Summarizing The Summarizing The Weight Management Weight Management

Wisdom: What Works in Wisdom: What Works in Weight Management?Weight Management?

Phillip J. Brantley, PhDPhillip J. Brantley, PhD

Pennington Biomedical Research CenterPennington Biomedical Research Center

A Typical Pattern of Weight Loss & A Typical Pattern of Weight Loss & Regain in Behavioral InterventionsRegain in Behavioral Interventions

Long-term outcomes for behavioral weight loss treatment (Kramer et al., 1989)

Review of Behavioral Weight Review of Behavioral Weight Loss Treatment Loss Treatment (Perri & Corsica, 2002)(Perri & Corsica, 2002)

Reviewed nine studies with follow-ups of Reviewed nine studies with follow-ups of two years or more (2-12 years) two years or more (2-12 years)

Initial weight loss across studies ranged Initial weight loss across studies ranged from 4.5 to 14.3 kg (M=8.3 kg)from 4.5 to 14.3 kg (M=8.3 kg)

Every study met the IOM criterion for Every study met the IOM criterion for maintenance at one year (>5% reduction)maintenance at one year (>5% reduction)

Net loss across studies at final follow-up Net loss across studies at final follow-up averaged 3 kg with only 2 of 9 meeting averaged 3 kg with only 2 of 9 meeting IOM Criterion at final follow-upIOM Criterion at final follow-up

Weight Loss Maintenance TrialWeight Loss Maintenance Trial

A multicenter, randomized clinical trial to determine the effectiveness of two innovative behavioral interventions, compared to an advice only control group in maintaining weight loss

WLM: SitesWLM: Sites Clinical Sites

• Pennington Biomedical Research Center • Duke University Medical Center• Johns Hopkins School of Medicine• Kaiser Center for Health Research

Coordinating Center• Kaiser Center for Health Research

Project Office• NHLBI Prevention Scientific Research Group

Reasons for Weight RegainReasons for Weight Regain

Loss of motivationLoss of motivation Life stressorsLife stressors Hunger/cravingsHunger/cravings Obesogenic environmentObesogenic environment Obesity is a chronic, possibly lifelong Obesity is a chronic, possibly lifelong

problemproblem

Factors Associated with Weight Factors Associated with Weight MaintenanceMaintenance

Extended Treatment Extended Treatment Treatment IntensityTreatment Intensity Continued ContactContinued Contact Level of Physical ActivityLevel of Physical Activity Motivational EnhancementMotivational Enhancement Maintenance Specific SkillsMaintenance Specific Skills OtherOther

Extended TreatmentExtended Treatment

Perri et al (1989) compared a standard 20 week program with an extended 40 week program. Clients in the extended treatment increased their weight losses by 35% during weeks 20-40. Follow-up data showed that after the extended treatment was concluded, clients reduced their adherence and began to regain weight. (Perri, Nezu, Patti, & McCann, 1989)

Review of Extended Behavioral Review of Extended Behavioral Treatment Treatment (Perri & Corsica, 2002)(Perri & Corsica, 2002)

Reviewed 13 studies that extended Reviewed 13 studies that extended group treatment more than 6 months group treatment more than 6 months using weekly or biweekly sessions using weekly or biweekly sessions (35-65 sessions over 40-78 weeks(35-65 sessions over 40-78 weeks

Extended Treatment groups Extended Treatment groups averaged maintaining 96 % of weight averaged maintaining 96 % of weight loss compared to 66% in controlsloss compared to 66% in controls

Major Problem with with Extended Major Problem with with Extended Treatment: Treatment: Low AdherenceLow Adherence

Attendance for 1Attendance for 1stst six months was six months was 65%, for next 12 months it 65%, for next 12 months it averaged 25% averaged 25%

Jeffery et al (1993) Jeffery et al (1993) PREMIER similar rates PREMIER similar rates

Factors Associated with Weight Factors Associated with Weight MaintenanceMaintenance

Extended Treatment Extended Treatment Treatment IntensityTreatment Intensity Continued ContactContinued Contact Level of Physical ActivityLevel of Physical Activity Motivational EnhancementMotivational Enhancement Maintenance Specific SkillsMaintenance Specific Skills OtherOther

Treatment IntensityTreatment Intensity

““Kicking it up a notch”Kicking it up a notch”

Structured meal plans and portion Structured meal plans and portion controlled diets early oncontrolled diets early on

Home based or supervised exercise Home based or supervised exercise Motivational strategies,e.g., recruit Motivational strategies,e.g., recruit

with friends, group competition with friends, group competition

Factors Associated with Weight Factors Associated with Weight MaintenanceMaintenance

Extended Treatment Extended Treatment Treatment IntensityTreatment Intensity Continued ContactContinued Contact Level of Physical ActivityLevel of Physical Activity Motivational EnhancementMotivational Enhancement Maintenance Specific SkillsMaintenance Specific Skills OtherOther

Telephone PromptsTelephone Prompts(Wing et al, 1996)(Wing et al, 1996)

Weekly telephone prompts used to promote self-monitoring of body weight and food intake over a 12 month post-treatment period.

Contacts were made by non-interventionists who did not offer counseling or guidance.

Although telephone prompts were associated with less weight regain (r=-.52), they did not enhance maintenance of weight loss compared to no-contact control condition.

Telephone and Mail Contacts by Telephone and Mail Contacts by Interventionists Interventionists (Perri et al, 1984)(Perri et al, 1984)

Most telephone and mail contacts Most telephone and mail contacts were made by the interventionist were made by the interventionist who conducted the initial weight who conducted the initial weight loss interventionloss intervention

Group who received post Group who received post treatment contacts maintained treatment contacts maintained greater weight lossgreater weight loss

Internet Technology to Promote Internet Technology to Promote Weight MaintenanceWeight Maintenance

Internet programs using email and Internet Web sites have been shown to improve diabetes management, promote physical activity and improve quality of life in patients with HIV/AIDS

Studies look promising for weight maintenance (e.g., Harvey-Berino et al, 2002;2004; Tate 2006; WLM Protocol)

Only people who already use internet will participant…will it maintain weight for extended time period ?

Factors Associated with Weight Factors Associated with Weight MaintenanceMaintenance

Extended Treatment Extended Treatment Treatment IntensityTreatment Intensity Continued ContactContinued Contact Level of Physical ActivityLevel of Physical Activity Motivational EnhancementMotivational Enhancement Maintenance Specific SkillsMaintenance Specific Skills OtherOther

Physical Activity & Weight LossPhysical Activity & Weight Loss

Even though physical activity is NOT the most efficient method of LOSING weight, it appears to be CRUCIAL to maintaining weight loss.

It may be more than calories burned It may be more than calories burned … exercise may enhance mood or … exercise may enhance mood or motivation for caloric control ?motivation for caloric control ?

Factors Associated with Weight Factors Associated with Weight MaintenanceMaintenance

Extended Treatment Extended Treatment Treatment IntensityTreatment Intensity Continued ContactContinued Contact Level of Physical ActivityLevel of Physical Activity Motivational EnhancementMotivational Enhancement Maintenance Specific SkillsMaintenance Specific Skills OtherOther

Motivational Enhancement Motivational Enhancement MethodsMethods

Financial IncentivesFinancial Incentives Social SupportSocial Support Motivational InterviewingMotivational Interviewing

Financial IncentivesFinancial Incentives Jeffery et al, 1993 Paid participants $25 Jeffery et al, 1993 Paid participants $25

per week over an 18 month period to per week over an 18 month period to loss and maintain loss and maintain weight…did not weight…did not improveimprove

Kramer et al, 1986 Collected $100 from Kramer et al, 1986 Collected $100 from participants at start of weight loss…at participants at start of weight loss…at beginning of maintenance either gave it beginning of maintenance either gave it back, paid it contingent on attendance back, paid it contingent on attendance or paid it contingent on weight or paid it contingent on weight maintenance… maintenance… no differenceno difference

Social SupportSocial Support Modest support for including spouses Modest support for including spouses

or significant othersor significant others Support triggered by financial Support triggered by financial

incentives for group weight loss is incentives for group weight loss is promising (Kramer et al, 1986: Perri promising (Kramer et al, 1986: Perri et al, 1988)et al, 1988)

Also promising is allowing groups of Also promising is allowing groups of friends to participate together in friends to participate together in weight loss (Wing and Jeffery, 1999)weight loss (Wing and Jeffery, 1999)

Motivational InterviewingMotivational Interviewing Interaction style: interact with participants

based on their level of motivation (“stage of change”)

Elicit change statements and realistic plans…Build confidence…avoid lecturing

Impacts treatment outcome by promoting Impacts treatment outcome by promoting better adherence (better attendance, more better adherence (better attendance, more participation)participation)

Zweben & Zuckoff in Miller and Rollnick, Zweben & Zuckoff in Miller and Rollnick,

20022002

Factors Associated with Weight Factors Associated with Weight MaintenanceMaintenance

Extended Treatment Extended Treatment Treatment IntensityTreatment Intensity Continued ContactContinued Contact Level of Physical ActivityLevel of Physical Activity Motivational EnhancementMotivational Enhancement Maintenance Specific SkillsMaintenance Specific Skills OtherOther

Maintenance Specific SkillsMaintenance Specific Skills

““Strategies that are effective for Strategies that are effective for maintaining an energy deficit in a maintaining an energy deficit in a period of weight loss may be period of weight loss may be different than those involved in different than those involved in maintaining a stable energy maintaining a stable energy balance around a lower weight”balance around a lower weight”

Jeffery et al, Jeffery et al, 20002000

Relapse Prevention TrainingRelapse Prevention Training

Teaches people to avoid or cope with Teaches people to avoid or cope with slips and relapsesslips and relapses

Slips lead to negative psychological Slips lead to negative psychological reactions that precipitate a return to reactions that precipitate a return to pretreatment patternspretreatment patterns

RPT in initial treatment phase isn’t very RPT in initial treatment phase isn’t very effective for maintenanceeffective for maintenance

Appears more effective during Appears more effective during maintenance phase of Txmaintenance phase of Tx

Factors Associated with Weight Factors Associated with Weight MaintenanceMaintenance

Extended Treatment Extended Treatment Treatment IntensityTreatment Intensity Continued ContactContinued Contact Level of Physical ActivityLevel of Physical Activity Motivational EnhancementMotivational Enhancement Maintenance Specific SkillsMaintenance Specific Skills Other Maintenance ToolsOther Maintenance Tools

Problem SolvingProblem Solving

Systematic method for coping with Systematic method for coping with barriers or problemsbarriers or problems

Uses: Problem Identification, Uses: Problem Identification, Generation of Alternatives, Selection Generation of Alternatives, Selection of Best Solution, Implementation, of Best Solution, Implementation, EvaluationEvaluation

Leader can do it or facilitate itLeader can do it or facilitate it Successful use in weight maintenance Successful use in weight maintenance

by Perri et al by Perri et al

Self-MonitoringSelf-Monitoring

Food and activity monitoring is one of best Food and activity monitoring is one of best predictors of success in weight predictors of success in weight loss….unclear of its role in maintenanceloss….unclear of its role in maintenance

Nearly all extended treatment studies Nearly all extended treatment studies promote recording of food intake and promote recording of food intake and weightweight

National Weight Control Registry…weigh National Weight Control Registry…weigh at least weekly…attempt to eat reduced at least weekly…attempt to eat reduced fat and caloriesfat and calories

What does not work by alone?What does not work by alone?

Individual monetary incentivesIndividual monetary incentives RPT without contactRPT without contact Telephone prompts by non-Telephone prompts by non-

interventionistsinterventionists Personal trainers Personal trainers Frequent group meetingsFrequent group meetings Supervised group exerciseSupervised group exercise Reliance on meal replacementsReliance on meal replacements

What works?What works?

Multi-component ProgramMulti-component Program• Continued contact providing Continued contact providing

accountability and motivationaccountability and motivation• Physical activity promotionPhysical activity promotion• RPT by interventionistRPT by interventionist• Problem solvingProblem solving• Weekly weighingWeekly weighing• Reduced calorie and fat dietReduced calorie and fat diet

Intervention ComponentsIntervention Components

Self-Self-MonitoringMonitoring

Food & Fitness Food & Fitness diaries, reports at diaries, reports at monthly contactsmonthly contacts

Web or IVR phone entry of F Web or IVR phone entry of F & F diary, at least weekly& F diary, at least weekly

FeedbackFeedback Reports at FTF Visits, Reports at FTF Visits, MI and support at all MI and support at all contacts contacts

Automated responses and Automated responses and MI messages after data MI messages after data entryentry

Problem Problem solvingsolving

Tailored responses to Tailored responses to pxs ID’d at monthly pxs ID’d at monthly contactscontacts

Tailored responses to pxs Tailored responses to pxs ID’d from automated ID’d from automated inquiresinquires

Relapse Relapse PreventionPrevention

Skills provided at Skills provided at monthly contacts, monthly contacts, particularly FTF visitsparticularly FTF visits

Skills provided based on Skills provided based on self-monitoring data and self-monitoring data and automated inquiresautomated inquires

Social Social SupportSupport

Phone and FTF visitsPhone and FTF visits Moderated bulletin boardModerated bulletin board

Diet and PA Diet and PA EducationEducation

Available at each Available at each contactcontact

Option on the Web siteOption on the Web site

PC IT