Park (2011) has opined that prevention can be accomplished even when a disease has advanced beyond its early stages into its late pathogenesis phase(Park, 2011). In rural America, obesity is more prevalent than in urban areas. As these areas are medically underserved, strategies to produce weight loss and improve health have not been implemented and supported here. The authors of this paper implemented a study comparing the effectiveness of three regimens of weight loss counseling sessions administered over a two-year period to a rural community in Northern Florida. They advocated a moderate prevention strategy in between what was traditionally practiced in primary health care settings (low intensity interventions) and the efficacy trials (high intensity interventions. They hypothesized that interventions of moderate intensity(24 sessions) would demonstrate higher, sustainable levels of weight loss as compared to low ( 16 sessions) or the high (48 sessions) interventions , at a lower cost(Michael G Perri et al., 2014)
There were 612 adults between the ages of 21-75 who participated in the study, with a BMI in the range of ≥ 30 and of ≤ 45 kg/m2,Confounders were controlled by removing patients with co-morbidities like hypertension, diabetes mellitus, cardiovascular disease, and renal/hepatic disease from the study group. 10 rural areas of Northern Florida were selected because they were identified to have a shortage of health professionals. In these counties, all households received study announcement mails, in response to which 1072 adults attended an orientation /screening session, where details about the research were provided and informed consent taken. During this screening visit, baseline investigations and a medical history were recorded. Outcomes studied (dependent variables): The percentage change in body weight from baseline to study completion at 24 months’ was taken as the primary outcome. Secondary outcomes studied were the percent of study participants who achieved weight reductions of ≥ 5% and the cost and cost effectiveness of each treatment in the 24-month period. The participants were classified into three groups LOW, MOD, HIGH, and control groups, randomly. The design used for the study was interventional. Chi-square and ANOVA tests were used at baseline to assess differences between the categories at baseline. Bayesian models were used for the analyses of weight changes and the percentages of groups achieving 5% weight loss. Various study costs were assessed like value of staff time for training and program delivery, rentals, telephone calls, program manuals, intervention materials etc.
Each intervention group (LOW, MOD and HIGH) was provided a calorie intake based on the weights of the participants -1200 kcal/day for < 114 kg, 1500 kcal/day 114-136 kg, and 1800 kcal/day >136kgs. The participants in each of these groups had to walk 30 minutes more than their baseline levels of walking per day. They were advised on goal setting, behavior modification, stimulus control, cognitive restructuring and problem solving methods. The LOW group had 8 sessions of each of these interventions, the MOD group had 16 sessions and the HIGH group had 24 sessions each. The CONTROL group participants were given 8 sessions of talks on proper diet and exercise for weight management, 8 sessions of lectures on topics relevant to nutrition , physical activity and diet, and 8 sessions of group discussions of how the information provided to them was relevant to health and weight management.
The percentage of individuals who achieved ≥ 5% weight loss at 6 months were 45%, 63%, 75% and 81% for the CONTROL, LOW, MOD and HIGH groups respectively. At 24 months (study completion), the ≥ 5% weight loss seen in each of these groups was 40%, 43%, 58% and 58% respectively. The program costs and cost per participant were the lowest in the MOD group in terms of the cost per kg of weight loss per participant.
This study proved what other studies like the efficacy trials had proved before that when behavioral management of obesity produces meaningful changes in weight. The study proved the hypothesis that the dose and cost of treatment can be significantly reduced with almost the same the percentage of individuals who achieve meaningful weight losses over a long term. At 6 months, all three behavioral intervention category participants showed larger mean weight loss as compared to the CONTROL group. The CONTROL group participants too showed ≥ 5% weight reductions showing that an 8 session educational program of weight management methods produces meaningful benefits for a large number of participants. If the number of sessions of behavior treatment was increased from 8 to 16, there was a significantly larger reduction in weight. So much of a difference was not noted if the number of sessions was increased from 16 to 24. Perri et al(1989) had conducted an earlier study whose results were different from the results of this study(M G Perri, Nezu, Patti, & McCann, 1989). The 2-year mean weight reduction of 6.7% of body weight in the MOD group is similar to the 2 year mean weight reductions seen in efficacy trials conducted in urban and academic centers. At 24 months, the LOW and CONTROL groups did not show as much of weight loss as the MOD and HIGH groups, revealing that reinforcement of behavioral changes is needed for sustaining weight loss over prolonged periods. Perri et al(2008) have later shown that the primary and secondary outcomes of the MOD and HIGH groups at 6 or 24 months were not significantly different, meaning that the high treatment doses can be reduced with the same results in the same period of time(Michael G Perri et al., 2008). Even though the total program costs and costs per participant showed the CONTROL group having the lowest costs followed by the LOW, MOD and HIGH groups, when costs were calculated as cost per kg lost per participant, the MOD treatment group was the most cost efficient one.
About 20% of study participants were lost to follow-up during the 2-year study period. Highly trained and educated people administered the study, care of which type is not available in usual rural settings.
Though knowledge and awareness about obesity management is common, its dissemination and application in rural settings is modest because of poor infrastructure in these areas. LOW dose care as is administered for weight loss management in primary health care settings is less effective and less cost effective than moderate dose treatment. Perri et al (2014) opine that the findings of this study are important for policy makers to design obesity interventions in rural, poorly served areas(Michael G Perri et al., 2014).
References
Park, K. (2011). Park’s Textbook of Preventive and Social Medicine 21 Edition by K. PARK. Retrieved November 26, 2014, from http://www.goodreads.com/book/show/16247589-park-s-textbook-of-preventive-and-social-medicine-21-edition
Perri, M. G., Limacher, M. C., Durning, P. E., Janicke, D. M., Lutes, L. D., Bobroff, L. B., Martin, A. D. (2008). Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial. Archives of Internal Medicine, 168(21), 2347–54. doi:10.1001/archinte.168.21.2347
Perri, M. G., Limacher, M. C., von Castel-Roberts, K., Daniels, M. J., Durning, P. E., Janicke, D. M., Martin, a D. (2014). Comparative effectiveness of three doses of weight-loss counseling: Two-year findings from the rural LITE trial. Obesity (Silver Spring, Md.), 22(11), 2293–300. doi:10.1002/oby.20832
Perri, M. G., Nezu, A. M., Patti, E. T., & McCann, K. L. (1989). Effect of length of treatment on weight loss. Journal of Consulting and Clinical Psychology, 57(3), 450–2. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2500466
