A randomized controlled trial testing an Internet delivered cost-benefit approach to weight loss maintenance.

Weight loss maintenance is a significant challenge in obesity treatment. During maintenance the "costs" of adhering to weight management behaviors may outweigh the "benefits." This study examined the efficacy of a novel approach to weight loss maintenance based on modifying the cost-benefit ratio. Individuals who achieved a 5% weight loss (N=75) were randomized to one of three, 10-month maintenance interventions. All interventions were delivered primarily via the Internet. The Standard arm received traditional weight maintenance strategies. To increase benefits, or rewards, for maintenance behaviors, the two cost-benefit intervention conditions received weekly monetary rewards for self-monitoring and social reinforcement via e-coaching. To decrease behavioral costs (boredom) and increase novelty, participants in the cost-benefit conditions also monitored different evidence-based behaviors every two weeks (e.g., Weeks 1 & 2: steps; Week 3 & 4: red foods). The primary difference between the cost-benefit interventions was type of e-coach providing social reinforcement: Professional (CB Pro) or Peer (CB Peer). Study procedures took place in Providence, RI from 2013 to 2014. Retention was 99%. There were significant group differences in weight regain (p=.01). The Standard arm gained 3.5±5.7kg. In contrast, participants in CB Pro and CB Peer lost an additional 1.8±7.0kg and 0.5±6.4kg, respectively. These results suggest that an Internet delivered cost-benefit approach to weight loss maintenance may be effective for long-term weight control. In addition, using peer coaches to provide reinforcement may be a particularly economic alternative to professionals. These data are promising and provide support for a larger, longer trial.

Delayed reward discounting and grit in men and women with and without obesity.

OBJECTIVE: The objective of this study was to examine how sensitivity to short-term reward and long-term goal perseverance are related to body mass index (BMI; kg m2) in a large sample of men and women with and without obesity. METHODS: A total of 450 participants (56.2% male; 73.1% non-Hispanic White) with mean ± standard deviation age of 30.7 ± 10.4 years and BMI of 29.3 ± 8.2 completed online versions of the Delayed Reward Discounting task to measure sensitivity to short-term reward and the Grit Scale to measure long-term goal perseverance. RESULTS: In regression analysis, higher sensitivity to short-term reward (i.e. a preference for receiving smaller rewards after a shorter delay; b = 0.49, p = 0.016) and lower long-term goal perseverance (b = -1.26, p = 0.042) were independently associated with higher BMIs. Individuals with a favourable score on one measure were not 'protected' from the risk associated with an unfavourable score on the other measure. CONCLUSIONS: An overvaluation of short-term reward (e.g. the taste of palatable food and the comfort of engaging in sedentary activities) and undervaluation of long-term health goals (e.g. achieving a healthy weight and avoiding obesity-related comorbidities) may contribute to excess weight. Additional research incorporating prospective experimental designs is needed to determine whether decision-making strategies can be targeted to improve weight management.

Impact of a diabetes control and management intervention on health care utilization in American Samoa.

OBJECTIVES: To examine the impact of a successful 12-month behavioral intervention to improve diabetes control on health care utilization in American Samoa. METHODS: A cluster-randomized design was used to assign 268 diabetes patients to a nurse-community health worker intervention or usual care. Hospitalizations, emergency department, and primary care physician visits were collected retrospectively for 1 year prior to, and during, the intervention to assess changes in health care utilization. The association of utilization changes with change in HbA1c during the intervention was assessed. RESULTS: Adjusted incidence rate ratios (RR) for primary care physician visits were significantly higher in the community health worker relative to the usual care group (RR = 1.71; 95% CI, 1.25-2.33). There was no main intervention effect on emergency department utilization, but visits in the prior year modified the intervention effect on emergency department visits. Increased primary care physician utilization was associated with greater decreases in HbA1c (b = -0.10, SE = 0.04, p = 0.01). CONCLUSIONS: A culturally adapted community health worker diabetes intervention in American Samoa significantly increased primary care physician visits, and decreased emergency department visits among those with high emergency department usage in the prior year. These changes suggest important and beneficial impacts on health system utilization from the diabetes intervention in a low resource and high-risk population.

Implementation of a culturally tailored diabetes intervention with community health workers in American Samoa.

PURPOSE: The purpose of this article is to answer key implementation questions from our translation research with a primary care-based, nurse-community health worker (CHW) team intervention to support type 2 diabetes self-management. METHODS: Descriptive data are given on intervention delivery, CHW visit content, patient safety, and intervention costs, along with statistical analyses to examine participant characteristics of higher attendance at visits. RESULTS: In the intervention sample (n = 104), 74% (SD = 16%) of planned intervention visits occurred, guided by an algorithm-based protocol. Higher risk participants had a significantly lower dose of their weekly assigned visits (66%) than those at moderate (74%) and lower risk (90%). Twenty-eight percent of participants moved to a lower risk group over the year. Estimated intervention cost was $656 per person. Participants with less education were more likely to attend optimal percentage of visits. CONCLUSIONS: A nurse-CHW team can deliver a culturally adapted diabetes self-management support intervention with excellent fidelity to the algorithm-based protocols. The team accommodated participants' needs by meeting them whenever and wherever they could. This study provides an example of adaptation of an evidence-based model to the Samoan cultural context and its resource-poor setting.

Nurse-community health worker team improves diabetes care in American Samoa: results of a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of a culturally adapted, primary care-based nurse-community health worker (CHW) team intervention to support diabetes self-management on diabetes control and other biologic measures. RESEARCH DESIGN AND METHODS: Two hundred sixty-eight Samoan participants with type 2 diabetes were recruited from a community health center in American Samoa and were randomly assigned by village clusters to the nurse-CHW team intervention or to a wait-list control group that received usual care. RESULTS: Participants had a mean age of 55 years, 62% were female, mean years of education were 12.5 years, 41% were employed, and mean HbA1c was 9.8% at baseline. At 12 months, mean HbA1c was significantly lower among CHW participants, compared with usual care, after adjusting for confounders (b = -0.53; SE = 0.21; P = 0.03). The odds of making a clinically significant improvement in HbA1c of at least 0.5% in the CHW group was twice the odds in the usual care group after controlling for confounders (P = 0.05). There were no significant differences in blood pressure, weight, or waist circumference at 12 months between groups. CONCLUSIONS: A culturally adapted nurse-CHW team intervention was able to significantly improve diabetes control in the U.S. Territory of American Samoa. This represents an important translation of an evidence-based model to a high-risk population and a resource-poor setting.

Long-term trends in food availability, food prices, and obesity in Samoa.

OBJECTIVES: To describe long-term food availability and prices from 1961 to 2007 and body mass index (BMI) trends from 1980 to 2010 in Samoa, and to contextualize these trends within political, economic, cultural, behavioral, and climatic influences. METHODS: National level data on food availability and pricing were obtained from the open access database FAO (http://faostat.fao.org). Data for Samoa were collected from annual food balance sheets available for the period 1961-2007. Mean BMI for Samoan men and women aged 35-44 years of age is reported from four different time periods, 1979-1982, 1991, 2003, and 2010. RESULTS: Total energy availability increased substantially, by 47%, with more than 900 extra calories available per capita per day in 2007 than in 1961. Many of these extra calories are supplied by dietary fat, the availability of which rose by a proportionally greater amount, 73%. Availability of both meat and vegetable oils rose substantially. Poultry meat increased the most proportionally, from 10 to 117 kcal per capita per day. Coconut products, fruits, and starchy root crops-all locally grown-showed little to no increase over this time. As import prices for poultry and mutton increased their availability decreased, but the availability of vegetable oils rose despite a rise in their price. Mean BMI for men and women aged 35-44 years rose 18% rise from 1980 to 2010. CONCLUSIONS: These long-term trends in food availability and prices, and the temporal pattern of BMI provide national level data for understanding the process of the nutritional transition in Samoa. Further work on consumer food prices, diet, food security, and health is needed to further contextualize the transformation of the local food system in Samoa.