Effect of a Stepped-Care Intervention Approach on Weight Loss in Adults

Jakicic, John M.; Tate, Deborah F.; Lang, Wei; Davis, Kelliann K.; Polzien, Kristen; Rickman, Amy D.; Erickson, Karen A.; Neiberg, Rebecca H.; Finkelstein, Eric A.

doi:10.1001/jama.2012.6866

Cited by 150 publications

(183 citation statements)

References 25 publications

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“…DSE, diabetes support and education; ILI, intensive lifestyle intervention; SD, standard deviation.Year 1 meal replacements averaged 360.8 units per person 19.…”

Section: Resultsmentioning

confidence: 99%

“…During year 1 of Look AHEAD, the per participant cost of an individual session was more than twice as much as a group class; however, by year 4, the study‐wide costs of group and individual sessions were similar because of the lower attendance at group sessions in later years. On the basis of the findings from the literature, use of meal replacement products was included in our lifestyle intervention to promote greater weight loss and maintenance 19. Although greater use of meal replacement products was associated with better outcomes 20, it is likely that those who use the meal replacement products were also adhering to other aspects of the intervention.…”

Section: Discussionmentioning

confidence: 99%

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Cost of intervention delivery in a lifestyle weight loss trial in type 2 diabetes: results from the Look AHEAD clinical trial

Rushing

Wing

Wadden

et al. 2017

Obesity Science & Practice

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SummaryObjectiveThe Action for Health in Diabetes (Look AHEAD) trial was a randomized controlled clinical trial to compare the effects of 10 years of intensive lifestyle intervention (ILI) with a control condition of diabetes support and education (DSE) on health outcomes in over 5,000 participants with type 2 diabetes. The ILI had significantly greater weight losses than DSE throughout the trial. The goal of this analysis is to describe the cost of delivering the intervention.MethodsThe ILI was designed to promote weight loss and increase physical activity. It involved a combination of group plus individual intervention sessions, with decreasing frequency of contact over the 10 years. The intervention incorporated a variety of strategies, including meal replacement products, to improve weight loss outcomes. The costs of intervention delivery were derived from staff surveys of effort and from records of intervention materials from the 16 US academic clinical trial sites. Costs were calculated from the payer perspective and presented in 2012 dollars.ResultsDuring the first year, when intervention delivery was most intensive, the annual cost of intervention delivery, averaged (standard deviation) across clinical sites, was $2,864.6 ($513.3) per ILI participant compared with $202.4 ($76.6) per DSE participant. As intervention intensity declined, costs decreased, such that from years 5 to 9 of the trial, the annual cost of intervention was $1,119.8 ($227.7) per ILI participant and $102.9 ($33.0) per DSE participant. Staffing accounted for the majority of costs throughout the trial, with meal replacements and materials to promote adherence accounting for smaller shares.ConclusionsThe sustained weight losses produced by the Look AHEAD intervention were supported by intervention costs that were within the range of other weight loss programmes. Future work will include an evaluation of the cost‐effectiveness of the ILI and will contain additional follow‐up data.

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“…DSE, diabetes support and education; ILI, intensive lifestyle intervention; SD, standard deviation.Year 1 meal replacements averaged 360.8 units per person 19.…”

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Cost of intervention delivery in a lifestyle weight loss trial in type 2 diabetes: results from the Look AHEAD clinical trial

Rushing

Wing

Wadden

et al. 2017

Obesity Science & Practice

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“…That is, an RCT is highly useful when investigators already have the theoretical basis and empirical evidence necessary for constructing the best/optimal adaptive intervention, and they wish to test the effectiveness of this already-developed AI by comparing it to a suitable control. For instance, Jakicic and colleagues [44] developed an 18-month stepped-care AI for weight loss, in which the "contact frequency, contact type and other strategies were modified over time depending on the achievement of weight loss goals at 3-month intervals". In developing this AI prior to study, decisions were made (i) about the total number of decision stages, including when and how often they would occur (i.e., there was a step every 3 months over 18 months), (ii) to use one tailoring variable (i.e., weight loss), (iii) about the treatment options (i.e., group sessions, behavioral lessons, 1 vs 2 sessions of telephone counseling, individual sessions, and meal replacements), and (iv) about the decision rules linking weight loss and treatment options at each time point (i.e., different weight loss cutoffs were decided on at different steps).…”

Section: Discussionmentioning

confidence: 99%

“…In the mental health and substance use literatures, they are more commonly known as adaptive treatment strategies [38,39]. Investigators often study a special type of adaptive intervention, known as a stepped-care intervention [40][41][42][43][44]. Stepped-care interventions begin with a low-intensity intervention that is increased if certain milestones are not achieved [45].…”

Section: Adaptive Interventionsmentioning

confidence: 99%

Introduction to SMART designs for the development of adaptive interventions: with application to weight loss research

Almirall

Nahum‐Shani

Sherwood

et al. 2014

Behav. Med. Pract. Policy Res.

361

274

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The management of many health disorders often entails a sequential, individualized approach whereby treatment is adapted and readapted over time in response to the specific needs and evolving status of the individual. Adaptive interventions provide one way to operationalize the strategies (e.g., continue, augment, switch, step-down) leading to individualized sequences of treatment. Often, a wide variety of critical questions must be answered when developing a highquality adaptive intervention. Yet, there is often insufficient empirical evidence or theoretical basis to address these questions. The Sequential Multiple Assignment Randomized Trial (SMART)-a type of research design-was developed explicitly for the purpose of building optimal adaptive interventions by providing answers to such questions. Despite increasing popularity, SMARTs remain relatively new to intervention scientists. This manuscript provides an introduction to adaptive interventions and SMARTs. We discuss SMART design considerations, including common primary and secondary aims. For illustration, we discuss the development of an adaptive intervention for optimizing weight loss among adult individuals who are overweight. KEYWORDS

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“…Following guidelines from personalized medicine [10], adaptive interventions [20], and stepped care [21], and what we now can call personalized behavioral medicine, other questions can be asked. After posttest, should non-or low responders to resistance training for glycemic control be assigned to a different empirically supported intervention such as dietary change and/or weight loss [3,4] and then assessed at the end of that intervention for prediabetes status?…”

Section: Changing the Approachmentioning

confidence: 99%

Using response variation to develop more effective, personalized behavioral medicine?: evidence from the Resist Diabetes study

Winett

Davy

Savla

et al. 2014

Behav. Med. Pract. Policy Res.

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Health behavior interventions have achieved some notable outcomes through generally higher dose interventions with intensive initial phases and longterm, faded contact maintenance phases with attention to mean changes and adherence rates. Interventions may be improved by shifting attention to the very large response variation that is typical for such protocols as exercise with non-, low, moderate, and high responders and even those who show adverse responses. Data from the Resist Diabetes study, which included adults (N=159, ages 50-69 years) with prediabetes who were overweight or obese (BMI 25-39.9 kg/m 2 ) and previously inactive, are presented. The data show a typical pattern of wide variation for changes on a 2-h oral glucose tolerance test (OGTT), defined by blood glucose concentration measured after 2 h following ingestion of 75 g of glucose, lean body mass, fat mass, strength, and blood pressure to the same resistance training protocol within a highly supervised phase and where adherence was high. A personalized behavioral medicine approach could focus on such individual patterns of response variation to tailor and alter additional intervention components, the staging of maintenance interventions, and then determining how to most effectively, and systematically, translate this adaptive intervention approach into practice to potentially achieve more optimal clinical outcomes. Implications Policy: Health behavior, lifestyle change programs are essential for reducing the costs and burdens of preventable diseases, but more optimal clinical outcomes may be achieved with personalized behavioral medicine programs that are designed for tailoring based on individual response patterns. KeywordsResearch: Research within personalized behavioral medicine can focus on how to design health behavior interventions with tailoring and adaptation based on individual response patterns and then translating this new adaptive intervention approach into practice.Practice: The wide variation in response to most treatment protocols such as exercise with non-, low, moderate, and high responders and even those who experience an adverse response is a key to more personalized behavioral medicine and can be a focus when designing initiation and maintenance phases of interventions requiring alteration and tailoring of adaptive interventions based on individual response to achieve optimal clinical outcomes. TBMpage 333 of 338

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Effect of a Stepped-Care Intervention Approach on Weight Loss in Adults

Cited by 150 publications

References 25 publications

Cost of intervention delivery in a lifestyle weight loss trial in type 2 diabetes: results from the Look AHEAD clinical trial

Cost of intervention delivery in a lifestyle weight loss trial in type 2 diabetes: results from the Look AHEAD clinical trial

Introduction to SMART designs for the development of adaptive interventions: with application to weight loss research

Using response variation to develop more effective, personalized behavioral medicine?: evidence from the Resist Diabetes study

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