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.

Differential impact of telehealth extended-care programs for weight-loss maintenance in African American versus white adults.

Extended-care interventions have been demonstrated to improve maintenance of weight loss after the end of initial obesity treatment; however, it is unclear whether these programs are similarly effective for African American versus White participants. The current study examined differences in effectiveness of individual versus group telephone-based extended-care on weight regain, compared to educational control, in 410 African American (n = 82) and White (n = 328) adults with obesity (mean ± SD age = 55.6 ± 10.3 years, BMI = 36.4 ± 3.7 kg/m2). After controlling for initial weight loss, multivariate linear models demonstrated a significant interaction between treatment condition and race, p = .048. Randomization to the individual telephone condition produced the least amount of weight regain in White participants, while the group condition produced the least amount of weight regain in African American participants. Future research should investigate the role of social support in regain for African American versus White participants and examine whether tailoring delivery format by race may improve long-term outcomes.

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.

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.

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.

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.

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.

Longitudinal Changes in Food Addiction Symptoms and Body Weight among Adults in a Behavioral Weight-Loss Program.

Interest in food addiction (FA) has increased, but little is known about its clinical implications or potential treatments. Using secondary analyses from a randomized controlled trial, we evaluated the associations between changes in FA, body weight, and "problem food" consumption during a 22-month behavioral weight-loss program consisting of an initial four-month in-person intervention, 12-month extended-care, and six-month follow-up (n = 182). Food addiction was measured using the Yale Food Addiction Scale. "Problem foods" were identified from the literature and self-reporting. Multilevel modeling was used as the primary method of analysis. We hypothesized that reductions in problem food consumption during the initial treatment phase would be associated with long-term (22-month) FA reductions. As expected, we found that reductions in problem foods were associated with greater initial reductions in FA symptoms; however, they were also associated with a sharper rebound in symptoms over time (p = 0.016), resulting in no significant difference at Month 22 (p = 0.856). Next, we hypothesized that long-term changes in FA would be associated with long-term changes in body weight. Although both FA and weight decreased over time (ps < 0.05), month-to-month changes in FA were not associated with month-to-month changes in weight (p = 0.706). Instead, higher overall FA (i.e., mean scores over the course of the study) were associated with less weight loss (p = 0.008) over time. Finally, we hypothesized that initial reductions in problem food consumption would be associated with long-term reductions in weight, but this relationship was not significant (ps > 0.05). Given the complexity of the findings, more research is needed to identify interventions for long-term changes in FA and to elucidate the associations between problem foods, FA, and weight.

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.

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 (ß = .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.

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.

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.