Combining Weight-Loss Counseling with the Weight Watchers Plan for Obese Breast Cancer Survivors

Combining Weight-Loss Counseling with the Weight Watchers Plan for Obese Breast Cancer Survivors Zora Djuric,* Nora M. DiLaura,* Isabella Jenkins,* Linda Darga,* Catherine K.-L. Jen,* Darlene Mood,* Ellen Bradley, and William M. Hryniuk* Abstract DJURIC, ZORA, NORA M. DILAURA, ISABELLA JENKINS, LINDA DARGA, CATHERINE K.-L. JEN, DARLENE MOOD, ELLEN BRADLEY, AND WILLIAM M. HRYNIUK. Combining weight-loss counseling with the Weight Watchers plan for obese breast cancer survivors. Obes Res. 2002;10:657 665. Objective: The objective was to develop effective weightloss methods for women who have had breast cancer, because obesity may result in an adverse prognosis. Research Methods and Procedures: This randomized pilot study tested an individualized approach toward weight loss in obese women who have had a diagnosis of breast cancer. An individualized approach was applied either alone or combined with the commercial Weight Watchers program. Forty-eight women (body mass index of 30 to 44 kg/m 2 ) were enrolled. Results: Weight change after 12 months of intervention was as follows (mean SD): 0.85 6.0 kg in the control group, 2.6 5.9 kg in the Weight Watchers group, 8.0 5.5 kg in the individualized group, and 9.4 8.6 kg in the comprehensive group that used both individualized counseling and Weight Watchers. Weight loss relative to control was statistically significant in the comprehensive group 3, 6, and 12 months after randomization, whereas weight loss in the individualized group was significant only at 12 months. Weight loss of 10% or more of initial body weight was observed in 6 of 10 women in the comprehensive group at 12 months. In the comprehensive and Weight Watchers Submitted for publication January 19, 2002. Accepted for publication in final form April 26, 2002. *Barbara Ann Karmanos Cancer Institute, Detroit, Michigan; and The WW Group, Inc., Farmington Hills, Michigan. Address correspondence to Zora Djuric, Ph.D., Barbara Ann Karmanos Cancer Institute, 110 E. Warren, Detroit, MI 48201. E-mail: djuricz@karmanos.org Copyright 2002 NAASO only groups, weight loss was significantly related to frequency of attendance at Weight Watchers meetings, and attendance was more frequent in the comprehensive group. Discussion: These data indicate that the most weight loss was achieved when the counseling approach combined both Weight Watchers and individualized contacts. This was effective even though most of the individualized contacts were by telephone. Key words: individualized counseling, community resources, group attendance, telephone counseling Introduction Finding effective methods for weight loss continues to be a challenge for research, and this has taken on new urgency as obesity rates continue to rise (1). Weight-loss research studies in the past mainly used a group-counseling approach or limited, individual contacts. Although some studies have demonstrated substantial weight losses in obese individuals, weight-loss results in general have been modest, and new approaches are needed (2). For long-term reduction in body weight, intensive, individualized approaches toward developing a new lifestyle may be required. Each individual has unique life circumstances that need to be addressed if beneficial lifestyle changes are to be accepted and followed over a lifetime. The aim of this study was to develop and test individualized methods for effective weight loss in obese breast cancer survivors. Although obesity has differential effects on initial breast cancer risk in pre- and postmenopausal women, once breast cancer has developed, both survival and recurrence may be adversely affected by obesity (3). For example, in a recent study of young women with breast cancer, higher body mass was associated with decreased survival from breast cancer and tumors of higher cellular proliferation (4). The effect of obesity on survival has been evident in most studies, but not all (5). One reason for OBESITY RESEARCH Vol. 10 No. 7 July 2002 657

discrepancies is the possibility that biological factors associated with obesity, and not the obesity per se, are responsible for the observed effect. There is considerable evidence that the effects of obesity on breast cancer risk may be mediated at least in part by the effect of obesity on insulin resistance (6 10). Studies on weight loss and recurrence are generally lacking except for one small study in Russia where energy restriction of 15% in breast cancer survivors reduced recurrence rates by 72% 3 years after diagnosis (11). The effects of obesity on breast cancer prognosis might be exacerbated by weight gain after initial diagnosis and treatment (12 16). This may be a result of reduced physical activity (13). Such weight gain can impact negatively on quality of life (12,14). The majority of breast cancer survivors are dissatisfied with their posttreatment weight and state that they are ready to take steps necessary to reduce their weight (12,16,17). Faced with the prospect of recurrence and death, they would seem to be an especially well-motivated group. Despite this, a previous attempt at weight reduction in breast cancer survivors resulted in loss of only 0.5 kg over 1 year (18). That study used a groupcounseling approach supplemented with individualized diet and exercise goals. Another study that involved a diet and exercise intervention, with emphasis on the exercise component, resulted in a loss of only 1.2 kg in 8 weeks (19). The most successful study showed maintenance of 6 kg of weight loss for 3 years in breast cancer survivors using a dietitian-led intervention that allowed patients time to discuss their concerns (20). Many factors contribute to an individual s dietary and exercise patterns including the well-studied influences of socioeconomic, cultural, and biological factors and the lessstudied familial influences that contribute to taste preferences, perceptions of the norm, and lifestyle habits. To attain a lower body weight, attitudes and habits regarding eating and exercise that have developed over a long period of time need to be addressed. Intensive, individualized counseling methods typically have not been used in weightloss research studies. This approach is, however, sensitive to the needs and abilities of each individual. One recent, large study used individualized counseling with seven sessions in the first year and resulted in a 4.2-kg weight loss in persons at risk for diabetes (21). Individualized counseling that was sensitive to individual food preferences also was found to be effective in a small study of low-income African Americans, which has historically been a difficult population to reach with weight-loss interventions (22). Intensive, individualized counseling can, however, be useful in large studies as well. A current dietary intervention using telephone contacts with participants to increase fruit and vegetable consumption and decrease fat intake in breast cancer survivors has been very successful (23). Therefore, the use of individualized counseling was investigated in this study of obese breast cancer survivors. Research Methods and Procedures Subjects Eligible subjects were ages 18 to 70 years. They had stage I or II breast cancer that was diagnosed within the past 4 years and were free of any recurrence as confirmed by a physician. Chemotherapy or radiation therapy was to have been completed at least 3 months previously with the exception of tamoxifen. Recruitment sources were direct mail to Race for the Cure participants, press releases, and brochures at breast clinics. Forty-eight subjects were randomly assigned to one of four groups: control, Weight Watchers (WW), individualized counseling, or a combination of WW and individualized counseling. Study participation was planned for 30 months, and the first 12 months of data are reported here. Nine of the 48 women did not complete 12 months of participation. Two were dropped for noncompliance after 3 and 6 months, respectively. Seven women withdrew from the study, and all but two did so before 3 months. Reasons for withdrawal were medical problems (n 1), too busy (n 2), emotional distress (n 3), and lost interest (n 1). After 12 months, subjects assigned to any intervention arm were given the option of continuing with the program. Assessments Questionnaires were administered at baseline and intervals thereafter. These included a demographic and healthhistory questionnaire at baseline, health update questionnaires thereafter, and the Functional Analysis of Chronic Illness and Therapy questionnaire at baseline and 12 months (24). The Health Status Questionnaire was administered once at baseline, and this provided information on the participant s demographics, gynecological history, medical history, and family history of cancer. A Lifestyle Questionnaire was administered at baseline and at 3, 6, 9, and 12 months. This provided information on any changes in medications, level of physical activity, menstrual status, and illness. A structured psychiatric interview was conducted at baseline, and this included inquiry into the nature of particular problems potentially underlying each subject s obesity. At baseline and at 3, 6, 9, and 12 months, the women were weighed in clothing but without shoes using a professional beam scale (model 402KLS; Health-o-Meter, Bridgeview, IL), and percentage of body fat was measured using tetrapolar bioelectrical impedance (model BIA101S; RJL Systems, Clinton Township, MI). Height was measured at baseline only. Three-day food records and physical activity logs were required at baseline and at 3, 6, and 12 months. The food records were kept on forms that enumerated the food eaten, time of day it was eaten, and amount eaten. A registered dietitian taught the women how to keep food records and estimate portion sizes. The records were reviewed together with the participant at each of the four scheduled data- 658 OBESITY RESEARCH Vol. 10 No. 7 July 2002

collection visits during the 12-month intervention. Nutrient calculations of the food records were performed using the Minnesota Nutrition Data System Research software, developed by the Nutrition Coordinating Center, University of Minnesota, Minneapolis, MN (Food Database version 14A, Nutrient Database version 24). Control Arm Subjects randomized to the control arm received the National Cancer Institute s Action Guide to Healthy Eating and the Food Guide Pyramid pamphlets, but they received no other dietary or exercise instructions or help. They met with the dietitian at baseline, 3, 6, and 12 months for the required assessments. Controls were allowed to follow a weight-reduction diet on their own if desired. Weight Watchers Arm For the WW arm, women were encouraged to attend WW meetings but received no other dietary or exercise instruction. These meetings were conveniently available throughout the Detroit area at various times during the day. Coupons for weekly attendance were provided free of charge. The weigh-in data card from the WW meetings was faxed or mailed to the dietitian as proof of attendance, and this also provided additional data to assess weight-loss patterns and attendance. The WW program is designed for weekly attendance. Individualized Arm Contacts by the dietitian were scheduled to be weekly for the first 3 months, biweekly for months 3 to 6, and monthly thereafter. Women were accommodated if they needed a greater or lesser frequency of contacts at any given time. They were also free to call the dietitian, and some women enjoyed sharing their successes as they occurred. Apart from the quarterly data collection visits, all of the individual contacts were by telephone appointment. A monthly group meeting was held during the lunch hour, and women were encouraged, but not required, to attend. A monthly packet of written information was prepared on various weight-loss topics (environmental control, serving-size control, exercise, motivation, goal setting, holiday eating, seasonal foods) and either presented to the women at the monthly meeting or mailed to their homes. One-on-one counseling was provided regarding diet and exercise by a registered dietitian. There was only one dietitian for the study, and she had over 10 years of experience in weight-loss counseling in clinical settings. The weightloss goal was an initial decrease of 10% of baseline weight over 6 months. This goal was discussed at the beginning of the study to determine if a woman s own goals needed to be adjusted to a reasonable body weight instead of an ideal body weight. Previous studies demonstrated that an average weight loss of 8% of body weight can be achieved in 6 months. Because this is an average figure, a goal of 10% of initial body weight is not unrealistic and is generally considered to be a reasonable and physiologically significant goal (25). The goal was to be achieved with a 1 to 2 lb/wk weight loss by decreasing energy and fat intakes combined with 30 to 45 min/d of moderate activity most days of the week. The dietary goals were derived for each woman using the American Dietetic Association Exchange List diet plan (26). Energy intake was decreased 500 to 1000 kcal/d relative to the calculated energy requirements for a sedentary person using an estimate of 11 kcal/lb body weight needed for weight maintenance (27). Target fat intake was 20% to 25% of energy from fat. The fruit and vegetable intake goal was at least 5 servings/d, and protein intake was up to 20% of energy. Emphasis was also placed on increasing fiber intakes through whole grain choices. Pedometers were provided for self-monitoring and goal-setting. It was requested that exercise and dietary logs be kept daily, and these were reviewed together with each subject. The overriding philosophy of the program was that a new lifestyle must be developed that supports a lower body weight. Contacts were by phone or in person, and food and exercise records were mailed to the dietitian before the scheduled contact. The counseling session varied in length depending on individual needs. The dietitian first verified whether or not the participant was meeting behavior-change goals set in the previous week. If not, the problem was delineated, and the dietitian helped the subject devise a plan that would be used to circumvent the problem. The techniques taught included goal-setting, menu planning, selfefficacy, self-monitoring, consideration of body image, social support, social eating, removing roadblocks, positive thinking, dealing with high-risk situations and slips, and cue elimination. The counseling approach used the theoretical framework of Bandura s social cognitive theory (28). This framework has been particularly useful in nutrition interventions, such as weight control and low-fat diets (29). According to the model, behavior is determined by an interaction between cognitive mediators (such as beliefs of self-efficacy, outcome expectancy, and self-regulatory processes) and influences of society and environment (28,30). Participants also were encouraged throughout the treatment to address their thoughts and beliefs about themselves and their weight, especially with regard to self-image and self-acceptance (31). Comprehensive Arm For the comprehensive arm, subjects received the individualized counseling described above and were asked to attend weekly WW meetings using free coupons. Because the subjects had group meetings with WW, and it was felt that adding the dietitian-led monthly group might be an overly burdensome time commitment, the monthly meeting was omitted. The WW program has dietary guidelines that OBESITY RESEARCH Vol. 10 No. 7 July 2002 659

coincide well with cancer-prevention guidelines and with the dietary-exchange goals that were presented to the participants, and this was explained in detail. The women learned how the points system of WW, which takes into account energy, fat, and fiber contents of foods, coincides well with the food-group exchanges that were assigned for each individualized diet plan. It was requested that exercise and dietary logs be kept daily. Statistical Methods The data were analyzed using SPSS 10.1 software (SPSS Inc., Chicago, IL). Means were compared using paired or Student s t test or ANOVA with a Scheffe post hoc test for significance between groups, as appropriate. Proportions were compared by a 2 test. Associations were evaluated by Pearson Product moment correlations. All tests were twotailed and p 0.05 was considered significant. Results Subjects The main recruiting source for this study was the Komen Foundation Race for the Cure mailing list. The subjects were predominantly white, postmenopausal, and married. Most of the women were currently taking tamoxifen (Table 1). One-half of the participants had gained, and then lost, more than 4.5 kg in the past 2 years, 69% of the participants had previously participated in a structured weight-loss program, and six participants were trying to lose weight at the present time. Participants felt that they had somewhat less control over their own body weight than is typical for any person (mean score of 2.5 on a scale of 5, with 3 being the value for a typical person). Mean body weight at age 18 was 59.5 kg (range, 37.2 to 94.1 kg). Weight Loss Control subjects exhibited minimal weight loss initially, and after 12 months, mean body weight increased by 0.85 kg. Some control subjects lost weight after randomization (4 of 13 women at 6 months and 4 of 12 women at 12 months), but greater weight loss occurred in all three intervention arms. Weight loss was most rapid in the comprehensive arm, with mean weight losses of 7.4, 9.3, and 9.4 kg at 3, 6, and 12 months, respectively (Figure 1). This weight loss was significantly different from control at 3, 6, and 12 months (p 0.05 in each case). Two women in the comprehensive arm gained weight relative to baseline by 12 months. The individualized counseling group experienced a statistically significant weight loss at 12 months only (Figure 1). All women in this arm exhibited weight loss at 6 months, ranging from 1.4 to 17.7 kg. After 6 months, six of nine women continued to lose weight, whereas three women regained 30% to 39% of their lost weight. At 12 months, the Table 1. Demographic characteristics of 48 enrolled women Characteristic Frequency or mean SD White* 35 (73%) African American 12 (25%) Bilateral cancer 5 (10%) Current tamoxifen use 30 (63%) Chemotherapy in the past 30 (63%) 51.7 8.4 Age (years) (range, 36 to 70) Postmenopausal 36 (75%) Married 31 (65%) College graduate 30 (63%) Currently employed outside home 42 (88%) Current smoker 4 (8%) Current arthritis 19 (40%) Current diabetes medication 3 (6%) Weight at study entry (kg) 95.4 13.6 Body mass index at study entry (kg/m 2 ) 35.5 3.9 * One study subject was Native American. One additional woman had tamoxifen use in the past. Three women were taking estrogen replacement therapy, and of those, one was taking both tamoxifen and hormone replacement therapy. range of weight loss from baseline was 3.2 to 20.9 kg, indicating a loss in every woman who completed 12 months on the individualized arm. No significant changes in mean body weight were observed in the WW-only arm. Weight change at 6 months ranged from a loss of 14.5 kg to a gain of 10 kg, and six of nine women lost 1 kg. The weight change from baseline to 12 months ranged from a loss of 11.4 kg to a gain of 4.8 kg, and five of eight women lost 1 kg, indicating that some women can benefit from a WW-only approach. Although the WW program alone did not result in significant weight loss, it did prevent weight gain relative to control. In the control arm, 7 of 12 women gained weight at 12 months relative to baseline, but only 3 of 8 women in WW arm gained weight. None of the women in the WW arm lost additional weight from 6 to 12 months (Figure 2). The number of women reaching a 10% weight-reduction goal was examined also because this amount of weight loss is known to result in significant changes in clinically rele- 660 OBESITY RESEARCH Vol. 10 No. 7 July 2002

Figure 2: Weight loss with time in each study arm given as mean and SD of change in body weight (A) or change in body mass index (BMI) (B). Data represent the difference of weight at the indicated time-point vs. that at study entry. WW, Weight Watchers; Individual, individualized dietary instruction. *Significant differences vs. control, within each time-point, from ANOVA analyses (p 0.05). There were no significant differences in body weight or BMI between study arms at baseline. Weight gain from 6 to 12 months in the control and Weight Watchers arms were significant (p 0.05 in each case from paired sample tests). vant measures such as insulin levels, blood pressure, and blood lipids (25). Statistical analysis of the results in Table 2 indicated that the comprehensive arm was the only intervention resulting in a higher than expected number of women with at least a 10% weight loss at 6 and 12 months. Figure 1: Attendance at Weight Watchers (WW) meeting vs. weight loss for the two arms that required Weight Watchers attendance (WW and Comprehensive). % meetings attended, percentage of the weekly meetings that were actually attended by subjects within the indicated time periods. The slope of the line indicates that greater attendance frequency is associated with greater weight loss. Group Attendance and Telephone Counseling In the two arms using WW, weight loss was significantly correlated with attendance at WW meetings (Figure 2). Attendance in both the WW and comprehensive arms declined with time. The mean percentages of attendance at weekly WW meetings were 76%, 50%, and 28% in the WW-only arm for the time periods of baseline to 3 months, 3 to 6 months, and 6 to 12 months, respectively. The respective mean attendance for women in the comprehensive arm were 93%, 79%, and 52%. Attendance at WW from 6 to 12 months was still associated significantly with incremental weight loss during that time period, and the only women who lost more weight from 6 to 12 months OBESITY RESEARCH Vol. 10 No. 7 July 2002 661

Table 2. Numbers of women achieving 10% weight loss 6 Months* 12 Months Study arm Yes No % Yes Yes No % Yes Control 1 12 8% 0 12 0% Weight Watchers 2 7 22% 2 6 25% Individualized 3 6 33% 2 7 22% Comprehensive 7 3 70% 6 4 60% * The Pearson 2 was significant with p 0.014, two-sided testing. The Pearson 2 was significant with p 0.016, two-sided testing. Yes includes subjects achieving a 10% weight loss or greater. The only intervention arm with more than the statistically expected number of subjects losing 10% or more of initial body weight was the comprehensive arm at both 6 and 12 months. were those in the comprehensive arm who also attended 47% or more of the weekly WW meetings (Figure 2). Attendance at group meetings in the individualized arm also seemed to be important for weight loss. From baseline to 3 months or from baseline to 6 months, the associations of weight loss with attendance at these groups was not statistically significant, perhaps because of the small sample size. The association of weight loss and average group attendance from 0 to 12 months was significant (r 0.775, p 0.014), with subjects attending 9% to 92% of the monthly groups during that time. Two of the nine women retained for 12 months on the individualized arm attended no groups after the first 3 months, but the rest of the women attended 28% or more of the sessions. The mean numbers of telephone contacts with participants in the individualized arm was 10 in the first 3 months, 6 in the next 3 months, and 10 in the last 6 months of intervention. In the comprehensive arm, the respective mean numbers of telephone contacts were 10, 7, and 12. The frequency of telephone contacts made with each subject varied. There was, however, no statistically significant association of number of contacts made and weight-loss extent during any time period, with r 0.28 in each case. The trend in the data was that a smaller number of contacts were made with women who lost more weight, which may be a result of the extent of support that these women needed. It should be noted that additional individual counseling contacts occurred at the data collection visits at baseline and at 3, 6, and 12 months for all subjects on the individualized and comprehensive arms. Dietary Intakes and Exercise Mean energy and fat intakes from self-reported 3-day food records were decreased in all three intervention arms (Table 3). In the control arm, mean reported energy intakes were 2246, 1691, 1918, and 2120 kcals at baseline and 3, 6, and 12 months, respectively, but the reported decrease in energy intake at 3 months was not evident in terms of weight loss. Similarly, the reported decrease in energy intake in the WW arm at 12 months was of similar magnitude as in the other Table 3. Reported dietary intakes from 3-day food records (mean SD) Study arm Energy intake (kcal/d)* Fat intake (% of energy) Baseline 12 Months Baseline 12 Months Control 2246 660 2120 528 33 9 40 5 Weight Watchers 2106 673 1490 281 34 7 32 3 Individualized 1833 358 1386 282 35 6 24 6 Comprehensive 1899 424 1437 122 30 7 28 5 * Nutrient intakes were calculated from the Nutrition Data System Research program. The conversion factor is 4.1868 kj/kcal. The numbers of women at baseline and 12 months were as follows: 13 and 11 for the control arm, 10 and 6 for the Weight Watchers arm, 13 and 9 for the individualized arm, and 11 and 8 for the comprehensive arm. 662 OBESITY RESEARCH Vol. 10 No. 7 July 2002

two intervention arms, but significant weight loss was not observed in the WW arm. The largest decrease in reported fat intake was in the individualized diet arm (Table 3). Subjects also self-reported intentional exercise during the same week that food records were kept. In the WW arm, the four subjects reporting no exercise beyond usual daily activities lost a mean of 1.0% of initial body weight at 12 months, and the four subjects reporting any exercise lost an average of 4.9% of initial body weight, but this was not a statistically significant difference (p 0.42). In the individualized arm, two of nine subjects reported no intentional exercise and these same two women also did not use their pedometers. Despite this, those two women exhibited weight losses of 5.8% and 8.9% of baseline weight at 12 months, which was not widely disparate from the mean weight loss of 9.2% in that arm. In the combination arm, 4 of 10 subjects reported no exercise, and those 4 subjects and one additional woman did not use their pedometers. The four subjects reporting no exercise lost a mean of 10.4% of their baseline weight, which was similar to the mean weight loss for that entire group of 11.6%. Our data therefore do not lend much support the concept that exercise is needed for weight loss, but it was a small study, and the effect may become evident later with regard to maintenance of weight loss. Discussion The main goal of the interventions tested in this study was weight loss. Because the subjects were breast cancer survivors, however, there was also emphasis in the counseling on quality of dietary intakes and exercise, both of which have been associated with breast cancer risk. Exercise, which is important for weight loss and weight maintenance, can also result in hormonal alterations that may be protective of breast cancer risk (32). Dietary changes that include decreased fat, increased fiber, and increased fruit and vegetable intakes have been suggested to be protective of breast cancer risk (33 35). Dietary changes that do not result in weight loss but improve diet quality can affect insulin and cholesterol levels favorably, as well as decrease diabetes risk (36 38). Whether diet quality can also reduce risk of recurrence in breast cancer survivors is currently being tested in a large, randomized trial (16,23). The comprehensive arm resulted in the most weight loss in this study. More than one-half the women achieved 10% weight loss in this arm, which is a level of weight loss documented to favorably affect insulin levels (25). Even modest weight loss has been shown to decrease insulin levels and diabetes risk (21,39). This is relevant to breast cancer because survival and recurrence rates have both been associated with fasting insulin levels (10). Another major protective effect of weight loss on breast cancer risk may be through a decrease in estradiol levels (3). For example, in postmenopausal obese women, a decrease of 30% in plasma estradiol levels was observed with a weight loss that was 15% of baseline weight (40). One novel aspect of the comprehensive intervention used here was the integration of WW with individualized counseling. The WW dietary and exercise goals are consistent with the goals of moderate fat intake, increased fiber intake, and plentiful fruits and vegetables used in the individualized program, which facilitated the integration of the two approaches. The WW program alone can result in significant weight loss, and 4.8 kg was achieved in one study that used WW only for 6 months (41). The mean weight loss we obtained with WW alone of 3.4 kg was somewhat less than that. The WW arm in this study did, however, seem to prevent weight gain relative to that in the control arm (see Results and Figure 1). Weight loss was greatly enhanced when supplemented with individualized counseling (9.4 kg loss at 6 months). Subjects in the comprehensive arm also attended WW more frequently, and the addition of the individualized counseling may provide greater accountability for meeting WW goals because the diet and exercise logs were reviewed by the counselor. Group approaches are useful because participants of the group can provide social support to each other. In our individualized program, group meetings were held once a month at one location because the number of women in that arm did not justify meetings at multiple times or locations. In the comprehensive group, which attended WW meetings, study participants had the opportunity to attend group meetings once a week with a choice of locations and times. In either case, attendance at group meetings varied, and frequency of attendance influenced weight-loss success (Figure 2). The combination of WW and individualized counseling was, however, the more effective approach, because mean weight loss was somewhat greater and occurred at a faster rate (Figure 1). This early weight-loss success was a motivational factor for the women in that arm and resulted in a statistically higher percentage of women reaching the 10% weight-loss goal (Table 2). In addition, once women complete the study, WW is available in the community for women to use for prevention of weight gain. Such continued contact is thought to be a key for weight-loss maintenance (25). The counseling approach used in the individualized and comprehensive arms was similar to the behavioral techniques used in the Lifestyle, Exercise, Attitudes, Relationships, and Nutrition (LEARN) program, which has been successful in many weight-loss programs (42,43). The current approach was, however, delivered using frequent individual contacts, all of which were by telephone except for that at the assessment visits (baseline and 3, 6, and 12 months). Telephone counseling is convenient and has been shown to be effective in both our study and a large prospective dietary intervention for breast cancer survivors [the Women s Healthy Eating and Living (WHEL) Study] that OBESITY RESEARCH Vol. 10 No. 7 July 2002 663

seeks to increase fruit and vegetable consumption and decrease fat intake (16,23). Telephone counseling has proved useful in other studies as well, including improving quality of life in breast cancer survivors (44) and increasing exercise in minority women (45). Individualized contacts by e-mail have also been shown to be effective for weight loss (46). It may well be the case that individualized counseling, regardless of the medium, provides each participant with more useful weight-loss advice than general group counseling. Such patient-centered counseling has been indicated to enhance long-term dietary adherence for treatment of hyperlipedemia (47). In summary, despite the small size of this study, the differences in weight loss observed between intervention arms were large, with the combination of individualized counseling and the commercial WW program proving to be the most effective approach. Both the complementary nature of the two approaches and the increased frequency of contacts with the subjects could have contributed to this success. This approach should be applicable to larger studies that test whether weight loss in breast cancer survivors can reduce their risk of disease recurrence. It also may be useful in populations who suffer from other medical complications of obesity. Acknowledgments This study was supported in part by grant RO3 CA89761 from NIH, The Weight Watchers Group, Inc, Farmington Hills, Michigan, and the Ford Motor Company Fund. We thank all the women who gave their time to participate in the Weight Loss After Breast Cancer (ABC) Diet Study. We thank Martin Atkins for assistance with the study newsletters and dietary data. References 1. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991 1998. JAMA. 1999;282:1519 22. 2. Jeffery RW, Drewnowski A, Epstein LH, et al. Long-term maintenance of weight loss: current status. Health Psychol. 2000;19:5 16. 3. Chlebowski RT, Aiello E, McTiernan A. Weight loss in breast cancer patient management. J Clin Oncol. 2002;20: 1128 43. 4. Daling JR, Malone KE, Doody DR, Johnson LG, Gralow JR, Porter PL. Relation of body mass index to tumor markers and survival among young women with invasive ductal breast carcinoma. Cancer. 2001;92:720 9. 5. Marret H, Perrotin F, Bougnoux P, et al. Low body mass index is an independent predictive factor of local recurrence after conservative treatment for breast cancer. Breast Can Res Treat. 2001;66:17 23. 6. Strickler HD, Wylie-Rosett J, Rohan T, et al. The relation of type 2 diabetes and cancer. Diabetes Technol Ther. 2001; 3:263 74. 7. Song E, Banerjee M, Du W, Hryniuk W. Diabetes but not obesity is a prognostic factor for disease free survival (DFS) in women with stage I, II and III breast carcinoma receiving Tamoxifen. Breast Can Res Treat. 2000;64:40. 8. 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Changes in weight, body composition, and factors influencing energy balance among premenopausal breast cancer patients receiving adjuvant chemotherapy. JClinOncol.2001;19:2381 9. 14. McInnes JA, Knobf MT. Weight gain and quality of life in women treated with adjuvant chemotherapy for early-stage breast cancer. Oncol Nurs Forum. 2001;28:675 84. 15. Loprinzi C, Athmann L, Kardinal C, et al. Randomized trial of dietician counseling to try to prevent weight gain associated with breast cancer adjuvant chemotherapy. Oncology. 1996;53:228 32. 16. Rock CL, Flatt SW, Newman V, et al. Factors associated with weight gain in women after diagnosis of breast cancer. Women s Healthy Eating and Living Study Group. J Am Diet Assoc. 1999;99:1212 21. 17. Demark-Wahnefried W, Peterson B, McBride C, Lipkus I, Clipp E. Current health behaviors and readiness to pursue life-style changes among men and women diagnosed with early stage prostate and breast carcinomas. Cancer. 2000;88: 674 84. 18. 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