This item is only available as the following downloads:
1 EFFECTS OF A LOW DOSE BEHAVIORAL TREATMENT FOR OBESITY By MANAL ALABDULJABBAR A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2013
2 2013 Manal Alabduljabbar
3 To my Dad for instilling love in our heart s, teaching us to be proud of our difference and allowing us to be creative, learn by travel, and s erve the community
4 ACKNOWLEDGMENTS I would like to thank my mentor, Dr. Michael Perri for his wisdom and guidance and his investment in international health and international educational exchange I would also like to thank my thesis defense committee Dr. Michael Marsiske, Dr. David Janicke, and Dr. Deidre Pereira, for their support and feedback. I would like to thank my colleague Tatiana Schember and my colleagues and staff at the UF Weight Management Lab for their support and assistance. Last but no t least, I would like to thank my wonderful mother, my family and relatives and my friends across the globe for their love and continuous support.
5 TABLE OF CONTENTS P age ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF FIGURES ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 11 Obesity and Health Disparities in Rural Areas ................................ ........................ 11 Rurality and Health ................................ ................................ ................................ 12 Cooperative Extension Service Offices (CES) ................................ ........................ 12 Beh avioral Lifestyle Treatment for Obesity ................................ ............................. 13 Defining Clinically Meaningful Weight Loss ................................ ............................ 14 Obesity and Health Related Quality of L ife ................................ ............................. 16 Weight Loss and Health Related Quality of Life ................................ ..................... 17 The Need to Study Low dose Behavioral Treatments for Obesity .......................... 17 Specific Aims and Hypotheses ................................ ................................ ............... 18 Specific Aim 1 ................................ ................................ ................................ ... 18 Specific Aim 2 ................................ ................................ ................................ ... 18 2 METHODS ................................ ................................ ................................ .............. 19 Rural LITE Study ................................ ................................ ................................ .... 19 Participants ................................ ................................ ................................ ............. 20 Procedures ................................ ................................ ................................ ............. 21 Measures ................................ ................................ ................................ ................ 22 Additional Outcome Measures ................................ ................................ ................ 23 Treatment Conditions ................................ ................................ .............................. 24 Statistical Analyses ................................ ................................ ................................ 25 3 RESULTS ................................ ................................ ................................ ............... 28 Sample Baseline Characteristics ................................ ................................ ............ 28 Effects of a Low Dose Behavioral Lifestyle Intervention on Weight Loss ............... 28 Effects of a Low Dose Behavioral Lifestyle Intervention on Health Related Quality of Life ................................ ................................ ................................ ....... 29 Qualit y of Life Scores ................................ ................................ .......................... 30 4 DISCUSSION ................................ ................................ ................................ ......... 33
6 LIST OF REFERENCES ................................ ................................ ............................... 38 BIOGR APHICAL SKETCH ................................ ................................ ............................ 44
7 LIST OF TABLES Table page 2 1 Baseline Characteristics for Participants ................................ ............................ 27 3 1 Mean Quality of Life Scores for Both Treatment Conditions at Baseline and Month 6 ................................ ................................ ................................ .............. 31 3 2 Mean Body Weight for Both Treatment Conditions at Baseline and Month 6 ..... 31
8 LIST OF FIGURES Figure page 3 1 Proportion of Participants Achieved >5% Weight Loss in Both Groups. ............. 31 3 2 Proportion of Participants Achieved >10% Weight Loss in Both Groups. ......... 32 3 3 Loss Program between both Groups ................................ ................................ ........... 32
9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science EFFECTS OF A LOW DOSE BEHAVIORAL TREATMENT F OR OBESITY By Manal Alabduljabbar August 2013 Chair: Michael G. Perri Major: Psychology Behavioral treatment of obesity, delivered via 16 24 weekly group sessions, commonly produces clinically meaningful weight changes. However, the cost of "high" dose in terventions represents a barrier to dissemination, and there is a need to examine the potential benefits of less costly, "low" dose interventions. The current study examined the effects of a low dose (8 session) behavioral treatment on weight change and r eported health related quality of life, compared with a n 8 session education program highlighting national recommendations for appropriate diet and exercise practices for weight management. Participants included 317 obese adults (mean SD, BMI = 36.2 3 .9 kg/m 2 ) recruited from rural counties in northern Florida. O utcomes included change in body weight and percentage of participants achieving a clinically meaningful weight loss (defined as body weight reduction > 5%) a s well as change s in h ealth related quality of life. Outcomes measures were taken prior to treatment and at a 6 month follow up assessment. The results showed that, compared with the education control group, the low dose behavioral intervention produced a great er mean change in body weight ( mean SD, 7.60 kg 6.40 vs. 4.46 kg 4.9 p < .001) and a higher percentage of participants achieving body weight reductions of 5% or more (55.4% vs.
10 36.1%, p < .001). The analysis of the quality of life data revealed that, compared with the health educa tion control group, the low dose behavioral intervention group reported significantly greater improvements in physical functioning ( F (1) = 3462.067, p < .001), general health ( F (1) = 12.826, p < .001), and vitality ( F (1) = 19.376, p < .001). Moreover, a mediation al analysis revealed that weight loss partially mediated the effect of the behavioral intervention on health re lated quality of life These findings demonstrate the potential benefits of low dose behavioral inte rventions for weight management.
11 CHAPTER 1 INTRODUCTION Obesity and Health Disparities in Rural Areas The United States today faces multiple public health issues including increased prevalence in chronic conditions such as diabetes mellitus, cardiovascular disease, and certain cancers. Furthermore, obesity is implicated in many of these chronic diseases contributing to both their etiology and poor treatment outcomes ( Allison Fontaine, Manson, Stevens, & VanItallie 1999; Lew & Garfinkel 1979 ; Manson et al ., 1990 ). Recent studies furt her confirm the scope of the problem of obesity in the United States; an estimated two thirds of the nation is either obese (with a body mass index > 30 kg/m 2 ) or overweight (with body mass index > 25 kg/m 2 ) (Flegal Carroll, Ogden, & Curtin 2010) Accord ing to the National Center for Health Statistics, the national death rate from ischemic heart disease and prevalence of cardiovascular disease is higher in rural areas than in urban areas (National Center for Health Statistics, 2008) O besity and physical inactivity are more prevalent in rural communities in the U.S. than in urban communities and is concentrated es pecially in the southern states (Bennett, Olatosi, & Probst 2008) In a recent study by Befort, Nazir, and Perri ( 2012 ) obesity prevalence was found to be 39.6% among rural adults and 33.4% among urban adults. This phenomenon maybe influenced by the infrastructure that rural counties have in terms of limited healthcare facilities, sport and recreational facilities as well as grocery stores that provide adequate healthy food items (Bennett, Olatosi, & Pumkam 20 11 ) Moreover, socio cultural factors that influence lifestyle further impact the health of rural communities. Factors such as high fat consumption ( which is typical of the southern
12 cuisine ) sedentary lifestyle and the increased mechanization in the agric ultural industry all contribute to the pro blem of obesity in rural areas (McIntosh & Sobal, 2004) Rurality and Health Geographic areas in the United States are classified in two main ca tegories according to the National Center for Health Statistics Urban Rural Cla ssification Scheme for Counties ( Ingram & Franco, 2012) : urban or large metropolitan areas and rural or small non metropolitan areas. Urban areas are counties with a population over 50,000; rural areas are counties with a population of 50,000 persons or less with some counties that may not have a city. This classification i s associated with differential access to health services and differential impacts on health. While metropoli tan areas may enjoy having large and advanced healthcare centers, rural areas may only have a small community primary healthcare center and individuals in need for healthcare may need to travel to metropolitan areas for t ertiary care. R ural communities hav e a greater shortage of healthcare professionals, higher rates of poverty, lower educational attainment, and greater number of individ uals without health insurance which lead to decreased access to healthcare and contribute to the health disparities in th ese areas ( Findeis et al., 2001) Cooperative Extension Service Offices (CES) The Cooperative Extension Service Office s w ere e stablished by the USDA in 1914 to serve individuals in the rural areas. Since its inception, the CES mission was to provide Am ericans in the rural areas public access to the latest advances in agricultural practices CES adopted a more comprehensive approach to the health and welfare of rural citizens over the years. Nutrition education for example became a key element of CES ser vices. Family and Consumer S ciences (FCS) agents were hired by
13 CES to hel p rural families live a healthier life physically and socially by teaching them about nu trition, food preparation positive child care, family communication, financ ial management, and positive strategies to manage services within the healthcare system ( National Institute of Food and Agriculture, 2007). Behavioral Lifestyle Treatment for Obesity Behavioral or lifestyle treatment for obesity had evolved over four decades of continuous s cientific investigation and clinical trials. Behavioral treatment approaches to obesity are specifically geared towards teaching participants the necessary skills to lower their calorie intake, eat a healthier and more nutritious diet, and increase their p hysical activity S trategies such as self monitoring, goal setting, problem solving, stimulus control, cognitive restructuring, and positive reinforcement are commonly used. Participants are typically asked to keep food logs of their daily food intake and physical activity as a for m of self monitoring and are coa ched by their clinical provider to learn the problem solving skills that enable them to tackle their daily challenges with their lifestyle choices (W ing et al 2011 ; Foster Makris, & Bailer 2005 ) In a review of beha vioral weight loss studies from 1996 to 1999, Wing et al., ( 2002 ) found that participants achieved a mean short term weight loss of 10.6% of their initial body weight during the treatment phase of 21 weeks and they maintained 8.6% at follow up s of 18 months. Most studies provide their behavioral lifestyle treatment during an average of 18 to 24 weeks as standard treatment duration ( Wing 2002) However, these studies were all conducted in urban settings and large academic medical cente rs lo cated in metropolitan areas. T his recommended treatment duration may not usually be feasible in rural areas given the lack of resources particularly specialized healthcare providers. Multiple studi es on the duration of behavioral treatment for obesit y have
14 indicated that increasing the duration of the treatment phase of a weight loss program will further increase the weight reductions achieved by participants and increase the percentage of that weight loss maintained at follow up after the maintenance phase (Perri, Nezu, Patti, & Mccann, 1989 ) However, some studies indicated that participants in low dose behavioral treatment programs may not achieve or maintain clinically significant weight loss of 5% or greater ( Wing 2002; Foster Makris, & Bailer 2005 ) Several studies indicated the efficacy and superiority of behavioral treatment over health education only interventi ons with obesity and overweight (Wadden Crerand & Brock, 2005; IOM Press, 1995 ) Nevertheless, weight loss programs that are typi cally offered in community settings usually span over 8 to 10 weeks of group meetings that provide mainly health education regarding weight loss (without behavioral strategies such as self monitoring and goal setting) and typically do not include maintenan ce programs in follow up care Moreover, few studies have investigated the effects of low dose behavioral treatment programs compared to non behavioral programs (Stern et al., 1995). Defining Clinically Meaningful Weight Loss A variety of studies show th at achievement of body weight reductions of 5% or greater are associated with clinically meaningful changes in health status. In a recent study by Goodpaster et al. (2010), patients with severe obesity were offered a life style intervention that included di et combined with initial physical activity or with delayed init iation of physical activity. T he study found that participants achieved clinically significant weight loss of 5% or greater of their initial body weight in both groups. Additionally, weight los s produced positive changes in cardiometabolic risk factors and
15 significant reductions on the following: waist circumference, visceral abdominal fat, hepatic fat content, blood pr essure, and insulin resistance (Goodpaster, et al, 2010) Another study exam ined the association between the amount of weight loss and changes in cardiovascular risk factors at 1 year after a lifestyle intervention on participants with type 2 diabetes. T meeting predefined criteria for clinically significant improvements in risk factors for individuals with type 2 diabetes. The study found that the amount of weight loss at 1 year was strongly associated with improvements in glycemic index, blood pressure, tryiglycerides, and HDL cho lester ol but not with LDL cholesterol. T hose who lost between 5 and < 10% of their body weight had increased chances of achieving a 0.5% point reduction in HbA1c, a 5 mmHg decrease in diastolic blood pressure, a 5 mmHg decrease in systolic blood pressure, a 5 mg/dL increase in HDL cholesterol, and a 40 mg/dL decrease in triglycerides. The findings further showed that the chances of clinically significant improvements in most of these risk factors were even greater for participants who lost 10 15% of their i nitial bo dy weight (Wing et al 2011) Multiple studies have confirmed the strong relationship between the magnitude of weight loss and the improvement in cr itical anthropometric variables In a lifestyle treatment study conducted ( Matvienko & Hoehns 2 009) on individuals at risk for diabetes or diagnosed with diabetes approximately 56% of patients lost 5% or greater of their initial bo dy weight after 6 months of the intervention, and that lead to significant improvements in their diastolic Blood Pressu re ( 4.1 mm Hg), total cholesterol ( 11.7%), LDL C ( 7.6%), HDL C ( 6.5%), Fasting glucose ( 12%), and systolic BP ( 8.4 mm Hg).
16 Moreover, 27% of the participants who were on diabetic medication had their drug discontinued a fter the lifestyle intervention ( Matvienko & Hoehns 2009). Obesity and Health Related Quality of Life Several aspects of quality of life are impacted by obesity and overweight, including vitality, physical and mental health and social functioning. In studies examining related quality of life (HRQL), which is the impact of on his/her quality of living obese individuals reported significantly lower HRQL than those with normal weight. The quality of life domains that are often affected by obes ity are physical functioning, general health, bodily pain and vitality ( Han, Tijhuis, Lean, & Seidell, 1998 ; Kolotkin, Head, Hamilton & Tse, 1995 ; Kruger, Bowles, Jones, Ainsworth, & Kohl, 2007 ; Doll, Petersen, & Stewart Brown, 2000 ; Fontaine & Barofsky, 2001 ; Larsson, Karlsson, & Sullivan, 2002 ). H igh er degrees of obesity are associated with lower quality of life. Jia and Lubetkin (2005) examined this relationship in a study and after the adjustment for other factors; health related quality of life was negatively associated with higher level s of ob esity. Individuals with severe obesity had significantly lower scores on the quality of life measures compared to their normal weight counterparts. The decrements in health related quality of life for those with severe obesity were similar to the decrement s seen in individuals diagnose d with diabetes or hypertension ( Jia & Lubetkin, 2005) S edentary lifestyle ( i. e. physical inactivity ) was also found to be negatively associated with quality of life independent of obesity or overweight status. Physically i nactive individuals were more likely to report poor quality of life regardless of their body mass index ( Andersen, Schnohr, Schroll, & Hein, 2000 ; Villeneuve, Morrison, Craig, & Schaubel, 1998 ; Kruger Bowle s, Jones, Ainsworth, & Kohl, 2007)
17 Weight Loss and Health Related Qual ity of Life Given the link between health related quality of life and body weight, we would expect weight loss to be associated with improvements in quality of life Fontaine Barofsky, Bartlett, Franckowiak, and Andersen ( 2004 ) have observed that weight loss was associated with a significant increase in the quality of life domains such as physical functioning, role physical, general health, vitality, and mental health scores from baseline to post weight loss intervention. The greatest improvements on hea lth related quality of life were on the vitality, general health and role physical SF 36 scales (Fontaine et al ., 2004 ) One of the limitations of these studies is the lack of control group to examine for the difference and the effect of health education o nly and subsequent weight loss on q uality of life. Studies have found that larger weight loss was associated with the greatest improvement in health related quality of life; more specifically, weight losses of 5% to 10% were associated with 2 unit changes in the SF 36 gen eral health scale ( Samsa Kolotkin, Williams, Nguyen, & Mendel, 2001; Karlsson, Sjtr, & Sullivan, 1998 ; Kral, Sjostrom, & Sullivan, 1992 ; Weiner, Datz, Wagner, & Bockhorn, 1999 ). Furthermore, some studies have reported increases in health related quality of life to be associated with increases in physical activity as an independent factor in weight loss (Ross, et al., 2009; Elavsky et al., 2005 ) thereby calling into question whether we ight loss mediated the effect of treatment on quality of life (Imayama et al 2011) The Need to Study Low dose Behavioral Treatments for Obesity It is well established that behavioral treatment for obesity delivered in 18 to 24 weeks will produce successful and clinically meaningful weight loss (Wadden Crerand & Brock, 2005; Wing, 2002; IOM Press, 1995; Perri et al. 1989 ) ; but few studies have examined the effects and clinical relevance of behavioral treatment delivered in lower
18 doses. Given the scope of the obesity problem in the United States, the unavailability of lower cost, low dose treatments with documented clinical benefits would repres ent an important option particularly in resource poor areas such as rural communities. Specific Aims and Hypotheses Specific Aim 1 Examine the effect of a low dose behavioral lifestyle intervention on weight loss compared with a health education compar ison group We hypothesized that the participants in low dose behavioral treatment group would experience greater weight loss than the participants in the health education only group. Furthermore, we hypothesize d that there would be a larger proportion of participants achieving a clinically meaningful weight loss ( > 5% reduction in body weight) in the behavioral treatment condition than in the health education only condition. Specific Aim 2 Examine the effect of a low dose behavioral lifestyle interventio n on health related quality of life compared to a health education comparison group We hypothesized that participants in the behavioral treatment group will report greater improvement on the health related quality of life measure than participants in the health education only group. Moreover, we also hypothesized that the between group difference in quality of life would be mediated by weight loss.
19 CHAPTER 2 METHODS Rural LITE Study This study is a secondary data analysis utilizing data driven from the R ural Lifestyle Intervention Treatment Effectiveness Trial (Rural LITE study) a single blind randomized controlled trial (RCT) in obese adults Rural LITE was designed to examine the effects of three different doses of lifestyle treatment on changes in bo dy weight, and several other outcomes such as quality of life compared to a health education only condition over a two year period The study was carried out through the Cooperative Extension Service Offices in eight rural counties in Northern Florida CES offices offered venues inside their buildings to conduct the groups; and several FCS agents were trained to join the current study as interventionists. The CES offices are funded by the state government, hence, their contribution to the current study w The study was conducted in two phases ; i n the first phase (6 months) participants attended weekly sessions for a varied number of weeks depending on their randomized assignment Eight weeks for the health education only and the low dose behavioral treatment conditions 16 weeks for the moderate dose behavioral treatment condition and 24 weeks for the high dose behavioral treatment condition These sessions focused on inducing weight l oss by teaching participants how to reduce their calorie intake and increase engagement in safe physical activity for all the conditions. However, cognitive behavioral strategies such as self monitoring and goal setting were integrated in the three behavio ral treatment conditions only (Low, Moderate, and High) to test for the difference in treatment effects among all conditions
20 compared to the health education condition. The intervention program was a modified curriculum derived from the Diabetes Prevention Program (DPP) and the Look AHEAD study ( Diabetes Prevention Program Research Group 2002 ; Wadden et al., 2006). Phase 2 (18 months) of the Rural LITE study focused on main tenance of behavior change and weight loss as an outcome and provide d extended care to the participants. This extended care was provided according to the same dosing schedule as for the original intervention weekly sessions (8 extended care sessions for th e health education and low dose behavioral treatment conditions, 16 sessions for the moderate dose behavioral treatment condition, and 24 sessions for the high dose behavioral treatment condition). These extended care sessions focused on helping participan ts to deal with issues related to maintenance of lost weight and the adopted health behaviors such as regular physical activity. Participants The participants in this study were obese ( BMI 30 to 45 kg/m 2 ) men and women between the age of 21 and 75 years old who reside d in one of the eight rural counties in North Central Florida. These participants had a mean age of 51.7 years (SD = 11.5) a nd mean BMI of 36.2 kg/m 2 (SD = 3.9); 19.7% of the sample were classified as of an ethnic or racial minority o rigin an d 80.3% were Caucasian; 78.9 % were women and 21.1% were men ( see Table 3 1 ) Exclusion from the study was limited to those with a life limiting disease such as myocardial infarction, or congestive heart failure, those who might be subjected to an increased risk by participating in our study, or those with an uncontrolled chronic medical condition such as hypertension or diabetes Individuals who reported using antipsychotic medications, human immunodeficiency antibiotics, monoamine oxidase inhibitors, syste mic corticosteroids, chemotherapy treatments or
21 weight loss medications were excluded as well. Additionally, anyone reported a psychiatric disorder o r excessive intake of alcohol, was unable or unwilling to accept random assignment or travel to the extensi on office for the weekly sessions, was unable to read English at a fifth grade level, was planning to move out from the county during the period of the study, lost 10 or more pounds in the past 6 months, was currently participating in another research stud pre vious trial was also excluded. Two thousand eight hundred and seventy nine individuals made telephone inquiries about the study, 1366 of them were excluded ttend the first screening visit and 1072 attended. Three hundred eighteen out of those attended screening visit 1 were eventually excluded. Subsequently, 612 participants were randomized to the four treatment conditions. A sub sample of 317 participants d erived from the Rural LITE overall sample were included in the current study, of which 169 were in the health education only condition and 148 in the low dose behavioral treatment condition. Procedures Participants in the current study were recruited util izing a variety of recruitment healthcare providers, culturally driven methods specifically to recruit ethnic minority participants, and presentations delivered by Exten sion agents at churches, social organization and community events. Those interested in the study underwent an initial telephone screening where they were interviewed to determine if they meet the basic study criteria to be deemed eligible for the study. S creening visit 1 was then conducted
22 details and were asked to sign the informed consent and fill in demographic and medication inventor ies. The assessment team then obtained the following measures for each participant: height, weight, girth, resting heart rate, blood pressure, b lood analyses for lipids and other micronutrients, and ph ysical p erformance. Data collected by the mobile clinical assessment team from screening visit 1 was then reviewed by the study Co PI Marian Limacher, MD., to determine whether participants are eligible for the study. Those who were considered eligible wer e contacted and scheduled another appointment to attend the screening visit 2 less than four weeks before the intervention. evaluated for possible changes in their medical status, their weight and blood pressure were measured again, and they completed a second walk test and asked to fill in a packet of self report questionnaires that includes the quality of life measure used in this study. Those who reported rapid changes in weight or other changes that met the ex clusionary criteria were excluded from the study. Participants who passed the screening visit 2 were randomized to two treatment conditions, either the health education condition or the low dose behavioral treatment condition. The study carried seven data collection visits, three main comprehensive assessments identical to the screening visit 2 assessment at month 0, 6, and 24; and four other assessments at Months 2, 4, 12, and 18 for weight and medical history updates only. For the purpose of this study, only data collected at month 0 and month 6 for participants in the two conditions were utilized. Measures Body weight: Weight was measured using a Tanita BWB 800S digital s cale at m onth 0 before the intervention and was measured again at month 6. Partici h eight was measured using a stadiometer at baseline for use in the calculation of
23 participant Body Mass Index (weight in kg / height in m 2 ) On both assessment occasions the measurement was conducted by the study nurse who was masked to the treatme nt condition Health Related Quality of Life : Health related quality of life was assessed utilizing t he MOS Short Form 36 Health Survey (SF 36) which asks the participant to answer 36 questions clustered in eight domains of health related quality of life, including: role limitations due to physical problems; bodily pain; general health perceptions; vitality; social functioning; physical functioning; role limitations due to emotional problem s; and mental health. The SF 36 has been shown to have excellent psychometric properties in a variety of populations including obese adults. Most reliability and validity coefficients exceeded r = 0.70 with many exceeding 0.80 ( McHorney, Ware & Raczek, 1993 ). Parti cipants in this study were asked to complete the SF 36 at month 0 and again at month 6. The standardized scores (on a scale of 0 to 100) on the eight domains were used in the analyses. A high reported score on any of the domains indicates a better reported quality of life or less impairment on the functioning domain measured. Additional Outcome Measures Program Satisfaction Questionnaire : Participants were asked to complete a satisfaction questionnaire that was designed by the study investigators for qua lity assurance purposes only For the purposes of this study, o nly one Item from the questionnaire was incorporated to evaluate the overall satisfaction on the study. This measure was included to examine whether the participants satisfaction differed as a function of treatment condition.
24 : Participants attendance at the eight treatment sessions was calculated to determine whether exposure to treatment differed as a function of condition. Treatment Conditions The re were two tre atment conditions in this study, a health education control condition and a low dose behavioral treatment condition. The health education condition used a curriculum that focused on health education geared to provide participants with latest government inf ormation about proper approaches to weight management It consisted of eight weekly weight loss treatment sessions during phase 1 (Months 0 6) and eight follow up sessions during phase 2 (Months 7 24) The health education curriculum focused on providing a dvice related to he althy eating, nutritional tips and recommendations on exercise safety following the recommendations of the Adult Treatment Panel III Report of the National Cholesterol Education Program along with mid ( The National Cholesterol Education Program 2001 ; US Department of Health and Human Services 2005 ) The goal was to help participants lower their calorie intake, increase their p hysical activity, and consume more healthy food. The low dose behavioral treatment condition incorporated the use of behavioral strategies such as self monitoring goal setting stimulus control, and problem solving to help participants achieve changes in their eating and physical activity patterns ( Wadden et al., 2006; Diabetes Prevention Program Research Group, 2002; Perri et al., 2001; Black, 1987) The use of the self monitoring concept in weight management is done by maintaining food and exercise logs, and the goal setting concept is typically accomplished by setting a calorie goal and a physical activity goal periodically and try ing to meet and/ or maintain that goal.
25 consisted of el graduate student in clinical psychology and an FCS agent employed by the extension offices. The interventionists underwent a thorough clinical training provided by the principal investigator through monthly face to face workshops and weekly telephone su pervision Statistical Analyses The statistical software package PASW SPSS 20.0 for Windows by IBM was used to calculate the statistical analyses for this research study. For the first aim an Independent t test analysis was calculated to determine wh ether the change in body weight from month 0 to month 6 differed by condition. Percentages of participants in each condition who achieved body weight reductions of > 5 % and > 10% were calc ulated with a chi square test. T tests were calculated to examine t he between group differences in attendance and treatment satisfaction. The second aim was examined by using the Repeated Measures Multivariate Analysis of Variance test, ( MANOVA ) on the MOS SF 36 Health Survey data The Wilks' Lambda criterion was used to test whether there were differences between the means of the targeted groups on a combination of depe nde nt variables and to test whether there were within subjects differences pre and post the behavioral treatment. The third aim was investigated by con ducting a Repeated Measures Multivariate Analysis of Covariance, ( MANCOVA ) using the same variables in the second aim and adding weight change from baseline to month 6 as a covariate so as to determine whether the effect of treatment on quality of life was mediated by weight loss (Baron & Kenny, 1986). Handling Missing Data : Forty of the 317 participants did not attend the 6 month assessment visit.
26 the hypothesis that the missing values in the sample were missing completely at random before applying the missing data methods. Subsequently, Chi square test statistics for all Expectation Maximization (EM) estimated statistics were found not statistically significant at p = 0.05 therefore, the null hypothesis was accepted and the missing values were determined to be missing completely at random, (X 2 = 52.444, ( df = 190; p = 1.0). t he Multiple Imputation method was used to complete missi n g values for these individuals. Missing values were predicted using existing values from other variables in the data set by performing ten separate imputations on the data set Results from the ten separate imputations were pooled to provide the overall av erage for the t statistics. Due to an administrative staff error, there were 90 missing SF 36 questionnaires at month 6 The Last Observation Carried Forward, ( LOCF ) was used to complete these missing values where p forward to complete missing data at month 6.
27 Table 2 1 Baseline characteristics for p articipants Variable (Unit) Low Dose Behavioral Condition (n = 148) Health Education (n= 169) Weight (kg) M 102 SD 16.6 M 100.1 SD 14.4 BMI (kg/m2) 36.1 4.2 36.3 3.9 Age (years) 51.5 12.3 52 10.8 Sex n % n % Female 112 75.7 138 81.7 Male 36 24.3 31 18.3 Race/Ethnicity n % n % Black, non Hispanic 25 16.9 29 17.2 Hispanic 3 2 10 5.9 Caucasian 118 79.7 124 73.4 Other/Multiple 2 1.4 6 3.6 Note: BMI = Body Mass Index
28 CHAPTER 3 RESULTS Sample Baseline Characteristics A sub sample of 317 participants from the Rural LITE overall sample were includ ed in the current study, of which 169 were in the health education only condition and 148 in the low dose behavioral treatment condition. The sub sample included 317, 78.9% were women and 21.1% were men. The mean age was 51.7 years (SD = 11.5) and the mea n BMI was 36.2 kg/m 2 (SD = 3.9). In the sub sample, 19.7% of the participants described themselves as members of an ethnic or racial minority group and 80.3% as of having a Caucasian origin. Effects of a Low Dose Behavioral Lifestyle Intervention on Weigh t Loss Results obtained from the independent t test analysis on weight change revealed a statistically significant difference between the two conditions, t (315) = 4.378 p < .001. Participants in the low dose behavioral treatment condition lost more weigh t ( 7.60 kg 6.4 ) than those in the health education only condition, (4.46 kg 4.9 ) (see Table 3 2) Moreover, there was a greater proportion of participants who achieved losses > 5% and > 10% in the low dose behavioral treatment condition compared to the h ealth education only condition. The difference between conditions was statistically significant for both the proportion of > 5% weight loss, X 2 (1, 317) = 11.88, p = .001; and the proportion of > 10% weight loss, X 2 (1, 317) = 15.47, p < .001 (s ee Figure s 3 1 and 3 2) The analyses on the participants reported program satisfaction showed no statistically significant difference between the health education only condition and the low dose behavioral treatment condition, t (222) = 1.173, p > .05 Participants in both conditions reported high overall program satisfaction: 92.5% and 89.9% respectively for the low dose
29 behavioral treatment condition and the health education only condition (s ee Figure 3 3 ) Furthermore, the analysis of data indicated no statistically significant difference between both conditions on the attendance rates for participants, t (315) = .678, p > .05 condition was similar to the attendance rate for p articipants in the low dose behavioral treatment condition, 87 % and 86% respectively. Effects of a Low Dose Behavioral Lifes tyle Intervention on Health Related Quality of Life The the eight quality of life scales indicated that the entire sample in both conditions had a statistically significant within subjects difference between their reported scores at month 0 and their reported scores at month 6 or after the intervention, F (8 276 ) = 428.487, p < .001. This significant statistical difference was observed in three quality of life domains or scales, physical functioning ( F (1) = 3462.067, p < .001), general health ( F (1) = 12.826, p < .001), and vitality ( F (1) = 19.376, p < .001 these health related quality of life domains in both conditions changed significantly from month 0 to month 6 Participants in both conditions reported improvement in their physical functioning, their general health and vitality. The analysis further revealed that there was a statistically significant difference between conditions on the quality of life domains of physical functioning, general health, and vitality with participants in the behavioral treatment condition reporting g reater improvements on the three domains than those in the health education only condition ( see Table 3 1 )
30 Would B ehavioral Treatment on Qua lity of Life Scores The mediation analysis was conducted according to Baron and Kenny model utilizing the Multivariate Analysis of Covariance test, ( MANCOVA ) wi th weight change as a covariate. The analysis demonstrated that weight change mediated the effect of treatment intervention on quality of life in bot h conditions. Wh en adding weight change as a covariate in the MANOVA analysis, weight change clearly diminished the relationship between the treatment interv ention and quality of life ( F (8, 276) = 525.103, p = .000 p 2 = .938 before adding weight change as a covariate; versus F (8, 279) = 2.119 p = .034 p 2 = .057 when adding the covariate) In other words, the observed c hange in quality of life was partially mediated by change in body weight.
31 Table 3 1 Mean quality of life scores for both treatment conditions at b aseline and m onth 6 (standard errors) Quality of Life S ubs cale s Low Dose Behavioral Condition (n = 148) Health Education (n = 169) Baseline Month 6 Baseline Month 6 Physical Functioning 77.7 (1.6) 85.9 (.18) 80.6 (1.5) 84.2 (.17) General Health 68.7 (1.7) 72.3 (1.6) 67.9 (1.6) 69.8 (1.6) Vitality 51.3 (1.9) 57.2 (1.9) 50.9 (1.8) 53.3 (1.8) Note: Significant between group effect at p < .001 Table 3 2. Mean body weight for both treatment conditions at baseline and m onth 6 (Standard Deviation) Low Dose Behavioral Condition (n = 148) Health Education (n = 169) Baseline Month 6 Baseline Month 6 Weight (kg) 102 ( 16.6 ) 93.37 (15.6) 100.1 ( 14.4 ) 94.76 (15.1) Figure 3 1 Proportion of participants a chieved > 5% weight l oss in both g roups Note: ( ) significant at p < .001
32 Figure 3 2. Proportion of participants a chieved >10% weight loss in both g roups Note: ( ) significant at p < .001 Figure 3 3 Percentage of p articipants overall s atisfaction with the weight loss p rogram between both g ro ups
33 CHAPTER 4 DISCUSSION T he current study had several objectives; the first was to determine the effects of a low dose behavioral lifestyle intervention on body weight in a sample of obese adults in a rural communi ty. The second objective was to examine the effects of a low dose behavioral lifestyle intervention on the health related quality of life. The major finding in this study was that p articipants in the behavioral treatment condition achieved a statistically significant mean weight loss that was greater than the mean weight loss achieved by those in the health education condition. On average participant s in the behavioral treatment condition lost 7.60 kg (SD = 6.40 ) of their initial body weight compared to 4. 4 6kg (SD = 4.9 ) in the health education only condition. Furthermore, a greater proportion of participants in the behavioral lifestyle treatment condition achieved clinically meaningful weight reductions ( > 5% of their initial weight) compared to the health education only condition. Approximately, 55% of the participants in the lifestyle behavioral treatment condition achieved 5% or greater weight loss from their initial weight Moreover, around 30% of the participants achieved weight losses > 10% of their initial body weight. In the health education only condition, only 36% of the participants achieved > 5% weight reduction an d only 12% achieved weight losses > 10% of their initial body weight. Weight losses of > 5% of the initial body weight have been asso ciated with greater improvements in several anthropometric indicators such as blood lipids, glycemic index insulin resistance, and high blood pressure. Hence, weight loss of 5% or greater of initial body weight has been found to be clinically meaningful t o the health outcomes of obese individuals. Furthermore, weight losses that are greater (i. e. 10% to
34 15% of the initial body weight ) was linked to a greater improvement on the above physical health measures and general wellbeing. While it is important to stress that the behavioral intervention was superior to the health education only intervention, it is equally important to highlight the notable weight loss observed with participants in the health education only condition. As noted previously weight lo ss programs based on health education without behavioral strategies such as self monitoring are still the most common form of weight loss programs in the community settings ( Stern et al., 1995 ) The second main finding of this study was the significant im provement in the health related quality of life for participants in the lifestyle behavioral treatment condition that was greater than that reported by participants in the health education only condition. An abundance of research has shown that weight loss is strongly associated with improvements in health related quality of life; furthe rmore, those who obtain greater weight losses consistently report greater improvements in health related quality of life (Karlsson et al, 2007) In our study, participants i n both conditions repor ted significant improvements in three domains of quality of life : physical functioning, general health, and vitality. As it was reported in previous research physical domains of quality of life are the most affected by obesity treat ment than the mental and social domains (Doll et al., 2000; Fontaine et al., 2004 ) Given that the improvement was observed in domains that are related to the physical component of the quality of life, we suspected that this effect occurred most likely due to the weight loss obtained in the groups. We further investigated the effect of our treatment intervention on the health related quality of life by exploring the possible meditational effects that weight loss could
35 have as an important contributor to th e improvement s in health and quality of life. We found that weight loss partially mediated the effect that treatment had on the quality of life domains. These findings highlight the impact of weight loss alone on quality of life (Ross et al., 2009; Imayama et al., 2011 ) Previous research on the effect of body weight on quality of life in the context of pain has indicated that improvement in body joint pain and other comorbidities attenuated the relationship between Body Mass Index and health related quali ty of life That is if an obese individual with joint pain loses weight, the relief in pain likely caused by weight loss (Heo, Allison, Faith, Zhu, & Fontaine, 2003) One potential explanation i s that this improvement was mainly due to the increased mobility and positive change in anthropometric indices. To our knowledge however, no previous studies investigated this meditational relationship and effect on quality of life in the context of low do se behavioral treatment Quality of life is an important indicator of success for clinical programs as well as for healthcare consumers; significant improvements in quality of life along with successful weight loss in this study could make this low dose ( 8 session) treatment option more attractive to policy makers than programs with the costly standard behavioral treatment consisting of 16 to 24 sessions However, regardless of the well established efficacy for lifestyle behavioral interventions for weight loss, the issue of whether these individuals are going to maintain this weight loss long term remains unresolved. In fact, multiple studies have indicated that this success is not well maintained over time and most participants regain the weight initially reduced
36 Therefore, the role of extended follow up care after weight loss programs i n enabling the participants to maintain the improvement i n quality of life should be investigated. This study had important limitations that should be addressed in futur e or subsequent research one of which is the issue of cost effectiveness of our program In a recent survey conducted by the University of Florida Weight Management Lab asking the administrators of the extension offices in the rural counties regarding the likelihood of funding these weight loss programs, more than 91.6% have indicated that a treatment program of 16 weeks (8 sessions of treatment and 8 sessions of extended care) would be moderately or highly feasible. Despite the abundance of research i ndicating the effectiveness of behavioral lifestyle treatment for obesity, these services are often not provided due to cost. There was no empirical data in current research on on in a According to the Center of Medicaid and Medicare Services guidelines, Intensive Behavioral Therapy for Obesity, (IBT) is to be covered and billed for if i t was offered in primary care centers by primary care physicians and specialized providers. Unfortunately, most rural areas experience a shortage in specialized healthcare providers and facilities and this still represents a barrier to their access to thes e services. However, providing weight loss programs via non traditional settings utilizing access to these services by obese individuals in rural areas ( Center s of Medicaid & Medicare Servic es 2012). Additionally, questions regarding the long term maintenance of the weight loss achieved or the health related quality of life obtained through this
37 program should be further investigated, a outcomes of individuals with significant health problems limits the generalizability of its findings In summary, the findings from this stud y demonstrate the potential benefits of low dose behavioral intervention for weight loss. Low dose treatment may represent an effective and less costly option to traditional high dose weight loss interventions.
38 LIST OF REFERENCES Allison, D. B., Fontaine K. R., Manson, J. E., Stevens, J., & VanItallie, T. B. (1999). Annual deaths attributable to obesity in the United States. J ournal of A merican M edical A ssociation 282 (16), 1530 1538. Andersen, L. B., Schnohr, P., Schroll, M., & Hein, H. O. (2000). All cause mortality associated with physical activity during leisure time, work, sports, and cycling to work. Arch ive of Intern al Med icine 160 (11), 1621 1628. Baron, R. M., & Kenny, D. A. (1986). The moderator mediator variable distinction in social psycho logical research: conceptual, strategic, and statistical considerations. J ournal of Pers onality & Soc ial Psychol ogy 51 (6), 1173 1182. Befort, C. A., Nazir, N., & Perr i, M. G. (2012). Prevalence of obesity among adults from rural and urban a reas of the U nited States: Findings f rom NHANES (2005 2008). Journal of Rural Health, 28 (4), 392 397. doi: 10.1111/j.1748 0361.2012.00411.x Bennett, K.J., Olatosi, B., & Probst, J.C. (2008). Health disparities: A rural urban chartbook South Carolina Rural Health Resea rch Center. Bennett, K. J., Probst, J. C., & Pumkam, C. (2011). Obesity among working age adults: The role of county level persistent poverty in rural disparities. Health Place, 17 (5), 1174 1181. doi: 10.1016/j.healthplace.2011.05.012 Black, D. R. (1987) A Minimal intervention p rogram and a problem solving program for w eight c ontrol. Cognitive Therapy and Research, 11 (1), 107 119. doi: 10.1007/Bf01183136 Butryn, M. L., Webb, V., & Wadden, T. A. (2011). Behavioral treatment of obesity. Psychiatr ic Clin ics of North Am erica 34 (4), 841 859. doi: 10.1016/j.psc.2011.08.006 Centers for Medicaid and Medicare Services. (2012). Intensive Behavioral Therapy Booklet. (1 st ed.) Retrieved from http://www.cms.gov/Outreach and Education/Medicare Learning Network MLN/MLNProducts/downloads/ICN907800.pdf Diabetes Prevention Program Research Group. (2002). The Diabetes Prevention Program (DPP): descr iption of lifestyle intervention. Diabetes Care 25(12), 2165 2171. Doll, H. A., Petersen, S. E. K., & Stewart Brown, S. L. (2000). Obesity and physical and emotional well being: Associations between body mass index, chronic illness, and the physical and mental components of the SF 36 questionnaire. Obes ity Res earch 8 (2), 160 170. doi: 0.1038/Oby.2000.17
39 Elavsky, S., McAuley, E., Motl, R. W., Konopack, J. F., Marquez, D. X., Hu, L., Diener, E. (2005). Physical activity enhances long term quality of life in older adults: Efficacy, esteem, and affective influences. Annals of Behavioral Medicine, 30 (2), 138 145. doi: 10.1207/s15324796abm3002_6 Elmer, P. J., Grimm, R., Jr., Laing, B., Grandits, G., Svendsen, K., Van Heel, N., et al. (1995). Lifes tyle intervention: results of the Treatment of Mild Hypertension Study (TOMHS). Prev entive Med icine 24 (4), 378 388. Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). (2001). Executive s ummary of the third report of t he National Cholesterol Education Program (NCEP). Journal of American Medical Association, 285 (19), 2486 2497. Findeis JL, Henry M, Hirschl TA, Lewis W, Ortega Sanchez I, Peine E et al. Welfare reform in rural America: A rev iew of current research. ( 2001 ). Columbia, MO: Rural Policy Research Institute (RUPRI). Flegal, K. M., Carroll, M. D., Kit, B. K., & Ogde n, C. L. (2012). Prevalence of obesity and trends in the distribution of body mass index among US a dults, 1999 2010. J ournal of the American Medical Association, 307 (5), 491 497. doi: 10.1001/Jama.2012.39 Flegal, K. M., Carroll, M. D., Ogden, C. L., & Curtin L. R. (2010). Prevalence and trends in obesity among US a dults, 1999 2008. Journal of the American Medical Associ ation, 303 (3), 235 241. doi: 10.1001/jama.2009.2014 Flegal, K. M., Carroll, M. D., Ogden, C. L., & Johnson, C. L. (2002). Prevalence and trends in obesity among US adults, 1999 2000. Journal of the American Medical Association, 288 (14), 1723 1727. doi: 10 .1001/jama.288.14.1723 Fontaine, K. R., & Barofsky, I. (2001). Obesity and health related quality of life. Obes ity Rev iews 2 (3), 173 182. Fontaine, K. R., Barofsky, I., Bartlett, S. J., Franckowiak, S. C., & Andersen, R. E. (2004). Weight loss and heal th related quality of life: results at 1 year follow up. Eat ing Behav ior 5 (1), 85 88. doi: 10.1016/S1471 0153(03)00059 X Foster, G. D., Makris, A. P., & Bailer, B. A. (2005). Behavioral treatment of obesity. Am erican J ournal of Clin ical Nutr ition 82 (1 S uppl), 230S 235S. Glasgow, N., Johnson, N. E., & Morton, L. W. (2004). Critical issues in rural health (1st ed.). Ames, Iowa: Blackwell Pub.
40 Goodpaster, B. H., Delany, J. P., Otto, A. D., Kuller, L., Vockley, J., South Paul, J. E., Jakicic, J. M. (2010). Effects of diet and physical activity interventions on weight loss and cardiometabolic risk factors in severely obese adults: a randomized trial. J ournal of A merican M edical A ssociation 304 (16), 1795 1802. doi: 10.1001/jama.2010.1505 Han, T. S., Tijhuis, M. A. R., Lean, M. E. J., & Seidell, J. C. (1998). Quality of life in relation to overweight and body fat distribution. Am erican J ournal of Public Health, 88 (12), 1814 1820. doi: 10.2105/Ajph.88.12.1814 Heo, M., Allison, D. B., Faith, M. S., Zhu S. K., & Fontaine, K. R. (2003). Obesity and quality of life: Mediating effects of pain and comorbidities. Obes ity Res earch 11 (2), 209 216. doi: 10.1038/Oby.2003.33 Howard, B. V., Manson, J. E., Stefanick, M. L., Beresford, S. A., Frank, G., Jones, B. T., Prentice, R. (2006). Low fat dietary pattern and weight change over 7 years The Women's Health Initiative Dietary Modification Trial. Journal of the American Medical Association, 295 (1), 39 49. doi: 10.1001/jama.295.1.39 Imayama, I., Alfano, C M., Kong, A., Foster Schubert, K. E., Bain, C. E., Xiao, L., McTiernan, A. (2011a). Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial. Int ernational J ou rnal of Behav ioral Nutr ition & Phys ical Act ivity 8 118. doi: 10.1186/1479 5868 8 118 Imayama, I., Alfano, C. M., Kong, A., Foster Schubert, K. E., Bain, C. E., Xiao, L. R., McTiernan, A. (2011b). Dietary weight loss and exercise interventions effe cts on quality of life in overweight/obese postmenopausal women: a randomized controlled trial. International Journal of Behavioral Nutrition and Physical Activity, 8 doi: Artn 118 Doi 10.1186/1479 5868 8 118 Ingram, D. D., & Franco, S. J. (2012). NCHS u rban rural classification scheme for counties. Vital & Health Stat istics, 2 (154), 1 65. Jia, H., & Lubetkin, E. I. (2005). The impact of obesity on health related quality of life in the general adult US population. J ournal of Public Health (Oxf), 27 (2), 156 164. doi: 10.1093/pubmed/fdi025 Johnson, F., & Wardle, J. (2011). The association between weight loss and engagement with a web based food and exercise diary in a commercial weight loss programme: a retrospective analysis. International Journal of Beh avioral Nutrition and Physical Activity 8 83. doi: 10.1186/1479 5868 8 83
41 Karlsson, J., Sjostrom, L., & Sullivan, M. (1998). Swedish obese subjects (SOS) -an intervention study of obesity. Two year follow up of health related quality of life (HRQL) an d eating behavior after gastric surgery for severe obesity. International journal of obesity and related metabolic disorders 22 (2), 113 126. Karlsson, J., Taft, C., Ryden, A., Sjostrom, L., & Sullivan, M. (2007). Ten year trends in health related qualit y of life after surgical and conventional treatment for severe obesity: the SOS intervention study International Journal of Obesity (Lond), 31 (8), 1248 1261. doi: 10.1038/sj.ijo.0803573 Kolotkin, R. L., Crosby, R. D., Williams, G. R., Hartley, G. G., & N icol, S. (2001). The relationship between health related quality of life and weight loss. Obes ity Res earch 9 (9), 564 571. doi: 10.1038/oby.2001.73 Kolotkin, R. L., Head, S., Hamilton, M., & T se, C. K. J. (1995). Assessing impact of w eight on quality of l ife. Obes ity Res earch 3 (1), 49 56. Kral, J. G., Sjostrom, L. V., & Sullivan, M. B. E. (1992). Assessment of q u ality of l ife before and after surgery for severe o besity. American Journal of Clinical Nutrition, 55 (2), S611 S614. Kruger, J., Bowles, H. R ., Jones, D. A., Ainsworth, B. E., & Kohl, H. W. (2007). Health related quality of life, BMI and physical activity among US adults (>= 18 years): National Physical Activity and Weight Loss Survey, 2002. International Journal of Obesity (Lond) 31 (2), 321 3 27. doi: 10.1038/sj.ijo.0803386 Larsson, U., Karlsson, J., & Sullivan, M. (2002). Impact of overweight and obesity on health related quality of life -a Swedish population study. International journal of obesity and related metabolic disorders 26 (3), 417 424. doi: 10.1038/sj.ijo.0801919 Lew, E. A., & Garfinkel, L. (1979). Varia tions in mortality by weight among 750,000 men and w omen. J ournal of Chronic Dis eases 32 (8), 563 576. doi: 10.1016/0021 9681(79)90119 X Manson, J. E., Colditz, G. A., Stampfer, M. J., Willett, W. C., Rosner, B., Monson, R. R., Hennekens, C. H. (1990). A prospective study of obesity and risk of coronary heart disease in women. N ew Engl and J ournal of Med icine 322 (13), 882 889. doi: 10.1056/NEJM199003293221303 Matvienko, O. A. & Hoehns, J. D. (2009). A lifestyle intervention study in patients with diabetes or impaired glucose tolerance: Translation of a research intervention into p ractice. Journal of the American Board of Family Medicine, 22 (5), 535 543. doi: 10.3122/jabfm.200 9.05.090012
42 McHorney, C. A., Ware, J. E., Jr., & Raczek, A. E. (1993). The MOS 36 Item Short Form Health Survey (SF 36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care 31(3), 247 263. McI ntosh W A & Sobal J (2004) Rural eating, diet, nutrition, and body w eight In N Glasgow L. Morton & N. Johnson (E ds. ) Critical Issues in Rural Health ( pp. 113 126). Ames IA : Blackwell O'Brien, P. E., Dixon, J. B., Brown, W., Schachter, L. M., C hapman, L., Burn, A. J., Baquie, P. (2002). The laparoscopic adjustable gastric band (Lap Band (R)): A prospective study of medium term effects on weight, health and quality of life. Obes ity Surg ery 12 (5), 652 660. doi: 10.1381/096089202321019639 P erri, M. G., Limacher, M. C., Durning, P. E., Janicke, D. M., Lutes, L. D., Bobroff, L. B., Martin, A. D. (2008). Extended care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) random ized trial. Arch ives of Intern al Med icine 168 (21), 2347 2354. doi: 10.1001/archinte.168.21.2347 Perri, M. G., Mcadoo, W. G., Spevak, P. A., & New lin, D. B. (1984). Effect of a multicomponent maintenance program on long term weight l oss. J ournal of Consul t ing & Clin ical Psychol ogy 52 (3), 480 481. doi: 10.1037//0022 006x.52.3.480 Perri, M. G., Nezu, A. M., Patti, E. T., & M ccann, K. L. (1989). Effect of length of treatment on weight l oss. Journal of Consulting & Clinical Psychology 57 (3), 450 452. doi: 1 0.1037//0022 006x.57.3. 450 Perri, M. G., Nezu, A. M., McKelvey, W. F., Shermer, R. L., Renjilian, D. A., & Viegener, B. J. (2001). Relapse prevention training and problem solving therapy in the long term management of obesity. Journal of Consulting & Clin ical Psychology, 69 (4), 722 726. Ross, K. M., Milsom, V. A., Rickel, K. A., Debraganza, N., Gibbons, L. M., Murawski, M. E., & Perri, M. G. (2009). The contributions of weight loss and increased physical fitness to improvements in health related quality o f life. Eat ing Behav ior 10 (2), 84 88. doi: 10.1016/j.eatbeh.2008.12.002 Samsa, G. P., Kolotkin, R. L., Williams, G. R., Nguyen, M. H., & Mendel, C. M. (2001). Effect of moderate weight loss on health related quality of life: an analysis of combined data from 4 randomized trials of sibutramine vs placebo. American Journal of Managed Care 7 (9), 875 883.
43 Stern, J. S., Hirsch, J., Blair, S. N., Foreyt, J. P., Frank, A., Kumanyika, S. K., Stunka rd, A. J. (1995). Weig hing the Options: Criteria for evaluatin g weight management p rograms. The Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity. Obesity Research 3(6), 591 604. Suh, D. C., Barone, J. A., Shin, H. C., Choi, I. S., & Vo, L. (2005). Prevalence trend s in overweight and obesity and weight control practices among adults in the US. Value in Health, 8 (6), A74 A74. doi: 10.1016/S1098 3015(10)67370 6 U.S. Department of Agriculture. National Institute of Food and Agriculture. (2007). Food, Nutrition, and He alth. Retrieved from http://www.csrees.usda.gov/nea/food/food.cfm United States. Dept. of Health and Human Services., United States. Dept. of Agriculture., & United States. Dietary Guidelines Ad visory Committee. (2005). Dietary guidelines for Americans, 2005 (6th ed.). Washington, D.C.: G.P.O. Villeneuve, P. J., Morrison, H. I., Craig, C. L., & Schaubel, D. E. (1998). Physical activity, physical fitness, and risk of dying. Epidemiology, 9 (6), 62 6 631. Wadden, T. A., Crerand, C. E., & Brock, J. (2005). Behavioral treatment of obesity. Psychiatr ic Clin ics of North Am erica 28 (1), 151 170, ix. doi: 10.1016/j.psc.2004.09.008 Wadden, T. A., & Stunkard, A. J. (2002). Handbook of obesity treatment N ew York: Guilford Press. Wadden, T. A., West, D. S., Delahanty, L., Jakicic, J., Rejeski, J., Kumanyika, S. (2006). The Look AHEAD study: A description of the lifestyle intervention and the evidence supporting it. Obesity (Silver Spring), 14(5), 737 752. doi: 10.1038/oby.2006.84 Weiner, R., Datz, M., Wagner, D., & Bockhorn, H. (1999). Quality of life outcome after laparoscopic adjustable gastric banding for morbid obesity. Obes ity Surg ery 9 (6), 539 545. doi: 10.1381/096089299765552639 Wing, R. R., Lang, W., Wadden, T. A., Safford, M., Knowler, W. C., Bertoni, A. G., Look, A. R. G. (2011). Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care, 34 (7), 1481 1486. doi: 10.2337/dc10 2415 Wing R R. (2002). Behavioral weight control. In: T. Wadden & A. Stunkard (Eds.), Handbook of obesity treatment (pp. 301 3 16 ). New York: Guilford Press.
44 BIOGRAPHICAL SKETCH Manal Alabduljabbar attended the University of Jordan Amma n and graduated in 2003 with a b achel sychology. She worked in Saad Specialist Hospital, Saudi Arabia in 2005 and developed a psychological service for bariatric surgery patients. Soon after, Manal started her post graduate studie s in Boston University and graduated in 2009 with a edicine. In 2011, Manal joined the Clinical & Health Psychology doctoral program and became a graduate assistant in the Weight Management Lab at the Uni ver sity of Florida, Gainesville. In 2013, Manal earned her Master of Science degree in clinical health psychology from the College of Public Health and Health Professions at the University of Florida.