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.

Prescribing exercise at varied levels of intensity and frequency: a randomized trial.

BACKGROUND: Regular physical activity produces beneficial effects on health, but the exercise prescription needed to improve cardiovascular disease risk factors in free-living sedentary individuals remains unclear. METHODS: Sedentary adults (N = 492, 64.0% women) were randomized to 1 of 4 exercise-counseling conditions or to a physician advice comparison group. The duration (30 minutes) and type (walking) of exercise were held constant, while exercise intensity and frequency were manipulated to form 4 exercise prescriptions: moderate intensity-low frequency, moderate intensity-high frequency (HiF), hard intensity (HardI)-low frequency, and HardI-HiF. Comparison group participants received physician advice and written materials regarding recommended levels of exercise for health. Outcomes included 6- and 24-month changes in cardiorespiratory fitness (maximum oxygen consumption), high-density lipoprotein cholesterol (HDL-C) level, and the total cholesterol-HDL-C ratio. RESULTS: At 6 months, the HardI-HiF, HardI-low-frequency, and moderate-intensity-HiF conditions demonstrated significant increases in maximum oxygen consumption (P < .01 for all), but only the HardI-HiF condition showed significant improvements in HDL-C level (P < .03), total cholesterol-HDL-C ratio (P < .04), and maximum oxygen consumption (P < .01) compared with physician advice. At 24 months, the increases in maximum oxygen consumption remained significantly higher than baseline in the HardI-HiF, HardI-low-frequency, and moderate-intensity-HiF conditions and in the HardI-HiF group compared with physician advice (P < .01 for all), but no significant effects on HDL-C level (P = .57) or total cholesterol-HDL-C ratio (P = .64) were observed. CONCLUSIONS: Exercise counseling with a prescription for walking at either a HardI or a HiF produced significant long-term improvements in cardiorespiratory fitness. More exercise or the combination of HardI plus HiF exercise may provide additional benefits, including larger fitness changes and improved lipid profiles.

Adherence to exercise prescriptions: effects of prescribing moderate versus higher levels of intensity and frequency.

Sedentary adults (N = 379) were randomly assigned in a 2 x 2 design to walk 30 min per day at a frequency of either 3-4 or 5-7 days per week, at an intensity of either 45%-55% or 65%-75% of maximum heart rate reserve. Analyses of exercise accumulated over 6 months showed greater amounts completed in the higher frequency (p = .0001) and moderate intensity (p = .021) conditions. Analyses of percentage of prescribed exercise completed showed greater adherence in the moderate intensity(p = .02) condition. Prescribing a higher frequency increased the accumulation of exercise without a decline in adherence, whereas prescribing a higher intensity decreased adherence and resulted in the completion of less exercise.

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.

Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings.

BACKGROUND: A major challenge after successful weight loss is continuing the behaviors required for long-term weight maintenance. This challenge can be exacerbated in rural areas with limited local support resources. OBJECTIVE: This study describes and compares program costs and cost effectiveness for 12-month extended-care lifestyle maintenance programs after an initial 6-month weight-loss program. DESIGN: We conducted a 1-year prospective randomized controlled clinical trial. PARTICIPANTS/SETTING: The study included 215 female participants age 50 years or older from rural areas who completed an initial 6-month lifestyle program for weight loss. The study was conducted from June 1, 2003 to May 31, 2007. INTERVENTION: The intervention was delivered through local Cooperative Extension Service offices in rural Florida. Participants were randomly assigned to a 12-month extended-care program using either individual telephone counseling (n=67), group face-to-face counseling (n=74), or a mail/control group (n=74). MAIN OUTCOME MEASURES: Program delivery costs, weight loss, and self-reported health status were directly assessed through questionnaires and program activity logs. Costs were estimated across a range of enrollment sizes to allow inferences beyond the study sample. STATISTICAL ANALYSES PERFORMED: Nonparametric and parametric tests of differences across groups for program outcomes were combined with direct program cost estimates and expected value calculations to determine which scales of operation favored alternative formats for lifestyle maintenance. RESULTS: Median weight regain during the intervention year was 1.7 kg for participants in the face-to-face format, 2.1 kg for the telephone format, and 3.1 kg for the mail/control format. For a typical group size of 13 participants, the face-to-face format had higher fixed costs, which translated into higher overall program costs ($420 per participant) when compared with individual telephone counseling ($268 per participant) and control ($226 per participant) programs. Although the net weight lost after the 12-month maintenance program was higher for the face-to-face and telephone programs compared with the control group, the average cost per expected kilogram of weight lost was higher for the face-to-face program ($47/kg) compared with the other two programs (approximately $33/kg for telephone and control). CONCLUSIONS: Both the scale of operations and local demand for programs are important considerations in selecting a delivery format for lifestyle maintenance. In this study, the telephone format had a lower cost but similar outcomes compared with the face-to-face format.

Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial.

BACKGROUND: Rural counties in the United States have higher rates of obesity, sedentary lifestyle, and associated chronic diseases than nonrural areas, yet the management of obesity in rural communities has received little attention from researchers. METHODS: Obese women from rural communities who completed an initial 6-month weight-loss program at Cooperative Extension Service offices in 6 medically underserved rural counties (n = 234) were randomized to extended care or to an education control group. The extended-care programs entailed problem-solving counseling delivered in 26 biweekly sessions via telephone or face to face. Control group participants received 26 biweekly newsletters containing weight-control advice. RESULTS: Mean weight at study entry was 96.4 kg. Mean weight loss during the initial 6-month intervention was 10.0 kg. One year after randomization, participants in the telephone and face-to-face extended-care programs regained less weight (mean [SE], 1.2 [0.7] and 1.2 [0.6] kg, respectively) than those in the education control group (3.7 [0.7] kg; P = .03 and .02, respectively). The beneficial effects of extended-care counseling were mediated by greater adherence to behavioral weight-management strategies, and cost analyses indicated that telephone counseling was less expensive than face-to-face intervention. CONCLUSIONS: Extended care delivered either by telephone or in face-to-face sessions improved the 1-year maintenance of lost weight compared with education alone. Telephone counseling constitutes an effective and cost-efficient option for long-term weight management. Delivering lifestyle interventions via the existing infrastructure of the Cooperative Extension Service represents a viable means of adapting research for rural communities with limited access to preventive health services. Trial Registration clinicaltrials.gov Identifier: NCT00201006.