May 3, 1995 - maintenance of weight loss following a very-low- calorie-diet and behavior modification program. A survey was mailed to a random sample of ...
Maintenance of Weight Loss: A Needs Assessment Judith D. DePue *I; Matthew M. Clark*-f,Laurie Ruggieros, Meredith L Medeiros*, Vincent Peru, Jr. *f Abstract DEPUE, JUDITH D, MATTHEW M CLARK, LAURIE RUGGIERO, MEREDITH L MEDEIROS AND VINCENT PERA, JR. Maintenance of weight loss: a needs assessment. Obes Res. 1995;3:241-248. This study identified facilitators and obstacles to maintenance of weight loss following a very-lowcalorie-diet and behavior modification program. A survey was mailed to a random sample of 178 program completers and received a 61% response rate; the most frequent follow-up period was more than 2 years. Twenty-nine percent reported weighing the same (within 10 lbs) or less than the end of their participation in the treatment program (maintainers), while 71% reported their present weight was a mean of 65% higher than their initial weight loss (regainers). Maintainers were significantly more likely to report engaging in regular aerobic exercise, attending a maintenance support group, and confidence in their ability to manage their weight in the future, while regainers were more likely to report stress and motivation as frequent weight management obstacles. Respondents consistently identified the need for lowlno cost ongoing support. Maintainers and relapsers reported similar challenges in managing their weight, yet with different results, suggesting the need to identify subgroups for which different posttreatment support options could be applied.
Key words: maintenance of weight loss, obesity treatment Submitted for publication April 11. 1994. Accepted for publication in final formNovember 21.1994. From the *Division of Behavioral Medicine, The Miriam Hospital, Providence, RI, the tDepartment of Psychiatry and Human Behavior, Brown University School of Medicine, the $Department of Psychology, University of Rhode Island, Kingston, RI. and the $Department of Medicine, Brown University School of Medicine. Reprint requests to Dr.DePue. Division of Behavioral Medicine, RISE Bldg.. The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906. Copyright 81995 NAASO.
Introduction Recidivism following weight loss is a serious problem for all obesity treatment approaches and the verylow-calorie-diet (VLCD) approach has received particular scrutiny in this regard (5). However, compared to other approaches, a VLCD offers advantages, including enhanced adherence, greater weight losses, and improved medical status (37). These advantages are especially important for the severely obese and those with chronic illnesses who face serious health risks as a function of their obesity. Researchers and clinicians, therefore, are faced with an important challenge to extend these advantages by improving long-term weight maintenance following VLCD treatment. Most research about weight maintenance has fDcused on use of behavior therapy with a balanceddeficit diet. Researchers have reported that familybased approaches (36), enrollment in a structured professionally led maintenance program (21), utilization of cognitive and behavioral coping responses (6), social support (21). participation in a supervised exercise program (35), and keeping food records (7) as well as combinations of these approaches (20,21,23) all improve weight maintenance. Kayman and colleagues (12) surveyed individuals who lost weight outside of formal weight loss programs. They compared women who maintained their weight loss with those who regained their weight, with those who always remained at the same non-obese weight (controls). They found that most maintainers and controls exercised regularly, used available social support, were conscious of the quantity and type of food they consumed, and confronted problems directly. In contrast, few regainers exercised, most ate unconsciously in response to emotions, few used available social support, and few confronted problems directly. Westover and Lanyon (34), in a review of the empirical literature on behavioral treatment of obesity, identified three general categories for the variables related to maintenance success: 1) adherence to treatment and use of behavioral skills, 2) post treatment vigilance OBESITY RESEARCH Vol. 3 No. 3 May 1995 241
Post Treatment Weight Maintenance Needs, DePue et al.
with weight fluctuations and continued use of skills learned in treatment, and 3) intraindividual physical and emotional factors (gender, % body fat, age of onset, stress, confidence). Additionally, a recent review of strategies for improving maintenance of weight loss by Perri and colleagues (22) underscores a robust association between the duration of therapist contact and continued weight loss progress. These researchers advocate a continuous care model of obesity management. Unfortunately, little is known about participants in VLCD programs and the factors associated with their long-term success (1). VLCD’s in conjunction with behavior therapy have been used for the severely obese to produce significant weight losses and provide skills to facilitate weight maintenance. This combined approach has been shown to be superior to VLCD alone and behavior therapy alone in producing significantly greater end-of-treatment weight losses (29,30,32,37) and maintenance of weight loss at l-year and 3-year follow-up (30,32). However, at the 5-year follow-up, there were no differences between VLCD alone, behavior therapy alone, and the combined approach, with an average of 117% weight regain for the combined treatment condition (29). Much variability exists in maintenance rates across other studies including both research and nonresearch settings (9-11,13). Comparisons across studies are difficult due to differing definitions of when “treatment” ended and when follow-up began. “Treatment” sometimes referred only to fasting, whereas other programs included reintroduction of food anb’a stabilizationperiod with food calories. Program components also varied (e.g., inclusion of exercise and/or nutrition instruction), as did professional qualifications of therapists (M.D., Ph.D., dietician, technician). Only two published reports have identified post treatment features that have been shown to facilitate maintenance with this population: receiving additional treatment (30) and participating in a supervised exercise program (17). Therefore, the purpose of this exploratory study was to examine which factors were facilitators or obstacles to maintenance following a hospital-based fee-for-service VLCD and behavior therapy program for individuals who were at least 30% overweight. Such a study of clinical participants is important since this population comprises a large proportion of the individuals seeking obesity treatment. Further, this population may differ from typical research populations, as research often excludes individuals with co-morbid medical or psychiatric diagnoses (21). Subjects and Methods A sample of 178 subjects was drawn, using a random number table, from individuals who completed at least 20 weeks of a 26-week treatment program between 242 OBESITY RESEARCH Vol. 3 No. 3 May 1995
March 1988 and August 1990. Since the follow-up survey was conducted between May and September 1991, the time period since the end of treatment ranged from 10 to 38 months. All subjects were evaluated before the treatment program to determine appropriateness for VLCD treatment, according to standard criteria (31,33). Subjects had to be a minimum of 30% over ideal weight. Contraindications included a recent myocardial infarction, history of cerebrovascular or renal disease, type I diabetes, cancer, pregnancy, and significant psychiatric illness. Treatment All subjects participated in the standard 26-week OETIFAST@Core treatment program (16), including one week of reduced energy, 12 weeks of a proteinsparing modified fast (OPTFAST@70 or OFTIFAST@ 800) providing 1758 kJ (420kcal) or 3349 kJ (800 kcal) energy/day, followed by six weeks of gradual refeeding, and seven weeks of “stabilization” with 5023 kJ (12001500 kcal) energy/day for women and 6279 kJ (15001800 kcal) energy/day for men. Subjects received ongoing medical supervision, behavior therapy, nutrition education, and a supervised on-site exercise program. Weekly group sessions were held with 10 to 15 subjects (closed-enrollment) with a clinical social worker or Ph.D. level psychologist as group leader. The program was designed to facilitate maintenance, incorporating behavioral techniques such as record keeping and identification of cues to overeating, along with stress management, assertiveness training, and relapse prevention training (15.16). Following the treatment program, individuals could enroll in a 6-month structured Maintenance Program. They could subsequently reenroll in the Maintenance Program for additional 6month cycles. The structured 6-month maintenance program consisted of 12 biweekly 1-hour group sessions led by a Ph.D level psychologist. Eight to 15 subjects participated in each group. Each group session consisted of weigh-in, a presentation, followed by group support and problem solving. Eight of the presentations focused on behavioral strategies for relapse prevention and four presentations (co-led by a registered dietitian) focused on nutrition education, including the role of dietary fat, label reading, and guidelines for holidays and restaurants. Subjects could also participate in a supervised exercise program prior to each group meeting or on “off’ weeks from group. Subjects were asked to continue completing food records and participating in exercise. Survey Method An important potential barrier to participation in follow-up from a weight loss program is embarrassment
Post Treatment Weight Maintenance Needs, DePue et al.
if the subject had regained weight. Such a barrier could produce a sample biased in favor of the successful maintainers. To address this barrier, we utilized a mailed questionnaire which would be returned anonymously. Included with the four-page questionnaire was a small thank-you gift of low-calorie recipes and a return postcard. Respondents were asked to mail the postcard separately at the same time as they returned their completed questionnaire. The postcard had an identifier number to signal the study team that further reminders would not be necessary, while preserving the respondent’s anonymity on the questionnaire. This technique is common in survey research with anonymous questionnaires and usually the number of postcards and questionnaires received are very similar (4). Three additional mailings plus a phone call were used as reminders to individuals who did not return their identifier postcards. The selfreported weight changes since the end of treatment were obtained primarily to categorize individuals for purposes of a needs assessment, to thus compare weight maintainers and relapsers, and to explore issues which may be a facilitator or obstacle to weight management. This study was approved by the hospital’s Clinical Research Review Board. Survey Topics Questions were developed by the study team to explore issues which were facilitators or obstacles to respondents’ weight management since the end of treatment. Demographic questions were limited to age and gender, and questions were carefully worded so that the respondent would feel hismer identity could not be discerned (for example, a set of categorical responses were offered for the range of months since end of treatment, rather than asking respondents to identify the exact number of months). A variety of potential facilitators to weight management were listed and respondents were asked to rate each on a four-point scale, from “not helpful” to “extremely helpful” (e.g., regular weigh-ins, recording calories/food groups, satisfactiodpride in appearance, self talk/self reinforcement, attending the hospital’s maintenance program, attending other weight loss programs, regular exercise, making low-cal low-fat food choices, family/friend support, informal network of program grads, and managing food “triggers”). Potential obstacles were also rated in the same way, from “never” to “frequently an obstacle” (e.g., personal or family stress, busy schedulehot enough time to plan, inappropriate food offers from others, family food preferences or demands, too much unstructured time, eating in restaurants, travel for business or pleasure, social gatherings/food available, controlling portion size with special foods, and low motivation). There was also space
provided to write in and rate additional facilitators or obstacles which may not have been listed. Other survey questions asked respondents to endorse suggestions from a list of program improvement ideas andor to write in further ideas (“Looking back from your current perspective, what suggestions would you offer to improve the Optifast [core, maintenance] program. Please check any items you would endorse and/or list other ideas.”) Since this was an exploratory study, we were interested in consumer input to expand on our own ideas. The suggestions proposed for treatment improvement were: more practice with behavioral skills, extend program until goal weight is reached, spouse/family involvement, and more nutrition education. The suggested ideas for maintenance program improvement included utilizing a buddy system, opportunity for social gatherings, cooking classes, restaurant field trip, opportunity for family involvement, newsletter mailed to home, lower cost or no cost options for weight maintenance support, peer led support groups. A final open-ended question asked respondents, “If you could design the perfect maintenance program for you, what would it be?’ Data Analyses Respondents were categorized into two groups: 1) maintainers, those who reported that their present weight was the same (within 10 lbs) or less than at the end of their participation in the treatment program, and 2) regainers, those who reported their present weight was 10 lbs or more than at the end of their participation in the treatment program. Maintenance within 3 kg (6.6 lbs) has been used by others for a similar population (28). We chose maintenance within 10 lbs. for ease of recognition in the survey format. Responses were then compared between these groups with t-tests for continuous variables and with chi-square analysis for categorical variables. SPSS-PC (26) was used for data analyses. Open-ended questions were coded according to common themes and the frequencies for each of these themes were included with other data. Because this was an exploratory study, we set a .05 level for significance, in spite of multiple comparisons and risk of type I error. Hypotheses thus generated could be further studied with experimental designs. Program improvement ideas were not compared by groups.
Results Survey Responses Sociodernographiccharacteristics. Sixty-one percent of the survey sample responded to the mailed questionnaire. The most frequent follow-up period (by 45% of respondents) was more than 2 years from the end of the treatment program. Twenty-nine percent reported OBESITY RESEARCH Vol. 3 No. 3 May 1995 243
Post Treatment Weight Maintenance Needs, DePue et al. rather than their end of treatment weight. Table 1. Characteristics of survey respondents versus nonrespondents* Characteristics % Female Mean age % Married % Employed Educational level % high school (112yrs) % some college % college graduate (116Yrs) Mean Weight Loss (end of 26 week treatment program) % Attended hospital maintenance program
Respondents (N=101)
Nonrespondents (N=77)
75 43 76 85
71 39** 65 75
18 23
27 39
59
34**
27.4kg
27.3 kg
44%
31%
*Information taken from medical charts of respondents who sent in postcard identifiers, and nonrespondents who did not send in postcard.
**P
