From efficacy to effectiveness: lessons learned from the Practice-Based Opportunities for Weight Reduction (POWER) trial.

Abstract

Despite the encouraging results of behavioral weight-loss interventions in effi cacy trials, primary care providers (PCPs) have expressed a lack of confidence that proven weight management models can be implemented in a primary care setting [1]. The Practice-Based Opportunities for Weight Reduction (POWER) trial conducted at Johns Hopkins University (MD, USA) compared the effectiveness of two behavioral weight-loss programs to a self-directed control group over 24 months among obese adults with at least one cardiovascular disease risk factor. In contrast to traditional efficacy studies that often enrolled convenience popula tions, POWER enrolled obese patients from primary care clinics and delivered interventions that could potentially be integrated into routine medical care. As a comparative effectiveness trial, our findings should be directly applicable to rou tine medical care and should inform patients, healthcare providers and delivery systems of effective treatment options [2]. This article highlights lessons learned from the design and implementation of the POWER trial. Details of the study design have been published [3,4]. Participants were obese patients from one of six participating primary care clinics, who had at least one cardiovascular risk factor (hypertension, hypercholesterolemia, or diabetes), regular internet access and basic computer skills (i.e., the ability to enter data into a website and send/receive email). Participants were randomized to one of three groups: control condition, remote intervention and in-person intervention. The primary outcome was weight loss at 24 months after randomization. The two behavioral interventions were based on previous trials conducted by the Hopkins investigative team that demonstrated the efficacy of lifestyle interventions in achieving and maintaining weight loss and improving cardiovascular disease risk factors [5–8]. The group receiving in-person support was offered group sessions, individual sessions (telephonic and in-person) and web support. The group receiving remote support was provided telephonic sessions and web support with no face-to-face contact. These active intervention groups were compared with the self-directed control group. A summary of the intervention recommendations and contact schedule have been published [3,4]. PCPs provided general encouragement for intervention participation and reviewed a one-page report of the participant’s progress at regularly scheduled clinic visits for those in the active interventions. The main results have been published and a brief review follows [4]. Of the 415 randomized participants, 64% were women and 41% were African–American; mean (standard deviation) age was 54 (10.2) years, and mean (standard deviation) BMI was 36.6 (5.4) kg/m 2 . The median number of completed coaching sessions in the remote support arm was 14 during the first 6 months (15 sessions were offered), 1