Systematic review: an evaluation of major commercial weight loss programs in the United States

BACKGROUND

Each year millions of Americans enroll in commercial and self-help weight loss programs. Health care providers and their obese patients know little about these programs because of the absence of systematic reviews.

PURPOSE

To describe the components, costs, and efficacy of the major commercial and organized self-help weight loss programs in the United States that provide structured in-person or online counseling.

DATA SOURCES

Review of company Web sites, telephone discussion with company representatives, and search of the MEDLINE database.

STUDY SELECTION

Randomized trials at least 12 weeks in duration that enrolled only adults and assessed interventions as they are usually provided to the public, or case series that met these criteria, stated the number of enrollees, and included a follow-up evaluation that lasted 1 year or longer.

DATA EXTRACTION

Data were extracted on study design, attrition, weight loss, duration of follow-up, and maintenance of weight loss.

DATA SYNTHESIS

We found studies of eDiets.com, Health Management Resources, Take Off Pounds Sensibly, OPTIFAST, and Weight Watchers. Of 3 randomized, controlled trials of Weight Watchers, the largest reported a loss of 3.2% of initial weight at 2 years. One randomized trial and several case series of medically supervised very-low-calorie diet programs found that patients who completed treatment lost approximately 15% to 25% of initial weight. These programs were associated with high costs, high attrition rates, and a high probability of regaining 50% or more of lost weight in 1 to 2 years. Commercial interventions available over the Internet and organized self-help programs produced minimal weight loss.

LIMITATIONS

Because many studies did not control for high attrition rates, the reported results are probably a best-case scenario.

CONCLUSIONS

With the exception of 1 trial of Weight Watchers, the evidence to support the use of the major commercial and self-help weight loss programs is suboptimal. Controlled trials are needed to assess the efficacy and cost-effectiveness of these interventions.

Telehealth Interventions Delivering Home-based Support Group Videoconferencing: Systematic Review

BACKGROUND

Group therapy and education and support sessions are used within health care across a range of disciplines such as chronic disease self-management and psychotherapy interventions. However, there are barriers that constrain group attendance, such as mobility, time, and distance. Using videoconferencing may overcome known barriers and improve the accessibility of group-based interventions.

OBJECTIVE

The aim of this study was to review the literature to determine the feasibility, acceptability, effectiveness, and implementation of health professional-led group videoconferencing to provide education or social support or both, into the home setting.

METHODS

Electronic databases were searched using predefined search terms for primary interventions for patient education and/or social support. The quality of studies was assessed using the Mixed Methods Appraisal Tool. We developed an analysis framework using hierarchical terms feasibility, acceptability, effectiveness, and implementation, which were informed by subheadings.

RESULTS

Of the 1634 records identified, 17 were included in this review. Home-based groups by videoconferencing are feasible even for those with limited digital literacy. Overall acceptability was high with access from the home highly valued and little concern of privacy issues. Some participants reported preferring face-to-face groups. Good information technology (IT) support and training is required for facilitators and participants. Communication can be adapted for the Web environment and would be enhanced by clear communication strategies and protocols. A range of improved outcomes were reported but because of the heterogeneity of studies, comparison of these across studies was not possible. There was a trend for improvement in mental health outcomes. Benefits highlighted in the qualitative data included engaging with others with similar problems; improved accessibility to groups; and development of health knowledge, insights, and skills. Videoconference groups were able to replicate group processes such as bonding and cohesiveness. Similar outcomes were reported for those comparing face-to-face groups and videoconference groups.

CONCLUSIONS

Groups delivered by videoconference are feasible and potentially can improve the accessibility of group interventions. This may be particularly useful for those who live in rural areas, have limited mobility, are socially isolated, or fear meeting new people. Outcomes are similar to in-person groups, but future research on facilitation process in videoconferencing-mediated groups and large-scale studies are required to develop the evidence base.

Cognitive-behavioral self-help for binge eating disorder: a controlled effectiveness study

The aim of this study was to evaluate the effectiveness of 2 methods of administering a cognitive-behavioral self-help program for binge eating disorder. The study was designed to reproduce many of the conditions that apply in settings in which self-help interventions are most relevant. Seventy-two women with binge eating disorder were randomly assigned to 1 of 3 conditions for 12 weeks: pure self-help (PSH), guided self-help (GSH), or a waiting list (WL) control condition (followed by PSH or GSH). They were then followed up for 6 months. Both PSH and GSH had a substantial and sustained impact with almost half the participants ceasing to binge eat. There was little change in the WL condition. Cognitive-behavioral self-help may be of value both as an initial treatment for binge eating disorder and as a form of secondary prevention.

Twelve-step and cognitive--behavioral treatment for substance abuse: a comparison of treatment effectiveness

The comparative effectiveness of 12-step and cognitive-behavioral (C-B) models of substance abuse treatment was examined among 3,018 patients from 15 programs at U.S. Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step-C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistent over several treatment subgroups: Patients attending the "purest" 12-step and C-B treatment programs, and patients who had received the "full dose" of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment.

Matching alcoholism treatments to client heterogeneity: treatment main effects and matching effects on drinking during treatment. Project MATCH Research Group

OBJECTIVE

This article examines client drinking and related psychosocial functioning during the course of alcoholism treatment. It focuses on (1) the main effects of the three Project MATCH treatments, (2) the prognostic value of client attributes employed in the matching hypotheses, and (3) the attribute by treatment interaction effects.

METHOD

Clients recruited from outpatient settings (n = 952) or from aftercare settings (n = 774) were randomized to one of the following treatments: Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT) and Twelve-Step Facilitation (TSF). Alcohol consumption and psychosocial functioning during treatment were assessed at the end of the 12-week treatment phase.

RESULTS

During the treatment phase, small but statistically significant differences among treatments were found only in the outpatient arm on measures of alcohol consumption and alcohol-related negative consequences. Forty-one percent (41%) of CBT and TSF clients were abstinent or drank moderately without alcohol-related consequences, compared with 28% of MET clients. Tests of 10 a priori primary client-treatment matching hypotheses failed to find any interaction effects that had an impact on drinking throughout the treatment phase.

CONCLUSIONS

In the outpatient setting there appears to be a temporary advantage to assigning individuals to CBT or TSF rather than MET. When there is a need to quickly reduce heavy drinking and alcohol-related consequences, it appears that CBT or TSF should be the treatment of choice.

Influence of outpatient treatment and 12-step group involvement on one-year substance abuse treatment outcomes

OBJECTIVE

This study examined whether substance abuse patients self-selecting into one of three aftercare groups (outpatient treatment only, 12-step groups only, and outpatient treatment and 12-step groups) and patients who did not participate in aftercare differed on 1-year substance use and psychosocial outcomes.

METHOD

A total of 3,018 male patients filled out a questionnaire at intake and 1 year following discharge from treatment. Patients were classified into aftercare groups at follow-up using information from VA databases and self-reports.

RESULTS

Patients who participated in both outpatient treatment and 12-step groups fared the best on 1-year outcomes. Patients who did not obtain aftercare had the poorest outcomes. In terms of the amount of intervention received, patients who had more outpatient mental health treatment, who more frequently attended 12-step groups or were more involved in 12-step activities had better 1-year outcomes. In addition, patients who kept regular outpatient appointments over a longer time period fared better than those who did not.

CONCLUSIONS

Encouraging substance abuse patients to regularly attend both outpatient aftercare and self-help groups may improve long-term outcomes.

After drug treatment: are 12-step programs effective in maintaining abstinence?

Although participation in 12-step programs is now widely utilized as a treatment aftercare resource by individuals with drug and alcohol problems, little is known about the effectiveness of such a practice. This paper identifies gaps in the existing literature and articulates methodological concerns that may compromise investigations of 12-step programs. It highlights the need for additional after-treatment studies, and it presents findings from a 24-month longitudinal after-treatment study that suggests the effectiveness of 12-step programs. Rather than a behavioral indicator of recovery motivation or a spurious relationship confounded by additional treatment, aftercare, or alumni activities that occur simultaneously with 12-step participation, the findings suggest that weekly or more frequent 12-step participation is associated with drug and alcohol abstinence. Less-than-weekly participation is not associated with favorable drug and alcohol use outcomes, and participation in 12-step programs seems to be equally useful in maintaining abstinence from both illicit drug and alcohol use. These findings point to the wisdom of a general policy that recommends weekly or more frequent participation in a 12-step program as a useful and inexpensive aftercare resource for many clients.

Accuracy and self correction of information received from an internet breast cancer list: content analysis

OBJECTIVES

To determine the prevalence of false or misleading statements in messages posted by internet cancer support groups and whether these statements were identified as false or misleading and corrected by other participants in subsequent postings.

DESIGN

Analysis of content of postings.

SETTING

Internet cancer support group Breast Cancer Mailing List.

MAIN OUTCOME MEASURES

Number of false or misleading statements posted from 1 January to 23 April 2005 and whether these were identified and corrected by participants in subsequent postings.

RESULTS

10 of 4600 postings (0.22%) were found to be false or misleading. Of these, seven were identified as false or misleading by other participants and corrected within an average of four hours and 33 minutes (maximum, nine hours and nine minutes).

CONCLUSIONS

Most posted information on breast cancer was accurate. Most false or misleading statements were rapidly corrected by participants in subsequent postings.

Long-term randomized controlled trials of tailored-print and small-group arthritis self-management interventions

OBJECTIVE

The objective of this study was to test the effectiveness of a mail-delivered, tailored self-management intervention (SMART) and to compare it with the classic Arthritis Self-Management Program (ASMP).

METHODS

We performed 2 randomized controlled trials: 1) a study of 1090 participants randomized to SMART or USUAL CARE, and 2) a study of 341 participants randomized to SMART or ASMP. Dependent variables included disability, pain, depression, role function, global severity, doctor visits, and self-efficacy. SMART interventions were provided in months 0-18 and not reinforced. Results were assessed at 1, 2, and 3 years using analyses of covariance (ANCOVA).

RESULTS

Compared with USUAL CARE, SMART participants at 1 year had decreased disability, improved role function, and increased self-efficacy (all P <0.01). At 2 years, decreases in global severity, doctor visits, and increases in self-efficacy (all P <0.01) were noted. At 3 years without reinforcement, no statistically significant effects remained. Compared with ASMP, SMART at 1 year had greater decreases in disability (P = 0.02) and increases in self-efficacy (P = 0.01). There were no differences at 2 years. At 3 years, role function (P = 0.04) and doctor visit (P = 0.03) were improved in ASMP as compared with SMART. Improvements from baseline were seen for nearly all variables in both groups.

CONCLUSIONS

A mail-delivered arthritis self-management program, SMART, was similarly effective to the classic ASMP, with slightly better results in the first year and a slightly more rapid attenuation over the next 2 years. Results suggest that both programs are effective, and that the addition of a mail-delivered program could improve accessibility to arthritis self-management treatment.

A qualitative study of breast cancer self-help groups

This study reports on the experience of women in four community breast cancer self-help groups in Ontario, Canada. Semi-structured interviews were conducted with 24 women, asking them about benefits and limitations of their group involvement, and about their perspectives on group processes and structures. Overall, participants reported their group involvement to be extremely helpful for navigating the short and long-term impact of breast cancer. Emotional support benefits included connecting with other breast cancer survivors, feeling understood and sharing experiences, providing hope, and sharing healing laughter. Informational and practical support benefits included sharing of important information and learning how to get what you want. Even where there were concerns about limitations or tensions of group experience, these occurred against a backdrop of appreciation and commitment. From the discussion of group processes and structures, a number of issues were identified as problematic. Most notable were how to deal with deaths of group members and how to balance the group's primary purpose of providing mutual support with secondary goals of dealing with group business and engaging in meaningful advocacy.

Consumers as mental health providers: first-person accounts of benefits and limitations

Community support programs are increasingly establishing paid service positions designated exclusively for consumers. Project WINS (Work Incentives and Needs Study), a hybrid case management-vocational program for individuals with severe mental illness, used consumers as peer support specialists (PSSs) to supplement professional roles. Semistructured interviews were conducted with PSSs about 12 months after their employment ended. They identified substantial personal benefits specific to consumer-designated roles (e.g., a "safe" employment setting with accommodations) and general benefits from employment. Problems described were just as numerous, encompassing attitudes toward assigned peers and costs to their own well-being. Critical commentary addressed program operations (structure, supervision, and training needs) and problems in the mental health system. The authors discuss the changed sense of self that service provider roles can create for consumers and suggest that mental health administrators provide anticipatory socialization for this service innovation throughout their agencies and ongoing supports for consumers in their new roles.

Superior efficacy of cognitive-behavioral therapy for urban crack cocaine abusers: main and matching effects

This study evaluated the efficacy of cognitive-behavioral therapy (CBT) and 12-step facilitation (12SF) in treating cocaine abuse. Participants (N = 128) were randomly assigned to treatment conditions and assessed at baseline and at Weeks 4, 8, 12, and 26. Treatment lasted for 12 weeks. It was hypothesized that participants treated with CBT would be significantly more likely to achieve abstinence from cocaine than participants treated with 12SF. A series of patient-treatment matching hypotheses was also proposed. Across 2 different outcome variables, it was found that participants in CBT were significantly more likely to achieve abstinence than participants in 12SF. In addition, some support for matching hypotheses was found, suggesting that both psychotherapies may be differentially effective for identified subgroups of persons that abuse cocaine.

Anxiety and depression in breast cancer patients before and after participation in a cancer support group

A prospective study was conducted to assess the long-term impact of attending a support group on the prevalence of psychological morbidity in patients with breast cancer before and after 1-year participation in the Iranian breast cancer support group. Psychological morbidity was measured using the hospital anxiety and depression scale (HADS). In addition, qualitative data were collected to throw some lights on the topic. All current members of the three Iranian breast cancer support groups (n=56) were interviewed. The mean age of patients was 45.4 (S.D.=9.2) years, most were married (n=46, 82%), and 54% of patients (n=30) were diagnosed as having breast cancer from 1 to 5 years ago. While at baseline 16 patients (29%) scored high on the anxiety sub-scale and eight patients (14%) scored high on the depression sub-scale, at follow-up only two patients (2%) were likely experiencing severe anxiety symptoms and there were no patients with probable severely depressed mood. Comparing anxiety and depression at baseline and follow-up, there was a statistically significant difference between baseline and follow-up anxiety (P=0.03) and depression (P=0.008) scores. Analysis of the qualitative data indicated that the group involvement was the most important factor that contributed to the patients' improved psychological well-being. The findings of this prospective study suggest that participation in cancer support groups could have a long-term effect in reducing anxiety and depression in breast cancer survivors.

Self-help on-line: an outcome evaluation of breast cancer bulletin boards

Many breast cancer patients find help from on-line self-help groups, consisting of self-directed, asynchronous, bulletin boards. These have yet to be empirically evaluated. Upon joining a group and 6 months later, new members (N=114) to breast cancer bulletin boards completed measures of depression (CES-D), growth (PTGI) and psychosocial wellbeing (FACT-B). Improvement was statistically significant on all three measures. This serves as a first validation of Internet bulletin boards as a source of support and help for breast cancer patients. These boards are of particular interest because they are free, accessible and support comes from peers and not from professional facilitators.

Review of group interventions for pediatric chronic conditions

OBJECTIVE

To identify treatment studies on group interventions for pediatric conditions and to review their efficacy using standardized criteria.

METHODS

Through a systematic literature review, we identified 125 studies describing group treatments for pediatric populations. Group interventions were classified into one of four types of groups distinguished by their primary goals and intended outcomes: emotional support, psychoeducation, adaptation/skill development, or symptom reduction. A fifth category, summer camps, contained elements of the other categories, but due to their unique setting, we considered them separately. Treatments were evaluated and designated as "promising," "probably efficacious," or "well-established," based on the Chambless/Society for Pediatric Psychology criteria.

RESULTS

Group interventions for children and adolescents have been developed to increase knowledge of illness, to increase psychological adaptation, and to decrease physical symptoms and side effects. This literature falls on a broad continuum, ranging from descriptive articles with no empirical assessment of outcome to treatment outcome studies employing randomized control conditions and standardized outcome measures.

CONCLUSIONS

Although well-established group interventions do exist, much work is required to establish the efficacy of most group treatments for children and adolescents with chronic illness. Recommendations for improving the status of research are offered.

Distance education and caregiver support groups: comparison of traditional and telephone groups

OBJECTIVE

To implement and evaluate the impact of telephone caregiver groups, compared with traditional face-to-face, on-site caregiver groups.

DESIGN

Quasi-experimental design comparing the two group types across time.

SETTING

An urban tertiary rehabilitation hospital with a brain injury program servicing a vast geographical area.

PARTICIPANTS

Caregivers of an adult person with a brain injury participated in either one of the 10 telephone groups (TGs) (N = 52 caregivers who completed a full set of research forms) or one of the 10 on-site groups (OGs) (N = 39 caregivers who completed a full set of research forms). The combined total from both groups was 91.

INTERVENTION

Caregivers who lived within 40 km of the facility were placed in one of the OGs, and all others were placed in one of the TGs. Both types of groups met weekly for 9 to 10 weeks and were led by either social work or psychology professionals. The TGs met using teleconference technology.

MAIN OUTCOME MEASURES

Profile of Moods States (POMS), Caregiver Burden Inventory (CBI), and the McMaster Model Family Assessment Devise (FAD), were administered 2 months before the first day of group, on the first day of group, on the last day of group, and 6 months after group. On the last day of group, a participant satisfaction survey was administered.

RESULTS

There were similar amounts of improvements for the outcomes from OGs and TGs. Rural caregivers had fewer difficulties on all measures at all measurement intervals. In both types of group, participants showed a statistically significant improvement in POMS scores and a trend toward improvement in FAD and CBI results. Participants of both group types rated their experience highly, although rural caregivers were somewhat more satisfied.

CONCLUSIONS

Telephone groups offer a method of providing support and education to rural caregivers that is as effective as traditional in-person OGs.

What can we learn from consumer studies and qualitative research in the treatment of eating disorders?

The aim of this paper is to review all qualitative research and questionnaire surveys with people who have experienced an eating disorder or received treatment for it. Studies were identified on PubMed and PsychInfo. Twenty-three studies were identified and key findings are reviewed. Support and understanding are critical aspects of treatment perceived as helpful. Empathic relationships, whether professional or non-professional, were reported as essential to recovery. Psychological interventions (counselling and therapy) are the most popular and perceived as the most helpful. Many patients report that "medical interventions" were unhelpful. Interventions which focus exclusively on weight are reported negatively and many studies identify the importance of addressing wider issues than food and weight in treatment.

Developmental challenges, stressors and coping strategies in medical residents: a qualitative analysis of support groups

OBJECTIVES

Stress and burnout are endemic in postgraduate medical training, but little research is available to guide supportive interventions. The identification of the longitudinal emotional and developmental coping needs of internal medicine residents could assist in the better design and implementation of supportive interventions.

METHODS

In this retrospective, exploratory study, six internal medicine resident support groups (n = 62; residents in postgraduate years [PGY] 1-3) were followed for a period of 2 years. Qualitative data were extracted from monthly support group process notes to identify common themes, stressors, emotions, coping strategies and developmental challenges faced during training. Quantitative questionnaire data were collected on burnout, group attendance and resident satisfaction.

RESULTS

Using professional identity development models and classic stress and coping theory as a starting point, a derivation of grounded theory was used to identify common themes and emotions documented in support group process notes. The most common themes included understanding resident roles and responsibilities, developing an identity as a resident and doctor, building professional confidence, cognitive and behavioural responses to stress, and concerns about flaws in local and national health care training and delivery systems. Anxiety and guilt were the most commonly reported emotions, followed by positive emotions and anger. Burnout scores were highest for the second half of PGY1, but improved over subsequent training years. Support group attendance and satisfaction were both high. Residents overwhelmingly pointed to peer relationships as the most critical source of support throughout postgraduate training.

CONCLUSIONS

Developmentally informed programmatic adaptations could better support the emotional growth and personal and professional development of postgraduate medical trainees. Future directions should include a controlled trial of resident support groups, assessments of 'active ingredients' (i.e. to establish which supportive interventions are most effective), and evaluations of programmatic adaptations.

Effects of information supply on satisfaction with information and quality of life in cancer patients receiving curative radiation therapy

In order to test the efficacy of various information inputs, 210 consecutive cancer patients were randomized to one of three information conditions before the start of curative radiation treatment: (1) standard information plus group and repeated individual information (n=70), (2) standard information plus brochure (n=70), and (3) standard information only (n=70). Patients completed questions regarding satisfaction with information, anxiety, depression, subjective distress and quality of life at inclusion, and 1h before the start of the radiation therapy treatment (approximately 4 weeks later). Patients receiving standard information plus group and repeated individual information were significantly more satisfied with the information than were patients in the remaining two groups. There were no differences with respect to any of the other outcome measures. This study has shown that the nurses group and individual information was of significant importance in preparing the patients for the procedure of receiving radiation therapy.

Peer Support Workers in Health: A Qualitative Metasynthesis of Their Experiences

OBJECTIVE

Peer support models, where an individual has a specific illness or lifestyle experience and supports others experiencing similar challenges, have frequently been used in different fields of healthcare to successfully engage hard-to-reach groups. Despite recognition of their value, the impact of these roles on the peer has not been systematically assessed. By synthesising the qualitative literature we sought to review such an impact, providing a foundation for designing future clinical peer models.

METHODS

Systematic review and qualitative metasynthesis of studies found in Medline, CINAHL or Scopus documenting peer worker experiences.

RESULTS

1,528 papers were found, with 34 meeting the criteria of this study. Findings were synthesised to reveal core constructs of reframing identity through reciprocal relations and the therapeutic use of self, enhancing responsibility.

CONCLUSIONS

The ability of the Peer Support Worker to actively engage with other marginalised or excluded individuals based on their unique insight into their own experience supports a therapeutic model of care based on appropriately sharing their story. Our findings have key implications for maximising the effectiveness of Peer Support Workers and in contributing their perspective to the development of a therapeutic model of care.

Acute alcoholic hepatitis, end stage alcoholic liver disease and liver transplantation: An Italian position statement

Alcoholic liver disease encompasses a broad spectrum of diseases ranging from steatosis steatohepatitis, fibrosis, and cirrhosis to hepatocellular carcinoma. Forty-four per cent of all deaths from cirrhosis are attributed to alcohol. Alcoholic liver disease is the second most common diagnosis among patients undergoing liver transplantation (LT). The vast majority of transplant programmes (85%) require 6 mo of abstinence prior to transplantation; commonly referred to as the “6-mo rule”. Both in the case of progressive end-stage liver disease (ESLD) and in the case of severe acute alcoholic hepatitis (AAH), not responding to medical therapy, there is a lack of evidence to support a 6-mo sobriety period. It is necessary to identify other risk factors that could be associated with the resumption of alcohol drinking. The “Group of Italian Regions” suggests that: in a case of ESLD with model for end-stage liver disease < 19 a 6-mo abstinence period is required; in a case of ESLD, a 3-mo sober period before LT may be more ideal than a 6-mo period, in selected patients; and in a case of severe AAH, not responding to medical therapies (up to 70% of patients die within 6 mo), LT is mandatory, even without achieving abstinence. The multidisciplinary transplant team must include an addiction specialist/hepato-alcohologist. Patients have to participate in self-help groups.

Weight reduction at the work site: a promise partially fulfilled

Three consecutive studies of weight reduction at the work site were conducted with 172 female union members, who participated in 16-week behavioral group programs. There was no significant difference in weight loss over the three studies, but attrition decreased from 57.5% to 33.8% and weight loss maintenance improved. Groups that met three to four times weekly had less attrition than those which met once a week, but had no more weight loss. These behavioral weight reduction programs were as effective as self-help and commercial groups, and lay leaders produced results equivalent to those produced by professional therapists at one-third the cost.