A recent randomized trial showed that increasing the intensity of weight loss interventions only in patients who do not succeed in reaching their goals may be an effective alternative to typical approaches.
According to John Jakicic, Ph.D., with the University of Pittsburgh, the findings did not demonstrate a significant difference in the number of patients who achieved a 10 percent reduction in weight after 18 months between a group that received stepped care and a group that received normal treatment (26 percent versus 32 percent). The two groups also reported similar average weight loss — 5.8 percent loss for the stepped care group versus 6.8% for the normal care group. “So the stepped-care approach may present an effective alternative to standard behavioral weight loss interventions,” said Jakicic.
Jakicic continued to note that 30 to 40 percent of the patients who received stepped care stayed at the first two steps, involving monthly group meetings, lessons mailed to the patients weekly, feedback from doctors on a weight loss diary that the patients completed, and one phone call every month.
Behavioral interventions that promote lifestyle changes have been previously shown to be effective in helping patients lose weight. However, the intensity of the intervention generally remains the same whether or not the patients are responding to the treatment.
Stepped approaches use feedback from the patient’s success with the program to determine its intensity. When a patient does not respond to the intervention, the intensity of the approach is increased. These types of intervention had not been previously compared to standard behavioral interventions for weight loss through the use of a randomized trial.
Jakicic and his team designed the Step Up study, an investigation of 364 overweight and obese men and women that randomly assigned stepped care or standard intervention to each participant. The participants’ mean age was 42.2 and mean body mass index was 33kg/m2. A significant majority of the participants were female (82.7 percent).
Both the standard and stepped care groups were given dietary goals intended to reduce total calorie intake as well as fat intake. Participants were also given targets for engaging in physical activity, increasing in duration to 300 minutes of moderate-to-vigorous exercise each week.
The stepped care group also attended a group session every month throughout the duration of the study and received weekly mailed lessons. They also kept diaries on their progress and received feedback from doctors on those diaries. Participants who failed to achieve their goals — 5 percent of the participants at three months, 7 percent at six months, and 10 percent at nine months — were contacted more frequently by researchers and saw the intensity of their interventions increased. The more high-intensity measures included two phone calls per month instead of one, two individual sessions per month to discuss weight loss, and meal replacements provided to the participants.
Participants in both the standard and stepped care groups lost weight. However, absolute weight loss was significantly higher in the standard care group for the first six months (22 pounds versus 17.6 pounds). For each follow-up beginning at six months from baseline, however, participants did not exhibit a significant difference in weight loss between the two groups.
According to Jakicic, more research is needed to determine the effectiveness of stepped care interventions. Factors that need to be addressed include: the effectiveness of each of the steps as compared to other steps; who responded to the stepped care approach; the possible effect of diet and physical activity; and different approaches that may be more useful in stepped care.
