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1.  Weight Loss With Naltrexone SR/Bupropion SR Combination Therapy as an adjunct to Behavior Modification: The COR-BMOD Trial 
Obesity (Silver Spring, Md.)  2010;19(1):110-120.
This 56-week, randomized, placebo-controlled trial examined the efficacy and safety of naltrexone plus bupropion as an adjunct to intensive behavior modification (BMOD). A total of 793 participants (BMI = 36.5 ± 4.2 kg/m2) was randomly assigned in a 1:3 ratio to: (i) placebo + BMOD (N = 202); or (ii) naltrexone sustained-release (SR, 32 mg/day), combined with bupropion SR (360 mg/day) plus BMOD (i.e., NB32 + BMOD; N = 591). Both groups were prescribed an energy-reduced diet and 28 group BMOD sessions. Co-primary end points were percentage change in weight and the proportion of participants who lost ≥5% weight at week 56. Efficacy analyses were performed on a modified intent-to-treat population (ITT; i.e., participants with ≥1 postbaseline weight while taking study drug (placebo + BMOD, N = 193; NB32 + BMOD, N = 482)). Missing data were replaced with the last observation obtained on study drug. At week 56, weight loss was 5.1 ± 0.6% with placebo + BMOD vs. 9.3 ± 0.4% with NB32 + BMOD (P < 0.001). A completers analysis revealed weight losses of 7.3 ± 0.9% (N = 106) vs. 11.5 ± 0.6% (N = 301), respectively (P < 0.001). A third analysis, which included all randomized participants, yielded losses of 4.9 ± 0.6 vs. 7.8 ± 0.4%, respectively (P < 0.001). Significantly more NB32 + BMOD- vs. placebo + BMOD-treated participants lost ≥5 and ≥10% of initial weight, and the former had significantly greater improvements in markers of cardiometabolic disease risk. NB32 + BMOD was generally well tolerated, although associated with more reports of nausea than placebo + BMOD. The present findings support the efficacy of combined naltrexone/bupropion therapy as an adjunct to intensive BMOD for obesity.
PMCID: PMC4459776  PMID: 20559296
2.  Promoting Healthy Weight With “Stability Skills First”: A Randomized Trial 
Although behavioral weight-loss interventions produce short-term weight loss, long-term maintenance remains elusive. This randomized trial examined whether learning a novel set of “stability skills” before losing weight improved long-term weight management. Stability skills were designed to optimize individuals’ current satisfaction with lifestyle and self-regulatory habits while requiring the minimum effort and attention necessary.
Overweight/obese women (N = 267) were randomly assigned to one of two 6-month interventions and assessed at baseline, 6, 12, and 18 months. Maintenance First women participated first in an 8-week stability skills maintenance module, then in a standard 20-week behavioral weight-loss program. Weight Loss First women participated first in a standard 20-week behavioral weight-loss program, then in a standard 8-week problem-solving skills maintenance module. There was no intervention staff contact during the 12-month follow-up (6–18 months).
As designed, Maintenance First participants lost the same percent of initial weight during the 6-month intervention period as Weight Loss First participants (M = −8.6%, SD = 5.7 vs. M = −9.1%, SD = 6.9, t = −0.6, p = .52). However, Maintenance First participants regained significantly less weight during the 12-month follow-up (6–18 months) than Weight Loss First participants (M = 3.2 lbs, SD = 10.4 vs. M = 7.3 lbs, SD = 9.9, t = 3.3, p = .001, d = 0.4).
Learning stability skills before losing weight was successful for maintaining weight loss without intervention staff contact during follow-up. These results can inform the study design of future innovative interventions. Trial Registration:
PMCID: PMC4428307  PMID: 23106759
Obesity; weight loss; weight maintenance; long-term; weight stability; randomized trial
3.  Translating Weight Loss and Physical Activity Programs Into the Community to Preserve Mobility in Older, Obese Adults in Poor Cardiovascular Health 
Archives of internal medicine  2011;171(10):880-886.
Limitations in mobility are common among older adults with cardiovascular and cardiometabolic disorders and have profound effects on health and well-being. With the growing population of older adults in the United States, effective and scalable public health approaches are needed to address this problem. Our goal was to determine the effects of a physical activity and weight loss intervention on 18-month change in mobility among overweight or obese older adults in poor cardiovascular health.
The study design was a translational, randomized controlled trial of physical activity (PA) and weight loss (WL) on mobility in overweight or obese older adults with cardiovascular disease (CVD) or at risk for CVD. The study was conducted within the community infrastructure of Cooperative Extension Centers. Participants were randomized to 1 of 3 interventions: PA, WL+PA, or a successful aging (SA) education control arm. The primary outcome was time to complete a 400-m walk in seconds (400MWT).
A significant treatment effect (P=.002) and follow-up testing revealed that the WL+PA group improved their 400MWT (adjusted mean [SE], 323.3 [3.7] seconds) compared with both PA (336.3 [3.9] seconds; P=.02) and SA (341.3 [3.9] seconds; P<.001). Participants with poorer mobility at baseline benefited the most (P<.001).
Existing community infrastructures can be effective in delivering lifestyle interventions to enhance mobility in older adults in poor cardiovascular health with deficits in mobility; attention should be given to intervening on both weight and sedentary behavior since weight loss is critical to long-term improvement in mobility.
PMCID: PMC4425192  PMID: 21263080
4.  Differential Response of African-American and Caucasian Women to Extended-Care Programs for Obesity Management 
Ethnicity & disease  2011;21(2):170-175.
The current study examined racial/ethnic differences in patterns of weight loss and regain in response to an initial behavioral weight loss intervention followed by an extended-care maintenance program.
We analyzed data from 224 women (African-American n = 43, Caucasian n = 181) from rural communities who participated in an initial 6-month lifestyle intervention for obesity and were then randomized to a face-to-face, telephone, or educational/control extended-care condition.
African-American participants lost less weight during the initial phase of treatment than Caucasian participants (mean ± SE = −6.8 ± .80 vs. −10.7 ± .38 kg, respectively, p = .003). Investigating weight change during month 6 to month 18, we found a significant interaction between race/ethnicity and the provision of an extended-care program. Caucasian participants randomized to either of two extended-care programs regained less weight than those assigned to the control condition (1.2 ± .58 and 4.2 ± .79 kg, respectively, p = .003), but the provision of extended care did not influence weight regain among African-American participants (1.9 ± 1.12 and 1.34 ± 2.04 kg, respectively, p = .815).
Collectively, these findings suggest that although African-American participants lost less weight during the initial phase of treatment, they exhibited better long-term weight-loss maintenance than Caucasian participants. Further, while the provision of extended care successfully enhanced weight maintenance among Caucasian participants, African-American participants maintained their initial weight losses regardless of extended care.
PMCID: PMC3772655  PMID: 21749020
Weight Loss; Weight Regain; Race; Racial Difference; Lifestyle Intervention
5.  Treatment of Obesity in Underserved Rural Settings (TOURS): A Randomized Trial of Extended-Care Programs for Weight Management 
Archives of internal medicine  2008;168(21):2347-2354.
Rural counties in the U.S. have higher rates of obesity, sedentary lifestyle, and associated chronic diseases than non-rural areas, yet the management of obesity in rural communities has received little attention from researchers.
To compare 2 extended-care programs for weight management with an education control group.
Design, Setting, and Participants
234 obese women from rural communities who completed an initial 6-month weight-loss program were randomized to extended-care, delivered via telephone counseling or face-to-face sessions, or to an education control group. Cooperative Extension Service offices in six medically underserved rural counties served as venues for the trial. The study was conducted from June 2003 to May 2007.
The extended-care programs entailed problem-solving counseling delivered in 26 biweekly sessions. Control group participants received 26 biweekly newsletters containing weight-control advice.
Main Outcome Measure
Change in weight from randomization.
Mean weight at study entry was 96.4 kg. Mean weight loss during the initial 6-month intervention was 10.0 kg. One year after randomization, participants in the telephone and face-to-face conditions regained less weight (means ± SE = 1.3 ± 0.7 and 1.2 ± 0.6 kg, respectively) than those in the education control group (3.7 ± 0.6 kg; Ps = 0.02 and 0.03). The beneficial effects of extended-care counseling were mediated by greater adherence to behavioral weight-management strategies, and cost analyses indicated that telephone counseling was less expensive than face-to-face intervention.
Extended care delivered either by telephone or face-to-face sessions improved the one-year maintenance of lost weight compared to education alone. Telephone counseling constitutes an effective and cost-efficient option for long-term weight management. Delivering lifestyle interventions via the existing infrastructure of the Cooperative Extension Service represents a viable means of research translation into rural communities with limited access to preventive health services.
Trial Registration number, NCT00201006.
PMCID: PMC3772658  PMID: 19029500
6.  Protocol and Recruitment Results from a Randomized Controlled Trial Comparing Group Phone-Based versus Newsletter Interventions for Weight Loss Maintenance among Rural Breast Cancer Survivors 
Contemporary clinical trials  2014;37(2):261-271.
Obesity is a risk factor for breast cancer recurrence and death. Women who reside in rural areas have higher obesity prevalence and suffer from breast cancer treatment-related disparities compared to urban women. The objective of this 5-year randomized controlled trial is to compare methods for delivering extended care for weight loss maintenance among rural breast cancer survivors. Group phone-based counseling via conference calls addresses access barriers, is more cost-effective than individual phone counseling, and provides group support which may be ideal for rural breast cancer survivors who are more likely to have unmet support needs. Women (n = 210) diagnosed with Stage 0 to III breast cancer in the past 10 years who are ≥ 3 months out from initial cancer treatments, have a BMI 27–45 kg/m2, and have physician clearance were enrolled from multiple cancer centers. During Phase I (months 0 to 6), all women receive a behavioral weight loss intervention delivered through group phone sessions. Women who successfully lose 5% of weight enter Phase II (months 6 to 18) and are randomized to one of two extended care arms: continued group phone-based treatment or a mail-based newsletter. During Phase III, no contact is made (months 18 to 24). The primary outcome is weight loss maintenance from 6 to 18 months. Secondary outcomes include quality of life, serum biomarkers, and cost-effectiveness. This study will provide essential information in how to reach rural survivors in future efforts to establish weight loss support for breast cancer survivors as a standard of care.
PMCID: PMC3992482  PMID: 24486636
breast cancer; obesity; behavioral weight control; rural; quality of life
7.  Cynicism: Incident diabetes and worsening of metabolic syndrome in postmenopausal women 
Diabetes & metabolic syndrome  2010;4(4):187-189.
To determine if self-reported cynical hostility predicted incident diabetes or increase in number of symptoms associated with metabolic syndrome in postmenopausal women.
Prospective study of a subsample of women (n = 3,658) participating in the Women's Health Initiative Clinical Trial.
Subjects: Postmenopausal women aged 50 to 79 years at baseline who were enrolled in the Women's Health Initiative Dietary Modification Trial, Hormone Trial or both. Measures: The Cynicism subscale of the Cook-Medley Hostility Questionnaire was used to assess cynical hostility at baseline. Incident diabetes was ascertained by self-report of treatment with insulin or oral hypoglycemic medication at one year. Metabolic syndrome was defined based on number of Adult Treatment Panel (ATP) III criteria met at one year. Statistical Analysis: The relationship between baseline cynical hostility and incident diabetes and worsening of metabolic syndrome was assessed from baseline to one year using multivariable Cox proportional hazards models and multivariable logistic regression models, respectively.
Incident diabetes was 36% higher among women in the upper tertile for baseline cynical hostility compared to the lowest tertile (p-trend = 0.05). The odds of a worsening of metabolic syndrome was 27% greater in the highest cynical hostility tertile compared to the lowest tertile (p-trend = 0.04).
Cynical hostility may increase the risk for developing diabetes and worsening of the metabolic syndrome in postmenopausal women.
PMCID: PMC4317350  PMID: 25663951
Diabetes; Metabolic syndrome; Mood; Cynicism; Cynical hostility; Postmenopausal women
8.  Effect of Dietary Restriction and Exercise on Lower Extremity Tissue Compartments in Obese, Older Women: A Pilot Study 
Accumulating evidence suggests that both dietary restriction and exercise (DR + E) should be incorporated in weight loss interventions to treat obese, older adults. However, more information is needed on the effects to lower extremity tissue composition—an important consideration for preserving mobility in older adults.
Twenty-seven sedentary women (body mass index: 36.3±5.4kg/m2; age: 63.6±5.6 yrs) were randomly assigned to 6 months of DR + E or a health education control group. Thigh and calf muscle, subcutaneous adipose tissue (SAT), and intermuscular adipose tissue (IMAT) size were determined using magnetic resonance imaging. Physical function was measured using a long-distance corridor walk and knee extension strength.
Compared with control, DR + E significantly reduced body mass (-6.6±3.7kg vs control: -0.05±3.5kg; p < .01). Thigh and calf muscle volumes responded similarly between groups. Within the DR + E group, adipose tissue was reduced more in the thigh than in the calf (p < .04). Knee extension strength was unaltered by DR + E, but a trend toward increased walking speed was observed in the DR + E group (p = .09). Post hoc analyses showed that reductions in SAT and IMAT within the calf, but not the thigh, were associated with faster walking speed achieved with DR + E (SAT: r = -0.62; p = .01; IMAT: r = -0.62; p = .01).
DR + E preserved lower extremity muscle size and function and reduced regional lower extremity adipose tissue. Although the magnitude of reduction in adipose tissue was greater in the thigh than the calf region, post hoc analyses demonstrated that reductions in calf SAT and IMAT were associated with positive adaptations in physical function.
PMCID: PMC4158399  PMID: 23682155
Body composition; Weight loss; Obesity; Aging; Disability.
9.  Benefits and risks of weight-loss treatment for older, obese women 
A key issue in the treatment of obesity in older adults is whether the health benefits of weight loss outweigh the potential risks with respect to musculoskeletal injury.
To compare change in weight, improvements in metabolic risk factors, and reported musculoskeletal adverse events in middle-aged (50–59 years) and older (65–74 years), obese women.
Materials and methods
Participants completed an initial 6-month lifestyle intervention for weight loss, comprised of weekly group sessions, followed by 12 months of extended care with biweekly contacts. Weight and fasting blood samples were assessed at baseline, month 6, and month 18; data regarding adverse events were collected throughout the duration of the study.
Both middle-aged (n = 162) and older (n = 56) women achieved significant weight reductions from baseline to month 6 (10.1 ± 0.68 kg and 9.3 ± 0.76 kg, respectively) and maintained a large proportion of their losses at month 18 (7.6 ± 0.87 kg and 7.6 ± 1.3 kg, respectively); there were no significant differences between the two groups with respect to weight change. Older women further experienced significant reductions in systolic blood pressure, HbA1c, and C-reactive protein from baseline to month 6 and maintained these improvements at month 18. Despite potential safety concerns, we found that older women were no more likely to experience musculoskeletal adverse events during the intervention as compared with their middle-aged counterparts.
These results suggest that older, obese women can experience significant health benefits from lifestyle treatment for obesity, including weight loss and improvements in disease risk factors. Further investigation of the impact of weight loss on additional health-related parameters and risks (eg, body composition, muscular strength, physical functioning, and injuries) in older adults is needed.
PMCID: PMC3573815  PMID: 23430455
lifestyle intervention; adverse events; metabolic risk factors
10.  Modifications in parent feeding practices and child diet during family-based behavioral treatment improve child zBMI 
Obesity (Silver Spring, Md.)  2014;22(5):E119-E126.
To examine associations between modifications in parent feeding practices, child diet, and child weight status after treatment and to evaluate dietary mediators.
Design and Methods
Children classified as overweight or obese and 7-11 years old (N=170) completed a 16-session family-based behavioral treatment program (FBT). Anthropometrics (standardized body mass index (zBMI)), Child Feeding Questionnaire, and 24-hr dietary recalls were collected at baseline and post-FBT. Linear regression predicted child zBMI change. Single and multiple mediation tested child dietary modifications as mediators between change in parent feeding practices and child zBMI.
Restrictive parent feeding practices significantly decreased during FBT. Reductions in parent restriction, child weight concern, child total energy intake, and percent energy from fat, and increases in parent perceived responsibility, and child percent energy from protein, predicted reductions in child zBMI. Change in child total energy intake mediated the relation between parent restriction and child zBMI change after accounting for covariates and additional dietary mediators.
FBT is associated with a decrease in parental restriction, which is associated with reductions in child relative weight, which was mediated by a decrease in child energy intake. Teaching parents to reduce children's energy intake without being overly restrictive may improve child weight.
PMCID: PMC4111631  PMID: 24458836
childhood obesity; parents; eating behaviors; weight loss
11.  A randomized trial comparing weight loss treatment delivered in large versus small groups 
Behavioral interventions for obesity are commonly delivered in groups, although the effect of group size on weight loss has not been empirically evaluated. This behavioral weight loss trial compared the 6- and 12-month weight changes associated with interventions delivered in a large group (LG) or small groups (SG).
Obese adults (N = 66; mean age = 50 years; mean BMI = 36.5 kg/m2; 47% African American; 86% women) recruited from a health maintenance organization were randomly assigned to: 1) LG treatment (30 members/group), or 2) SG treatment (12 members/group). Conditions were comparable in frequency and duration of treatment, which included 24 weekly group sessions (months 1–6) followed by six monthly extended care contacts (months 7–12). A mixed effects model with unstructured covariance matrix was applied to analyze the primary outcome of weight change while accounting for baseline weight and dependence among participants’ measurements over time.
SG participants lost significantly more weight than LG participants at Month 6 (−6.5 vs. -3.2 kg; p = 0.03) and Month 12 (−7.0 vs. -1.7 kg; p < 0.002). SG participants reported better treatment engagement and self-monitoring adherence at Months 6 and 12, ps < 0.04, with adherence fully mediating the relationship between group size and weight loss.
Receiving obesity treatment in smaller groups may promote greater weight loss and weight loss maintenance. This effect may be due to improved adherence facilitated by SG interactions. These novel findings suggest that the perceived efficiency of delivering behavioral weight loss treatment to LGs should be balanced against the potentially better outcomes achieved by a SG approach.
PMCID: PMC4180323  PMID: 25249056
Weight loss; Group size; Lifestyle intervention; Randomized trial
12.  How Much Walking Is Needed To Improve Cardiorespiratory Fitness? An Examination of the 2007 ACSM/AHA Physical Activity Recommendations 
The 2007 American College of Sports Medicine (ACSM) and the American Heart Association (AHA) physical activity guidelines recommend adults engage in either 150 minutes of moderate intensity or 60 minutes of vigorous intensity physical activity per week to derive health benefits.
In a 6-month clinical trial, we examined whether walking programs of moderate (leisurely-paced) and vigorous (fast-paced) intensity produced improvements in cardiorespiratory fitness as predicted by the ACSM/AHA guidelines.
Participants (N = 155) were instructed to walk 30 minutes per day on 5 or more days per week, at either a moderate or vigorous intensity level (45–55% or 65–75% of maximum heart rate reserve [HRres ], respectively). Within each condition, we categorized participants based on their mean weekly amounts of exercise as reflected in written self-monitoring logs. Fitness was assessed by a maximal graded exercise test at pre- and post-treatment. This trial was conducted in Gainesville, FL between 1999 and 2003.
Mean minutes of walking were related to changes in cardiorespiratory fitness in the vigorous (r = .47; p = < .001) but not moderate intensity condition (r = .07; p = .52). Within the vigorous intensity condition, significantly greater improvements in fitness were achieved by participants with high and medium amounts of accumulated exercise compared with those with low amounts of exercise.
Clinically meaningful improvements in cardiorespiratory fitness were observed in participants who walked a minimum of 60 minutes per week at a fast-pace but not those who walked at a leisurely-pace. These findings support the 2007 ACSM/AHA physical activity recommendations regarding vigorous, but not moderate, intensity physical activity for cardiorespiratory fitness.
PMCID: PMC4126169  PMID: 21699118
walking; exercise intensity; intensity; fitness; physical activity; physical activity guidelines
13.  Successful long-term weight loss maintenance in a rural population 
Few investigations of successful long-term weight loss beyond two years have been conducted, and none has examined weight changes in medically underserved rural populations of older adults. The purpose of this study was to assess long-term weight loss maintenance 3.5 years after the completion of an initial six-month lifestyle intervention for obesity among women aged 50–75 years residing in rural communities.
One hundred and ten obese women with a mean (± standard deviation) age of 60.08 ± 6.17 years and mean body mass index of 36.76 ± 5.10 kg/m2 completed an in-person assessment during which their weight and adherence to behavioral weight management strategies were evaluated.
Participants showed a mean weight reduction of 10.17% ± 5.0% during the initial six- month intervention and regained 6.95% ± 9.44% from the completion of treatment to follow-up assessment 3.5 years later. A substantial proportion of participants (41.80%) were able to maintain weight reductions of 5% or greater from baseline to follow-up. “Successful” participants (those who maintained losses of 5% or greater at follow-up) reported weighing themselves, self-monitoring their intake and calories, planning meals in advance, and choosing lower calorie foods with greater frequency than “unsuccessful” participants (those who lost less than 5%).
Collectively, these findings indicate that a large proportion of participants were able to maintain clinically significant weight losses for multiple years after treatment, and that self-monitoring was a key component of successful long-term weight management.
PMCID: PMC3230584  PMID: 22162646
obesity; weight loss; weight maintenance; lifestyle intervention; rural; health disparities
14.  Problem Solving, Treatment Adherence, and Weight-Loss Outcome Among Women Participating in Lifestyle Treatment for Obesity 
Eating behaviors  2009;10(3):146-151.
This study examined whether improvements in problem-solving abilities mediate the relation between treatment adherence and weight-loss outcome in the behavioral treatment of obesity.
272 women (mean ± SD age = 59.4 ± 6.2 years, BMI = 36.5 ± 4.8) participated in a 6-month lifestyle intervention for obesity. Body weight and problem-solving skills (as measured by the Social Problem Solving Inventory—Revised) were assessed pre- and posttreatment. The completion of self-monitoring logs during the intervention served as the marker of treatment adherence.
At posttreatment, participants lost 8.4 ± 5.8 kg, an 8.8% reduction in body weight. Changes in weight were associated with increased problem-solving skills and with higher levels of treatment adherence. Improvements in problem-solving skills partially mediated the relation between treatment adherence and weight-loss outcome. Moreover, participants with weight reductions > 10% demonstrated significantly greater improvements in problem-solving skills than those with reductions < 5%.
Improvements in problem-solving skills may enable participants to overcome barriers to adherence and thereby enhance treatment-induced weight losses.
PMCID: PMC2726832  PMID: 19665096
Obesity; Weight Loss; Problem-Solving; Adherence; Self-Monitoring
15.  Bayesian Inference for the Causal Effect of Mediation 
Biometrics  2012;68(4):1028-1036.
We propose a nonparametric Bayesian approach to estimate the natural direct and indirect effects through a mediator in the setting of a continuous mediator and a binary response. Several conditional independence assumptions are introduced (with corresponding sensitivity parameters) to make these effects identifiable from the observed data. We suggest strategies for eliciting sensitivity parameters and conduct simulations to assess violations to the assumptions. This approach is used to assess mediation in a recent weight management clinical trial.
PMCID: PMC3927554  PMID: 23005030
16.  The Contributions of Weight Loss and Increased Physical Fitness to Improvements in Health-Related Quality of Life 
Eating behaviors  2008;10(2):84-88.
The relative contribution of obesity versus poor fitness to adverse health outcomes and diminished quality of life remains an area of controversy. Indeed, some researchers contend that poor cardiorespiratory fitness represents a greater threat to health and health-related quality of life than excess body weight. We addressed this issue by providing 298 obese 50–75 year-old women with a six-month lifestyle intervention that incorporated a low-calorie eating pattern coupled with an aerobic exercise program consisting of 30 min/day of brisk walking. The results showed that weight loss exhibited a significant individual contribution to improvements in seven of the nine domains of quality of life assessed by the Medical Outcomes Study Short Form (SF-36). With the exception of physical functioning, however, physical fitness did not significantly contribute to improvements beyond the effects weight loss. Moreover, weight loss functioned as a full mediator of the association between increases in physical fitness and improvements in general health, vitality, and change in health relative to the previous year. Collectively, these findings suggest that for treatment-seeking obese individuals, weight loss rather than increased fitness contributes significantly to improvements in health-realted quality of life.
PMCID: PMC2720563  PMID: 19447349
Obesity; Health Related Quality of Life; Physical Fitness; Weight Loss
17.  Prevalence of Obesity Among Adults From Rural and Urban Areas of the United States: Findings From NHANES (2005–2008) 
Rural residents have higher rates of chronic diseases compared to their urban counterparts, and obesity may be a major contributor to this disparity. This study is the first analysis of obesity prevalence in rural and urban adults using body mass index classification with measured height and weight. In addition, demographic, diet, and physical activity correlates of obesity across rural and urban residence are examined.
Analysis of body mass index (BMI), diet, and physical activity from 7,325 urban and 1,490 rural adults in the 2005–2008 National Health and Nutrition Examination Survey (NHANES).
The obesity prevalence was 39.6% (SE = 1.5) among rural adults compared to 33.4% (SE = 1.1) among urban adults (P = .006). Prevalence of obesity remained significantly higher among rural compared to urban adults controlling for demographic, diet, and physical activity variables (odds ratio = 1.18, P = .03). Race/ethnicity and percent kcal from fat were significant correlates of obesity among both rural and urban adults. Being married was associated with obesity only among rural residents, whereas older age, less education, and being inactive was associated with obesity only among urban residents.
Obesity is markedly higher among adults from rural versus urban areas of the United States, with estimates that are much higher than the rates suggested by studies with self-reported data. Obesity deserves greater attention in rural America.
PMCID: PMC3481194  PMID: 23083085
epidemiology; health disparities; obesity; rural; social determinants of health
18.  Comparison of Program costs for Parent-Only and Family-Based Interventions for Pediatric Obesity in Medically Underserved Rural settings 
To compare the costs of parent-only and family-based group interventions for childhood obesity delivered through Cooperative Extension Services in rural communities.
Ninety-three ovenueight or obese children (aged 8 to 14 years) and their parent(s) participated in this randomized controlled trial, which included a 4-month intervention and 6-month follow-up. Families were randomized to either a behavioral family-based intervention (n = 33), a behavioral parent-only intervention (n = 34), or a waitlist control condition (n = 26). Only program costs data for the parent-only and family-based programs are reported here (n = 67). Assessments were completed at baseline, post-treatment (month 4) and follow-up (month 10). The primary outcome measures were total program costs and cost per child for the parent-only and family interventions.
Twenty-six families in the parent-only intervention and 24 families in the family intervention completed all 3 assessments. As reported previously, both intervention programs led to significantly greater decreases in weight status relative to the control condition at month 10 follow-up. There was no significant difference in weight status change between the parent-only and family interventions. Total program costs for the parent-only and family interventions were $13,546 and $20,928, respectively. Total cost per child for the parent-only and family interventions were $521 and $872, respectively.
Parent-only interventions may be a cost-effective alternative treatment for pediatric obesity, especially for families in medically underserved settings.
PMCID: PMC3782094  PMID: 19566621
19.  Comparison of Parent-Only vs Family-Based Interventions for Overweight Children in Underserved Rural Settings 
To assess the effectiveness of parent-only vs family-based interventions for pediatric weight management in underserved rural settings.
A 3-arm randomized controlled clinical trial.
All sessions were conducted at Cooperative Extension Service offices in underserved rural counties.
Ninety-three overweight or obese children (8–14 years old) and their parent(s).
Families were randomized to (1) a behavioral family-based intervention, (2) a behavioral parent-only intervention, or (3) a wait-list control group.
Outcome Measure
The primary outcome measure was change in children’s standardized body mass index (BMI).
Seventy-one children completed posttreatment (month 4) and follow-up (month 10) assessments. At the month 4 assessment, children in the parent-only intervention demonstrated a greater decrease in BMI z score (mean difference [MD], 0.127; 95% confidence interval [CI], 0.027 to 0.226) than children in the control condition. No significant difference was found between the family-based intervention and the control condition (MD, 0.065; 95% CI, −0.027 to 0.158). At month 10 follow-up, children in the parent-only and family-based intervention groups demonstrated greater decreases in BMI z score from before treatment compared with those in the control group (MD, 0.115; 95% CI, 0.003 to 0.220; and MD, 0.136; 95% CI, 0.018 to 0.254, respectively). No difference was found in weight status change between the parent-only and family-based interventions at either assessment.
A parent-only intervention may be a viable and effective alternative to family-based treatment of childhood overweight. Cooperative Extension Service offices have the potential to serve as effective venues for the dissemination of obesity-related health promotion programs.
PMCID: PMC3782102  PMID: 19047538
20.  The Association Between Rate of Initial Weight Loss and Long-Term Success in Obesity Treatment: Does Slow and Steady Win the Race? 
Controversy exists regarding the optimal rate of weight loss for long-term weight management success.
This study examined whether gradual initial weight loss was associated with greater long-term weight reduction than rapid initial loss.
Groups were drawn from participants in the TOURS trial, which included a sample of middle-aged (mean =59.3 years) obese women (mean BMI =36.8) who received a 6-month lifestyle intervention followed by a 1-year extended care program. Participants were encouraged to reduce caloric intake to achieve weight losses of 0.45 kg/ week. Groups were categorized as “FAST” (≥0.68 kg/week, n=69), “MODERATE” (≥0.23 and <0.68 kg/week, n= 104), and “SLOW” (<0.23 kg/week, n=89) based on rate of weight loss during first month of treatment.
The FAST, MODERATE, and SLOW groups differed significantly in mean weight changes at 6 months (−13.5, −8.9, and −5.1 kg, respectively, ps <0.001), and the FAST and SLOW groups differed significantly at 18 months (−10.9, −7.1, and −3.7 kg, respectively, ps <0.001). No significant group differences were found in weight regain between 6 and 18 months (2.6, 1.8, and 1.3 kg, respectively, ps < 0.9). The FAST and MODERATE groups were 5.1 and 2.7 times more likely to achieve 10% weight losses at 18 months than the SLOW group.
Collectively, findings indicate both short- and long-term advantages to fast initial weight loss. Fast weight losers obtained greater weight reduction and long-term maintenance, and were not more susceptible to weight regain than gradual weight losers.
PMCID: PMC3780395  PMID: 20443094
Obesity; Weight loss; Lifestyle modification
21.  Comparing Costs of Telephone versus Face-to-Face Extended Care Programs for the Management of Obesity in Rural Settings 
A major challenge following successful weight loss is continuing the behaviors required for long-term weight maintenance. This challenge may be exacerbated in rural areas with limited local support resources.
This study describes and compares program costs and cost-effectiveness for 12-month extended care lifestyle maintenance programs following an initial 6-month weight loss program.
A 1-year prospective controlled randomized clinical trial.
The study included 215 female participants age 50 or older from rural areas who completed an initial 6-month lifestyle program for weight loss. The study was conducted from June 1, 2003, to May 31, 2007.
The intervention was delivered through local Cooperative Extension Service offices in rural Florida. Participants were randomly-assigned to a 12-month extended care program using either individual telephone counseling (n=67), group face-to-face counseling (n=74), or a mail/control group (n=74).
Main Outcome Measures
Program delivery costs, weight loss, and self-reported health status were directly assessed through questionnaires and program activity logs. Costs were estimated across a range of enrollment sizes to allow inferences beyond the study sample.
Statistical Analyses Performed
Non-parametric and parametric tests of differences across groups for program outcomes were combined with direct program cost estimates and expected value calculations to determine which scales of operation favored alternative formats for lifestyle maintenance.
Median weight regain during the intervention year was 1.7 kg for participants in the face-to-face format, 2.1 kg for the telephone format, and 3.1 kg for the mail/control format. For a typical group size of 13 participants, the face-to-face format had higher fixed costs, which translated into higher overall program costs ($420 per participant) when compared to individual telephone counseling ($268 per participant) and control ($226 per participant) programs. While the net weight lost after the 12-month maintenance program was higher for the face-to-face and telephone programs compared to the control group, the average cost per expected kilogram of weight lost was higher for the face-to-face program ($47/kg) compared to the other two programs (approximately $33/kg for telephone and control).
Both the scale of operations and local demand for programs are important considerations in selecting a delivery format for lifestyle maintenance. In this study, the telephone format had a lower cost, but similar outcomes compared to the face-to-face format.
PMCID: PMC3432696  PMID: 22818246
Obesity; cost-effectiveness; randomized trial; rural health
22.  Outcomes of a Weight Loss Intervention among Rural Breast Cancer Survivors 
Obese breast cancer survivors have increased risk of recurrence and death compared to their normal weight counterparts. Rural women have significantly higher obesity rates, thus weight control intervention may be a key strategy for prevention of breast cancer recurrence in this population. This one arm treatment study examined the impact of a group-based weight control intervention delivered through conference call technology to obese breast cancer survivors living in remote rural locations. The intervention included a reduced calorie diet incorporating prepackaged entrees and shakes, physical activity gradually increased to 225 min/week of moderate intensity exercise, and weekly group phone sessions. Outcomes included anthropomorphic, diet, physical activity, serum biomarker, and quality of life changes. Ninety-one percent of participants (31 of 34) attended > 75% of intervention sessions and completed post-treatment data collection visits. At 6 months, significant changes were observed for weight (-12.5 ± 5.8 kg, 13.9% of baseline weight), waist circumference (-9.4 ± 6.3 cm), daily energy intake (-349 ± 550 kcal/day), fruits and vegetables (+3.7 ± 4.3 servings/day), percent kcal from fat (-12.6 ± 8.6%), physical activity (+1235 ± 832 kcal/week; all p’s < .001), as well as significant reductions in fasting insulin (16.7% reduction, p = .006) and leptin (37.1% reduction, p < .001). Significant improvements were also seen for quality of life domains including mood, body image, and sexuality. In conclusion, the intervention produced > 10% weight loss as well as significant improvements across multiple endpoints. The group phone-based treatment delivery approach may help disseminate effective weight control intervention to hard-to-reach breast cancer survivors.
PMCID: PMC3314288  PMID: 22198470
breast cancer; survivors; rural; weight control; physical activity
23.  Behavioral Economic Predictors of Overweight Children’s Weight Loss 
Our goal was to determine whether behavioral economic constructs—including impulsivity (i.e., steep discounting of delayed food and monetary rewards), the relative reinforcing value of food (RRVfood), and environmental enrichment (i.e., the presence of alternatives to unhealthy foods in the home and neighborhood environments)—are significant pretreatment predictors of overweight children’s weight loss within family-based treatment.
Overweight children (N = 241; ages 7–12 years; 63% female; 65% non-Hispanic White) enrolled in a 16-week family-based obesity treatment with at least one parent. At baseline, children completed a task to assess RRVfood and delay discounting measures of snack foods and money to assess impulsivity. Parents completed questionnaires to assess environmental enrichment.
Children who found food highly reinforcing and steeply discounted future food rewards at baseline showed a blunted response to treatment compared with children without this combination of risk factors. High environmental enrichment was associated with treatment success only among children who did not find food highly reinforcing. Monetary discounting rate predicted weight loss, regardless of children’s level of RRVfood.
Investigation is warranted into novel approaches to obesity treatment that target underlying impulsivity and RRVfood. Enriching the environment with alternatives to unhealthy eating may facilitate weight loss, especially for children with low RRVfood.
PMCID: PMC3514606  PMID: 22924332
pediatric obesity treatment; impulsivity; reinforcing value of food; environmental enrichment
24.  An Exploratory Analysis of the Effects of a Weight Loss Plus Exercise Program on Cellular Quality Control Mechanisms in Older Overweight Women 
Rejuvenation Research  2011;14(3):315-324.
Obese older adults are particularly susceptible to sarcopenia and have a higher prevalence of disability than their peers of normal weight. Interventions to improve body composition in late life are crucial to maintaining independence. The main mechanisms underlying sarcopenia have not been determined conclusively, but chronic inflammation, apoptosis, and impaired mitochondrial function are believed to play important roles. It has yet to be determined whether impaired cellular quality control mechanisms contribute to this process. The objective of this study was to assess the effects of a 6-month weight loss program combined with moderate-intensity exercise on the cellular quality control mechanisms autophagy and ubiquitin-proteasome, as well as on inflammation, apoptosis, and mitochondrial function, in the skeletal muscle of older obese women. The intervention resulted in significant weight loss (8.0 ± 3.9 % vs. 0.4 ± 3.1% of baseline weight, p = 0.002) and improvements in walking speed (reduced time to walk 400 meters, − 20.4 ± 16% vs. − 2.5 ± 12%, p = 0.03). In the intervention group, we observed a three-fold increase in messenger RNA (mRNA) levels of the autophagy regulators LC3B, Atg7, and lysosome-associated membrane protein-2 (LAMP-2) compared to controls. Changes in mRNA levels of FoxO3A and its targets MuRF1, MAFBx, and BNIP3 were on average seven-fold higher in the intervention group compared to controls, but these differences were not statistically significant. Tumor necrosis factor-α (TNF-α) mRNA levels were elevated after the intervention, but we did not detect significant changes in the downstream apoptosis markers caspase 8 and 3. Mitochondrial biogenesis markers (PGC1α and TFAm) were increased by the intervention, but this was not accompanied by significant changes in mitochondrial complex content and activity. In conclusion, although exploratory in nature, this study is among the first to report the stimulation of cellular quality control mechanisms elicited by a weight loss and exercise program in older obese women.
PMCID: PMC3136739  PMID: 21631380
25.  The Extension Family Lifestyle Intervention Project (E-FLIP for Kids): Design and Methods 
Contemporary clinical trials  2010;32(1):50-58.
The Extension Family Lifestyle Intervention Project (E-FLIP for Kids) is a three-arm, randomized controlled trial assessing the effectiveness of two behavioral weight management interventions in an important and at-risk population, overweight and obese children and their parents in rural counties.
Participants will include 240 parent-child dyads from nine rural counties in north central Florida. Dyads will be randomized to one of three conditions: (a) a Family-Based Behavioral Group Intervention, (b) a Parent-Only Behavioral Group Intervention, and (c) an Education Control Condition. Child and parent participants will be assessed at baseline (month 0), post-treatment (month 12) and follow-up (month 24). Assessment and intervention sessions will be held at Cooperative Extension Service offices within each participating county. The primary outcome measure is change in child BMI z-score. Additional key outcome measures include child body fat, waist circumference, dietary intake, physical activity, blood lipids, blood glucose, blood pressure, physical fitness, quality of life, and program and participants costs. Parent BMI, dietary intake, and physical activity also will be assessed.
Randomized controlled trials testing the effectiveness of childhood obesity interventions in real-world community-based settings are extremely valuable, but much too rare. The E-FLIP for Kids trial will evaluate the impact of a community based intervention delivered to families in rural settings utilizing the existing Cooperative Extension Service network on long-term child behavior, weight status and biological markers of diabetes and early cardiovascular disease. If successful, a Parent-Only intervention program may provide a cost-effective and practical intervention for families in underserved rural communities.
PMCID: PMC3006088  PMID: 20708715
Obesity; Children; Behavioral Intervention; Treatment; Randomized Controlled Trial

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