1. Summarizing The Weight Management Wisdom: What Works in Weight Management? Phillip J. Brantley, PhD Pennington Biomedical Research Center

2. A Typical Pattern of Weight Loss & Regain in Behavioral Interventions Long-term outcomes for behavioral weight loss treatment (Kramer et al., 1989)

3. Review of Behavioral Weight Loss Treatment (Perri & Corsica, 2002) Reviewed nine studies with follow-ups of two years or more (2-12 years) Reviewed nine studies with follow-ups of two years or more (2-12 years) Initial weight loss across studies ranged from 4.5 to 14.3 kg (M=8.3 kg) Initial weight loss across studies ranged from 4.5 to 14.3 kg (M=8.3 kg) Every study met the IOM criterion for maintenance at one year (>5% reduction) Every study met the IOM criterion for maintenance at one year (>5% reduction) Net loss across studies at final follow-up averaged 3 kg with only 2 of 9 meeting IOM Criterion at final follow-up Net loss across studies at final follow-up averaged 3 kg with only 2 of 9 meeting IOM Criterion at final follow-up

4. Weight Loss Maintenance Trial A multicenter, randomized clinical trial to determine the effectiveness of two innovative behavioral interventions, compared to an advice only control group in maintaining weight loss

5. WLM: Sites Clinical Sites Pennington Biomedical Research Center Duke University Medical Center Johns Hopkins School of Medicine Kaiser Center for Health Research Coordinating Center Kaiser Center for Health Research Project Office NHLBI Prevention Scientific Research Group

6. Reasons for Weight Regain Loss of motivation Loss of motivation Life stressors Life stressors Hunger/cravings Hunger/cravings Obesogenic environment Obesogenic environment Obesity is a chronic, possibly lifelong problem Obesity is a chronic, possibly lifelong problem

7. Factors Associated with Weight Maintenance Extended Treatment Extended Treatment Treatment Intensity Treatment Intensity Continued Contact Continued Contact Level of Physical Activity Level of Physical Activity Motivational Enhancement Motivational Enhancement Maintenance Specific Skills Maintenance Specific Skills Other Other

8. Extended Treatment Perri et al (1989) compared a standard 20 week program with an extended 40 week program. Clients in the extended treatment increased their weight losses by 35% during weeks 20-40. Follow-up data showed that after the extended treatment was concluded, clients reduced their adherence and began to regain weight. (Perri, Nezu, Patti, & McCann, 1989)

9. Review of Extended Behavioral Treatment (Perri & Corsica, 2002) Reviewed 13 studies that extended group treatment more than 6 months using weekly or biweekly sessions (35-65 sessions over 40-78 weeks Reviewed 13 studies that extended group treatment more than 6 months using weekly or biweekly sessions (35-65 sessions over 40-78 weeks Extended Treatment groups averaged maintaining 96 % of weight loss compared to 66% in controls Extended Treatment groups averaged maintaining 96 % of weight loss compared to 66% in controls

10. Major Problem with with Extended Treatment: Low Adherence Attendance for 1 st six months was 65%, for next 12 months it averaged 25% Attendance for 1 st six months was 65%, for next 12 months it averaged 25% Jeffery et al (1993) PREMIER similar rates PREMIER similar rates

11. Factors Associated with Weight Maintenance Extended Treatment Extended Treatment Treatment Intensity Treatment Intensity Continued Contact Continued Contact Level of Physical Activity Level of Physical Activity Motivational Enhancement Motivational Enhancement Maintenance Specific Skills Maintenance Specific Skills Other Other

12. Treatment Intensity

13. “Kicking it up a notch” Structured meal plans and portion controlled diets early on Structured meal plans and portion controlled diets early on Home based or supervised exercise Home based or supervised exercise Motivational strategies,e.g., recruit with friends, group competition Motivational strategies,e.g., recruit with friends, group competition

14. Factors Associated with Weight Maintenance Extended Treatment Extended Treatment Treatment Intensity Treatment Intensity Continued Contact Continued Contact Level of Physical Activity Level of Physical Activity Motivational Enhancement Motivational Enhancement Maintenance Specific Skills Maintenance Specific Skills Other Other

15. Telephone Prompts (Wing et al, 1996) Weekly telephone prompts used to promote self-monitoring of body weight and food intake over a 12 month post- treatment period. Contacts were made by non- interventionists who did not offer counseling or guidance. Although telephone prompts were associated with less weight regain (r=-.52), they did not enhance maintenance of weight loss compared to no-contact control condition.

16. Telephone and Mail Contacts by Interventionists (Perri et al, 1984) Most telephone and mail contacts were made by the interventionist who conducted the initial weight loss intervention Most telephone and mail contacts were made by the interventionist who conducted the initial weight loss intervention Group who received post treatment contacts maintained greater weight loss Group who received post treatment contacts maintained greater weight loss

17. Internet Technology to Promote Weight Maintenance Internet programs using email and Internet Web sites have been shown to improve diabetes management, promote physical activity and improve quality of life in patients with HIV/AIDS Studies look promising for weight maintenance (e.g., Harvey-Berino et al, 2002;2004; Tate 2006; WLM Protocol) Only people who already use internet will participant…will it maintain weight for extended time period ?

18. Factors Associated with Weight Maintenance Extended Treatment Extended Treatment Treatment Intensity Treatment Intensity Continued Contact Continued Contact Level of Physical Activity Level of Physical Activity Motivational Enhancement Motivational Enhancement Maintenance Specific Skills Maintenance Specific Skills Other Other

19. Physical Activity & Weight Loss Even though physical activity is NOT the most efficient method of LOSING weight, it appears to be CRUCIAL to maintaining weight loss. It may be more than calories burned … exercise may enhance mood or motivation for caloric control ? It may be more than calories burned … exercise may enhance mood or motivation for caloric control ?

20. Factors Associated with Weight Maintenance Extended Treatment Extended Treatment Treatment Intensity Treatment Intensity Continued Contact Continued Contact Level of Physical Activity Level of Physical Activity Motivational Enhancement Motivational Enhancement Maintenance Specific Skills Maintenance Specific Skills Other Other

21. Motivational Enhancement Methods Financial Incentives Financial Incentives Social Support Social Support Motivational Interviewing Motivational Interviewing

22. Financial Incentives Jeffery et al, 1993 Paid participants $25 per week over an 18 month period to loss and maintain weight…did not improve Jeffery et al, 1993 Paid participants $25 per week over an 18 month period to loss and maintain weight…did not improve Kramer et al, 1986 Collected $100 from participants at start of weight loss…at beginning of maintenance either gave it back, paid it contingent on attendance or paid it contingent on weight maintenance… no difference Kramer et al, 1986 Collected $100 from participants at start of weight loss…at beginning of maintenance either gave it back, paid it contingent on attendance or paid it contingent on weight maintenance… no difference

23. Social Support Modest support for including spouses or significant others Modest support for including spouses or significant others Support triggered by financial incentives for group weight loss is promising (Kramer et al, 1986: Perri et al, 1988) Support triggered by financial incentives for group weight loss is promising (Kramer et al, 1986: Perri et al, 1988) Also promising is allowing groups of friends to participate together in weight loss (Wing and Jeffery, 1999) Also promising is allowing groups of friends to participate together in weight loss (Wing and Jeffery, 1999)

24. Motivational Interviewing Interaction style: interact with participants based on their level of motivation (“stage of change”) Elicit change statements and realistic plans…Build confidence…avoid lecturing Impacts treatment outcome by promoting better adherence (better attendance, more participation) Impacts treatment outcome by promoting better adherence (better attendance, more participation) Zweben & Zuckoff in Miller and Rollnick, 2002

25. Factors Associated with Weight Maintenance Extended Treatment Extended Treatment Treatment Intensity Treatment Intensity Continued Contact Continued Contact Level of Physical Activity Level of Physical Activity Motivational Enhancement Motivational Enhancement Maintenance Specific Skills Maintenance Specific Skills Other Other

26. Maintenance Specific Skills “Strategies that are effective for maintaining an energy deficit in a period of weight loss may be different than those involved in maintaining a stable energy balance around a lower weight” “Strategies that are effective for maintaining an energy deficit in a period of weight loss may be different than those involved in maintaining a stable energy balance around a lower weight” Jeffery et al, 2000

27. Relapse Prevention Training Teaches people to avoid or cope with slips and relapses Teaches people to avoid or cope with slips and relapses Slips lead to negative psychological reactions that precipitate a return to pretreatment patterns Slips lead to negative psychological reactions that precipitate a return to pretreatment patterns RPT in initial treatment phase isn’t very effective for maintenance RPT in initial treatment phase isn’t very effective for maintenance Appears more effective during maintenance phase of Tx Appears more effective during maintenance phase of Tx

28. Factors Associated with Weight Maintenance Extended Treatment Extended Treatment Treatment Intensity Treatment Intensity Continued Contact Continued Contact Level of Physical Activity Level of Physical Activity Motivational Enhancement Motivational Enhancement Maintenance Specific Skills Maintenance Specific Skills Other Maintenance Tools Other Maintenance Tools

29. Problem Solving Systematic method for coping with barriers or problems Systematic method for coping with barriers or problems Uses: Problem Identification, Generation of Alternatives, Selection of Best Solution, Implementation, Evaluation Uses: Problem Identification, Generation of Alternatives, Selection of Best Solution, Implementation, Evaluation Leader can do it or facilitate it Leader can do it or facilitate it Successful use in weight maintenance by Perri et al Successful use in weight maintenance by Perri et al

30. Self-Monitoring Food and activity monitoring is one of best predictors of success in weight loss….unclear of its role in maintenance Food and activity monitoring is one of best predictors of success in weight loss….unclear of its role in maintenance Nearly all extended treatment studies promote recording of food intake and weight Nearly all extended treatment studies promote recording of food intake and weight National Weight Control Registry…weigh at least weekly…attempt to eat reduced fat and calories National Weight Control Registry…weigh at least weekly…attempt to eat reduced fat and calories

31. What does not work by alone? Individual monetary incentives Individual monetary incentives RPT without contact RPT without contact Telephone prompts by non- interventionists Telephone prompts by non- interventionists Personal trainers Personal trainers Frequent group meetings Frequent group meetings Supervised group exercise Supervised group exercise Reliance on meal replacements Reliance on meal replacements

32. What works? Multi-component Program Multi-component Program Continued contact providing accountability and motivationContinued contact providing accountability and motivation Physical activity promotionPhysical activity promotion RPT by interventionistRPT by interventionist Problem solvingProblem solving Weekly weighingWeekly weighing Reduced calorie and fat dietReduced calorie and fat diet

33. Intervention Components Intervention Components Self- Monitoring Food & Fitness diaries, reports at monthly contacts Web or IVR phone entry of F & F diary, at least weekly Feedback Reports at FTF Visits, MI and support at all contacts Automated responses and MI messages after data entry Problem solving Tailored responses to pxs ID’d at monthly contacts Tailored responses to pxs ID’d from automated inquires Relapse Prevention Skills provided at monthly contacts, particularly FTF visits Skills provided based on self-monitoring data and automated inquires Social Support Phone and FTF visits Moderated bulletin board Diet and PA Education Available at each contact Option on the Web site PCIT