TITLE OF YOUR - UW-Stout · successful weight loss is lacking. ... rise; this includes money spent on gym memberships, over-the-counter diet pills and supplements, and many other

Author: Fahey, Shannon

Title: Evaluation of a Community Based Weight Loss Program, Assessing Lifestyle Changes for Effectiveness in Weight Loss

The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial

completion of the requirements for the

Graduate Degree/ Major: MS Food and Nutritional Sciences

Research Adviser: Carol Seaborn, Ph.D., RD, CD, CFCS

Submission Term/Year: Fall, 2011

Number of Pages: 60

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STUDENT'S NAME: Shannon Fahey

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This section to be completed by the Graduate School This final research report has been approved by the Graduate School.

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2

Fahey, Shannon. Evaluation of a Community Based Weight Loss Program, Assessing

Lifestyle Changes for Effectiveness in Weight Loss

Abstract

Obesity is currently contributing to rising rates of chronic conditions and health care

costs in the United States. There are many treatment strategies for obesity, including

programs that educate and support diet and exercise behavior modification. Research

evaluating weight loss program components, including behavior change that results in

successful weight loss is lacking.

The methods of this study included the evaluation of a completed 12-week

community weight loss program through a survey submitted by active participants (N =

23) at final weigh-in. The survey contained questions about behaviors and perceived

changes made by participants during the program. Survey answers were analyzed in

comparison to successful weight loss (> 5% total body weight).

Sixty-one percent of participants were successful in their weight loss. There were

two significant relationships, the participant’s satisfaction with their weight loss and the

participant’s perceived diet change during the program. Both of these measures were

positively related to successful weight loss.

Community weight loss programs are a safe and effective treatment and

prevention tool for obesity. Based on the study’s results, individual behaviors cannot be

linked to successful weight loss. Those who successfully lost weight were satisfied with

their weight loss.

3

Table of Contents

Abstract ............................................................................................................................................2

List of Tables ...................................................................................................................................5

List of Figures ..................................................................................................................................6

Chapter I: Introduction ....................................................................................................................7

Statement of the Problem ......................................................................................................9

Purpose of the Study ............................................................................................................10

Assumptions of the Study ....................................................................................................10

Definition of Terms .............................................................................................................10

Body Mass Index .................................................................................................................10

Metabolic Syndrome ...........................................................................................................10

Limitations of the Study ......................................................................................................11

Methodology .......................................................................................................................12

Program History ..................................................................................................................12

Research ..............................................................................................................................12

Chapter II: Literature Review ........................................................................................................13

Rising Obesity Rates ...........................................................................................................14

Screening for Obesity ..........................................................................................................14

Environmental Factors ........................................................................................................15

Weight Loss .........................................................................................................................16

Community Weight Loss Programs ....................................................................................17

Diabetes Prevention Program ..............................................................................................19

Dietary Approaches to Stop Hypertension ..........................................................................20

4

The Wise Women Project ..................................................................................................21

Summary ............................................................................................................................22

Chapter III: Methodology ..............................................................................................................24

Program History ...............................................................................................................24

Subject Selection and Description ....................................................................................25

Instrumentation .................................................................................................................25

Data Collection Procedures ..............................................................................................25

Data Analysis ...................................................................................................................26

Limitations ........................................................................................................................26

Chapter IV: Results ........................................................................................................................27

Item Analysis ....................................................................................................................28

Chapter V: Discussion ...................................................................................................................42

Limitations ........................................................................................................................43

Conclusions ......................................................................................................................43

Recommendations ............................................................................................................49

References ......................................................................................................................................51

Appendix A: Letter of Research Approval from UCare ................................................................56

Appendix B: Data Collection Survey ............................................................................................57

Appendix C: Weight Loss Program Article Featured in The Circle ..............................................60

5

List of Tables

Table 1: Percentage Frequencies of Weight Loss among Weight Loss Program Participants ......29

Table 2: Weigh-In Frequencies Related to Successful Weight Loss as Reported

by Weight Loss Program Participants.............................................................................36

Table 3: Food Journal Completion Related to Successful Weight Loss as Reported by

Weight Loss Program Participants..................................................................................36

Table 4: Utilization of Nutritionist Compared to Successful Weight Loss in Weight Loss

Program Participants .......................................................................................................37

Table 5: Perceived Healthfulness of Diet Related to Successful Weight Loss as Reported

by Weight Loss Program Participants.............................................................................38

Table 6: Perceived Diet Change Related to Successful Weight Loss as Reported by


Table 7: Exercise Frequency Related to Successful Weight Loss as Reported by


Table 8: Participant Satisfaction of Weight Loss Related to Successful Weight Loss

as Reported by Weight Loss Program Participants .........................................................41

6

List of Figures

Figure 1: Percentage of total body weight loss among weight loss program participants .............28

Figure 2: Number of participants that reported regular or non-regular weigh-in frequency

during the weight loss program .......................................................................................30

Figure 3: Number of participants that reported food journal usage during the

weight loss program .....................................................................................................31

Figure 4: Number of participants that reported meeting with the nutritionist during the

weight loss program ......................................................................................................32

Figure 5: Healthiness of diet during the weight loss program as reported by participants ............33

Figure 6: Diet change during the weight loss program as reported by participants ......................34

Figure 7: Frequency of exercise throughout the weight loss program as reported

by participants…………………………………………………………………………35

7

Chapter I: Introduction

Obesity is a growing health concern in the United States. The prevalence of obesity has

doubled from 1980 to 2004 (Ogden, Carroll, McDowell, & Flegal, 2007). In 2007, 34% of

adults (>20 years old) in the United States were classified as obese, defined by having a body

mass index (BMI) greater than 30 (CDC, 2011). Excess weight is contributing to increasing

prevalence of diabetes mellitus, hypertension, cardiovascular disease, and other weight related

health conditions (Shaper, Wannamethee, & Walker, 1997). The rapid increase in obesity has

left health care providers with inadequate evidenced based research to use in their education and

prevention efforts. Obesity treatment and prevention is a relatively new area of focus. Evidence

that these treatment and prevention efforts are lacking is that the majority of obese patients in the

United States report they have not been counseled about weight loss by their physicians

(Jackson, Doescher, Saver, & Hart, 2005).

The benefits of weight loss in overweight and obese persons are numerous. Even modest

weight loss (5-10 pounds) has been shown to improve blood glucose levels, insulin sensitivity,

lipid panel readings and blood pressure (National Heart, Lung and Blood Institute [NHLBI],

2011). Through these mechanisms, weight loss aids in the management and prevention of

chronic conditions such as diabetes mellitus, hypertension, and dyslipidemia.

Weight management is a complex area for healthcare professionals to address.

Physicians, pharmacists, physical therapists, dietitians, and psychologists are continually

researching and experimenting to find comprehensive treatment plans that will result in

successful and maintainable weight management. Currently, there is no research concluding that

there is one safe, risk-free pharmacotherapy or surgery treatment available to treat obesity.

Research has shown that successful approaches to weight management are multidimensional

8

including diet and lifestyle counseling (Gebel, 2011). Weight management intervention should

be considered by persons with a BMI >30, persons with a BMI 25-29.9 and have two or more

risk factors such as hypertension or diabetes, and persons who are ready to change (NHLBI,

2000). Assessing a person’s readiness to change is important in tailoring the weight

management messages that are provided to the client or patient. People who are not ready to

change are not suitable candidates for weight management intervention (Turner, Thomas,

Wagner, & Moseley, 2008).

Behavior change methods in weight loss need to be individualized based on many

lifestyle conditions and personal preferences. Learning which lifestyle changes are most

effective in producing weight loss is beneficial in creating protocols for weight management

treatment. Rothblum (1999) reviewed weight loss programs for counseling and psychological

tools used and found that many weight loss programs did not support the psychological health of

participants. A study conducted by Turner et al. (2008) evaluated a weight loss program and

found that readiness to change played a major factor in the program. Readiness and willingness

to change needs to be addressed in weight loss. Behavior changes associated with successful

weight loss should be advised and supported by healthcare professionals making weight

management treatment recommendations.

Weight loss efforts are being made by over one-third of the population as 28.8% of men

and 43.6% of women are attempting to lose weight (Serdula et al., 1999). There are various

methods of intervention for weight management from primary care in a weight management

clinic to at-home self-care such as over-the-counter dietary supplements. Depending upon an

individual’s demographic and socioeconomic status, availability to weight management

programs and tools will differ.

9

The amount of money spent by consumers on weight management efforts continues to

rise; this includes money spent on gym memberships, over-the-counter diet pills and

supplements, and many other resources available to consumers. In the United States, consumers

spend on average $33 billion each year on services and products related to weight loss. Health

care costs related to obesity is even greater, totaling $70 billion annually (Cleland et al., 2001).

Yet, the consumer and health care investment in weight loss products and treatments is not

decreasing the obesity rates in the United States.

One effort currently being implemented throughout the country to combat the obesity

epidemic is community weight loss programs. These programs have various formats from

support groups to individuals competing in weight loss challenges. Group weight management

programs are effective because they offer accountability, education, and support to participants

(Wing, Crane, Thomas, Kumar, & Weinberg, 2010). These programs are often evaluated solely

by how much weight the participants lose. Through evaluating participants diet and exercise

approaches to weight loss, effective trends can be identified and applied to weight loss

recommendations.

Statement of the Problem

Currently there are numerous weight management approaches being implemented in

various community settings. Research evaluating these efforts is lacking. More research is

needed on the behavior change methods used in community-based weight management programs

which are successful. The present research will provide data to develop a simplified program

designed for use in community settings.

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Purpose of the Study

Community weight loss programs have the potential to offer education and support to

large audiences at a lower cost. A research-based program design for health professionals that is

flexible and meets community and cultural needs is greatly needed in many low-income areas.

Identifying the key components for weight loss is helpful in designing a cost-effective, simplified

weight loss program that can be implemented by a variety of health care professionals.

The purpose of the study was to evaluate a completed 12-week weight loss program

offered in a community clinic. The program provided nutrition and lifestyle coaching to promote

healthy goal setting by participants. The program evaluation research was completed in an effort

to identify diet and exercise trends associated with weight loss and to gain an understanding of

successful weight management techniques.

Assumptions of the Study

The study assumed participants honestly completed the questions about diet and exercise

trends that accompanied weight loss on the survey. The study also assumed that participants did

not use any pharmacotherapy to aid in weight loss during the program.

Definition of Terms

Body mass index. Body mass index (BMI) is a number calculated from a person's weight

and height. BMI provides a reliable indicator of body fatness for most people and is used

to screen for weight categories that may lead to health problems. (CDC, 2011, p. 1)

Metabolic syndrome. Metabolic syndrome is the name for a group of risk factors that

raise our risk for heart disease and other health problems, such as diabetes and stroke.

You must have at least three metabolic risk factors to be diagnosed with metabolic

syndrome: 1) A large waistline. This also is called abdominal obesity. Excess fat in the

http://diabetes.niddk.nih.gov/intro/index.htm

http://www.nhlbi.nih.gov/health/dci/Diseases/stroke/stroke_what.html

11

abdominal area is a greater risk factor for heart disease than excess fat in other parts of

the body, such as on the hips. 2) A high triglyceride level (or you're on medicine to treat

high triglycerides). Triglycerides are a type of fat found in the blood. 3) A low HDL

cholesterol level (or you're on medicine to treat low HDL cholesterol). HDL sometimes is

called "good" cholesterol. This is because it helps remove cholesterol from your arteries.

A low HDL cholesterol level raises your risk for heart disease. 4) High blood pressure

(or you're on medicine to treat high blood pressure). Blood pressure is the force of blood

pushing against the walls of your arteries as your heart pumps blood. If this pressure rises

and stays high over time, it can damage your heart and lead to plaque buildup. 5) High

fasting blood sugar (or you're on medicine to treat high blood sugar). Mildly high blood

sugar may be an early sign of diabetes. (NHLBI, 2011, p. 1)

Limitations of the Study

Using self-reported survey results has the possibility of limitations such as

misinterpretation of the questions or biased answers related to diet and exercise. The study also

has limitations related to human behavior. Participants come from different demographic

backgrounds with various health conditions impacting their ability to lose weight in a weight

management program.

Methodology

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Program history. A grant was awarded from UCare to the Native American Community

Clinic (NACC) to provide support to a 12-week weight loss challenge. Participant requirements

were that the participants must be 18 years of age, paid the $1.00 entrance fee, and completed the

weigh-in process. A $500.00 incentive was provided for the participant who lost the greatest

percentage of total body weight (see Appendix C). The participant who lost the second most

amount of weight received $205.00 (a collection of entrance fees) and any participant who lost

10% of their body weight received a $20.00 gift card to Target.

Nutrition counseling services and food journals were offered and recommended but not

required by participants. Two times during the week were provided for participant weigh-ins

(Mondays and Fridays, 10 am-2 pm). Participants were recommended to weigh-in every two

weeks but this weigh-in was not required. A final weigh-in was required to be eligible for prizes.

Research. The research was conducted by a 12-question survey that was distributed to

program participants who attended the final weigh-in. The survey included questions about the

participant’s weight loss efforts, and the percentage of total body weight loss was recorded on

the participant’s survey (See Appendix B).

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Chapter II: Literature Review

Community weight loss programs are an important intervention tool being implemented

across the United States in various settings to combat the increasing rates of overweight and

obesity in the country. Weight loss programs at the community level are seen in various settings

and use multiple behavioral change intervention models. When providing an individualized

approach specific to a community, cultural and environmental factors impacting the

community’s food and activity lifestyle choices should be addressed. Community members who

are trusted and recognized are the best tools for implementation.

Obesity is a complex health condition contributing to other physical and psychological

health conditions. The increased prevalence of obesity is a contributor to the rising rates of

diabetes and heart disease in the United States (Lien et al., 2007). These conditions can be

addressed and delayed in some cases through the prevention measures of changing lifestyle

choices to healthier food choices and increasing physical activity (Lien et al., 2007).

The research reviewed in this chapter includes an overview of obesity in the United

States including epidemiology and proposed explanations for the current situation. The benefits

of weight management on an individual’s health are outlined in detail and recommendations are

assessed. More specifically, weight loss strategies and methods are covered in this chapter

giving a better understanding into the complexity of obesity as a health issue. Finally,

community weight loss programs and other public health efforts are reviewed in this section.

Three important studies that use research-based intervention models and resulted in significant

weight loss and improved health outcomes are highlighted. Weight loss is a comprehensive area

of research and this review covers some of the more important social and personal components

involved and the efforts needed to make significant public health changes.

14

Rising Obesity Rates

Obesity rates in the United States are rising. The prevalence of obesity has doubled from

1980 to 2004 (Ogden et al., 2007). In 2007, 34% of adults (>20 years old) in the United States

were classified as obese, defined by having a body mass index (BMI) greater than 30 (Center for

Disease Control [CDC], 2011). This equals one in every three adult individuals in the United

States is in need of weight management to achieve optimal health. Yet, the majority of obese

patients in the United States report having never been counseled about weight loss by their

physicians (Jackson et al., 2005). There is a lack of physician intervention in the prevention

stages of obesity. Obesity is continuing its upward trend and will be difficult to reverse.

To make a significant impact there needs to be environmental and societal interventions

as well as large individual changes that need to be recommended by health care providers

(Serdula et al., 1999). Health care providers that are trained on delivering effective weight

management advice to their patients throughout the BMI spectrum can play an important role in

obesity prevention and treatment.

Screening for obesity. Several measurements are used to evaluate a person’s body

composition and provide data to determine the health of an individual. These include: waist-to-

hip ratio, waist circumference, bioelectrical impedance analysis, and elbow frame size

measurements. Body mass index (BMI) is the current standard for screening an individual’s

weight status. BMI provides a useful clinical assessment tool and is easy to measure, using only

height and weight measurements. However, BMI but does not address body shape, frame size,

or muscle composition (Richards, 2011, Flegal, Carroll, Ogden, & Curtin, 2010) and thus is not

an accurate measure of health for certain individuals such as athletes or lean persons (Jakicic et

al., 2001).

15

BMI (kg/m2) categorizes persons into the following categories: underweight (BMI <

18.5), normal/healthy (BMI 18.5-25), overweight (BMI 25-30), and obese (BMI >30). The

obese category is further divided into obese (BMI 30-40), morbidly obese (BMI 40-50), and

extremely obese (BMI >50). (CDC, 2011) The CDC guidelines for BMI are the most commonly

used in health care and used by government-funded interventions and policy implementation.

The World Health Organization (2004) has slightly different obesity classifications: class I (BMI

30-35), class II (BMI 35-40), and class III (BMI >40) (World Health Organization, 2004).

Environmental factors. There are many environmental factors that contribute to the

health of a person and the community. Many communities are predisposed to health disparities

due to poor quality of basic needs such as food and water. Obesity is an example of a health

condition that is closely linked to the environment of the individual. The quality and price of

food in a community impacts the availability and affordability of healthy choices, and the safety

of the neighborhood can greatly determine the activity level of the community (Samuel-Hodge et

al., 2009). Lack of education is another limiting factor contributing to health disparities,

especially obesity. An environment that does not provide a basic education on food safety,

nutrition, and exercise places an individual at greater risk for health disparities.

Health disparities, including obesity counseling, and patients not receiving professional

advice about weight management, especially those patients with less education or at a lower

socioeconomic status, increased from 1994 to 2000. Lack of sufficient income and education

heightens the risk for obesity in the affected populations (Samuel-Hodge et al., 2009). Obesity is

a condition that is impacted greatly by health disparities, especially in the area of obesity

prevention; this type of situation explains an important aspect of the rising rates of obesity in the

United States.

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Weight Loss

A significant portion of the adult population is making some effort to lose weight. In the

overweight and obese population, 46% of women and 33% of men report trying to lose weight

(Bish et al., 2005). In another study, Serdula et al. (1999) reported even higher numbers of US

adults are trying to lose weight, over two-thirds of the sampled population. Results indicated

that women report wanting to lose weight at a lower BMI than men as 60% of overweight

women (BMI 25-30) want to lose weight; however, not as many men want to lose weight when

they are in the overweight category. The numbers between men and women wanting to lose

weight become more comparable in the obese category. This number increases, as people are

more aware of their health status and making efforts to receive preventive care. Adults who

receive medical advice to lose weight at a routine check-up are more likely to report they are

trying to lose weight.

Although a great portion of the population has the desire to lose weight, many are not

making the effort to change lifestyle behaviors. Bish et al. (2005) further assessed study

participant’s efforts to lose weight and found that 20% of subjects trying to lose weight were

following the minimum guidelines recommended for weight loss. Serdula and colleagues (1999)

similarly concluded that although weight management efforts are common in the United States,

many people making an effort do not meet the recommendations for weight loss. A large gap

exists between our population’s desire to lose and maintain a healthier weight and the behavior

modification needed for success.

Obesity exacerbates other health conditions and is expensive to treat. Wolf and Colditz

(1998) stated that health care dollars spent annually exceed $100 billion dollars for the treatment

of obesity-related conditions. More specifically, 5.7% of total health expenditures made by the

17

United States are directly related to obesity alone (Wolf & Colditz (1998). Both direct and indirect

costs of obesity on the health expenditures of the United States are significant and continue to

increase.

Weight management by losing weight or preventing future weight gain can be beneficial

for any individual. Weight management intervention should be seriously considered by persons

with a BMI >30, persons with a BMI 25-29.9 and have two or more risk factors (hypertension,

diabetes), and persons who are ready to change (NHLBI, 2000). Readiness to change is a strong

indicator in weight loss success and is important to evaluate before recommending an

intervention program to a patient (Hickson, Macqueen, & Frost, 2009).

Even modest weight loss (5-10 pounds) in overweight individuals has been shown to

improve blood glucose levels, insulin sensitivity, lipid panel readings, and blood pressure

(NHLBI, 2010). Similarly, Jakicic et al. (2001) states that optimal body weight does not need to

be met, a 5-10% weight loss will result in significant health improvements. Depending upon a

person’s weight, 5-10% on average varies from 10 pounds to 40 pounds, and this amount of

weight can safely be lost in 3-5 months. Community intervention programs are shown to be

helpful in supporting participants through their initial 5-10% weight loss (Wolf & Colditz (1998).

Community Weight Loss Programs

Many weight loss programs have been designed and researched. Linde, Erickson,

Jeffery, Pronk, and Boyle (2006) evaluated a two-year weight loss trial that counseled

participants through phone or mail interventions. Overall participants reported making efforts

towards a weight loss strategy (diet or exercise improvements) only one in every four days

during the study. This study supports the fact that more intense intervention, such as one on one

18

counseling and group education sessions, is needed to see results in participant’s behavior

modification.

Grace (2011) reviewed weight management interventions in the United Kingdom and

concluded that interventions for weight management need to have multiple components

including diet, exercise and behavior modification. In addition to a multi-component program,

Hickson and colleagues (2009) stressed that the program needs to perform an initial readiness-to-

change assessment and have a structured agenda to achieve successful weight loss in a group

program setting. With this type of program, group interventions may be a better use of a

dietitian’s time than general clinic one-on-one counseling sessions (Hickson et al., 2009).

Jackson and colleagues concluded after studying weight management intervention at the

physician level that programs need to be developed to target groups that are not likely to receive

counseling about diet and exercise from their physician (2005). This population is an ideal target

group for obesity prevention before their weight becomes a clinical issue. Jackson’s findings are

supporting community program implementation at the clinic setting using professionals like

registered dietitians and community health educators to reach out the community and facilitate

the program (Jackson et al., 2005).

There are program designs that have shown successful results in reducing body weight,

preventing diabetes, and lowing blood pressure. The most noteworthy studies on lifestyle

modification are now being replicated with funds from governmental and private agencies and

are being implemented in communities throughout the United States. The Diabetes Prevention

Program, The PREMIER Trial, including the DASH diet, and The Wise Women Project are all

examples of evaluated lifestyle intervention programs that have successfully improved health

outcomes of participants. One limitation in evaluating the success of these programs is that the

19

control group is receiving at least some lifestyle counseling so the findings reported are actually

more conservative than if compared to a group not receiving any intervention ((Wolf & Colditz

(1998).

Diabetes Prevention Program. From 1996 to 1999 the Diabetes Prevention Research

Group (2002) randomly assigned 3234 eligible participants with elevated fasted glucose (95 to

125 mg/dl) and an elevated two-hour reading (140 to 199 mg/dl) after a 75 g dose of oral

glucose. Participants were assigned to one of three treatment groups: standard lifestyle

recommendations with placebo pill twice a day, standard lifestyle recommendations with

metformin, a biguanide antihyperglycemic agent, twice a day totaling 850 mg, or an intensive

program of lifestyle modification.

The standard lifestyle recommendation group received annual 20-30 minute interventions

educating on a healthy lifestyle alone. The lifestyle modification group (intensive program) met

with a case manager on a one-on-one basis for 24 weeks and had a 16-lesson curriculum focused

on a low-fat, low-calorie diet, exercise and behavior modification. The intervention goal was for

participants to lose 7% of total body weight and complete 150 minutes of moderate intensity

activity (Diabetes Prevention Research Group, 2002).

The lifestyle modification group showed the lowest incidence of diabetes of the three

groups, 4.8% of participants in comparison to 11% in the placebo group and 7.8% in the

metformin group. The average weight loss throughout the 24-week period was 0.1 kg for the

placebo group, 2.1 kg for the metformin group, and 5.6 kg for the lifestyle intervention group (p

< .05). The incidence of diabetes was reduced significantly (58%) in the lifestyle modification

group (p < .05). The lifestyle modification had a 50% success rate in participants reaching 7%

body weight loss by the end of the curriculum (24 weeks). The exercise success rate (150

minutes per week of physical activity) was 74% of the lifestyle modification group.

20

The diet compliance was more difficult to monitor but of the reported data the

participant’s caloric intake was reduced on average by 450 Kcals/day and fat gram intake was

reduced by 6.6%. The intense lifestyle intervention was more effective than pharmacotherapy in

improving blood glucose metabolism and storage pathways. The effects of the treatment groups

were similar among gender and ethnic groups. The versatility of the demographics used in this

study support its applicability to ethnically and culturally diverse communities across the United

States.

Dietary Approaches to Stop Hypertension (DASH). The PREMIER trial studied two

lifestyle intervention models on persons with pre-hypertension or stage-1 hypertension (Lien et

al., 2007, Svetkey et al., 2002). This study also screened participants for metabolic syndrome

that were identified in the analysis. Participants were assigned to one of three groups for six

months: advice only control group, intensive behavioral intervention group of established

recommendations (EST), or behavioral intervention (EST) plus DASH group. The advice only

group received a 30-minute individual session after randomization and no further contact was

made. The other two intervention groups were advised to complete 18, one-on-one intervention

sessions throughout the six-month study.

Participants in both EST and EST plus DASH interventions had a goal of losing > 15 lbs

for participants with a BMI >25. Physical activity was prescribed at > 180 minutes per week of

moderate-intensity activity. Sodium restrictions were set at < 100 mmol/day and alcohol

restrictions of < 1 oz/day of alcohol for men and < .5 oz/day for women. Participants in the EST

plus DASH also were instructed to follow the DASH dietary pattern which includes consuming

9-12 servings of fruits and vegetables, 2-3 servings of low-fat dairy servings; total fat is limited

to < 25% of calories and saturated fat is limited to < 7% of calories consumed by participants.

21

The results of this six month intervention showed that the participants in all treatment

groups had a significant decrease in systolic blood pressure. EST and EST plus DASH treatment

groups were successful in achieving weight loss. Participants with metabolic syndrome lost 4.8

+/- 5.8 kg in the EST group and 6.0 +/- 6.5 kg in the EST plus DASH group, participants without

metabolic syndrome lost 4.9 +/- 5.2 kg in the EST group and 5.4 +/- 4.9 kg in the EST plus

DASH group (Lien, 2007). The participants with metabolic syndrome were less responsive to

EST behavioral intervention than participants without metabolic syndrome. The intervention

also measured insulin sensitivity and triglycerides, but no significant differences were found.

This trial of using behavioral and dietary intervention to improve health outcomes

provided evidence that regular counseling on behavior-therapy focusing on diet and exercise is

the most important piece in making lifestyle changes to improve health. The EST behavioral

model was beneficial in both groups and the addition of the DASH dietary guidelines did not

significantly improve the outcomes of participants in the EST plus DASH group.

The Wise Women Program. An example of a behavioral weight loss intervention

program is The Weight Wise Program (WWP) using the Center for Disease Control and

Prevention’s women who qualified through the Well Integrated Screening and Evaluation for

Women across the Nation (WISEWOMAN) program (Samuel-Hodge et al., 2009). The WWP

study split 143 participants between a control group and the intervention group enrolled in The

WWP for five months. The WWP was created from the Diabetes Prevention Program (DPP) and

the Dietary Approaches to Stop Hypertension (DASH) intervention. The program offered 16

group education sessions weekly at a local church at four different times throughout the week.

The WWP showed significant results in comparison with the control group. WWP

participants lost an average of 3.7 kg in comparison to the control group that gained 0.7 kg (p <

22

.05). This program resulted in a significant short-term weight loss in comparison to the control

group. There were also significant changes in the WWP participant’s blood pressure. The

outcomes of this intervention on low-income women show the effectiveness of a community

based weight management program.

Other findings in the study showed incentives and attendance as predictors of successful

weight loss. Samuel-Hodge and coworkers (2009) stated that the use of incentives for the

weekly meetings may be beneficial in improving attendance. Attendance at group settings was a

strong predictor of the participant’s weight loss. No significant relationships were found in the

other demographic and psychosocial factors that were evaluated in the study. The intensity of

this intervention increases the cost of the program and the author recognizes the difficulty of

implementing this type of structured program in clinics with limited resources serving low-

income populations.

Summary

Based on the literature reviewed it is evident that community weight loss programs are

beneficial in weight management and improving health outcomes such as blood pressure and

insulin sensitivity. Obesity continues to be an issue of concern for the public health of the

United States and the various treatment options need further consideration and evaluation to be

user-friendlier for consumers and patients.

All of the reviewed intervention models provide relevant background for the weight

management program evaluation that is completed in this thesis. The Diabetes Prevention

Program resulted in diabetes prevention through lifestyle modification. The PREMIER trial

literature concluded that the behavioral intervention was the important piece in creating

improved health outcomes. The Wise Women Program showed an intervention in a low-income

23

setting and the results were promising but clearly identified the limitation of cost to implement

an intense program in most low-income settings. All of these studies validate the use of

intervention programs to improve the health status of participants.

24

Chapter III: Methodology

Community weight management programs are being implemented in various settings, yet

evaluation research of these programs is lacking. More research is needed on community-based

weight management programs to validate future use and funding support. A brief program

history, participant selection, and an overview of the data analysis are addressed to give

understanding into the research conducted. Through assessing the behaviors of participants and

their perceived efforts in the weight loss program, future community weight loss programs will

have information to use in making their program design decisions.

Program History

A program grant was written and awarded to the Native American Community Clinic

from UCare, a supplemental health insurance company. The program grant was awarded to

support a 12-week weight loss challenge at the Native American Community Clinic (NACC).

The grant totaled $1,000.00 dollars, which included a $500.00 incentive that was awarded to the

participant who lost the greatest percentage of body weight. Additional funds were collected

through a $1.00 entrance fee charge. The entrance fee provided funds for the second place price

of $205.00. Other prizes include: $20.00 Target gift cards awarded to participants that lose 10%

of their body weight (see Appendix C).

At enrollment, initial weight was taken and a health history form, including lifestyle

questions related to diet and exercise, was completed and reviewed by community health worker.

At this time diet and exercise goals were set by participants. Nutrition counseling services and

food journals were provided by a Registered Dietitian and recommended but not required by

participants. Participants were given two time options during the week to weigh in (Mondays

and Fridays from 10 am-2 pm). A weigh-in every two weeks was recommended, but not

25

required. The last recorded weight on June 29th at 5:00 pm was used to determine the weight

loss challenge winner.

Subject Selection and Description

The research study was approved by the appropriate staff of the funding source, UCare,

and at the location of the research, the Native American Community Clinic (See Appendix A).

Participants were recruited through newspaper advertisements, fliers, and promotion at the clinic

by physicians and community health educators. Participant selection was open to the general

population but required that participants must be at least 18 years of age. There were no

requirements based on ethnicity or receiving clinic services. Participants were required to pay a

$1.00 entrance fee to enroll in the program.

Instrumentation

The survey used for the research contained 13 questions, which included 10 multiple

choice, two open-ended questions, and one yes/no question (See Appendix B). The percentage

of weight loss was also included on the survey by the data collector at the time of the final

weigh-in. The survey included questions about the participant's weight loss efforts but did not

contain the participant’s name or personal health information. The survey took participants five

minutes to complete and was collected upon completion.

Data Collection Procedures

The research data was conducted through a 13-question exit survey (see Appendix B).

The survey was distributed to participants completing their final weigh-in who were involved in

the 12-week weight loss challenge. Past collected data, such as initial weight and intake

assessments, was not used in the data collection. An implied consent for the use of the survey

data was obtained.

26

Data Analysis

The data collected from the completed 13-questions surveys (n = 23) was analyzed to

compare behaviors of successful weight loss participants (> 5% total body weight loss) to

unsuccessful weight loss participants (< 5% total body weight loss). The Statistical Program for

Social Sciences version 10.0 (SPSS, 2002) was used to analyze the data. ANOVA and Chi-

square tests were completed comparing successful and unsuccessful weight loss participants on

questions related to behaviors during the weight loss program. The data collection survey

answers were simplified into fewer categories to generate more significant findings (See Chapter

4).

Limitations

Due to the small amount of surveys completed, regression analysis could not be

conducted. Thus no comparison or regression could be made between the actual amount of

weight lost to the actual and perceived behaviors measured in the survey to establish a

relationship. Instead both the weight variable and behavioral variables being measured were

made into categorical variables.

27

Chapter IV: Results

Community weight loss programs are important in the effort to fight the rising rates of

obesity. The results of an evaluation of a community weight loss program will be detailed and

explained in this chapter.

The purpose of the study was to evaluate a completed 12-week weight loss program

offered in a community clinic. The program provided nutrition and lifestyle coaching to promote

healthy goal setting by participants. Community weight loss programs have the potential to offer

education and support to large audiences at a lower cost. There is a need for a research-based

program for health professionals to use that is adaptable to meet community and cultural needs in

low-income areas. Therefore, identifying the key components for successful weight loss would

be helpful in designing a cost-effective, simplified weight loss program that can be implemented

by a variety of health care professionals.

The subjects (N = 23) represent the active participants in the weight loss program. An

active participant is defined as a participant who fulfilled the following requirements: paid the

registration fee, weighed-in during the final weigh-in week, and completed the evaluation data

collection survey. See Appendix B. Demographic data such as age, gender, and ethnicity was

not collected. Collecting demographic data from low-income participants often discourages

participants from completing survey materials. All data being analyzed for this study was

collected at the end of the program after IRB approval and consent was obtained from

participants.

Participants’ weight loss was measured by calculating the total body weight loss

percentage from the beginning of the program to the final weigh-in. Only the percentage of

weight loss was recorded on the evaluation data collection survey. The calculation of the weight

28

loss percentage was performed by research staff and was reviewed with the participants before

being added to the evaluation surveys.

Item Analysis

Total weight loss percentage was calculated on all active participants (N=23).

Participants weight loss percentage ranged from 0% to 16.4% (M = 6.15, Mdn = 5.80, SD =

4.34). Figure 1 reviews the distribution of participants total body weight percentage lost. The

categories were divided into 0-5%, > 5-10%, and > 10% of total body weight. The distribution is

as follows: 9 participants lost 0-5%, 10 participants lost > 5-10% and 4 participants lost > 10%

of their total body weight. The largest number of participants were in the 5-10% group (N = 10)

followed closely by the 0-5% group (N = 9) and the least amount of participants were in the >

10% group (N = 4).

Figure 1. Percentage of total body weight loss among weight loss program participants (N = 23)

Table 1 lists the percentage of total weight loss by individual participants. Each

participant represents 4.3% of the total distribution. The most frequent weight loss percentages

were 1.6% and 5.8% (N = 2 at each percentage). The distribution shows that 21.7% of

0-5% 5-10%

>10%

29

participants lost < 2% total body weight and 34.8% of participants lost 7% or more total body

weight.

Table 1

Percentage Frequencies of Weight Loss among Weight Loss Program Participants (N = 23)

Percentage Frequency Percent Cumulative Percent .0 1 4.3 4.3

1.0 1 4.3 8.7

1.6 2 8.7 17.4

1.8 1 4.3 21.7

2.7 1 4.3 26.1

3.1 1 4.3 30.4

3.7 1 4.3 34.8

4.1 1 4.3 39.1

5.0 1 4.3 43.5

5.7 1 4.3 47.8

5.8 2 8.7 56.5

6.3 1 4.3 60.9

6.7 1 4.3 65.2

7.0 1 4.3 69.6

7.4 1 4.3 73.9

7.9 1 4.3 78.3

9.4 1 4.3 82.6

12.2 1 4.3 87.0

12.6 1 4.3 91.3

13.7 1 4.3 95.7

16.4 1 4.3 100.0

Weigh-in frequency was self-reported by participants on the evaluation data collection

survey (See Appendix B). The available answers to the weigh-in frequency question were:

30

weekly, every other week, monthly, rarely, and twice (initial and final weigh-ins). After

compiling the data, the data was simplified into two categories: regular and non-regular weigh-in

frequency. It was recommended to participants to weight in weekly or every other week.

‘Regular’ weigh-in frequency included the answers weekly and every other week. ‘Non-regular’

weigh-in frequency included the answers monthly, rarely, and twice. Participants reported

‘regular’ weigh-in frequency (N = 17, 73.9%) more that ‘non-regular’ frequency (N = 6, 26.0%).

See Figure 2.

Figure 2. Number of participants that reported regular or non-regular weigh-in frequency during the weight loss program (N = 23)

Food journal usage was assessed among active participants in the weight loss program

survey. The survey question asked,”Did you keep a food journal?” with the following possible

answers: always, most of the time, at the beginning, rarely, and never. This data was then

simplified into two categories ‘yes’ or ‘no’ for data analysis. The ‘yes’ category included the

answers always and most of the time and the ‘no’ category included the answers at the

beginning, rarely, and never. Eight participants were in the ‘yes’ category (34.8%) and 15

participants are in the ‘no’ category (65.2%). See Figure 3.

02468

1012141618

Regular Non Regular

Nu

mb

er o

f P

art

icip

an

ts

Weigh-In Frequency

31

Figure 3. Number of participants that reported food journal usage during the weight loss program (N = 23)

The data collection survey included a question stating, “Did you meet with the

nutritionist (Shannon)?” Shannon is the name of the nutritionist that the participants were

recommended to meet with during the challenge. Many participants have a limited

understanding of health care professional roles and the addition of the name was used to help the

participants to more accurately answer the question. Weigh-ins were performed by either the

nutritionist or another qualified member of the clinic staff where the program was being

sponsored. The answers available to the question were as follows: yes, no, or at weigh-ins only.

Seventy percent (N = 16) of participants reported meeting the nutritionist, 21.7% (N = 5)

reported meeting the nutritionist only at weigh-ins, and 8.7% (N = 2) reported not meeting the

nutritionist during the weight loss program. See Figure 4.

0

2

4

6

8

10

12

14

16

Yes No

Nu

mb

er o

f p

art

icip

an

ts

Food journal usage

32

Figure 4. Number of participants that reported meeting with the nutritionist during the weight loss program (N = 23)

Figures 5, 6 and 7 analyze participant’s perceived effort and lifestyle behaviors, diet and

exercise. The data was self-reported by participants on the data collection survey at the time of

the final weigh-in for the weight loss program. These questions are first analyzed independently

and then in relation to successful weight loss.

Question number 4 on the evaluation data collection survey stated, “During this

challenge, how would you describe your diet?” The following answers were available: very

healthy, mostly healthy, somewhat healthy, mostly unhealthy, and very unhealthy. All

participants (N = 23) answered very healthy, mostly healthy or somewhat healthy to the survey

question. No participants answered the question with the answers mostly unhealthy or very

unhealthy. Very healthy was answered by 34.8% of participants (N = 8), mostly healthy was

answered by 30.4% of participants (N = 7) and somewhat healthy was answered by 34.8% of

participants (N = 8).

Yes

No

Only at Weigh-Ins

33

Figure 5. Healthiness of diet during the weight loss program as reported by participants (N = 23)

Question 5 of the evaluation data collection survey stated, “How much did your diet

change during the weight loss challenge?” Participants were given the following answers to

choose from: improved greatly, improved somewhat, stayed the same, and worse than before

challenge. All participants who completed the survey chose one of the following, improved

greatly, improved somewhat or stayed the same. There were no participants that answered that

their diet was worse than before the challenge. Of the answers submitted (N = 23), improved

greatly included 52.2% (N = 12) of participants, improved somewhat included 34.8% (N = 8),

and stayed the same included 13.0% (N = 3) participants. See Figure 6.

Very Healthy

Mostly Healthy

Somewhat Healthy

34

Figure 6. Diet change during the weight loss program as reported by participants (N = 23) Figure 7 shows the answers to the data collection survey’s question 7, “How often were

you active (exercise)?” The following answers were listed for participants to choose from: daily,

5 times a week, 3 times a week, 1 time a week, occasionally, and never. The three most common

answers were ‘5 times a week’ (N = 7, 30.4%), ‘3 times a week’ (N = 7, 30.4%) and daily (N = 6,

26.1%). Less frequently reported answers were ‘1 time a week’ (N = 2, 8.7%) and occasionally

(N = 1, 4.3%). The answer ‘never’ was not reported in the data collection survey.

Improved Greatly

Improved Somewhat

Stayed the same

35

Figure 7. Frequency of exercise throughout the weight loss program as reported by participants (N = 23)

The following analysis compares successful weight loss to the behaviors reported in the

evaluation survey. Successful weight loss is defined by the loss of > 5% total body weight,

unsuccessful weight loss is defined as the loss of less than or equal to 5% total body weight.

Many of the behaviors (data collection survey answers) were compiled to make categorical

variables for analyses. Chi-squared was the statistics used to compare successful weight loss to

the behaviors and perceptions measured through the data collection survey.

The frequency of weigh-ins by participants, per their reporting in the data collection

survey was compared to successful weight loss. By chi-square analyses the weigh-in answers

were simplified into two categories: regular and non-regular weigh-in frequency. ‘Regular’

weigh-in frequency included the answers weekly and every other week. ‘Non-regular’ weigh-in

frequency included the answers monthly, rarely, and twice. There was no significant difference

when successful and unsuccessful weight loss was compared to the frequency of weighing in

[χ2(1) = 2.58, p > .05].

Daily

5 times a week

3 times a week

1 time a week

occasionally

36

Table 2 Weigh-In Frequency Related to Successful Weight Loss as Reported by Weight Loss Program

Participants (N = 23)

Weigh-In Weight Loss Frequency Successful (>5%) Unsuccessful (<5%) χ2

Regular 5 (29.4) 12 (70.6) 2.58 Non-regular 4 (66.7) 2 (33.3) Note. * = p ≤ .05

The data collected about whether or not the participant kept a food journal was analyzed

in relation to whether the participant had successful weight loss or unsuccessful weight loss

during the program (Table 3). This data was simplified into two categories ‘yes’ or ‘no’ for data

analysis. The ‘yes’ category included the answers always and most of the time and the ‘no’

category included the answers at the beginning, rarely, and never. Successful weight loss was

not significantly related to the completion of food journals by the participants [χ2(1) = 1.03, p >

.05].

Table 3 Food Journal Completion Related to Successful Weight Loss as Reported by Weight Loss

Program Participants (N = 23)

Food Journal Weight Loss Completion Unsuccessful (<5%) Successful (>5%) χ2

Yes 2 (25.0) 6 (75.0) 1.03 No 7 (46.7) 8 (53.3) Note. * = p ≤ .05

37

The utilization of the nutritionist, which was recommended to the participants, was

analyzed in conjunction with whether or not the weight loss of the participant was successful

(Table 4). In the data collection survey the answers available to the question of whether the

nutritionist was used were as follows: yes, no, at weigh-ins only. These answers were then

combined to make two categories, yes and no. The ‘no’ category contained the answers no and

at weigh-ins only, the ‘yes’ category remained the same. The relationship between the use of the

nutritionist during the program and successful weight loss was not significant [χ2(1) = .06, p >

.05]. There was no significant difference in the successfulness of weight loss when comparing it

to the use of the nutritionist.

Table 4 Utilization of Nutritionist Compared to Successful Weight Loss in Weight Loss Program


Met with Weight Loss Nutritionist Unsuccessful (<5%) Successful (>5%) χ2

Yes 6 (37.5) 10 (62.5) .06 No 3 (42.9) 4 (57.1) Note. * = p ≤ .05

Table 5 contains the data relating successful weight loss and the participants perceived

healthfulness of their diet during the weight loss program, as self-reported on the data collection

survey (Appendix B). The following answers were available: very healthy, mostly healthy,

somewhat healthy, mostly unhealthy, and very unhealthy. To better analyze the data, the

answers were reassigned into two categories, ‘very healthy’ and ‘not very healthy’. The ‘very

healthy’ category contained the answer very healthy and the ‘not very healthy’ category

38

contained the remaining answers, mostly healthy, somewhat healthy, mostly unhealthy, and very

unhealthy. The perceived healthiness of the participant’s diet was not significantly related to

successful or unsuccessful weight loss [χ2(1) = 3.65, p > .05].

Table 5 Perceived Healthfulness of Diet Related to Successful Weight Loss as Reported by Weight Loss

Program Participants (N = 23)

Diet Weight Loss Description Unsuccessful (<5%) Successful (>5%) χ2

Very healthy 1 (12.5) 7 (87.5) 3.65 Not very healthy 8 (53.3) 7 (46.7) Note. * = p ≤ .05

Table 6 analyzes the relationship between the participant’s perceived diet change and

successful weight loss. The participants were asked to assess their diet change during the weight

loss challenge. Participants were given the following answers to choose from: improved greatly,

improved somewhat, stayed the same, and worse than before challenge. All participants who

completed the survey chose one of the following: improved greatly, improved somewhat or

stayed the same. These answers were further simplified for analyzing into two categories;

‘improved greatly’ which used the answer improved greatly and ‘did not improve greatly,’ which

used the answers improved somewhat and stayed the same. Based on this criteria there was a

significant relationship between perceived diet change and successful weight loss [χ2(1) = 5.32, p

< .05]. The “improved diet greatly” group was significantly related to successful weight loss.

Further discussion on the reasons behind these results will be discussed in the next chapter.

39

Table 6 Perceived Diet Change Related to Successful Weight Loss as Reported by Weight Loss Program


Diet Weight Loss Change Unsuccessful (<5%) Successful (>5%) χ2

Improved Greatly 2 (16.7) 10 (83.3) 5.32* Did Not Improve Greatly 7 (63.6) 4 (36.4)

Note. * = p ≤ .05

Exercise frequency was analyzed in comparison to successful weight loss. Exercise

frequency was self-reported by participants in the data collection survey. The following answers

were listed for participants to choose from: daily, 5 times a week, 3 times a week, 1 time a week,

occasionally, and never. For the chi-square analysis the exercise frequency answers were

categorized into two categories, very often and not very often. ‘Very often’ contained the

answers daily, 5 times a week, and 3 times a week. ‘Not very often’ contained the answers 1

time a week, occasionally, and never. The analysis did not show a significant relationship

between exercise frequency and successful weight loss [χ2(1) = .62, p > .05]. See Table 7.

40

Table 7 Exercise Frequency Related to Successful Weight Loss as Reported by Weight Loss Program


Exercise Weight Loss Frequency Unsuccessful (<5%) Successful (>5%) χ2

Very Often 6 (46.2) 7 (53.8) .62 Not Very Often 3 (30.0) 7 (70.0)

Note. * = p ≤ .05

The last chi-square analysis was on the relationship between successful weight loss and

the satisfaction of the participant with their weight loss. See Table 8. Participants were asked to

assess their satisfaction with their weight loss in the first question of the data collection survey,

which stated, “Are you satisfied with your weight loss results?” The available responses were as

follows: very satisfied (N = 8, 34.8%), mostly satisfied (N = 7, 30.4%), somewhat satisfied (N =

3, 13.0%), neutral (N = 1, 4.3%), somewhat unsatisfied (N = 3, 13.0%), mostly unsatisfied (N =

1, 4.3%), and very unsatisfied (N = 0, 0.0%). For this analysis the answers were placed into two

categories ‘satisfied’ or ‘unsatisfied’. The ‘satisfied’ category was comprised of the following

answers: very satisfied, mostly satisfied, and somewhat satisfied. The ‘unsatisfied’ category was

used for these answers: neutral, somewhat unsatisfied, mostly unsatisfied, and very unsatisfied.

The relationship between the satisfaction of weight loss and the successfulness of the participants

weight loss was significant [χ2(1) = .62, p < .05].

41

Table 8 Participant Satisfaction of Weight Loss Related to Successful Weight Loss as Reported by Weight

Loss Program Participants (N = 23)

Satisfied with Weight Loss Weight Loss Unsuccessful (<5%) Successful (>5%) χ2

Satisfied 4 (22.2) 14 (77.8) 9.94* Unsatisfied 5 (100.0) 0 (0.0)

Note. * = p ≤ .05 The results analyzed in this chapter were based on the weight loss percentage recorded at

the final weigh-in and the answers reported by participants in the data collection survey. The

findings in the figures and tables will be discussed in further detail in the next chapter. The

discussion will include rational and explanation, both theoretical and research-based, for the data

included in the results chapter.

42

Chapter V: Discussion

The community weight loss program that was evaluated in this study was 12-weeks long

and provided an opportunity for community members to take part in a competitive, supportive

program. Research regarding safe and effective weight loss has shown that in most cases a

combination of diet and exercise is the best approach even when surgery and pharmaceutical

options are available (Gebel, 2011). The program supported healthy eating and exercise and

recommended participants to weigh-in regularly, keep a food journal, and meet with a

nutritionist. As a result of the recommendations and support provided, many participants were

successful in their weight loss efforts. Their behaviors and perception of change in behaviors

were evaluated through a data collection survey distributed at the end of the program. The

completed surveys were analyzed to evaluate the various levels of participation of the

participants and the weight loss efforts during the weight loss challenge. These efforts were then

analyzed in relation to the successfulness of the participant’s weight loss.

This chapter will discuss the results of the data analysis and identify trends and rationale

for findings through similar research. The first section will cover the limitations of the study that

may have influenced the data collected and analysis of the data. Later, the chapter will highlight

the conclusions and possible trends that can be identified from this study’s data analysis. Lastly,

recommendations will be made for future research and possible improvements to the study

design to create more beneficial data and analyses.

43

Limitations

The limitations of this study included the structure of the program and content of the data

collection survey. The lack of demographic and health information collected at the beginning of

the study and small sample size that completed the data collection survey limited the amount of

descriptive data collected. Other limitations include human error in completing a self-reporting

survey tool and not analyzing the many other variables contributing to the ability of a participant

to lose weight.

There were other limitations related to the program design and implementation, aside

from the evaluation that was used for this study. There was lack of resources and staff to

perform anthropometric, laboratory, and behavioral assessments throughout the study. There

was also lack of qualified staff to perform intervention and support for nutrition and exercise

programs. With adequate resources the program would have had the potential to reach greater

success.

Conclusions

The conclusions of this study focus both on data analysis and descriptive statistics to

evaluate the successfulness of the program and which behaviors and perceptions were most

related to successful weight loss (>5% total body weight loss). The chi-square data analysis

resulted in two significant findings in relating survey answers to successful weight loss. The

frequency data and descriptive statistics were insightful in providing descriptive data about the

program structure and participant behavior during the program.

The program design used in this study included community-based outreach with in-clinic

intervention weigh-ins. The success of this program further supports Drieling and colleagues’

(2011) claim that coordinated efforts between clinic and community-based obesity interventions

44

together can be more effective in producing weight loss that one approach alone. The

partnership between a healthcare setting and community involvement, especially in low-income

areas has been shown effective in health promotion programs; this was also true for the weight

loss program evaluated in this study.

The program started with 202 self-referred participants who completed the initial weigh-

in and paid the enrollment fee of $1.00. Overall the program had 23 active participants that

completed the data collection survey questions and had their total body weight loss during the

program recorded. This concludes that 11% of the enrolled participants attended the final weigh-

in and completed the data collection survey used for this study. This program can be compared

to the retention rates for a six-month program with structured once-a-month appointments which

had 33% (103/313) of referred participants not come in for an initial visit (Hickson, Macqueen,

& Frost, 2009). In the patients who attended the initial visit only 19% (18/93) completed the

general program (5 visits) and 53% complete the more structured program (6 visits) (Hickson,

Macqueen, & Frost, 2009). When combining the statistics of total referred participants and the

participants who completed either of the program requirements, 20% is greater than the retention

rates for the program in this present study but is still a low retention level. Based on the Hickson

and coworkers’ programs (2009) and the program in this present study, the retention rates for

weight loss programs are low. It is possible that readiness to change needs to be assessed and a

more structured approach followed to result in better retention rates in weight loss programs.

The weight loss program resulted in weight loss for most participants. Weight loss

ranged from 0 to 16.4% total body weight. The average weight loss for participants was 6.2%

after the 12-week intervention program. This amount of weight loss is within the National Heart,

Lung, and Blood Institute’s (2000) weight loss recommendations of 5 to 10% weight loss for

45

improved health outcomes. Based on this data a 12-week weight loss program would be

effective in aiding most people to reach the NHLBI’s recommendations for weight loss.

In comparison to other health behavior intervention studies, the Diabetes Prevention

Program (DPP) resulted in 50% of their participants losing 7% of their total body weight after 24

weeks (DPP Research Group, 2002). The 12-week weight loss program executed for this present

study resulted in 34.5% of participants losing 7% of their total body weight. This study was

conducted for half the time as the DPP study. Another year-long intervention study that

measured the effectiveness of primary care-relevant treatments for obesity found that participants

in the behavior treatment group, receiving 12 to 26 intervention sessions lost on average 6% of

their total body weight (LeBlanc, O’Connor, Whitlock, Patnode, & Kapka, 2011). This weight

loss is comparable to the weight that was lost in the active participants in this study in only a

quarter of the time. These comparisons highlight the significance of weight loss in the 12-week

program evaluated in this study. Another study that did not have a program but mailed a

questionnaire to adults reporting that they are trying to lose weight found that 31% had been

successful in any amount of weight loss with any efforts (Kruger, Blanck, & Gillespie, 2006).

This study’s results in comparison to the DPP and the program for the Kruger study show the

importance of a structured program with offered support for participants to reach the amount of

weight loss that is recommended.

The first question evaluated in the data collection survey asked the participants to rate

their satisfaction with the weight loss achieved during this program. There was a significant

relationship between the participant’s satisfaction with their weight loss and the successfulness

of weight loss (> 5% total body weight loss) by the participant during the program. This is

similar to the results of a previous study conducted by Baldwin, Rothman, and Jeffery (2009)

46

that found a significant, positive relationship between the amount of weight the participants lost

from baseline and the satisfaction with their weight loss. The results are similar in that

participants who lost a greater amount were more satisfied with their weight loss. This question

was asked to participants after they were weighed in for the final time and participants were

aware of the amount of weight they lost during the program. This correlation may show that

participants are aware of what successful weight loss is, by societal standards, and if they had

lost enough to be satisfied. If participants were unaware of the amount of weight they had lost

the results may have differed.

The second question of the survey asked participants to report the frequency of their

weigh-ins during the weight loss program. Seventy-four percent of participants reported regular

weigh-ins, which was a recommendation at the beginning of the program. The frequency of

weigh-ins was not significantly related to successful weight loss among participants. A similar

study conducted by Grace (2011) found that weight monitoring is important in weight loss after

the initial assessment and intervention, performed by a dietitian. Regular weigh-ins were

recommended and may have benefitted participants who needed more support during the

program but were not used by the more independent participants. Also, participants may have

monitored their weight loss on another scale and not attended weigh-ins.

Food journal utilization was measured by the third question in the survey. Thirty-five

percent of the participants reported regular usage of the food journal provided by the program or

a food journal of their own. The usage of a food journal throughout the program was not linked

to successful weight loss. Another 35% of participants reported use of the provided food journal

only at the beginning of the program. The ‘only at the beginning’ category was not included in

the ‘regular use’ of the food journal category. Yet these participants may have received many of

47

the benefits of the food journal through using it at the beginning of the study such as, knowledge

of their food intake, accountability, food calorie intake awareness, learning food calories of

commonly eaten foods, and food intake reporting skill. After the discontinuation of the food

journal, participants may have maintained these habits of food intake awareness and

accountability attributing to their weight loss success.

After the final weigh-in, participants were asked to rate how healthy their diet was during

the challenge on the data collection survey. All participants perceived their diet as at least

somewhat healthy to very healthy. There was no significant relationship between the perceived

healthiness of diet and the successfulness of weight loss. This lack of relationship could possibly

be explained due to the high ratings of healthfulness of diet across participants. Participants may

have reported healthier diets than actually consumed during the challenge.

In addition to the healthfulness of the participants’ diet, participants were asked to define

how their diet changed during the program. The perceived change in the participant’s diet was

significantly related to successful or unsuccessful weight loss. Participants who stated that their

diet improved greatly were significantly more likely to have successful weight loss (>5% total

body weight) than those who stated that their diet did not improve greatly (improved somewhat

or stayed the same). This relationship is also seen in the findings of Palmeria et al. (2007) who

reported that the participant’s change in eating management self-efficacy was the best indicator

for weight reduction when compared to several other variables. In a similar 12-week study

comparing an intervention group and control group, the intervention group lost significantly

more weight and all participants reported making sustained improvements to their diet (Craigie,

Macleod, Barton, Treweek, & Anderson, 2011). Diet improvement was significantly related to

48

weight loss in both previous studies and the data collected from the program reviewed in this

study.

At the beginning of the program participants were encouraged to meet with the

nutritionist at the clinic where the program was located. Seventy percent of participants met with

nutritionist during the program. Whether or not the participant met with the nutritionist was not

significantly related successful weight loss during the program. Grace (2011) identifies the

psychological support and empathy in diet, physical activity, and behavior modification as a key

piece to a multi-component intervention. Many of the participants who lost weight but not

significant amounts may not have achieved their weight loss without the support and guidance of

the nutritionist; even though it was not significantly related to successful weight loss. Behavioral

intervention, offered by the nutritionist, may improve weight loss outcomes with minimal costs

(Wing, 2010).

Another study conducted on men participating in a weight-loss intervention concluded

that participants can successfully improve some aspects of their diet with minimal nutrition and

exercise advice (Collins, Morgan, Warren, Lubans, & Callister, 2010). By contrast, Craigie and

colleagues (2011) found that the intervention of one-on-one counseling on nutrition and physical

activity was received well and was found useful by participants. Based on these findings and the

findings in this study, the role of the nutritionist in a weight loss program remains unclear.

The final question that was analyzed assessed the amount of exercise participants

reported during the weight loss program. The recommended amount of exercise for weight loss

is greater than or equal to 150 minutes per week (NHLBI, 2000; Jakicic et al., 2001). The DPP

program reported 74% of participants met this requirement (DPP Research Group, 2002).

Although minutes of exercise were not evaluated in this study, over half (56%) of the

49

participants reported exercising at least 5 days a week. It has been shown through research that

the more frequently participants exercise; the more weight they lost (Turner, Thomas, Wagner, &

Moseley, 2008). Exercise frequency was not significantly related to the successfulness of weight

loss among participants in this present study. Although exercise was not related to weight loss in

the study, this program may have increased the frequency that participants exercised. Without

weight loss programs, most persons are not meeting the minimum recommended about of

physical activity when trying to lose weight (Bish, 2005). Change in activity level was asked on

the data collection survey but the results were not analyzed.

Recommendations

Future research is needed on weight loss programs both at the community level and

examining the clinic’s role in weight loss programs as an intervention tool to treat and prevent

obesity. At the community level, identifying effective persons to promote, recruit, and

implement a program curriculum would be the next step in creating a useful weight loss

program. Identifying the type of program curriculum that is most cost beneficial while still

resulting in successful weight loss should be addressed in future research. Costs to consider

include: staff time, tools needed (food journals, scale, tape measures, and body fat analyzers),

and space rental. Also, research on the professionals needed versus what components can be

delivered by community members would be beneficial on creating a cost-effective, culturally

specific program. By including community members, especially in low-income areas can

promote ownership of the program as well as funding for employment within the community as

program directors and interventionist.

The research practices used for this study could be revised to better obtain demographic

data about participants. Demographics would benefit the study to learn about specific

50

populations and separate the weight loss and behaviors by age, gender, and race. This analysis

would aid in the tailoring of the program to specific community groups based on their

demographic data. Perry, Hickson, & Thomas (2011) reviewed weight loss program data and

identified the difficulty of concluding themes due to low retention and lack of quantitative and

qualitative data collected during weight loss programs.

More detailed anthropometric data such as waist circumference, fat distribution, and body

fat percentage should be obtained for more detailed analysis. These measures would be useful to

measure benefits of exercise in addition to weight loss. Also, body types could be identified and

weight loss trends based on the participant’s anthropometric data.

51

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programmes: Systematic review and phenomenological approach. Journal of Human

Nutrition and Dietetics, 24, 227-310.

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& Keyserling, T. C. (2009). Randomized trial of a behavioral weight loss intervention for

low-income women: The Weight Wise Program. Obesity, 17(10), 1891-1899.

doi:10.1038/oby.2009.128

Serdula, M. K., Mokdad, A. H., Williamson, D. F., Galuska, D. A., Mendlein, J. M., & Heath, G.

W. (1999). Prevalence of attempting weight loss and strategies for controlling weight.

Journal of the American Medical Association, 282(14), 1353-1358.

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Shaper, A. G., Wannamethee, S. G., & Walker, M. (1997). Body weight: Implications for the

prevention of coronary heart disease, stroke, and diabetes mellitus in a cohort study of

middle aged men. British Medical Journal, 314, 1311-1317.

Svetkey, L. P., Harsha, D. W., Vollmer, W. M., Stevens, V. J., Obarzanek, E., Elmer, P. J., …

Appel, L. J. (2002). Premier: A clinical trial of comprehensive lifestyle modification for

blood pressure control: Rationale, design and baseline characteristics. Annals of

Epidemiology, 13(6), 462-471.

Turner, S. L., Thomas, A. M., Wagner, P. J., & Moseley, G. C. (2008). A collaborative approach

to wellness: Diet, exercise, and education to impact behavior change. American Academy

of Nurse Practitioners, 20, 339-344. doi:10.1111/j.1745-7599.2008.00325.x

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loss outcomes in community interventions by incorporating behavioral strategies.

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doi:10.2105.AJPH.2009.183616

Wolf, A. M., & Colditz, G. A. (1998). Current estimates of the economic cost of obesity in the

United States. Obesity, 6, 97-106.

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56

Appendix A: Letter of Research Approval from UCare

From: May Seng Cha [[email protected]] Sent: Tuesday, May 03, 2011 3:30 PM To: Shannon Fahey Cc: Lydia Caros; Carol Berg Subject: RE: Permission request/exit survey for Wt. Loss Challenge

Hi Shannon,

I just wanted to share that I discussed this with my manager, Carol Berg, and we do not see an issue with you using the data for your thesis since individuals do not provide any PHI. Also, UCare would love to see the findings. The program/challenge is going so well. GREAT JOB!!!!

May Seng Cha

County Relations Coordinator UCare 612-676-3565

From: Shannon Fahey [mailto:[email protected]] Sent: Thursday, April 21, 2011 11:18 AM To: May Seng Cha Cc: Lydia Caros Subject: Permission request/exit survey for Wt. Loss Challenge

Hello May- I hope you’re enjoying the cold spring weather J.

I am requesting approval to use the data from an exit survey for my thesis project. I’m not sure if you’re the correct person to be requesting approval from or if this is something you need to forward on to someone else.

I attached the survey I will be handing out (without the permission piece added). I will be using coded surveys without any patient identifiers. I am only doing a 2 credit thesis so it will not be too extensive.

I wanted to have your approval before I continue the work. The data I collect will also be available for your use and evaluation of the program. Let me know if there is any other information you would like me to collect from participants.

I am completing my IRB currently and hope to have it approved before the final weigh-in week (June 27th-29th). I will be following all of the ‘human subject’ treatment/confidentiality protocol through The University of Wisconsin-Stout.

My objectives are basically to find a relationship between perceived behaviors and their weight loss percentage. Ex- how drastically they changed their habits, their overall health improvements, efforts taken-food journals, exercise frequency…

Shannon Fahey

Registered Dietitian The Native American Community Clinic 1213 East Franklin Avenue Minneapolis, MN 55404

57

Appendix B: Data Collection Survey

Percentage of weight loss:__________

1. Are you satisfied with your weight loss results?

a. Very satisfied b. Mostly satisfied c. Somewhat satisfied d. Neutral e. Somewhat unsatisfied f. Mostly unsatisfied g. Very unsatisfied

2. How often did you weigh-in?

a. Weekly b. Every other week c. Monthly d. Rarely e. Twice

3. Did you keep a food journal?

a. Always b. Most of the time c. At the beginning d. Rarely e. Never

4. During this challenge, how would you describe your diet?

a. Very healthy b. Mostly healthy c. Somewhat healthy d. Mostly unhealthy e. Very unhealthy

5. How much did your diet change during the weight loss challenge?

a. Improved greatly b. Improved somewhat c. Stayed the same d. Worse than before challenge

6. Did you meet with the nutritionist (Shannon)?

a. Yes b. No c. At weigh-ins only

58

7. How often were you active (exercise)?

a. Daily b. 5 times a week c. 3 times a week d. 1 time a week e. Occasionally f. Never

8. How does your activity level compare to before the challenge?

a. Improved greatly b. Improved somewhat c. Stayed the same d. Worse than before challenge

9. Do you plan to continue your diet and exercise routine after the weight loss challenge?

a. Yes b. Some parts, not others c. No

10. Overall, how satisfied with the weight loss challenge are you?

a. Very b. Mostly c. Somewhat d. Not satisfied e. Very unsatisfied

11. Did you learn or try something new that you will continue to practice in the future?

______________________________________

12. What would you change about the program?

_______________________________________

13. Would you participate in this program again?

a. Yes b. No, why not?_______________________

See research disclaimer on backside of survey.

59

Consent to Participate In UW-Stout Approved Research

Title: Evaluation of Weight Loss Program

Investigator: Shannon Fahey, 612-760-0617, [email protected] Research sponsor: Carol Seaborn, 715-232-2216, [email protected]

Description: To evaluate a 12-week weight loss program with monetary incentives and available nutrition counseling. To identify diet and exercise trends associated with weight loss over a 12-week program. To gain understanding of successful weight management techniques.

Risks and Benefits: Risks: possible emotional discomfort completing lifestyle questions on survey.

Benefits: Contribution to weight loss research to benefit the health of the broader population.

Time Commitment and Payment: Time commitment: 5 minutes. No incentive for completion.

Confidentiality: Your name will not be included on any documents. We do not believe that you can be identified from any of this information.

Right to Withdraw: Your participation in this study is entirely voluntary. You may choose not to participate without any adverse consequences to you. However, should you choose to participate and later wish to withdraw from the study, there is no way to identify your anonymous document after it has been turned into the investigator.

IRB Approval: This study has been reviewed and approved by The University of Wisconsin-Stout's Institutional Review Board (IRB). The IRB has determined that this study meets the ethical obligations required by federal law and University policies. If you have questions or concerns regarding this study please contact the Investigator or Advisor. If you have any questions, concerns, or reports regarding your rights as a research subject, please contact the IRB Administrator.

Investigator: Shannon Fahey, 612-760-0617, [email protected] Advisor: Dr. Carol Seaborn, 715-232-2216, [email protected]

IRB Administrator: Sue Foxwell, Director, Research Services, 152 Vocational Rehabilitation Bldg, [email protected]

Statement of Consent: By completing the following survey you agree to participate in the project entitled, Evaluation of Weight Loss Program.

mailto:[email protected]

60

Appendix C: Weight Loss Program Article Featured in The Circle

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