG) or small groups (SG).

Methods

Obese adults (N = 66; mean age = 50 years; mean BMI = 36.5 kg/m²; 47% African American; 86% women) recruited from a health maintenance organization were randomly assigned to: 1) LG treatment (30 members/group), or 2) SG treatment (12 members/group). Conditions were comparable in frequency and duration of treatment, which included 24 weekly group sessions (months 1–6) followed by six monthly extended care contacts (months 7–12). A mixed effects model with unstructured covariance matrix was applied to analyze the primary outcome of weight change while accounting for baseline weight and dependence among participants’ measurements over time.

Results

SG participants lost significantly more weight than LG participants at Month 6 (−6.5 vs. -3.2 kg; p = 0.03) and Month 12 (−7.0 vs. -1.7 kg; p < 0.002). SG participants reported better treatment engagement and self-monitoring adherence at Months 6 and 12, ps < 0.04, with adherence fully mediating the relationship between group size and weight loss.

Conclusions

Receiving obesity treatment in smaller groups may promote greater weight loss and weight loss maintenance. This effect may be due to improved adherence facilitated by SG interactions. These novel findings suggest that the perceived efficiency of delivering behavioral weight loss treatment to LGs should be balanced against the potentially better outcomes achieved by a SG approach.

Dietary self-monitoring and long-term success with weight management

OBJECTIVE

To examine the contributions of frequency, consistency, and comprehensiveness of dietary self-monitoring to long-term weight change.

METHODS

Participants included 220 obese women (mean ± SD, age = 59.3 ± 6.1 years; BMI = 36.8 ± 4.9 kg/m(2) ) who achieved a mean weight loss of -10.39 ± 5.28% from baseline during 6 months of behavioral treatment and regained 2.30 ± 7.28% during a 12-month extended-care period. The contributions of cumulative frequency of self-monitoring (total number of food records), consistency across time (number of weeks with ≥3 records), and comprehensiveness of information recorded were examined as predictors of weight regain in a hierarchical linear regression analysis. The mediating role of adherence to daily caloric intake goals was tested using a bootstrapping analysis.

RESULTS

The association between high total frequency of self-monitoring and reduced weight regain was moderated by weekly consistency of self-monitoring, P = 0.004; increased frequency produced beneficial effects on weight change only when coupled with high consistency (>3 days/week). There was no impact of comprehensiveness on weight change, P > 0.05. The favorable effect of high frequency/high consistency self-monitoring on weight change was partially mediated by participants' success in meeting daily caloric intake goals (P < 0.001).

CONCLUSION

The combination of high frequency plus high consistency of dietary self-monitoring improves long-term success in weight management.

Modifications in parent feeding practices and child diet during family-based behavioral treatment improve child zBMI

OBJECTIVE

To examine associations between modifications in parent feeding practices, child diet, and child weight status after treatment and to evaluate dietary mediators.

METHODS

Children classified as overweight or obese and 7-11 years old (N = 170) completed a 16-session family-based behavioral weight loss treatment (FBT) program. Anthropometrics (standardized body mass index (zBMI)), Child Feeding Questionnaire, and 24-hr dietary recalls were collected at baseline and post-FBT. Linear regression predicted child zBMI change. Single and multiple mediation tested child dietary modifications as mediators between change in parent feeding practices and child zBMI.

RESULTS

Restrictive parent feeding practices significantly decreased during FBT. Reductions in parent restriction, child weight concern, child's total energy intake, and percent energy from fat, and increases in parent perceived responsibility, and child percent energy from protein, predicted reductions in child zBMI. Change in child total energy intake mediated the relation between parent restriction and child zBMI change after accounting for covariates and additional dietary mediators.

CONCLUSIONS

FBT is associated with a decrease in parental restriction, which is associated with reductions in child relative weight, which was mediated by a decrease in child energy intake. Teaching parents to reduce children's energy intake without being overly restrictive may improve child weight.

A randomized trial investigating the effect of a brief lifestyle intervention on freshman-year weight gain

OBJECTIVE

The current study was a randomized controlled trial investigating the effect of an innovative, short-term lifestyle intervention on weight gain in female freshman college students.

PARTICIPANTS

Ninety-five freshmen were recruited from a large public university in the United States.

METHODS

Participants completed baseline assessments and were randomized to a 5-session, 4-week intervention or wait-list control, with assessments at posttest and 3-month follow-up.

RESULTS

The hypothesized time by group interaction was not significant, p = .393; however, trends suggested that control participants maintained baseline weight, whereas intervention participants lost -2.07 kg by posttest but regained 1.05 kg at follow-up. Significantly more intervention participants (47.0%) decreased their daily caloric intake by ≥ 200 kcal compared with control (31.7%), p = .050.

CONCLUSION

Brief intervention to prevent weight gain was not effective in this sample. Future studies should investigate lengthening the intervention to enhance effectiveness and increasing recruitment to improve statistical power.

Effects of prescribing 1,000 versus 1,500 kilocalories per day in the behavioral treatment of obesity: a randomized trial

OBJECTIVE

Controversy exists regarding the optimal energy prescription to promote successful long-term behavioral management of obesity. Prescribing intake of 1,000 (vs. 1,500) kcal/day may produce larger initial weight reduction, but long-term advantage remains unclear. The effects of prescribing 1,000 versus 1,500 kcal/day on 6- and 12-month weight changes within behavioral treatment of obesity were examined.

DESIGN AND METHODS

Participants were 125 obese women (mean ± SD; BMI = 37.84 ± 3.94 kg/m(2) ) randomly assigned goals of 1,000 or 1,500 kcal/day.

RESULTS

From months 0 to 6, participants prescribed 1,000 kcal/day lost more weight than those prescribed 1,500 kcal/day (mean ± SE = -10.03 ± 0.92g vs. -6.23 ± 0.94 kg, P = 0.045); however, from months 7 through 12, only the 1,000 kcal/day condition experienced a significant weight regain (1.51 ± 0.77 kg, P = 0.025). Baseline caloric consumption moderated the effect of treatment on regain; participants with baseline intakes ≧2,000 kcal/day who were assigned 1,000 kcal/day were significantly more susceptible to weight regain than those assigned 1,500 kcal/day (P = 0.049). At month 12, a significantly greater percentage of 1,000 kcal/day participants achieved weight reductions of 5% or more than those prescribed 1,500 kcal/day.

CONCLUSION

Encouraging obese individuals in behavioral treatment to adhere to a 1,000 kcal/day intake may increase their likelihood of achieving clinically meaningful weight losses.

Developing a research agenda for cardiovascular disease prevention in high-risk rural communities

The National Institutes of Health convened a workshop to engage researchers and practitioners in dialogue on research issues viewed as either unique or of particular relevance to rural areas, key content areas needed to inform policy and practice in rural settings, and ways rural contexts may influence study design, implementation, assessment of outcomes, and dissemination. Our purpose was to develop a research agenda to address the disproportionate burden of cardiovascular disease (CVD) and related risk factors among populations living in rural areas. Complementary presentations used theoretical and methodological principles to describe research and practice examples from rural settings. Participants created a comprehensive CVD research agenda that identified themes and challenges, and provided 21 recommendations to guide research, practice, and programs in rural areas.

Effect of dietary restriction and exercise on lower extremity tissue compartments in obese, older women: a pilot study

BACKGROUND

Accumulating evidence suggests that both dietary restriction and exercise (DR + E) should be incorporated in weight loss interventions to treat obese, older adults. However, more information is needed on the effects to lower extremity tissue composition-an important consideration for preserving mobility in older adults.

METHODS

Twenty-seven sedentary women (body mass index: 36.3±5.4kg/m(2); age: 63.6±5.6 yrs) were randomly assigned to 6 months of DR + E or a health education control group. Thigh and calf muscle, subcutaneous adipose tissue (SAT), and intermuscular adipose tissue (IMAT) size were determined using magnetic resonance imaging. Physical function was measured using a long-distance corridor walk and knee extension strength.

RESULTS

Compared with control, DR + E significantly reduced body mass (-6.6±3.7kg vs control: -0.05±3.5kg; p < .01). Thigh and calf muscle volumes responded similarly between groups. Within the DR + E group, adipose tissue was reduced more in the thigh than in the calf (p < .04). Knee extension strength was unaltered by DR + E, but a trend toward increased walking speed was observed in the DR + E group (p = .09). Post hoc analyses showed that reductions in SAT and IMAT within the calf, but not the thigh, were associated with faster walking speed achieved with DR + E (SAT: r = -0.62; p = .01; IMAT: r = -0.62; p = .01).

CONCLUSIONS

DR + E preserved lower extremity muscle size and function and reduced regional lower extremity adipose tissue. Although the magnitude of reduction in adipose tissue was greater in the thigh than the calf region, post hoc analyses demonstrated that reductions in calf SAT and IMAT were associated with positive adaptations in physical function.