Extended-Care Programs for Weight Management in Rural Communities The Treatment of Obesity in Underserved Rural Settings (TOURS) Randomized Trial

College of Public Health and Health Professions, University of Florida, 101 S Newell Dr, Ste 4101, Gainesville, FL 32610-0185, USA.
Archives of internal medicine (Impact Factor: 17.33). 12/2008; 168(21):2347-54. DOI: 10.1001/archinte.168.21.2347
Source: PubMed


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.
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.
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.
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 Identifier: NCT00201006.

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    • "Despite the important role of this approach, few prospective studies have been conducted. Perri and colleagues [38-40] have demonstrated that extended programs for obese women, using problem solving for self-management, are associated with better outcomes compared to standard behavior therapies or education-only interventions. Murawski et al. [40] found that participants with ≥ 10% weight reductions demonstrated significantly greater improvement on a self-report measure of problem-solving skill than those with < 5% reductions. "
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    ABSTRACT: Individual barriers to weight loss and physical activity goals in the Diabetes Prevention Program, a randomized trial with 3.2 years average treatment duration, have not been previously reported. Evaluating barriers and the lifestyle coaching approaches used to improve adherence in a large, diverse participant cohort can inform dissemination efforts. Lifestyle coaches documented barriers and approaches after each session (mean session attendance = 50.3 +/- 21.8). Subjects were 1076 intensive lifestyle participants (mean age = 50.6 years; mean BMI = 33.9 kg/m2; 68% female, 48% non-Caucasian). Barriers and approaches used to improve adherence were ranked by the percentage of the cohort for whom they applied. Barrier groupings were also analyzed in relation to baseline demographic characteristics. Top weight loss barriers reported were problems with self-monitoring (58%); social cues (58%); holidays (54%); low activity (48%); and internal cues (thought/mood) (44%). Top activity barriers were holidays (51%); time management (50%); internal cues (30%); illness (29%), and motivation (26%). The percentage of the cohort having any type of barrier increased over the long-term intervention period. A majority of the weight loss barriers were significantly associated with younger age, greater obesity, and non-Caucasian race/ethnicity (p-values vary). Physical activity barriers, particularly thought and mood cues, social cues and time management, physical injury or illness and access/weather, were most significantly associated with being female and obese (p < 0.001 for all). Lifestyle coaches used problem-solving with most participants (>=75% short-term; > 90% long term) and regularly reviewed self-monitoring skills. More costly approaches were used infrequently during the first 16 sessions (<=10%) but increased over 3.2 years. Behavioral problem solving approaches have short and long term dissemination potential for many kinds of participant barriers. Given minimal resources, increased attention to training lifestyle coaches in the consistent use of these approaches appears warranted.
    Full-text · Article · Feb 2014 · International Journal of Behavioral Nutrition and Physical Activity
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    • "Statistical significance was likely affected by the small sample size. With strong evidence that some type of weight loss maintenance treatment is needed to prevent weight regain after intentional weight loss [12,16], the next step is to identify cost-effective program options. Even though we did not evaluate the cost of our pilot programs, interventions delivered by phone generally cost less than face-to-face contacts (both in terms of program costs and costs to the participants [10,12]. "
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    ABSTRACT: Despite high obesity prevalence rates, few low-income midlife women participate in weight loss maintenance trials. This pilot study aims to assess the effectiveness of two weight loss maintenance interventions in this under-represented population. Low-income midlife women who completed a 16-week weight loss intervention and lost >= 8 lbs (3.6 kg) were eligible to enroll in one of two 12-month maintenance programs. The programs were similar in content and had the same number of total contacts, but were different in the contact modality (Phone + Face-to-Face vs. Face-to-Face Only). Two criteria were used to assess successful weight loss maintenance at 12 months: (1) retaining a loss of >= 5% of body weight from the start of the weight loss phase and (2) a change in body weight of < 3%, from the start to the end of the maintenance program. Outcome measures of changes in physiologic and psychosocial factors, and evaluations of process measures and program acceptability (measured at 12 months) are also reported. For categorical variables, likelihood ratio or Fisher's Exact (for small samples) tests were used to evaluate statistically significant relationships; for continuous variables, t-tests or their equivalents were used to assess differences between means and also to identify correlates of weight loss maintenance. Overall, during the 12-month maintenance period, 41% (24/58) of participants maintained a loss of >= 5% of initial weight and 43% (25/58) had a <3% change in weight. None of the comparisons between the two maintenance programs were statistically significant. However, improvements in blood pressure and dietary behaviors remained significant at the end of the 12-month maintenance period for participants in both programs. Participant attendance and acceptability were high for both programs. The effectiveness of two pilot 12-month maintenance interventions provides support for further research in weight loss maintenance among high-risk, low-income women.Trial Identifier: NCT00288301.
    Full-text · Article · Jul 2013 · BMC Public Health
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    • "CW: 60.1 (±0.5) Income: AAW: <$50,000/y: 70% CW: <$50,000/y: 66% Education: High school degree or less AAW: 28% WW: 39% Health status: BMI > 30.0 kg/m 2 Formal Theoretical Framework: NDR Cultural Adaptations: Southern-focused Duration of maintenance phase: 12 months Criteria for entry into WL Maintenance Phase: None Components Targeted at WL Maintenance: Calorie control Didactic Nutrition PA (self, goal 30 min/day walking) Behavioral Modification Strategies (i) Problem solving (ii) Self-monitoring [68] "
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    ABSTRACT: We performed a systematic review of the behavioral lifestyle intervention trials conducted in the United States published between 1990 and 2011 that included a maintenance phase of at least six months, to identify intervention features that promote weight loss maintenance in African American women. Seventeen studies met the inclusion criteria. Generally, African American women lost less weight during the intensive weight loss phase and maintained a lower % of their weight loss compared to Caucasian women. The majority of studies failed to describe the specific strategies used in the delivery of the maintenance intervention, adherence to those strategies, and did not incorporate a maintenance phase process evaluation making it difficult to identify intervention characteristics associated with better weight loss maintenance. However, the inclusion of cultural adaptations, particularly in studies with a mixed ethnicity/race sample, resulted in less % weight regain for African American women. Studies with a formal maintenance intervention and weight management as the primary intervention focus reported more positive weight maintenance outcomes for African American women. Nonetheless, our results present both the difficulty in weight loss and maintenance experienced by African American women in behavioral lifestyle interventions.
    Full-text · Article · Apr 2013 · Journal of obesity
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