.ki&~irr
Brha~iors. Vol.
Copyright 5
1992 Pergamon
Press Ltd.
2.5 YE_$RS FOLLO\V-UP OF FREIGHT AND BODY MASS INDEX VALUES IN THE WEIGHT CONTROL FOR LIFE! PROGRAikI: A DESCRIPTIVE ANALYSIS R. G. NUNN, K. S. NEWTON. and P. FAUCHER The Dannis
Group.
San Diego. CA
Abstract - This descriptive study monitored weight. Body Mass Index. and percent excess weight changes in 60 clients. (4-I women. 16 men) at about I year and 2.5 years following participation in the Weight Control for Life! program. The program integrates the habit reversal treatment model with contingency management and operant reinforcement principles: nutrition education: physical activit): stress management: cognitive-restructuring: relapse prevention: social support: intensive. on-going maintenance: self-monitoring: and the use of a medically supervised very-low-calorie diet or low-calorie-diet. Clients’ pretreatment and posttreatment weights averaged 104.28 kg (229.42 lb) and 79.89 kg (175.76 lb). respectiveI>. representing a 689io reduction in excess body weight at the end of the weight loss phase of the program. Mean weight loss at about I year and 2.5 years post weight loss was 19.X kg (42.42 lb) and 13.09 kg (28.80 lb). indicating subjects maintained 75% and 52% of their \\eight losses at these two time periods. Men lost more weight and maintained better losses than women. Overall. there was a 4 1% reduction in excess body weight at the end of 2.5 years.
Obesity is a seriously escalating health problem. Various treatments for obesity are available: however. behavioral approaches, independently or in combination with verylolv-calorie-diets (VLCDs). appear more effective than traditional methods (Brownell, Marlatt. Lichtenstein, & Wilson. 1986: Wadden & Stunkard. 1986: Wadden, Stunkard. & Liebschutz. 1988: Wadden. Sternberg. Letizia. Stunkard. & Foster. 1989). Hotvever. no single method has been effective for long term maintenance (Kayman, Bruvold, & Stern. 1990: Wadden et al., 1988). Fore)z and Goodrick ( I99 1) concluded that. “After decades ofresearch. effective and long-lasting treatments have not been found” (p. 292). One promising behavioral model that incorporates several relapse prevention strategies has been the habit reversal approach developed by Azrin and Nunn (1973. 1974. 1977). The distinctive features of the habit reversal treatment include:
1. .-i~~mw~~s tmir~ing for habit-prone situations. 3 .\/otirntion enlmncemmt to identify annoyances/benefits to increase motivation _. and commitment to change. 5. Cmqwtirlg I-cspor~w.~traini,?g to practice functional. alternative behaviors. -I. Rchwtior~ truiuiug to handle stressful and emotional situations. 5. B&~~ioral wl7cami and irmgcvy‘ training to rehearse control methods in habit prone situations. 6. Hdir cwwctiot? rrnripvcwv~tiontmining to practice competing behaviors Lvhenever the habit occurs or is likely to occur. Requests for reprints should be sent to R. G. Nunn. I I I63 Collegio Dribe. San Diego. CA 92 121. Gratitude is c\prrssed to the statTat Smith-Glknn Callo*a! Clinic. Springtield. MO. Bethesda Healthcare. Cincinnati. OH. Burlington Clinic. Burlington. \+‘I. and BroiLne-McHardy Xledical Group. Metairie. L.4. for their assistance in conducting the program and compiling the data at their sites: to Richard Garfsin and \luhrsh hlalani for their statistical assistance: to .Alice Chaxez for her secretarial help and to the D\NNIS Group for pro, iding facilities and financial assistance. 579
580
R. G. SUNY et a1
7. Pllh/ic,-ni.Fpla!.~~here clients deliberately enter and practice their competing behaviors in habit-prone situations. 8. Social support training to teach friends and family positive ways to encourage and remind clients to control the habit. 9. S~+monitoring and recording of urges and actual occurrences to further increase awareness and motivation to change. The Weight Control for Life! (WCFL!) program is a comprehensive, lifestyle education approach that integrates the conceptual model of the habit reversal treatment and recommendations by Brownell et al. (1986) for nutrition education. physical activity. stress management. cognitive restructuring, relapse prevention, social support, and an intensive maintenance program. A medically supervised VLCD or low-calorie-diet (LCD) and calorie/portion controlled packaged entrees also are incorporated as a part of the weight loss protocol. PURPOSE
OF
THE
STUD)’
This study reports changes in weight. percent excess weight. and body mass index (BIMI) for 60 randomly selected men and women at the end of the weight loss phase, and at about I year and 2.5 years post weight loss. Only a few studies have reported weight changes of clients 2 years or more following weight loss (Wadden et al 1988: Wadden et al., 1989: Lavep et al., 1989). This study also reports the percentage of participants maintaining varying degrees of weight loss. Blackburn and Kanders (1987) suggest that modest decreases ( lo- 15?/,)in weight reduce risk of medical illness and are better criteria ofweight loss success than focusing exclusively on the attainment of ideal body weight. hl E T H 0 D
Sl1h;rct.s
Sixty clients (44 vvomen. 16 men) were randomly selected from four sites (1 hospital, 3 multi-specialty medical groups). Most participants were white, middle class adults between the ages of 18 and 70 years-old.
Subjects were randomly selected from all participants attending at least one class in 1988. Table I shows the ses, pretreatment mean age, weight. BMI, and percent escess Table I. Clients’ characteristics at the beginning of the Weight Control for Life! program hlales & Females
Males
Females
Pretreatment
Mean
(SD)
Mean
(SD)
Mean
(SD)
Sumber Age Height (centimeters) Weight (kilograms) Percent over IBW Body Mass Index (Bhll)
60 50.04 168.20 104.28 51.77 38.05
_ (10.94) (9.66) (23.4 I) (33.20)b (8.19)
I6 48.44 180.86 I 19.06 45. I4 37.52
_ (8.83) (5.09) (20.89) (23.95) (6.09)
44 50.61 163.60 98.91 55.55 38.15
(I 1.56) (6.20) (21.91) (35.60) (8.82)
“hlean i: Standard Deviation. bBased on the midpoint for ideal weight for each height of 1983 llletropolitan Tables.
2.5 >ears
follo~~-up ofthe
WCFL!
581
program
weight based on the midpoint for ideal weight for each height ofthe 1983 Metropolitan Height and Weight Tables. Subjects entered the program because they sought professional assistance in Lveight-management. There were no statistical differences between subjects included in this study and the total population from which they were selected at each site.
The al’srage cost of the program was $3.500.00 with weekly payments made during the 25 to 30 week Lveight loss period. This fee included a complete medical history and physical exam, laboratory panel and resting electrocardiogram prior to beginning the program and bi-lveekly lab work, weekly classes and medical visits. dietary supplements and food. and all necessary materials and supplies. A mandatory maintenance fee of about $400.00 was also included in this fee and entitled the client to 21 bi-weekly, maintenance classes during the first year post weight loss. Clients could earn additional classes the second maintenance year by regular attendance during the first year. This intensity of medical screening. ongoing monitoring and supervision by physicians and staff trained in the safe and effective use of VLCDs has been recommended by N‘adden. Van Itallie. and Blackburn ( 1990). Progrrrm mw.w~xvUs
and screening
pretrt~cltmmt
Prior to starting the program, clients underwent tlvo separate evaluations to rule out contraindications for safe and active participation. The initial rwtiicul rduntion included a medical history and physical examination by a physician as described above. The second assessment ivas conducted by a counselor/instructor and consisted of iveight, BhII. and percent excess weight measurements. These physical measurements Lvere taken again as post-tests at the start of the maintenance phase.
The two follow-up weight and related measures were recorded at about 1 year and again at 2.5 years post weight loss. Eighty-two percent (47/57) of the final (2.5 years) follow-up measures were obtained in either face-to-face interviews or by abstracting clients’ medical charts. The remaining weights ( 18%) were self-reports obtained through telephone intervie\vs and have been corrected for underreporting bias (Tell. Jeffery. Kramer. & Snell. 1987) by adding 2.27 kg (4.99 lb) to their self-reported weights. Additionally, three clients re-enrolled in the weight loss phase of the program, and one client enrolled in a separate commercial weight loss program during the follow-up period. Data have been corrected by adding the additional weight losses to their maintenance/ follow-up weights (Wadden et al., 1988). All dependent measures reported in this stud) have been corrected to account for these two factors. U’EIGHT
COSTROL
FOR
LIFE!
PROGRAM
During the weight loss phase, participation included weekly physician visits. biweekly lab tests. and weekly 2 hour classes. The Lveight loss phase began with 3 weeks of awareness training and motivation enhancement via record keeping. lifestyle analysis. and benefit/annoyance review. Based upon analysis of their food and behavior records, clients identified and began developing and practicing their individualized competing behaviors nithin the frame-
582
R. G. NUNS
et al.
work ofthe habit reversal treatment plan. Classes covered a wide range ofsubject areas including problem-solving. effective communication. time management. cognitiverestructuring, managing self-talk. physical activity, and nutrition education. Clients began either a VLCD or LCD on week 4, contingent upon class attendance. application of the habit-reversal treatment model, and losing 2 lb during the first 3 weeks. The VLCD/LCD provided a daily intake ofbetween 420-I .OOOcalories fortified with IOO- 150% of the U.S. Recommended Dietary Allowances (RDAs) for all essential nutrients. Clients were routinely placed on the VLCD (420-520 calories) unless weight loss or pre-existing medical conditions indicated a higher caloric intake was more appropriate. Clients generally continued the VLCD/LCD protocol for I I!- 16 weeks.
At least 6 weeks prior to beginning the maintenance phase. clients entered the weight balance phase of the program. During this phase, they attended a series of nutrition, self-management. and relapse-prevention workshops. For at least the last 2 weeks ofthis phase. they followed their own individualized food plans and were required to demonstrate “balance competency” by maintaining their weights within 2 lb for 2 consecutive Lveeks.
Clients entered the maintenance phase contingent upon, (a) demonstrating mastery of nutrition, self-management. and relapse-prevention skills and. (b) maintaining their weights within 2 lb weight-ranges for 2 consecutive weeks. This phase included 24 biweekly classes for 1 year. The maintenance classes emphasized practical, adult education-type information and fine-tuning of personalized maintenance plans. RESULTS
Table 2 shows the mean weight, BMI, percent excess weight and related changes at different intervals in the program, and the number ofclients included in the analysis at each phase. Pretreatment and ending weight loss phase measures are included for all 60 clients. Eighty-five percent (5 l/60) completed at least 20 weeks ofthe weight loss classes. Ofthe remaining 15% (9/60), their last recorded dates ofattendance and weight measures have been entered as their ending values for purposes of analysis. Fifty-four (90%) clients’ weights and related measures tvere available at the end of the balance phase: 50 (85%) at the initial follow-up, and 57 (95%) were included in the final follow-up. Some values were missing for some ofthe clients at a particular phase in the program, but subsequent values were recorded at a later date. In this event, previous missing values were interpolated. Of the three clients not available for the final follow-up. one had moved and left no forwarding address, one refused to be interviewed or to report her weight. and one died between the first and second follow-up. Mean ending and follow-up weight. BMI, and percent excess lveight values were significantly different from pretreatment values (p < .OOI). The mean weight loss for men and Lvomen was 27.7 kg (60.94 lb) and 23.19 kg (5 1.02 lb), respectively. representing about one-quarter oftheir total body Lveights. On average, men and women spent about 33 weeks in the weight loss phase and lost 1.32 kg (2.90 lb) and 1.04 kg (2.29 lb) per week. respectively. At the I year follo\v-up, subjects maintained a weight loss of 19.28 kg (42.42 lb), representing a 64% reduction of their initial excess weight. The 7.j-year
2.5 )ears follow-up of the WCFL! program
583
Table 2. Clients’ changes and percentage change in weight (kg). BMI (kg/m2). and % over Ideal Body Weight (IBW’) from pretreatment. at the end of treatment and at about I year and 2.5 years post-treatment Males & Females Change from pretreatment to end of weight loss phase (week 25) Number Weight (kg) BMI % over IBW’ O/Oof excess weieht lost % change in weight. B>lI. % excess weight Weeks in weight loss phase Change from pretreatment to first followupat 1 year Number Weight (kg) BMI % over I BW % of excess weight lost % change in weight. BXII. ‘Yoexcess weight % ofweight loss maintained Change from pretreatment to second follow-up at 2.5 years Number Weight (kg) BMI % over IB\\ % of excess weight lost 96 change in weight. BhII. % excess weight % ofweight loss maintained
Mean 60” - 24.40 -8.91 -35.91 68% 24% 22.36
(SD)
(7.87) (2.85) (I 1.53P
(4.13)
Males Mean
[Mean 50 - 19.28 -7.07 -28.49 64% 19% 76%
(SD)
(8.87) (3.41) (13.46)
(.25)
Males 8i Females Mean 57 - 13.09’ -4.77’ - 19.19’ 41% 13% 52%
(SD)
I6 - 77.70 -8.76 -34.00 75% 249b ‘1.63
Males & Females
Females
(6.75) (2.1 I) (8.20)
(3.79)
Males AJean I4 -22.30 - 7.04 -29.43 64% 19% 80%
Mean 44 -23.19 -8.96 -36.61 66% 24% 22.63
(SD)
(7.9O)J (3.08) (12.4j)
(4.21)
Females (SD)
(8.43) (1’3::;;
(28)
Males
Mean 36 -18.13 - 7.08 -28.18 64% 19% 74%
(SD)
(8.77)“ (3.65) (14.38)
(.23)
Females
(SD)
Mean
(SD)
Mean
(SD)
(I 1.29) (4.14) (16.72)
- *$t29c -5.17’ -22.43’ 49% 16% 65%
(IO.44) (3.23) (12.63)
- :1339 - 4.44c - 18.14’ 39% 12% 48%
( 11.03)
(.53)
(.32)
(4.34) (17.73)
(.j8)
“n = 60 at pretreatment and at the end of the weight loss phase. bBased on the midpoint for ideal weight for each height of 1983 Metropolitan Tables. ‘Indicates weight. BXII & % over IBW changes are significantly different at p < ,001. d,‘Men and women different at p < .Ol and p < .05. respectively.
follow-up measures showed men and women had maintained an average weight loss of 18.29 kg (10.24 lb) and 11.39 kg (25.06 lb), respectively. Analysis of variance of weight. BMI, and percent excess weight showed that males lost more weight than did females in absolute terms F( I .j8) = 6.73. p < .O1 and maintained their weight losses better at the 1 year (r, < .OOI) and 2.Syear follow-up periods. F( 1.55) = 5.5 1. !I< .03. There were no statistical differences between men and women in their pretreatment and follow-up BMI and percent excess weight measures. The overall changes in weight. BMI, and percent excess weight values from pretreatment to the final follovv-up represent a 16% reduction for men and a 12% reduction for women. Table 3 shovvs the percentage of clients maintaining varying amounts of weight loss at the two follovv-up periods. Men and women each maintained at least 21% of their original weight losses; more than 70% of them maintained greater than 6 1% of their weight losses: and 36% of the men and 23% of the women maintained greater than 90% oftheir original weight losses at the end of 1 year. At the end of 2.5 years. approximately 70% of subjects maintained an average 52% of their weight losses. The ISyear followup shovvs that men did better than did women in maintaining weight losses. Five per-
584
R. G. NUNN et al
Table 3. Percentage of clients maintaining varying amounts of their weight loss at the end ofabout I year and 2.5 years post-treatment First follow-up at I year Percent of weight loss maintained Lost Additional Weight 9l-100% 8 I-90% 7 I-80% 6 l-70% 5 l-60% 4 I-50% 3 I-40% 2 l-30% I I-20% o- IO% Re-gained weight + some
Second follow-up at 2.5 years
Males Males Females Females Valid % (Cum %) Valid % (Cum %) Valid% (Cum 96) Valid % (Cum %) 7.1 28.5 21.4 7.1 7.1 14.3 7.1 7.1 -
(7.1) (35.7) (57. I) (64.3) (71.4) (85.7) (92.9) (100.0, -
13.5 8.10 18.9 16.2 13.5 10.8 13.5 2.7 2.7 -
(13.5) (21.6) (40.5) (56.8) (70.3) (81.1) (94.6) (97.3) (100.0) -
21.4 14.2 21.4 14.2 7.1 28.5 -
-
(21.4) (35.7) (50.0) (64.3) (71.1, (100.0) -
-
9.3 9.3 7.0 7.0 Il.6 4.6 18.6 4.7 14.0 9.4 4.7
(9.3) (18.6) (25.6) (32.6) (44.2) (48.8) (67.4) (72. I) (86.0) (95.3) (100.0)
cent of the women regained their original weight losses plus some, while about 9% lost additional weight beyond their initial losses at the end of the weight loss phase. DISCUSSION The results indicate the WCFL! program helps obese clients lose and maintain a clinically significant portion of their weight losses over time. The results are better than those seen in programs using primarily behavior therapy and compare favorably with programs that combine behavioral approaches with VLCDs in terms of initial weight loss (Wadden et al., 1988; Hovel1 et al., 1988). The clients appear to do better. however, in maintaining their losses at 2.5 years post weight loss than those in other published studies. The best results have shown that at 1 year about l/3 of the weight has been regained, at 3 years 74-85% has been regained (Wadden et al., 1988) and at 5 years almost all of the weight has been regained (Wadden et al., 1989). In the present study, men and women regained an average of 25% of their losses at 1 year and 48% at 2.5 years after treatment. Blackburn and Kanders ( 1987) have suggested that modest decreases in Lveight of IO15% reduce medical risk and are better criteria of success than focusing exclusively on the attainment of ideal body weight. In this study, all of the clients maintained at least 20% of their weight losses at the end of 1 year and more than 70% maintained at least this amount at the end of 2.5 years. The program is a developmental “package” approach that integrates numerous lifestyle and psychological methodologies: thus. it is not possible to assess the relative contributions of each component to the program’s overall success. Based upon published reports. more developmental studies are necessary before comparative. rigorously controlled. experimental studies are undertaken to isolate the most important components of the program. Although the results of this descriptive report provide reason for optimism. evaluation of its effectiveness must await controlled studies. including larger numbers of clients. Nevertheless. the program appears to be an effective, clinical treatment for moderately to morbidly obese adults.
7.5 qears follow-up ofthe WCFL! program
REFERENCES
Aztin. N. H.. & Sunn. R. G. (1973). Habit reversal: A method ofeliminating nervous habits and tics. B&vior Research and Therapy. Il,6
19-628.
Azrin. N. H., & Nunn, R. G. (1974). A rapid method of eliminating stuttering by a regulated breathing approach. Behavior Research and Therapy. 12. 279-286. Azrin. N. H.. & Nunn. R. G. (1977). Habit control in a day. New York: Simon R: Schuster. Blackburn. G.. & Kanders. B. (1987). Medical evaluation and treatment ofobese patientswith cardiovascular disease. .-lmerican Journal oj‘Cardiolog,v. 60, 55. Brownell. K. D.. Marlatt, G. A.. Lichtenstein. E.. & Wilson. G. T. (1986). Understanding and pre\enting relapse. .4merican Psyho[ogisr. 41. 765-782. Forebt. J. P. & Goodrick, G. K. (199 I). Factors common to successful therap! for the obese patient. .\/edrcine and Scirnce in Sports and E.uercise. 23( 3). 292-197.
Kaqman. S.. Bruvold. W., & Stern. J. S. (1990). Maintenance and relapse after weight loss in women: Behavioral aspects. .4merican Journal of Clinical tVlttrition. 52. 800-807. HovelI. M. F.. Koch. A.. Hofstetter, C. R., Sipon. C.. Faucher. P.. Dellinger. .A.. Brook. G.. Forsythe. A.. Bc Felitti, V. J.. (1988). Long-term weight loss maintenance: Assessment ofa behavioral and supplemental fasting regimen. .-Lmerican Journal ofPublic Healrh. 78(6). 663-666. LaveE. M. A.. Loewy, J. W.. Kapodia. A. S.. Nichaman. M. Z.. Fore)t. J. P.. & Gee. >l. G. ( 1989). Long. term follow-up of weight status of subjects in a behavioral weight control program. Jo~rrml q/‘~he .-lmrrican Dieleiic .-lssocialion. 89. I259- 1264. 1983 1Ietropolitan Height and Weight Tables. (1983). Statistics Bullrlin. 6-t. 2. Tell. G. S., Jeffen;. R. W.. Kramer. F. M.. & Snell. M. K. (1987). Can self-reported weight be used to evaluate long-term follow-up of a weight loss program? Journal qftlte.1r,lerisan Divleric .4sioc,lufion. 87. I 13% 1101. Wadden. T. A.. s( Stunkard, A. (1986). Controlled trial of very low calorie diet. behavior therapy. and their combination in the treatment of obesity. Journal qfComxlring & Clinical P.s~~cho/o~~51. 482-485. Wadden. T. A.. Stunkard. A. J.. & Liebschutz. J. (1988). Three-year follow-up ofthe treatment of obesity b> \ery low calorie diet, behavior therapy, and their combination. Juurmi ~fCon.s~ric~u~ & Clinrcai Ps!.chology. 56. 925-928.
Wadden. T. A.. Sternberg. J. A.. Letizia. K. A.. Stunkard. A. J.. & Foster. G. D. ( 1989). Treatment ofobesit! by very low calorie diet, behavior therapy. and their combination: a li\e-bear perspective. Irlrcvnari~vu~i Journal ql‘ODrsit!:
13(Z). 39-46.
Wadden. T. A.. Van Itallie, T. B.. & Blackburn. G. L. (1990). Responsible and irresponsible use of vet low calorie diets in the treatment of obesity. Journal q/‘1he.4mericun .Ifedical.4s.sociarrcv~. 163(,I). 83-85.
Brha~iors. Vol.
Copyright 5
1992 Pergamon
Press Ltd.
2.5 YE_$RS FOLLO\V-UP OF FREIGHT AND BODY MASS INDEX VALUES IN THE WEIGHT CONTROL FOR LIFE! PROGRAikI: A DESCRIPTIVE ANALYSIS R. G. NUNN, K. S. NEWTON. and P. FAUCHER The Dannis
Group.
San Diego. CA
Abstract - This descriptive study monitored weight. Body Mass Index. and percent excess weight changes in 60 clients. (4-I women. 16 men) at about I year and 2.5 years following participation in the Weight Control for Life! program. The program integrates the habit reversal treatment model with contingency management and operant reinforcement principles: nutrition education: physical activit): stress management: cognitive-restructuring: relapse prevention: social support: intensive. on-going maintenance: self-monitoring: and the use of a medically supervised very-low-calorie diet or low-calorie-diet. Clients’ pretreatment and posttreatment weights averaged 104.28 kg (229.42 lb) and 79.89 kg (175.76 lb). respectiveI>. representing a 689io reduction in excess body weight at the end of the weight loss phase of the program. Mean weight loss at about I year and 2.5 years post weight loss was 19.X kg (42.42 lb) and 13.09 kg (28.80 lb). indicating subjects maintained 75% and 52% of their \\eight losses at these two time periods. Men lost more weight and maintained better losses than women. Overall. there was a 4 1% reduction in excess body weight at the end of 2.5 years.
Obesity is a seriously escalating health problem. Various treatments for obesity are available: however. behavioral approaches, independently or in combination with verylolv-calorie-diets (VLCDs). appear more effective than traditional methods (Brownell, Marlatt. Lichtenstein, & Wilson. 1986: Wadden & Stunkard. 1986: Wadden, Stunkard. & Liebschutz. 1988: Wadden. Sternberg. Letizia. Stunkard. & Foster. 1989). Hotvever. no single method has been effective for long term maintenance (Kayman, Bruvold, & Stern. 1990: Wadden et al., 1988). Fore)z and Goodrick ( I99 1) concluded that. “After decades ofresearch. effective and long-lasting treatments have not been found” (p. 292). One promising behavioral model that incorporates several relapse prevention strategies has been the habit reversal approach developed by Azrin and Nunn (1973. 1974. 1977). The distinctive features of the habit reversal treatment include:
1. .-i~~mw~~s tmir~ing for habit-prone situations. 3 .\/otirntion enlmncemmt to identify annoyances/benefits to increase motivation _. and commitment to change. 5. Cmqwtirlg I-cspor~w.~traini,?g to practice functional. alternative behaviors. -I. Rchwtior~ truiuiug to handle stressful and emotional situations. 5. B&~~ioral wl7cami and irmgcvy‘ training to rehearse control methods in habit prone situations. 6. Hdir cwwctiot? rrnripvcwv~tiontmining to practice competing behaviors Lvhenever the habit occurs or is likely to occur. Requests for reprints should be sent to R. G. Nunn. I I I63 Collegio Dribe. San Diego. CA 92 121. Gratitude is c\prrssed to the statTat Smith-Glknn Callo*a! Clinic. Springtield. MO. Bethesda Healthcare. Cincinnati. OH. Burlington Clinic. Burlington. \+‘I. and BroiLne-McHardy Xledical Group. Metairie. L.4. for their assistance in conducting the program and compiling the data at their sites: to Richard Garfsin and \luhrsh hlalani for their statistical assistance: to .Alice Chaxez for her secretarial help and to the D\NNIS Group for pro, iding facilities and financial assistance. 579
580
R. G. SUNY et a1
7. Pllh/ic,-ni.Fpla!.~~here clients deliberately enter and practice their competing behaviors in habit-prone situations. 8. Social support training to teach friends and family positive ways to encourage and remind clients to control the habit. 9. S~+monitoring and recording of urges and actual occurrences to further increase awareness and motivation to change. The Weight Control for Life! (WCFL!) program is a comprehensive, lifestyle education approach that integrates the conceptual model of the habit reversal treatment and recommendations by Brownell et al. (1986) for nutrition education. physical activity. stress management. cognitive restructuring, relapse prevention, social support, and an intensive maintenance program. A medically supervised VLCD or low-calorie-diet (LCD) and calorie/portion controlled packaged entrees also are incorporated as a part of the weight loss protocol. PURPOSE
OF
THE
STUD)’
This study reports changes in weight. percent excess weight. and body mass index (BIMI) for 60 randomly selected men and women at the end of the weight loss phase, and at about I year and 2.5 years post weight loss. Only a few studies have reported weight changes of clients 2 years or more following weight loss (Wadden et al 1988: Wadden et al., 1989: Lavep et al., 1989). This study also reports the percentage of participants maintaining varying degrees of weight loss. Blackburn and Kanders (1987) suggest that modest decreases ( lo- 15?/,)in weight reduce risk of medical illness and are better criteria ofweight loss success than focusing exclusively on the attainment of ideal body weight. hl E T H 0 D
Sl1h;rct.s
Sixty clients (44 vvomen. 16 men) were randomly selected from four sites (1 hospital, 3 multi-specialty medical groups). Most participants were white, middle class adults between the ages of 18 and 70 years-old.
Subjects were randomly selected from all participants attending at least one class in 1988. Table I shows the ses, pretreatment mean age, weight. BMI, and percent escess Table I. Clients’ characteristics at the beginning of the Weight Control for Life! program hlales & Females
Males
Females
Pretreatment
Mean
(SD)
Mean
(SD)
Mean
(SD)
Sumber Age Height (centimeters) Weight (kilograms) Percent over IBW Body Mass Index (Bhll)
60 50.04 168.20 104.28 51.77 38.05
_ (10.94) (9.66) (23.4 I) (33.20)b (8.19)
I6 48.44 180.86 I 19.06 45. I4 37.52
_ (8.83) (5.09) (20.89) (23.95) (6.09)
44 50.61 163.60 98.91 55.55 38.15
(I 1.56) (6.20) (21.91) (35.60) (8.82)
“hlean i: Standard Deviation. bBased on the midpoint for ideal weight for each height of 1983 llletropolitan Tables.
2.5 >ears
follo~~-up ofthe
WCFL!
581
program
weight based on the midpoint for ideal weight for each height ofthe 1983 Metropolitan Height and Weight Tables. Subjects entered the program because they sought professional assistance in Lveight-management. There were no statistical differences between subjects included in this study and the total population from which they were selected at each site.
The al’srage cost of the program was $3.500.00 with weekly payments made during the 25 to 30 week Lveight loss period. This fee included a complete medical history and physical exam, laboratory panel and resting electrocardiogram prior to beginning the program and bi-lveekly lab work, weekly classes and medical visits. dietary supplements and food. and all necessary materials and supplies. A mandatory maintenance fee of about $400.00 was also included in this fee and entitled the client to 21 bi-weekly, maintenance classes during the first year post weight loss. Clients could earn additional classes the second maintenance year by regular attendance during the first year. This intensity of medical screening. ongoing monitoring and supervision by physicians and staff trained in the safe and effective use of VLCDs has been recommended by N‘adden. Van Itallie. and Blackburn ( 1990). Progrrrm mw.w~xvUs
and screening
pretrt~cltmmt
Prior to starting the program, clients underwent tlvo separate evaluations to rule out contraindications for safe and active participation. The initial rwtiicul rduntion included a medical history and physical examination by a physician as described above. The second assessment ivas conducted by a counselor/instructor and consisted of iveight, BhII. and percent excess weight measurements. These physical measurements Lvere taken again as post-tests at the start of the maintenance phase.
The two follow-up weight and related measures were recorded at about 1 year and again at 2.5 years post weight loss. Eighty-two percent (47/57) of the final (2.5 years) follow-up measures were obtained in either face-to-face interviews or by abstracting clients’ medical charts. The remaining weights ( 18%) were self-reports obtained through telephone intervie\vs and have been corrected for underreporting bias (Tell. Jeffery. Kramer. & Snell. 1987) by adding 2.27 kg (4.99 lb) to their self-reported weights. Additionally, three clients re-enrolled in the weight loss phase of the program, and one client enrolled in a separate commercial weight loss program during the follow-up period. Data have been corrected by adding the additional weight losses to their maintenance/ follow-up weights (Wadden et al., 1988). All dependent measures reported in this stud) have been corrected to account for these two factors. U’EIGHT
COSTROL
FOR
LIFE!
PROGRAM
During the weight loss phase, participation included weekly physician visits. biweekly lab tests. and weekly 2 hour classes. The Lveight loss phase began with 3 weeks of awareness training and motivation enhancement via record keeping. lifestyle analysis. and benefit/annoyance review. Based upon analysis of their food and behavior records, clients identified and began developing and practicing their individualized competing behaviors nithin the frame-
582
R. G. NUNS
et al.
work ofthe habit reversal treatment plan. Classes covered a wide range ofsubject areas including problem-solving. effective communication. time management. cognitiverestructuring, managing self-talk. physical activity, and nutrition education. Clients began either a VLCD or LCD on week 4, contingent upon class attendance. application of the habit-reversal treatment model, and losing 2 lb during the first 3 weeks. The VLCD/LCD provided a daily intake ofbetween 420-I .OOOcalories fortified with IOO- 150% of the U.S. Recommended Dietary Allowances (RDAs) for all essential nutrients. Clients were routinely placed on the VLCD (420-520 calories) unless weight loss or pre-existing medical conditions indicated a higher caloric intake was more appropriate. Clients generally continued the VLCD/LCD protocol for I I!- 16 weeks.
At least 6 weeks prior to beginning the maintenance phase. clients entered the weight balance phase of the program. During this phase, they attended a series of nutrition, self-management. and relapse-prevention workshops. For at least the last 2 weeks ofthis phase. they followed their own individualized food plans and were required to demonstrate “balance competency” by maintaining their weights within 2 lb for 2 consecutive Lveeks.
Clients entered the maintenance phase contingent upon, (a) demonstrating mastery of nutrition, self-management. and relapse-prevention skills and. (b) maintaining their weights within 2 lb weight-ranges for 2 consecutive weeks. This phase included 24 biweekly classes for 1 year. The maintenance classes emphasized practical, adult education-type information and fine-tuning of personalized maintenance plans. RESULTS
Table 2 shows the mean weight, BMI, percent excess weight and related changes at different intervals in the program, and the number ofclients included in the analysis at each phase. Pretreatment and ending weight loss phase measures are included for all 60 clients. Eighty-five percent (5 l/60) completed at least 20 weeks ofthe weight loss classes. Ofthe remaining 15% (9/60), their last recorded dates ofattendance and weight measures have been entered as their ending values for purposes of analysis. Fifty-four (90%) clients’ weights and related measures tvere available at the end of the balance phase: 50 (85%) at the initial follow-up, and 57 (95%) were included in the final follow-up. Some values were missing for some ofthe clients at a particular phase in the program, but subsequent values were recorded at a later date. In this event, previous missing values were interpolated. Of the three clients not available for the final follow-up. one had moved and left no forwarding address, one refused to be interviewed or to report her weight. and one died between the first and second follow-up. Mean ending and follow-up weight. BMI, and percent excess lveight values were significantly different from pretreatment values (p < .OOI). The mean weight loss for men and Lvomen was 27.7 kg (60.94 lb) and 23.19 kg (5 1.02 lb), respectively. representing about one-quarter oftheir total body Lveights. On average, men and women spent about 33 weeks in the weight loss phase and lost 1.32 kg (2.90 lb) and 1.04 kg (2.29 lb) per week. respectively. At the I year follo\v-up, subjects maintained a weight loss of 19.28 kg (42.42 lb), representing a 64% reduction of their initial excess weight. The 7.j-year
2.5 )ears follow-up of the WCFL! program
583
Table 2. Clients’ changes and percentage change in weight (kg). BMI (kg/m2). and % over Ideal Body Weight (IBW’) from pretreatment. at the end of treatment and at about I year and 2.5 years post-treatment Males & Females Change from pretreatment to end of weight loss phase (week 25) Number Weight (kg) BMI % over IBW’ O/Oof excess weieht lost % change in weight. B>lI. % excess weight Weeks in weight loss phase Change from pretreatment to first followupat 1 year Number Weight (kg) BMI % over I BW % of excess weight lost % change in weight. BXII. ‘Yoexcess weight % ofweight loss maintained Change from pretreatment to second follow-up at 2.5 years Number Weight (kg) BMI % over IB\\ % of excess weight lost 96 change in weight. BhII. % excess weight % ofweight loss maintained
Mean 60” - 24.40 -8.91 -35.91 68% 24% 22.36
(SD)
(7.87) (2.85) (I 1.53P
(4.13)
Males Mean
[Mean 50 - 19.28 -7.07 -28.49 64% 19% 76%
(SD)
(8.87) (3.41) (13.46)
(.25)
Males 8i Females Mean 57 - 13.09’ -4.77’ - 19.19’ 41% 13% 52%
(SD)
I6 - 77.70 -8.76 -34.00 75% 249b ‘1.63
Males & Females
Females
(6.75) (2.1 I) (8.20)
(3.79)
Males AJean I4 -22.30 - 7.04 -29.43 64% 19% 80%
Mean 44 -23.19 -8.96 -36.61 66% 24% 22.63
(SD)
(7.9O)J (3.08) (12.4j)
(4.21)
Females (SD)
(8.43) (1’3::;;
(28)
Males
Mean 36 -18.13 - 7.08 -28.18 64% 19% 74%
(SD)
(8.77)“ (3.65) (14.38)
(.23)
Females
(SD)
Mean
(SD)
Mean
(SD)
(I 1.29) (4.14) (16.72)
- *$t29c -5.17’ -22.43’ 49% 16% 65%
(IO.44) (3.23) (12.63)
- :1339 - 4.44c - 18.14’ 39% 12% 48%
( 11.03)
(.53)
(.32)
(4.34) (17.73)
(.j8)
“n = 60 at pretreatment and at the end of the weight loss phase. bBased on the midpoint for ideal weight for each height of 1983 Metropolitan Tables. ‘Indicates weight. BXII & % over IBW changes are significantly different at p < ,001. d,‘Men and women different at p < .Ol and p < .05. respectively.
follow-up measures showed men and women had maintained an average weight loss of 18.29 kg (10.24 lb) and 11.39 kg (25.06 lb), respectively. Analysis of variance of weight. BMI, and percent excess weight showed that males lost more weight than did females in absolute terms F( I .j8) = 6.73. p < .O1 and maintained their weight losses better at the 1 year (r, < .OOI) and 2.Syear follow-up periods. F( 1.55) = 5.5 1. !I< .03. There were no statistical differences between men and women in their pretreatment and follow-up BMI and percent excess weight measures. The overall changes in weight. BMI, and percent excess weight values from pretreatment to the final follovv-up represent a 16% reduction for men and a 12% reduction for women. Table 3 shovvs the percentage of clients maintaining varying amounts of weight loss at the two follovv-up periods. Men and women each maintained at least 21% of their original weight losses; more than 70% of them maintained greater than 6 1% of their weight losses: and 36% of the men and 23% of the women maintained greater than 90% oftheir original weight losses at the end of 1 year. At the end of 2.5 years. approximately 70% of subjects maintained an average 52% of their weight losses. The ISyear followup shovvs that men did better than did women in maintaining weight losses. Five per-
584
R. G. NUNN et al
Table 3. Percentage of clients maintaining varying amounts of their weight loss at the end ofabout I year and 2.5 years post-treatment First follow-up at I year Percent of weight loss maintained Lost Additional Weight 9l-100% 8 I-90% 7 I-80% 6 l-70% 5 l-60% 4 I-50% 3 I-40% 2 l-30% I I-20% o- IO% Re-gained weight + some
Second follow-up at 2.5 years
Males Males Females Females Valid % (Cum %) Valid % (Cum %) Valid% (Cum 96) Valid % (Cum %) 7.1 28.5 21.4 7.1 7.1 14.3 7.1 7.1 -
(7.1) (35.7) (57. I) (64.3) (71.4) (85.7) (92.9) (100.0, -
13.5 8.10 18.9 16.2 13.5 10.8 13.5 2.7 2.7 -
(13.5) (21.6) (40.5) (56.8) (70.3) (81.1) (94.6) (97.3) (100.0) -
21.4 14.2 21.4 14.2 7.1 28.5 -
-
(21.4) (35.7) (50.0) (64.3) (71.1, (100.0) -
-
9.3 9.3 7.0 7.0 Il.6 4.6 18.6 4.7 14.0 9.4 4.7
(9.3) (18.6) (25.6) (32.6) (44.2) (48.8) (67.4) (72. I) (86.0) (95.3) (100.0)
cent of the women regained their original weight losses plus some, while about 9% lost additional weight beyond their initial losses at the end of the weight loss phase. DISCUSSION The results indicate the WCFL! program helps obese clients lose and maintain a clinically significant portion of their weight losses over time. The results are better than those seen in programs using primarily behavior therapy and compare favorably with programs that combine behavioral approaches with VLCDs in terms of initial weight loss (Wadden et al., 1988; Hovel1 et al., 1988). The clients appear to do better. however, in maintaining their losses at 2.5 years post weight loss than those in other published studies. The best results have shown that at 1 year about l/3 of the weight has been regained, at 3 years 74-85% has been regained (Wadden et al., 1988) and at 5 years almost all of the weight has been regained (Wadden et al., 1989). In the present study, men and women regained an average of 25% of their losses at 1 year and 48% at 2.5 years after treatment. Blackburn and Kanders ( 1987) have suggested that modest decreases in Lveight of IO15% reduce medical risk and are better criteria of success than focusing exclusively on the attainment of ideal body weight. In this study, all of the clients maintained at least 20% of their weight losses at the end of 1 year and more than 70% maintained at least this amount at the end of 2.5 years. The program is a developmental “package” approach that integrates numerous lifestyle and psychological methodologies: thus. it is not possible to assess the relative contributions of each component to the program’s overall success. Based upon published reports. more developmental studies are necessary before comparative. rigorously controlled. experimental studies are undertaken to isolate the most important components of the program. Although the results of this descriptive report provide reason for optimism. evaluation of its effectiveness must await controlled studies. including larger numbers of clients. Nevertheless. the program appears to be an effective, clinical treatment for moderately to morbidly obese adults.
7.5 qears follow-up ofthe WCFL! program
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Wadden. T. A.. Sternberg. J. A.. Letizia. K. A.. Stunkard. A. J.. & Foster. G. D. ( 1989). Treatment ofobesit! by very low calorie diet, behavior therapy. and their combination: a li\e-bear perspective. Irlrcvnari~vu~i Journal ql‘ODrsit!:
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Wadden. T. A.. Van Itallie, T. B.. & Blackburn. G. L. (1990). Responsible and irresponsible use of vet low calorie diets in the treatment of obesity. Journal q/‘1he.4mericun .Ifedical.4s.sociarrcv~. 163(,I). 83-85.
