Abstract
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. To evaluate the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System. 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. 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. 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. 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). 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. ClinicalTrials.gov Identifier: NCT02054624.
Highlights
The burden of obesity in the US disproportionately affects rural communities
Mean weight regains at follow-up were 2.3 (95% credible interval [credible intervals (CrIs)], 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
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%])
Summary
The burden of obesity in the US disproportionately affects rural communities. Compared with urban and suburban locales, rural areas have a greater prevalence of obesity[1,2] and higher rates of obesity-related morbidity and mortality.[3,4] Rural communities have less access to preventive health care services,[4,5,6] including comprehensive lifestyle treatment for obesity—the criterion standard recommended by the US Preventive Services Task Force[7] and multiple scientific societies.[8]. Comprehensive lifestyle interventions can produce initial body weight reductions of 5% to 10%,7-11 a magnitude of weight loss that can yield clinically significant reductions in hypertension and hyperlipidemia and prevent the onset of type 2 diabetes.[13] after treatment ends, participants typically begin to regain weight—often regaining one-third to one-half of initial weight losses within 1 year.[8,11,14] Supplementing initial treatment with extended care programs delivered via face-to-face sessions can improve the maintenance of weight loss.[15,16,17,18] in rural communities, the long distances that participants must travel to attend face-to-face sessions constitutes a major barrier to implementation.[5] The Treatment of Obesity in Underserved Rural Settings trial[19,20] demonstrated that providing extended care via individual telephone counseling improved the maintenance of weight loss, comparable with face-to-face sessions (and at a lower cost), compared with an education control. That study provided participants with 2 free meal-replacements per day during initial treatment While such an approach may increase initial weight loss, it complicates the interpretation of the effects of extended care interventions, which began at the same time that meal replacements ended. No trial has examined the effectiveness of group-based telephone counseling as an extended-care intervention in rural areas absent the use of study-provided meal replacements
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