Psychosocial predictors of weight regain in the weight loss maintenance trial.

This study's purpose was to identify psychosocial predictors of weight loss maintenance in a multi-site clinical trial, following a group-based weight loss program. Participants (N = 1025) were predominately women (63%) and 38% were Black (mean age = 55.6 years; SD = 8.7). At 12 months, higher SF-36 mental health composite scores were associated with less weight regain (p < .01). For Black participants, an interaction existed between race and friends' encouragement for exercise, where higher exercise encouragement was related to more weight regain (p < .05). At 30 months, friends' encouragement for healthy eating was associated with more weight regain (p < .05), whereas higher SF-36 mental health composite scores were related to less weight regain (p < .0001). Perceived stress and select health-related quality of life indices were associated with weight regain; this relationship varied across gender, race, and treatment conditions. Temporal changes in these variables should be investigated for their impact on weight maintenance.

Weight loss history as a predictor of weight loss: results from Phase I of the weight loss maintenance trial.

Past studies have suggested that weight loss history is associated with subsequent weight loss. However, questions remain whether method and amount of weight lost in previous attempts impacts current weight loss efforts. This study utilized data from the Weight Loss Maintenance Trial to examine the association between weight loss history and weight loss outcomes in a diverse sample of high-risk individuals. Multivariate regression analysis was conducted to determine which specific aspects of weight loss history predict change in weight during a 6-month weight loss intervention. Greater weight loss was predicted by fewer previous weight loss attempts with assistance (p = 0.03), absence of previous dietary/herbal weight loss supplement use (p = 0.01), and greater maximum weight loss in previous attempts (p < 0.001). Future interventions may benefit from assessment of weight loss history and tailoring of interventions based on past weight loss behaviors and outcomes.

Associations of internet website use with weight change in a long-term weight loss maintenance program.

BACKGROUND: The Weight Loss Maintenance Trial (WLM) compared two long-term weight-maintenance interventions, a personal contact arm and an Internet arm, with a no-treatment control after an initial six-month Phase I weight loss program. The Internet arm focused on use of an interactive website for support of long-term weight maintenance. There is limited information about patterns of website use and specific components of an interactive website that might help promote maintenance of weight loss. OBJECTIVE: This paper presents a secondary analysis of the subset of participants in the Internet arm and focuses on website use patterns and features associated with long-term weight maintenance. METHODS: Adults at risk for cardiovascular disease (CVD) who lost at least 4 kilograms in an initial 20-week group-based, behavioral weight-loss program were trained to use an interactive website for weight loss maintenance. Of the 348 participants, 37% were male and 38% were African American. Mean weight loss was 8.6 kilograms. Participants were encouraged to log in at least weekly and enter a current weight for the 30-month study period. The website contained features that encouraged setting short-term goals, creating action plans, and reinforcing self-management habits. The website also included motivational modules, daily tips, and tailored messages. Based on log-in and weight-entry frequency, we divided participants into three website use categories: consistent, some, and minimal. RESULTS: Participants in the consistent user group (n = 212) were more likely to be older (P = .002), other than African American (P = .02), and more educated (P = .01). While there was no significant difference between website use categories in the amount of Phase I change in body weight (P = .45) or income (P = .78), minimal website users (n = 75) were significantly more likely to have attended fewer Phase I sessions (P = .001) and had a higher initial body mass index (BMI) (P < .001). After adjusting for baseline characteristics including initial BMI, variables most associated with less weight regain included: number of log-ins (P = .001), minutes on the website (P < .001), number of weight entries (P = .002), number of exercise entries (P < .001), and sessions with additional use of website features after weight entry (P = .002). CONCLUSION: Participants defined as consistent website users of an interactive behavioral website designed to promote maintenance of weight loss were more successful at maintaining long-term weight loss. TRIAL REGISTRATION: NCT00054925; http://clinicaltrials.gov/ct2/show/NCT00054925 (Archived by WebCite at http://www.webcitation.org/5rC7523ue).

Design of the Prevention of Adult Caries Study (PACS): a randomized clinical trial assessing the effect of a chlorhexidine dental coating for the prevention of adult caries.

BACKGROUND: Dental caries is one of the primary causes of tooth loss among adults. It is estimated to affect a majority of Americans aged 55 and older, with a disproportionately higher burden in disadvantaged populations. Although a number of treatments are currently in use for caries prevention in adults, evidence for their efficacy and effectiveness is limited. METHODS/DESIGN: The Prevention of Adult Caries Study (PACS) is a multicenter, placebo-controlled, double-blind, randomized clinical trial of the efficacy of a chlorhexidine (10% w/v) dental coating in preventing adult caries. Participants (n = 983) were recruited from four different dental delivery systems serving four diverse communities, including one American Indian population, and were randomized to receive either chlorhexidine or a placebo treatment. The primary outcome is the net caries increment (including non-cavitated lesions) from baseline to 13 months of follow-up. A cost-effectiveness analysis also will be considered. DISCUSSION: This new dental treatment, if efficacious and approved for use by the Food and Drug Administration (FDA), would become a new in-office, anti-microbial agent for the prevention of adult caries in the United States. TRIAL REGISTRATION NUMBER: NCT00357877.

Effectiveness of the 5-As tobacco cessation treatments in nine HMOs.

BACKGROUND: Smoking remains the leading cause of preventable mortality in the US. The national clinical guideline recommends an intervention for tobacco use known as the 5-As (Ask, Advise, Assess, Assist, and Arrange). Little is known about the model's effectiveness outside the research setting. OBJECTIVE: To assess the effectiveness of tobacco treatments in HMOs. PARTICIPANTS: Smokers identified from primary care visits in nine nonprofit health plans. DESIGN/METHODS: Smokers were surveyed at baseline and at 12-month follow-up to assess smoking status and tobacco treatments offered by clinicians and used by smokers. RESULTS: Analyses include the 80% of respondents who reported having had a visit in the previous year with their clinician when they were smoking (n = 2,325). Smokers were more often offered Advice (77%) than the more effective Assist treatments-classes/counseling (41%) and pharmacotherapy (33%). One third of smokers reported using pharmacotherapy, but only 16% used classes or counseling. At follow-up, 8.9% were abstinent for >30 days. Smokers who reported being offered pharmacotherapy were more likely to quit than those who did not (adjusted OR = 1.73, CI = 1.22-2.45). Compared with smokers who didn't use classes/counseling or pharmacotherapy, those who did use these services were more likely to quit (adjusted OR = 1.82, CI = 1.16-2.86 and OR = 2.23, CI = 1.56-3.20, respectively). CONCLUSIONS: Smokers were more likely to report quitting if they were offered cessation medications or if they used either medications or counseling. Results are similar to findings from clinical trials and highlight the need for clinicians and health plans to provide more than just advice to quit.

Development and implementation cost analysis of telephone- and Internet-based interventions for the maintenance of weight loss.

OBJECTIVES: The Weight Loss Maintenance Trial (WLM) was a multicenter, randomized trial comparing two weight loss maintenance interventions, a personal contact (PC) program with primarily telephone-based monthly contacts, and an Internet-based program (interactive technology, IT), to a self-directed control group, among overweight or obese individuals at high cardiovascular risk. This study describes implementation costs of both interventions as well as IT development costs. METHODS: Resources were micro-costed in 2006 dollars from the primary perspective of a sponsoring healthcare system considering adopting an extant intervention, rather than developing its own. Costs were discounted at 3 percent annually. Length of trial participation was 30 months (randomization during February-November 2004). IT development costs were assessed over 36 months. Univariate and multivariate, including probabilistic, sensitivity analyses were performed. RESULTS: Total discounted IT development costs over 36 months were $839,949 ($2,414 per IT participant). Discounted 30-month implementation costs for 342 PC participants were $537,242 ($1,571 per participant), and for 348 IT participants, were $214,879 ($617 per participant). Under all plausible scenarios, PC implementation costs exceeded IT implementation costs. CONCLUSIONS: Costs of implementing and operating an Internet-based intervention for weight loss maintenance were substantially less than analogous costs of an intervention using standard phone and in-person contacts and are of a magnitude that would be attractive to many health systems, subject to demonstration of cost-effectiveness.

Implementing a tobacco assisted referral program in dental practices.

OBJECTIVES: The objectives of this study are to design and implement a system-level tobacco-control intervention in a large prepaid dental group practice and assess effects on staff performance measures and patient satisfaction. METHODS: We matched 14 dental facilities on size, socioeconomic status, smoking rate, and periodontal status, and then randomly assigned them to intervention or usual-care control. We trained intervention staff in an "Assisted Referral" team approach for assessing tobacco use, providing tailored advice and brief counseling, and encouraging smokers to talk by telephone with a specially trained tobacco counselor. Patients could call from the office or ask that the counselor call them later. Telephone counselors helped patients explore motivations and barriers for quitting; review available cessation-support strategies, programs, and medications; and identify next steps. RESULTS: During the 14-month study period, 66,516 members had annual- or new-patient examinations. Both intervention and control sites had high rates of tobacco assessment (97 percent) and advice (93 percent). Intervention patients were more likely than controls (69 percent versus 3 percent, P < 0.01) to receive additional chair-side tobacco counseling and assistance, and 11 percent agreed to receive additional telephone counseling. Intervention patients were more satisfied than controls with the dental team's tobacco-control efforts (P < 0.03). Referral rates varied substantially for different staff. CONCLUSIONS: The Assisted Referral approach was successfully integrated into routine dental care, was well received by patients, and resulted in increased patient satisfaction. Because free telephone-based tobacco counseling is now available nationwide, the approach may be a practical strategy for most dental-care settings.

Weight loss during the intensive intervention phase of the weight-loss maintenance trial.

BACKGROUND: To improve methods for long-term weight management, the Weight Loss Maintenance (WLM) trial, a four-center randomized trial, was conducted to compare alternative strategies for maintaining weight loss over a 30-month period. This paper describes methods and results for the initial 6-month weight-loss program (Phase I). METHODS: Eligible adults were aged > or =25, overweight or obese (BMI=25-45 kg/m2), and on medications for hypertension and/or dyslipidemia. Anthropomorphic, demographic, and psychosocial measures were collected at baseline and 6 months. Participants (n=1685) attended 20 weekly group sessions to encourage calorie restriction, moderate-intensity physical activity, and the DASH (dietary approaches to stop hypertension) dietary pattern. Weight-loss predictors with missing data were replaced by multiple imputation. RESULTS: Participants were 44% African American and 67% women; 79% were obese (BMI> or =30), 87% were taking anti-hypertensive medications, and 38% were taking antidyslipidemia medications. Participants attended an average of 72% of 20 group sessions. They self-reported 117 minutes of moderate-intensity physical activity per week, kept 3.7 daily food records per week, and consumed 2.9 servings of fruits and vegetables per day. The Phase-I follow-up rate was 92%. Mean (SD) weight change was -5.8 kg (4.4), and 69% lost at least 4 kg. All race-gender subgroups lost substantial weight: African-American men (-5.4 kg +/- 7.7); African-American women (-4.1 kg +/- 2.9); non-African-American men (-8.5 kg +/- 12.9); and non-African-American women (-5.8 kg +/- 6.1). Behavioral measures (e.g., diet records and physical activity) accounted for most of the weight-loss variation, although the association between behavioral measures and weight loss differed by race and gender groups. CONCLUSIONS: The WLM behavioral intervention successfully achieved clinically significant short-term weight loss in a diverse population of high-risk patients.

Design and implementation of an interactive website to support long-term maintenance of weight loss.

BACKGROUND: For most individuals, long-term maintenance of weight loss requires long-term, supportive intervention. Internet-based weight loss maintenance programs offer considerable potential for meeting this need. Careful design processes are required to maximize adherence and minimize attrition. OBJECTIVE: This paper describes the development, implementation and use of a Web-based intervention program designed to help those who have recently lost weight sustain their weight loss over 1 year. METHODS: The weight loss maintenance website was developed over a 1-year period by an interdisciplinary team of public health researchers, behavior change intervention experts, applications developers, and interface designers. Key interactive features of the final site include social support, self-monitoring, written guidelines for diet and physical activity, links to appropriate websites, supportive tools for behavior change, check-in accountability, tailored reinforcement messages, and problem solving and relapse prevention training. The weight loss maintenance program included a reminder system (automated email and telephone messages) that prompted participants to return to the website if they missed their check-in date. If there was no log-in response to the email and telephone automated prompts, a staff member called the participant. We tracked the proportion of participants with at least one log-in per month, and analyzed log-ins as a result of automated prompts. RESULTS: The mean age of the 348 participants enrolled in an ongoing randomized trial and assigned to use the website was 56 years; 63% were female, and 38% were African American. While weight loss data will not be available until mid-2008, website use remained high during the first year with over 80% of the participants still using the website during month 12. During the first 52 weeks, participants averaged 35 weeks with at least one log-in. Email and telephone prompts appear to be very effective at helping participants sustain ongoing website use. CONCLUSIONS: Developing interactive websites is expensive, complex, and time consuming. We found that extensive paper prototyping well in advance of programming and a versatile product manager who could work with project staff at all levels of detail were essential to keeping the development process efficient. TRIAL REGISTRATION: clinicaltrials.gov NCT00054925.

Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial.

CONTEXT: Behavioral weight loss interventions achieve short-term success, but re-gain is common. OBJECTIVE: To compare 2 weight loss maintenance interventions with a self-directed control group. DESIGN, SETTING, AND PARTICIPANTS: Two-phase trial in which 1032 overweight or obese adults (38% African American, 63% women) with hypertension, dyslipidemia, or both who had lost at least 4 kg during a 6-month weight loss program (phase 1) were randomized to a weight-loss maintenance intervention (phase 2). Enrollment at 4 academic centers occurred August 2003-July 2004 and randomization, February-December 2004. Data collection was completed in June 2007. INTERVENTIONS: After the phase 1 weight-loss program, participants were randomized to one of the following groups for 30 months: monthly personal contact, unlimited access to an interactive technology-based intervention, or self-directed control. Main Outcome Changes in weight from randomization. RESULTS: Mean entry weight was 96.7 kg. During the initial 6-month program, mean weight loss was 8.5 kg. After randomization, weight regain occurred. Participants in the personal-contact group regained less weight (4.0 kg) than those in the self-directed group (5.5 kg; mean difference at 30 months, -1.5 kg; 95% confidence interval [CI], -2.4 to -0.6 kg; P = .001). At 30 months, weight regain did not differ between the interactive technology-based (5.2 kg) and self-directed groups (5.5 kg; mean difference -0.3 kg; 95% CI, -1.2 to 0.6 kg; P = .51); however, weight regain was lower in the interactive technology-based than in the self-directed group at 18 months (mean difference, -1.1 kg; 95% CI, -1.9 to -0.4 kg; P = .003) and at 24 months (mean difference, -0.9 kg; 95% CI, -1.7 to -0.02 kg; P = .04). At 30 months, the difference between the personal-contact and interactive technology-based group was -1.2 kg (95% CI -2.1 to -0.3; P = .008). Effects did not differ significantly by sex, race, age, and body mass index subgroups. Overall, 71% of study participants remained below entry weight. CONCLUSIONS: The majority of individuals who successfully completed an initial behavioral weight loss program maintained a weight below their initial level. Monthly brief personal contact provided modest benefit in sustaining weight loss, whereas an interactive technology-based intervention provided early but transient benefit. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00054925.

The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline.

OBJECTIVES: State and national tobacco quitlines have expanded rapidly and offer a range of services. We examined the effectiveness and cost effectiveness of offering callers single session versus multisession counselling, with or without free nicotine patches. METHODS: This 3x2 randomised trial included 4614 Oregon tobacco quitline callers and compared brief (one 15-minute call), moderate (one 30-minute call and a follow-up call) and intensive (five proactive calls) intervention protocols, with or without offers of free nicotine patches (nicotine replacement therapy, NRT). Blinded staff assessed tobacco use by phone at 12 months. RESULTS: Abstinence odds ratios were significant for moderate (OR = 1.22, CI = 1.01 to 1.48) and intensive (OR = 1.29, CI = 1.07 to 1.56) intervention, and for NRT (OR = 1.58, CI = 1.35 to 1.85). Intent to treat quit rates were as follows: brief no NRT (12%); brief NRT (17%); moderate no NRT (14%); moderate NRT (20%); intensive no NRT (14%); and intensive NRT (21%). Relative to brief no NRT, the added costs for each additional quit was $2467 for brief NRT, $1912 for moderate no NRT, $2109 for moderate NRT, $2641 for intensive no NRT, and $2112 for intensive NRT. CONCLUSION: Offering free NRT and multisession telephone support within a state tobacco quitline led to higher quit rates, and similar costs per incremental quit, than less intensive protocols.

The feasibility of connecting physician offices to a state-level tobacco quit line.

BACKGROUND: Telephone counseling for tobacco cessation is an effective and evidence-based approach to address tobacco use. The wide dissemination of region- and state-level quit lines has been a major goal for public health agencies. However, connecting patients in primary care settings to state-level quit lines has not been evaluated. METHODS: Observational study describing two methods (fax referral and providing a brochure) to connect private physician offices with a state-level quit line in Oregon. This study describes the resources required to create a clinical pathway for the 5A's in primary care (ask, advise, assess, assist, and arrange) using a state-level telephone quit line as an intervention for cessation in primary care clinics sharing a common electronic medical record system, focusing on the costs and generalizability of this approach. RESULTS: Of the 15,662 smokers identified in 19 primary care clinics, 745 patients were referred to the Oregon Tobacco Quit Line during the study period. The program cost in the first year was $15 to $22 per patient connected with the quit line; in subsequent years, the cost decreased to $4 to $6 per quit-line connection. CONCLUSIONS: Connecting private physician offices to a state-level quit line is feasible, can be accomplished at low cost with minimal use of resources, and may be cost effective. Regional, state, and local tobacco quit lines should consider a physician office "quit-line connection" as a practical approach to increase utilization.

The impact of continued intervention on weight: Five-year results from the weight loss maintenance trial.

OBJECTIVE: In the Weight Loss Maintenance (WLM) Trial, a personal contact (PC) intervention sustained greater weight loss relative to a self-directed (SD) group over 30 months. This study investigated the effects of continued intervention over an additional 30 months and overall weight change across the entire WLM Trial. METHODS: WLM had 3 phases. Phase 1 was a 6-month weight loss program. In Phase 2, those who lost ≥4 kg were randomized to a 30-month maintenance trial. In Phase 3, PC participants (n = 196, three sites) were re-randomized to no further intervention (PC-Control) or continued intervention (PC-Active) for 30 more months; 218 SD participants were also followed. RESULTS: During Phase 3, weight increased 1.0 kg in PC-Active and 0.5 kg in PC-Control (mean difference 0.6 kg; 95% CI:-1.4 to 2.7; P = 0.54). Mean weight change over the entire study was -3.2 kg in those originally assigned to PC (PC-Combined) and -1.6 kg in SD (mean difference -1.6 kg; 95% CI:-3.0 to -0.1; P = 0.04). CONCLUSIONS: After 30 months of the PC maintenance intervention, continuation for another 30 months provided no additional benefit. However, across the entire study, weight loss was slightly greater in those originally assigned to PC.

Tobacco-cessation services and patient satisfaction in nine nonprofit HMOs.

BACKGROUND: The U.S. Public Health Service clinical practice guideline calls for clinicians and healthcare organizations to identify and treat every tobacco user seen in a healthcare setting. There is little information on the extent of compliance with the guideline's treatment model described by the "5A's" (Ask, Advise, Assess, Assist, Arrange). METHODS: In 1999-2000 a survey was mailed to 64,764 members aged 25 to 75 years, of nine nonprofit HMOs participating in the National Cancer Institute-funded Cancer Research Network. These plans provide medical care to more than 8 million Americans including a minority enrollment of 30%. Smokers were asked about tobacco-cessation treatments received during primary care visits in the past year. RESULTS: A 70% response rate identified a smoking prevalence of 10% (n=4207). Results indicated that 90% of smokers were asked about smoking, 71% were advised to quit, 56% were assessed for their willingness to quit, 49% received assistance interventions, and 9% had follow-up arranged. Treatment was provided more often to smokers who asked for help and/or intended to quit. Few and only modest associations were found between other patient characteristics and receipt of 5A's cessation services. In contrast to widely reported concerns about smokers' resistance to tobacco interventions, smokers who received treatment were more satisfied with health plan services. CONCLUSIONS: Results demonstrate substantial clinician compliance with the first two steps-Ask and Advise. Greater efforts are needed in providing the more effective tobacco treatments-Assist and Arrange. Compliance with the guideline is associated with greater patient satisfaction.

Natural language processing in the electronic medical record: assessing clinician adherence to tobacco treatment guidelines.

BACKGROUND: Comprehensively assessing care quality with electronic medical records (EMRs) is not currently possible because much data reside in clinicians' free-text notes. METHODS: We evaluated the accuracy of MediClass, an automated, rule-based classifier of the EMR that incorporates natural language processing, in assessing whether clinicians: (1) asked if the patient smoked; (2) advised them to stop; (3) assessed their readiness to quit; (4) assisted them in quitting by providing information or medications; and (5) arranged for appropriate follow-up care (i.e., the 5A's of smoking-cessation care). DESIGN: We analyzed 125 medical records of known smokers at each of four HMOs in 2003 and 2004. One trained abstractor at each HMO manually coded all 500 records according to whether or not each of the 5A's of smoking cessation care was addressed during routine outpatient visits. MEASUREMENTS: For each patient's record, we compared the presence or absence of each of the 5A's as assessed by each human coder and by MediClass. We measured the chance-corrected agreement between the human raters and MediClass using the kappa statistic. RESULTS: For "ask" and "assist," agreement among human coders was indistinguishable from agreement between humans and MediClass (p>0.05). For "assess" and "advise," the human coders agreed more with each other than they did with MediClass (p<0.01); however, MediClass performance was sufficient to assess quality in these areas. The frequency of "arrange" was too low to be analyzed. CONCLUSIONS: MediClass performance appears adequate to replace human coders of the 5A's of smoking-cessation care, allowing for automated assessment of clinician adherence to one of the most important, evidence-based guidelines in preventive health care.

Tobacco use patterns and attitudes among teens being seen for routine primary care.

PURPOSE: To describe the tobacco-related attitudes, behaviors, and needs of smoking and nonsmoking teens being seen for routine pediatric care and to identify predictors of tobacco use. DESIGN: Cross-sectional survey of adolescent primary care patients who completed self-administered questionnaires in medical office waiting rooms while waiting for routine care visits. SETTING: A group-practice HMO in the Pacific Northwest. SUBJECTS: A sample of 2526 teenagers, ages 14 to 17, who consented to receive health promotion interventions as a part of a randomized trial in seven pediatric and family practice offices. MEASURES: A 38-item questionnaire assessed tobacco use history, attitudes, quit attempts, and stage of acquisition or cessation along with gender, age, race/ethnicity, body mass index, educational plans, frequency of exercise, attempts to lose weight, and depressed mood. RESULTS: Sixty-seven percent of teens approached (2526 of 3747) consented to complete a questionnaire and receive tobacco- or diet-related interventions as a part of their medical visit. About 23% of teen patients reported smoking at least one cigarette in the last month, although only 14% described themselves as current "smokers." Most current smokers (84%) smoked at least 20 days in the last month. Logistic regression predictors of smoking included older age, Native American ethnicity, lower educational aspirations, lower body mass index, smoking among half or more friends, smokers at home, and a positive depression screen. Among ever-regular smokers, most were in the action (28%), preparation (21%), or contemplation (22%) readiness to quit smoking stages, and 77% of current smokers had made one or more serious quit attempts in the last year. CONCLUSIONS: Most teens in these medical facilities consented to receive tobacco and diet interventions, and most self-described current smokers were contemplating or preparing to quit. Medical visits provide attractive opportunities for tobacco intervention, but messages should be tailored based on the patient's tobacco status and stage of acquisition or cessation.

Depressed mood and smoking experimentation among preteens.

The authors examined children's depressed mood, parental depressed mood, and parental smoking in relation to children's smoking susceptibility and experimentation over 20 months in a cohort of 418 preteens (ages 10-12 at baseline) and their parents. Depressed mood in preteens was strongly related to experimentation but not to susceptibility. In cross-sectional analyses parental depressed mood was related to children's experimentation, but in longitudinal analyses parental depressed mood at baseline did not differentiate children who experimented from those who did not. Although parental smoking was strongly related to experimentation, it was not related to susceptibility either cross-sectionally or longitudinally. Depressed mood among preteens and parents appeared to be more strongly related to children's smoking behaviors than to their intentions to smoke.

Steps to soulful living (steps): a weight loss program for African-American women.

BACKGROUND: The disproportionate disease burden experienced by African-American women can be explained partially by the higher rates of obesity in this population. African-American women who can benefit from weight loss may be less likely to attempt it and may have relatively less success in using traditional weight loss programs compared to White women. Steps to Soulful Living (Steps) was a pilot study to test the effects of a culturally adapted weight loss program on weight loss in African-American women. METHODS: Sixty-six African-American women participated in a 6-month weight loss program that included weekly group meetings and supervised exercise sessions. Mean baseline body mass index was 39 kg/m2, and mean baseline weight was 107 kg. Cultural adaptations, defined as program adjustments, made in response to women's preferences as expressed in focus group interviews included changes in intervention format, the content of the group meetings, and the location and format of the exercise sessions. RESULTS: Seventy-six percent of the participants attended at least 50% of the 26 weekly sessions, and 56% attended at least 75% of the sessions. Average hours of exercise per week approximately doubled during the program in comparison to baseline levels. Mean weight loss at 26 weeks was 3.7 kg, categorizing those who were lost to follow-up as having zero weight loss. Participants who attended at least 75% of the group meetings lost a mean of 6.2 kg at six months. Those who attended fewer meetings lost a mean of 0.9 kg. CONCLUSIONS: This 6-month program was associated with relatively larger weight losses, particularly among participants with high attendance, than have usually been observed in culturally adapted programs for African-American women.

Greater weight loss with increasing age in the weight loss maintenance trial.

OBJECTIVE: To determine the effect of age on weight loss and weight loss maintenance in participants in the Weight Loss Maintenance trial (WLM). DESIGN AND METHODS: Secondary analysis of a randomized controlled trial of overweight/obese adults with CVD risk factors was conducted. Participants were 1685 adults with baseline BMI 25-45 kg m(2) with hypertension and/or dyslipidemia. Those who lost at least 4kg in an initial 6-month behavioral weight loss intervention (N = 1,032) were randomly assigned to a 30-month maintenance phase of self-directed control (SD), monthly personal counseling (PC), or unlimited access to an internet-based intervention (IT). Age groups were defined post-hoc and weight change was compared among age groups. RESULTS: Participants ≥60 years old initially lost more weight than younger individuals, and sustained greater weight loss in IT and PC but not in SD (P value for trend 0.024, 0.002, and 0.36, respectively). CONCLUSIONS: In WLM, adults age ≥60 years had greater initial weight loss and greater sustained weight loss over 3 years, compared to younger adults. Older adults had greater weight loss maintenance with either personal counseling or internet-based intervention. Future research should determine optimal implementation strategies and effects of weight loss on health outcomes in older adults.

Predictors of dietary change among those who successfully lost weight in phase I of the Weight Loss Maintenance Trial.

AIM: Dietary changes occurring during weight loss interventions can vary. The present study tested if pretreatment psychosocial, dietary and demographic factors were associated with changes in fat intake and fruit and vegetable intake during a weight loss intervention. METHODS: This analysis includes participants who lost at least four kilograms during the initial six month weight loss phase (phase I) of the Weight Loss Maintenance Trial, a group format behavioural intervention emphasising a low-fat diet and increased physical activity. Multiple linear regression was used to determine associations between pretreatment psychosocial, dietary, physical activity, and demographic variables and changes from pretreatment to six months in fat intake and fruit and vegetable intake. RESULTS: Participants (n = 1032) were 63.4% female, 62.4% non-African American, and had a mean age of 55.6 and BMI of 34.1 kg/m2. Being African American (P < 0.0001) and higher baseline kilojoule intake (P < 0.01) were associated with smaller reductions in fat intake. Being African American (p < 0.001) and older age (P = 0.02) were associated with smaller increases in fruit and vegetable intake, whereas a history of 10 or more past weight loss episodes of at least 10 lb (4.5 kg; P < 0.01) was associated with greater increases. CONCLUSIONS: Few psychosocial factors examined contributed to variability in dietary change. Even when achieving meaningful weight losses during a behavioural weight loss intervention, African Americans may make fewer beneficial changes in fat and fruit and vegetable intake than non-African Americans.