Phone, Internet Intervention Achieves, Maintains Weight Loss

November 15, 2011

Updated November 15, 2011 (Orlando, Florida) - A weight-loss program conducted solely by telephone and via internet was just as effective as a program attended in person, with face-to-face coaching, at promoting meaningful weight loss and helping to keep it off, in a two-year study reported today in the New England Journal of Medicine [1].

In the randomized Practice-Based Opportunities for Weight Reduction (POWER) trial, also presented today here at the American Heart Association (AHA) 2011 Scientific Sessions, about half of the patients participating in either weight-loss intervention lost at least 5% of their initial body weight (the primary end point) within six months. The lost weight stayed off after two years in about 40% of both groups.

The degree of weight loss achieved was similar to that of other weight-loss studies, according to the authors, led by Dr Lawrence J Appel (Johns Hopkins University, Baltimore, MD). "In contrast with the findings in most weight-loss trials, however, participants sustained weight loss to the end of the trial," they write.

At a media briefing, Dr Frank Sacks (Harvard School of Public Health, Boston, MA), who wasn't involved in the trial, called it "a very important advance" of the use of behavioral weight-loss strategies in showing such a benefit from the combination of phone and internet contact plus the participation of trained weight-loss counselors.

Importantly, he said, the fact that the participants didn't regain the lost weight after two years is "really unprecedented. In all weight-loss studies, there is some regain, either total regain or partial regain. So this is really a remarkable achievement; it could be considered something of a breakthrough."

Challenging the Traditional Paradigm

"The effectiveness of remote support is particularly noteworthy because of the flexibility it offers to both participants and coaches and because it is scalable," the authors note in their report.

Participants also seemed to prefer it over the face-to-face approach, Appel told heartwire . "The in-person group was the least preferable when the patients were randomized, that was our sense," he said.

And there's some data to back that up: patients who followed the remote program completed nearly all of the recommended telephone calls with counselors throughout the trial. But those randomized to the in-person group and one-on-one counseling sessions--who had the option of telephoning as well--completed only about half of their recommended face-to-face sessions, Appel said. Attendance at live-group and one-on-one sessions fell off almost completely, and telephone contact became much more frequent by the end of the study.

That, Appel said, "really does question the traditional paradigm" that holds group support as important to success in weight-loss programs.

Three Groups, Two Behavior-Based Strategies

The 415 randomized obese adult patients, of whom 64% were women and 41% were African American, who weighed an average of 104 kg with a mean body-mass index (BMI) of 36.6, also had at least one other cardiovascular risk factor such as hypertension, dyslipidemia, or diabetes. Those assigned to the remote intervention (n=139) received support from weight-loss coaches by telephone and email and through a dedicated website, which they were encouraged to access at least once a week.

Mean Weight Change at Six and 12 Months for Patients in the Remote, in-Person, or Self-Directed Weight Loss Groups

Time of evaluation Remote, n=139 In-person, n=138 Self-directed, n=138
6 mo, kg –6.1 –5.8 –1.4
12 mo, kg –4.6 –5.1 –0.8

p<0.001 for differences between self-directed and both the remote and in-person groups

Those randomized to the in-person approach (n=138) were also offered the remote-support options but primarily engaged in group- and one-on-one support sessions. There was a third randomization group (n=138) that met face-to-face with a weight-loss coach once at the beginning and, optionally, at 24 months.

Goals of the weight-loss intervention, beyond >5% weight loss, included adoption of a "healthy dietary pattern," with reduced overall calorie intake, at least three hours of exercise per week, and self-monitoring of weight, calorie intake, and exercise levels.

Rate of Achieving Weight Loss at Six Months and at Two Years, by Intervention Group, in POWER

Degree of weight loss Remotely, n=139 (%) In-person, n=138 (%) Self-directed, n=138 (%)
>5% at 6 mo 52.7a 46.0a 14.2
>5% at 24 mo 38.2a 41.4a 18.8
>10% at 6 mo 23.3a 25.0a 3.5
>10% at 24 mo 18.3b 19.5c 8.6

a. p<0.001 vs self-directed (control)

b. p=0.02 vs self-directed (control)

c. p=0.01 vs self-directed (control)

"An important feature of our study is that we had outstanding follow-up," Appel said. By the end of the study, 95% of participants provided their weight; the rates were 88% at six months and 86% at 12 months. "So our results reflect the whole cohort, not a selection of people who just showed up," he said.

The Program's Future

"The use of mobile technologies to delivery behavioral weight-loss treatment in primary care appears to be promising," according to Dr Susan Z Yanovski (National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD) in an editorial accompanying the published POWER report [2].

"Such interventions may present fewer barriers to adherence than interventions delivered in person, since they allow for greater scheduling flexibility, decreased travel time, and lower transportation costs." They also have the potential for success in different practice settings and geographically isolated areas, she writes.

Appel said that their preliminary estimates from an ongoing cost-effectiveness analysis of the study suggest that the remote intervention "could probably be implemented for six to eight hundred dollars" over two years. Informally, he said, participants in the study said they would probably find that cost acceptable. And that may be a good sign for the program's future: Appel said that Healthways--the company that owns the website and participated in the program's development--aims to make it commercially available.

POWER is just one of two studies at the AHA meeting that supports a role for some type of personal contact as a strategy for boosting weight-loss efforts. Results of the unrelated POWER-UP trial were released Monday afternoon and also published simultaneously in the New England Journal of Medicine, as reported by heartwire.

Appel had no disclosures. Disclosures for the coauthors are listed in the paper. POWER was supported by the National Heart, Lung, and Blood Institute. The POWER trial web portal states, "Healthways developed the website . . . in collaboration with Hopkins investigators and provided coaches for the call-center directed intervention. Healthways also provided some research funding to supplement [ National Institutes of Health] NIH support. . . . The Johns Hopkins University has an institutional consulting agreement with Healthways. Under this institutional agreement, the university is entitled to fees for consulting services. Those faculty investigators who participate in the consulting services receive a portion of the university fees, either as research support or salary supplement as determined by their supervisors."


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