Dr. Mike Perri. Dean, College of Public Health and Health Professions University of Florida

Transcription

1 Dr. Mike Perri Dean, College of Public Health and Health Professions University of Florida

2 Comparative Effectiveness of Three Doses of Behavioral Weight-Loss Treatment Delivered via Cooperative Extension Offices in Rural Communities Michael G. Perri, Marian C. Limacher, Kristina von Castel-Roberts, Michael J. Daniels, Patricia E. Durning, David M. Janicke, Linda B. Bobroff, Tiffany A. Radcliff, Vanessa A. Milsom, Chanmin Kim, & A. Daniel Martin University of Florida Supported by NIH R18 HL

3 Obesity in America: Two Key Facts 1. The majority of Americans are overweight or obese. 2. The prevalence of obesity is higher in rural areas of the U.S.

4 Goals of this Presentation 1. Provide a brief overview of obesity and health disparities in rural America 2. Describe the Rural LITE Study An effectiveness trial Targeted to obese residents of rural counties Conducted via Cooperative Extension Service offices 3. Present 6-month findings Acceptability and satisfaction Changes in body weight

5 Defining Rural U.S. Office of Management and Budget (OMB) classification of U.S. counties Metropolitan (urban) counties A. Large central metropolitan areas (pop. > 1 million) B. Fringe (suburban) counties of large metro areas C. Small metropolitan areas (city with pop. > 50,000) Non-metropolitan (rural) counties D. Rural county a city (pop. = 10,000 to 50,000) E. Rural county without a city

6 Urban/Rural Disparities Rural counties 17% of U.S. population (~ 49 million people) 75% of the medically underserved areas Higher rates of poverty Higher proportion of residents without health insurance Greater percentage of people with chronic diseases

7 Urban/Rural Death Rates From Ischemic Heart Disease

8 Contributors to the Urban/Rural Disparity in Heart Disease Mortality Poverty and low SES Limited access to medical care Virtual absence of preventive health services Lifestyle factors o Smoking o o o Sedentary behavior + decrease in occupational physical activities High-fat, high calorie diets Obesity

9 Urban/Rural Disparity in the Prevalence of Obesity* *NHANES data from Befort, Nazir & Perri, J Rural Health, 2012.

10 Lifestyle or Behavioral Treatments for Weight Management Focus on changes in energy intake and energy expenditure Use of behavioral strategies to accomplish changes in diet and exercise Initial weight losses of approximately 8kg followed by regains of approximately 2 kg per year Beneficial changes in blood pressure, blood glucose, and blood lipids Prevent or delay the onset of diabetes in at-risk individuals

11 Comprehensive Behavioral/Lifestyle Interventions: Key Components Goal setting o 1200 calories per day intake for women; 1500 for men o 150+ additional minutes per week of exercise Self-Monitoring o daily written logs of eating and exercise Self-Evaluation o Self-reinforcement Stimulus Control o Limiting eating environments and occasions o Avoiding triggers for overeating (e.g., skipping meals, eating out, alcohol, snack foods)

12 Behavioral Treatment: Additional Components Changing Diet Composition o decrease saturated fats and simple sugars o increase complex carbs, fiber, fruits, and vegetables Increasing physical activity o Add 30+ min per day of walking Social Support o Enlisting help of others Cognitive Reframing o Decreasing negative thoughts and developing positive mindset Problem Solving o Structured approach to dealing with obstacles

13 The Challenges of Translation, Dissemination, and Implementation

14 Efficacy Versus Effectiveness Efficacy studies Conducted under ideal conditions Academic centers Interventions led by doctoral-level experts Highly selected middleclass volunteers from urban and suburban areas Effectiveness studies Conducted under real world conditions Community settings Interventions led by usual care providers Participation open to most members of the community

15 Disseminating Obesity Treatment in Rural America The Potential of Cooperative Extension Service (CES) Partnership of federal + county governments + land-grant universities Mission targets application of agricultural research and includes nutrition education CES offices are in > 3,000 counties of the U.S. High visibility in rural communities Culturally acceptable place to get assistance

16 Translating the Lifestyle Treatment to Rural Communities Issues of special concern in rural areas: Heritage of country cooking o Vegetables as high fat foods Barriers to exercise o Absence of safe places to walk Limited support for weight loss o Lack of family support for participation

17 Prior Research: Results of the TOURS Trial (Perri et al, Arch Intern Med, 2008; 168: ) An intensive group-based behavioral weight-loss program o Delivered by county agents and/or bachelors-level staff: o 50 sessions over 18 months (24 weekly + 26 biweekly) Results: o Mean change of -10 kg from baseline to 6 months o Mean change of -8 kg from baseline to 18 months Implications: o CES Offices can serve as excellent venues for disseminating lifestyle interventions into rural communities o Bachelors-level providers can deliver weight-management interventions in an effective manner

18 Barriers to Implementation The resources required to mount the program are high with respect to interventionist time o 24 sessions of initial treatment o 26 sessions of extended care County Extension Directors are reluctant to invest such a high level of extension agent time (Survey of 67 CES directors) o 24 sessions viewed as too high o 8 to 10 sessions are the norm o 16 sessions viewed as maximum feasible

19 Rural LITE Trial: Key Questions Can the high dose of treatment commonly used in efficacy studies be reduced and still achieve good weight-loss outcomes? o Can a moderate dose of treatment produce clinically meaningful changes in body weight? What is the effectiveness of the low treatment dose most commonly used in rural settings? o Are there benefits associated with low-dose treatment behavioral treatment compared with education alone?

20 Rural LITE Trial (N=612) Random assignment High Dose Behavioral Treatment o 24 initial sessions over 6 months o 24 extended care sessions over 18 months Moderate Dose Behavioral Treatment o 16 initial sessions over 6 months o 16 extended care sessions over 18 months Low Dose Behavioral Treatment o 8 initial sessions over 6 months o 8 extended care sessions over 18 months Education Control o 8 initial sessions over 6 months o 8 extended care sessions over 18 months

21 Goals for Participants 1. Improve the quality of diet o Increase vegetable, fruit, and fiber o Decrease saturated fat and simple sugars 2. Increase physical activity o Increase walking by 30 min or (3,000 steps) per day 3. Improve management of stress 4. Control weight o Prevent further weight gain o Achieve weight loss

22 Behavioral Program: Key Components Weekly groups sessions o 5 to 15 participants per group o 90 minutes in length Meetings held at Cooperative Extension Offices o 10 rural counties of north Florida Group leaders o Family and Consumer Science Agents or o Providers with a bachelors degree in nutrition or psychology Ongoing training for group leaders o bimonthly workshops o weekly telephone supervision

23 Study Participants Characteristic N = 612 Sex, % women 78% BMI, mean 36.3 Age, mean 52 yr Race/Ethnicity Black, Non-Hispanic 16% Hispanic 4% White, Non-Hispanic 77% Other/multiple 3% Education, <12 yrs 68% Household income, <$50K/yr 50%

24 Percent Participant Attendance at Group Sessions 100 No significant between-group CONTROL LOW MOD HIGH Condition

25 Satisfaction Participant Program Satisfaction Ratings (0-100%) 100 No significant between-group differences CONTROL LOW MOD HIGH Condition

26 Rural LITE Trial: 6 Month Weight Changes (kg) kg CONTROL LOW MOD HIGH Month 0 Month a -7.2 b -9.3 c c Note. Dissimilar superscripts at 6 months indicate significant between-groups differences (ps <.05).

27 Percentage of Participants Achieving > 5% Losses at Months 6 in Rural LITE Trial Note. Dissimilar superscripts at 6 months indicate significant between-groups differences (ps <.05).

28 Take Home Messages CES may represent an effective infrastructure for the delivery of lifestyle interventions Low-dose treatment has benefits but is less effective than moderate-dose treatment. Moderate dose of behavioral treatment can produce clinically meaningful reductions in body weight that are similar to high-dose treatment (but at a lower cost). The long-term effects of the different doses remains to be seen; 24-month results will be available in November. Findings have the potential to influence policy decisions regarding allocation of resources for obesity treatment.

29 Acknowledgements Manal Alabduljabbar Katherine Allen Rachel Andre Stephen Anton Aviva Ariel Trinity Cromwell Renee Degener Linda Garzarella Valerie Hoover Danielle Lespinasse Wendy Lynch Ann Mathews Stacey Maurer Kristen Medina Kathryn Middleton Vanessa Milsom Samantha Minski Lisa Nackers Allison Onkala Ninoska Peterson Cathy Rogers

30 Thank You!