SummaryIn partnership with the University of Florida, local county offices of the United States Department of Agriculture Cooperative State, Research, Education, and Extension Service implemented the Treatment of Obesity in Underserved Rural Settings (also known as TOURS) program, which offered biweekly, one-on-one telephone counseling or face-to-face group sessions over a year-long period to rural women who successfully completed a lifestyle intervention program. Counselors used an established five-stage, problem-solving model to address barriers to maintaining eating and exercise behaviors required to sustain the initial weight loss. A randomized controlled trial found that both telephone and face-to-face counseling were equally effective, with participants in both groups exhibiting greater adherence to weight-management strategies and regaining less weight and body mass index than did those in a control group. The telephone option was significantly less expensive than face-to-face counseling and required less time of participants. Since the demonstration study (and its associated funding) ended, the developer has been working with county extension offices to develop and test lower-cost alternatives to allow the program to continue.Strong: The evidence consists of an RCT that compared key outcomes, including changes in weight and BMI, in three groups—face-to-face group counseling, telephone-based counseling, and biweekly educational newsletters (the control group).
Developing OrganizationsU.S. Department of Agriculture Cooperative State, Research, Education, and Extension Service; University of Florida College of Public Health and Health Professions
Date First Implemented2003
Patient PopulationThe pilot study included rural women between the ages of 50 and 75 years, although the program could be used with other populations as well. (See Adoption Considerations section for further discussion.)Gender > Female; Vulnerable Populations > Rural populations; Women
Problem AddressedLifestyle interventions can be effective in helping individuals lose weight, but participants commonly regain much of the weight in the year after program completion. In-person, extended care programs can help in maintaining weight loss, but individuals who live in rural areas—who are more likely to be obese—may find it difficult to travel to such programs.
- Temporal benefits of lifestyle interventions: Although programs that promote improved diet, exercise, and other behavior modifications have been shown to produce clinically significant weight reductions, participants commonly regain one-third to one-half of the lost weight in the year after completion of the program.1
- Unrealized benefits of extended care programs: Clinic-based follow up sessions can help individuals to maintain weight loss, but rural residents often find traveling to such sessions difficult.1 Those living in rural areas, moreover, are most in need of long-term weight loss programs, as they have higher rates of obesity, physical inactivity, and associated clinical problems.2,3,4
Description of the Innovative ActivityAs part of a demonstration study, county offices of the United States Department of Agriculture (USDA) Cooperative Extension Service in northern Florida offered 24 biweekly counseling sessions to rural women who had previously completed a 6-month lifestyle modification program. During either telephone or group face-to-face sessions, counselors used an established five-stage problem-solving model to help participants address barriers to maintaining appropriate eating and exercise behaviors. Key elements of the program are described below:
- Target population: The program served rural women between the ages of 50 and 75 years who had previously completed a 6-month group lifestyle modification program at local extension service offices. Participants were recruited through flyers sent to households, with all volunteers being accepted except those identified during medical screening as requiring immediate medical care. The initial program included weekly group counseling sessions that promoted a low-calorie eating plan, increased physical activity, and training in behavior modification strategies. Approximately 79 percent of initial participants completed the program, losing an average of 10 kg and 3.8 points in body mass index (BMI).1
- Extended care program options: Trained counselors worked with those who completed the initial program during 24 biweekly sessions conducted in face-to-face group meetings or over the phone.
- Face-to-face group meetings: Groups of 10 to 12 individuals met with a counselor for an hour-long session that consisted of three parts: an individual weigh-in; reports from select group members about what did and did not go well during the previous 2 weeks (with the rest of the group and the counselor sharing advice and suggestions); and a formal lesson on a new technique or strategy to try during the upcoming weeks (e.g., reducing fat and calorie content when cooking). Each week, different individuals discussed their experiences so that everyone received individualized feedback at least once every few sessions.
- Telephone counseling: The telephone counseling approach involved 15- to 20-minute phone conversations in which the counselor and participant discussed what had and had not been working over the previous 2 weeks and brainstormed strategies for addressing challenges and barriers.
- Five-stage, problem-solving model: Counselors in both the group and telephone sessions used an established five-stage, problem-solving model to help address barriers to maintaining healthy eating and physical activity.5 Counselors worked through these stages one-on-one with participants during the phone sessions but incorporated input from the entire group during in-person sessions.
- Orientation: This stage focuses on developing an appropriate coping perspective by emphasizing that problems are a normal part of managing weight that can be dealt with effectively. The goal is to ease the minds of participants who may be struggling with issues by emphasizing that such roadblocks should be expected and can be overcome.
- Definition: This stage specifies the problems being faced and establishes goals related to overcoming them and changing behaviors. For example, if someone gains 2 pounds while on vacation, the counselor works with the individual to identify the cause(s) of the weight gain, such as lack of an eating plan. The counselor and participant then set a goal for the next time away from home, such as limiting caloric intake to 1,500 calories a day.
- Generating alternatives: This stage focuses on brainstorming potential strategies for achieving the established goal, with consideration of a broad range of ideas so as to increase the odds of finding an effective one. To continue the example from above, this stage would focus on identifying roughly 10 strategies for limiting caloric intake to 1,500 calories a day while away from home, such as avoiding fast-food restaurants.
- Decisionmaking: This stage focuses on evaluating and discussing probable short- and long-term consequences of the various options and deciding on an approach that has the most potential, such as eating a healthy sandwich at Subway rather than a hamburger at a fast-food restaurant.
- Implementation and evaluation: During this stage, the participant agrees to try one or two ideas in the coming weeks and to discuss and evaluate them at a future session.
- Food-intake and activity logs: Three times a week (twice on weekdays and once over the weekend), participants recorded daily food intake and physical activity levels on a log. Participants received pedometers to help them track and record the number of steps taken during the day. Those participating in telephone counseling used postage-paid envelopes to send in their logs.
Context of the InnovationThe USDA Cooperative State, Research, Education, and Extension Service runs county offices in the vast majority of U.S. counties and is affiliated with a land-grant university in each state. In Florida, counties provide roughly one-half of the funding for local offices, with the remainder coming from the Federal government (10 percent) and the state (40 percent, funded through the University of Florida, the land-grant university for the area). In addition to supporting agriculture and farming, most extension offices have nutrition education as part of their mission, with family and consumer science agents on staff being responsible for this component. The initial weight-management program was developed by University of Florida researchers in response to studies showing higher rates of chronic disease in rural areas. The program was modeled after the Diabetes Prevention Program, a lifestyle intervention that significantly reduces the risk of diabetes.6 The extended-care program options were added in response to studies showing the potential for relapse among those who initially lose weight, particularly in rural areas where residents may have difficulties accessing ongoing support. After initially considering working through local county health departments (which have to means-test participants and thus serve only low-income populations), developers approached local cooperative extension offices in six counties about running the programs.
ResultsA randomized controlled trial (RCT) found that both the telephone and face-to-face counseling were equally effective, with participants in both groups exhibiting greater adherence to weight-management strategies and regaining less weight and BMI than a control group receiving biweekly newsletters. Telephone counseling was significantly less expensive and required less time of participants.
Strong: The evidence consists of an RCT that compared key outcomes, including changes in weight and BMI, in three groups—face-to-face group counseling, telephone-based counseling, and biweekly educational newsletters (the control group).
- Strong adherence to weight-management strategies: Analysis of food-intake logs show that those individuals who received counseling (72 via telephone and 83 via face-to-face group sessions) exhibited stronger adherence to weight-management strategies than did the control group (79 individuals). Within and across groups, differences in adherence to these strategies were tied closely to maintaining weight and BMI loss (see next bullet).
- Equally effective in maintaining weight loss: Individuals receiving either type of counseling regained an average of 1.2 kg, significantly less than the 3.7-kg average gain for those in the control group. Average BMI increased by 0.5 points in the telephone group and 0.4 points in the face-to-face group, both well below the 1.4-point average gain in the control group.1
- No significant differences in cardiovascular risk factors: The demonstration study lacked adequate size to detect differences in cardiovascular risk factors, which were secondary measures. Available results suggest that improvements in cardiovascular risk factors from the initial 6-month lifestyle intervention were generally maintained by all three groups. The only exception was for cholesterol levels, which rose in each group (particularly the face-to-face counseling group), perhaps because participants maintained low-calorie diets but switched back to higher-fat foods.
- Telephone counseling more cost-effective, less time-consuming: Telephone counseling proved much less costly, with the average cost per participant being less than half that of the face-to-face option ($192 vs. $397). In addition, telephone-counseling participants saved over 13 hours of travel time to and from the sessions over the course of the year and spent approximately 11 hours less time in counseling (because the telephone-based sessions were shorter).1
Planning and Development ProcessKey steps in the planning and development process included the following:
- Meeting with county boards and extension offices: Program leaders met with county boards to present the program, emphasizing the importance of weight management in reducing the risk of chronic diseases. The boards overwhelmingly supported the concept. Leaders then met with county extension office directors, who felt liberated to implement the program because of the board's support. Program developers periodically report back to the these boards and office directors on the project's progress.
- Identifying and funding counselors: For those offices that did not have in-house staff to serve as counselors, program leaders helped to identify qualified individuals. Two counties used program funds to hire individuals on a part-time basis who already had a relationship with the extension office, while two other counties used program funding to hire former University of Florida students identified by program developers. For those offices that already had family and consumer science agents on staff, pilot study funding covered that portion of their time that was dedicated to this program.
- Training counselors: Counselors attended a series of workshops on how to run counseling sessions and participated in weekly calls during the pilot study to discuss what was and was not working with respect to these sessions.
- Demonstration study: The demonstration study of the extended-care programs ran for 12 months after participants completed the initial 6-month weight loss program.
- Revamping and testing model for ongoing use: Program leaders are currently working with county extension office directors to develop and test a lower-cost counseling model. A survey of all 67 Florida counties found that one-half of extension office directors felt they could afford to offer 16 sessions a year for 2 years, and nearly all offices felt they could cover 8 sessions a year. A new study, known as Rural Lifestyle Intervention and Treatment Effectiveness, will test the effectiveness of these approaches versus an education-only comparison group.
Resources Used and Skills Needed
- Staffing: Counselors generally had a bachelor's degree in nutrition, exercise science, psychology, or behavioral science. During the year-long pilot, counselors spent 63 hours providing telephone counseling to the 72 participants, with an additional 24 hours of support from a program assistant. Counselor time for the 83 face-to-face participants (six groups) totaled 126 hours, along with 78 hours of support from the program assistant.
- Costs: The cost per participant averaged $397 for face-to-face counseling and $192 for phone-based counseling. Costs primarily consist of counselor's time, telephone, postage, handouts, and office space.1 As noted, development and testing of new, lower-cost models are under way.
Funding SourcesNational Heart, Lung, and Blood Institute (U.S.); U.S. Department of Agriculture Cooperative State, Research, Education, and Extension Service
The pilot study was funded by the National Heart, Lung, and Blood Institute, a part of the National Institutes of Health. County extension offices donated space for the in-person sessions.
Tools and Other ResourcesMore information on the five-stage model is available in: Perri MG, Nezu AM, Viegener BJ. Improving the long-term management of obesity: theory, research, and clinical guidelines. New York, NY: John Wiley & Sons; 1992.
Getting Started with This Innovation
- Get community buy-in: Meet with local county boards, extension office directors, or other potential program sponsors to secure buy-in. Emphasize the higher rates of obesity and chronic disease in rural areas and the potential for weight loss/management to reduce these risks. The focus should be on the tangible health benefits of losing weight, not improved appearance.
- Include maintenance: Too often programs focus only on initial weight loss, with little or no attention paid to helping individuals maintain their healthy habits and thus avoid relapse.
Sustaining This Innovation
- Elicit participant input: Regularly eliciting and reviewing participant opinions can lead to effective changes that may boost program attendance. For example, after participants expressed some level of boredom with group sessions, program leaders encouraged counselors to introduce new material each time, such as distributing a new article or discussing a new strategy.
- Report results regularly: To maintain support and enthusiasm, meet with key stakeholders at least once a year to report on program benefits.
- Consider less-expensive models: County extension offices and other would-be sponsors may find it difficult to support biweekly face-to-face or telephone counseling sessions. As a result, consideration may have to be given to less frequent sessions and/or other cost-reducing measures (e.g., offering group telephone counseling, which is being tested in other studies).
- Consider serving other populations: Although the demonstration study focused on postmenopausal women (a high-risk group that generally has the time and motivation to participate), the program could be offered to other populations. Developers believe that the same approach could work with older men. Younger populations may also benefit, although compliance rates tend to be lower, particularly among women juggling work and childcare demands.
- Although the demonstration study tested a program operated out of county extension offices, other types of organizations could adopt the same approach, including a health plan, health system, hospital, physician group, employer, fitness facility, or weight loss program.
Contact the InnovatorMichael G. Perri, PhD, ABPP
Dean, College of Public Health and Health Professions
The Robert G. Frank Endowed Professor of Clinical and Health Psychology
University of Florida
PO Box 100185
1225 Center Drive, HPNP Suite 4101
Gainesville, FL 32610
Innovator DisclosuresDr. Perri has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesPerri MG, Limacher MC, Durning PE, et al. Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial. Arch Intern Med. 2008;168(21):2347-54. [PubMed]
Perri MG, Limacher MC, Durning PE, et al. Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial. Arch Intern Med. 2008;168(21):2347-54. [PubMed]
Jackson DE, Doescher MP, Jerant AF, et al. A national study of obesity prevalence and trends by type of rural county. J Rural Health. 2005;21(2):140-8. [PubMed]
Lutfiyya MN, Lipsky MS, Wisdom-Behounek J, et al. Is rural residency a risk factor for overweight and obesity in US children? Obesity. 2007;15(9):2348-56. [PubMed]
Patterson PD, Moore CG, Probst JC, et al. Obesity and physical inactivity in rural America. J Rural Health. 2004;20(2):151-9. [PubMed]
5 Perri MG, Nezu AM, Viegener BJ. Improving the long-term management of obesity: theory, research, and clinical guidelines. New York, NY: John Wiley & Sons; 1992.
Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. 2002;25(12):2165-71. [PubMed]
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Original publication: June 22, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 06, 2014.
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