SummaryOverweight, active-duty Air Force personnel at three bases participated in an Internet-based behavioral therapy program designed to help them prevent future weight gain and potentially lose a moderate amount of weight. Key program components included regular reporting on food intake, physical activity, and weight; personalized written feedback on this information from a counselor; 24 weekly interactive lessons related to behavior-related weight-control strategies; and two 15-minute telephone calls with the counselor. The program, which terminated after grant funding ended, moderately reduced weight, waist circumference, percent fat content, and body mass index; increased the likelihood of weight loss of 5 percent or more of initial weight; reduced the risk of weight gain; and improved eating habits and the ability to manage weight effectively.Strong: The evidence comes from a randomized controlled trial (RCT) of 446 healthy adults (222 men, 224 women) that compared key metrics related to weight management in program participants and a control group; key metrics included weight, BMI, waist circumference, percent body fat, the percentage within the group losing 5 percent or more of initial weight, the percentage within each group gaining weight, self-reported eating and exercise habits, and survey findings related to the ability to manage weight.
Developing OrganizationsU.S. Air Force
Date First Implemented2003
The randomized controlled trial enrolled participants between June 2003 and October 2005.
Vulnerable Populations > Military/Dependents/Veterans
Problem AddressedOverweight and obesity have been well documented as major, growing problems that negatively affect the health status of Americans, even among active military personnel who need to be in good physical shape and who usually receive weight-management support. Although most people become overweight or obese slowly over time, most weight management programs focus on achieving moderate to large reductions for those already in need of significant weight loss. In addition, active military personnel and other time-pressed and/or geographically isolated individuals often do not have access to—or may find it difficult or impossible to consistently attend—traditional, face-to-face weight loss programs.
- Growing overweight/obesity epidemic: The average body weight of adults in the United States has increased significantly over the last 30 years, with nearly two-thirds of adults now being classified as overweight (with a body mass index, or BMI, of 25 or above) or obese (BMI of 30 or above).1 Overweight and obesity contribute to the development and/or exacerbation of chronic health conditions, and lead to an estimated 400,000 deaths annually, second only to smoking as an underlying cause of mortality.2
- Slow weight gain over time: Most adults who become overweight or obese do so slowly over time, gaining 1 to 2 pounds a year.2
- Active military not immune: Contrary to conventional wisdom, many active military personnel face weight-related problems. Within the United States Air Force (USAF), roughly 60 percent of active personnel were overweight in 2005, while 13.4 percent were obese.3 Overweight and obesity are estimated to cost USAF $23 million a year, including $19 million in health care expenditures and $4 million in lost workdays.2 Like other adults, overweight and obese military personnel also tend to gain weight slowly over time; in the USAF, for example, weight gain averages 1 to 2 pounds a year.3
- Even with substantial existing support: Weight problems within the military exist even though many bases offer regular support in this area. For example, the three bases implementing this program provided the following "usual care" with respect to weight management: at least annual preventive health visits that include a weight assessment, availability of one or more onsite fitness centers, weight loss and healthy cooking classes, nutrition consultants, and individual fitness assessments and recommendations. USAF also expects active personnel on these bases to work out with their unit at least three times per week, and the bases conduct annual fitness tests and BMI and waist circumference measurements to gauge adherence to established USAF standards. Consistent failure to meet these standards can lead to loss of promotion opportunities and in rare instances to discharge from the military.
- Inadequacies of traditional face-to-face programs: Many traditional weight management programs focus on those who desire to lose a moderate or large amount of weight, with relatively little attention paid to those hoping to avoid modest weight gain or achieve modest loss. In addition, many traditional programs focus on face-to-face interactions, requiring attendance at specific times and locations, an approach that may not work well for time-pressed and/or geographically isolated individuals, or for those who do not like face-to-face encounters with a counselor.1 Often people sign up for such face-to-face programs, only to stop attending the sessions over time. For these individuals, an Internet-based approach offers significant potential.
Description of the Innovative ActivityOverweight, active-duty Air Force personnel at three bases participated in a 24-week Internet-based behavioral therapy program designed to help them prevent future weight gain and potentially lose a moderate amount of weight. (This program supplemented the existing weight management support offered on these bases, described in the Problem Addressed section above.) Key program components included regular reporting on food intake, physical activity, and weight; personalized written feedback on this information from a counselor; 24 weekly interactive lessons related to behavior-related weight-control strategies; and two 15-minute telephone calls with a counselor using motivational interviewing techniques. Additional details on these key elements are provided below:
- Target population: The program targeted active USAF military personnel who weighed within 5 pounds of or above their maximum allowable weight (calculated based on a BMI of 25 for women and 27.5 for men); those above the maximum weight had to take concrete steps to lose weight or face potential consequences, such as being ineligible for promotion. All participants had a personal computer with Internet access. The initial study excluded those planning to leave the area within 1 year; those who had lost more than 10 pounds in the last 3 months; those who used prescription or over-the-counter weight reduction medications in the last 6 months; those with restrictions on physical activity; those with a history of myocardial infarction, stroke, or cancer in the last 5 years; those with diabetes, angina, thyroid difficulties, or orthopedic joint problems that prevent exercise; and those pregnant, breastfeeding, or planning to become pregnant within 1 year.
- Marketing the program: Eligible personnel learned about the program through flyers, e-mails, or during their annual physical examination, which includes a weigh-in and fitness test. Because these individuals knew they had to do something to avoid being over the maximum allowable weight, most of those eligible for the program expressed an interest in participating.
- In-person orientation to learn about system: Participants attended an inperson orientation to learn the Internet-based system, including how to calculate calories and energy expenditure and how to submit electronic food and exercise diaries. The session also explained when to expect weekly feedback from the counselor and how to set goals related to weight loss and calorie intake.
- Internet-based behavioral therapy: The program provided behavioral, dietary, and physical activity recommendations designed to facilitate small to moderate weight loss and to prevent future weight gain. To that end, the program included the following:
- Setting of initial parameters: Depending on starting weight, the system asked participants to restrict calorie intake (generally to 1,200 to 1,500 kilocalories a day), keep calories from fat below 30 percent of total calories, and increase physical activity until estimated expenditure of energy equaled at least 1,000 kilocalories per week.
- Food and exercise diaries: Participants logged into the system—ideally at least five times a week—to report on their food intake, physical activity, and weight (monitored through a weight-tracking chart). During the trial, most participants did not meet the five-times-a-week goal, with only about 17 percent meeting or exceeding this threshold. The average participant logged in a little over twice a week, and many (42 percent) did so once a week or less.1
- Weekly interactive lessons and assigned readings: Each week participants completed a 20- to 30-minute interactive lesson focused on strategies associated with changing behaviors so as to promote weight loss, such as stimulus control, stress management, and other behavior modification. Lessons include interactive quizzes, with access to subsequent sessions being dependent on successful completion of the previous lesson. Participants also received the Lifestyle, Exercise, Attitudes, Relationships, and Nutrition (LEARN) Program for Weight Management 2000 guide, which includes 5 minutes of weekly assigned reading designed to complement the interactive lessons.
- Weekly Web-based feedback from counselor: Each week, a counselor assigned to the individual reviewed the participant's self-reported information on weight, exercise, and food intake, and then provided written feedback and guidance. For example, if a counselor noticed that an individual seemed to be consuming too many sugary beverages and/or not engaging in an adequate amount of physical activity, the written feedback would emphasize the need to alter those behaviors and provide practical suggestions for how to do so. Conversely, for participants following an appropriate diet or exercise schedule, the counselor would provide positive reinforcement and emphasize the benefits of continuing such behaviors.
- Telephone-based motivational interviews: Twice during the 24-week program (after weeks 4 and 8), participants engaged in a 15-minute phone call with the same counselor who provided the weekly written feedback. (During the initial study, 93.4 percent of program participants completed the call after week 4, while 78.4 percent completed the call after week 8.1) These motivational interviews focused on eliciting behavior change by increasing the participant's awareness of the discrepancy between present behaviors and future goals. Counselors tailored the content of the call to the individual's needs, with the goal being to help individuals to understand the costs and benefits of both the status quo (e.g., not eating properly or engaging in regular physical activity) and of adopting healthier behaviors. The goal was to get individuals to conclude on their own that they needed to eat better and/or exercise more, and then to assist them in doing so by offering practical advice on how to change, such as by initially setting achievable goals and then ratcheting them up over time. For example, for someone who found the notion of 30 minutes of daily exercise daunting, the counselor helped the person set an initial goal of walking for 10 minutes a day, and then increase the duration of walking by 30 seconds or a minute each day until the 30-minute goal was met.
- Incentives: As with other LEARN-based programs, participants received modest incentives to encourage ongoing participation, including small gifts (e.g., T-shirts, pedometers, stress balls, coffee mugs) that had a total value of no more than $25. Participants typically received these gifts during a face-to-face assessment, such as a periodic weigh-in.
References/Related ArticlesHunter CM, Peterson AL, Alvarez LM, et al. Weight management using the Internet: a randomized controlled trial. Am J Prev Med. 2008;34(2):119-26. [PubMed]
Rasu RS, Hunter CM, Peterson AL, et al. Economic evaluation of an Internet-based weight management program. Am J Manag Care. 2010;16(4):e98-e104. [PubMed]
Contact the InnovatorRafia S. Rasu, PhD
Associate Professor of Pharmacy Practice and Administration
Schools of Pharmacy and Nursing
Doctoral Faculty of Henry W. Bloch School of Management
University of Missouri-Kansas City
4247 New Health Sciences Building
2464 Charlotte Street
Kansas City, MO 64108
Phone: (816) 235-5498
Fax: (816) 235-6008
Web site: http://pharmacy.umkc.edu/faculty-staff/directory/rafia-rasu/
Alan L. Peterson, PhD, ABPP
Professor, Department of Psychiatry
Chief, Division of Behavioral Medicine
University of Texas Health Science Center at San Antonio
7550 IH 10 West, Suite 1325
San Antonio, TX 78229
Phone: (210) 562-6700
Fax: (210) 562-6710
Innovator DisclosuresDr. Peterson reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.
Dr. Rasu has not indicated whether she 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.
ResultsThe program moderately reduced weight, waist circumference, percent fat content, and BMI; increased the likelihood of weight loss of 5 percent or more of initial weight; reduced the risk of weight gain; and improved eating habits and the ability to manage weight effectively.
Strong: The evidence comes from a randomized controlled trial (RCT) of 446 healthy adults (222 men, 224 women) that compared key metrics related to weight management in program participants and a control group; key metrics included weight, BMI, waist circumference, percent body fat, the percentage within the group losing 5 percent or more of initial weight, the percentage within each group gaining weight, self-reported eating and exercise habits, and survey findings related to the ability to manage weight.
- Moderate reductions in weight, waist circumference, and BMI: Participants lost an average of 1.3 kg, while those in a control group receiving "usual care" (i.e., the weight management support offered to all active duty personnel on the bases, described earlier) gained an average of 0.6 kg. This difference was statistically significant. Participants also experienced moderate, statistically significant declines in waist circumference and percent body fat, and a moderate (but not statistically significant) decline in BMI as compared with those receiving usual care. Those who used the Web site and its self-monitoring tools more often tended to lose more weight; for example, participants logging in 5 or more days per week lost more than 4 kg while those logging in less than once a week gained weight.1
- More likely to lose 5 percent or more of initial weight: Nearly one-fourth (22.6 percent) of participants lost at least 5 percent of their initial body weight, compared with just 6.8 percent of those receiving usual care. This difference was statistically significant.1
- Less likely to gain weight: A little more than four in 10 participants (41.8 percent) gained weight during the program, well below the 59.7 percent of those receiving usual care; this finding was statistically significant.1
- Better eating, no change in physical activity: Participants improved their eating habits, consuming more fruits and vegetables and doing a better job of controlling fat intake than did those in the control group. The program had no meaningful impact on levels of physical activity.
- Better able to manage weight: Post-implementation self-reported scores on measures included in the Weight Efficacy Lifestyle (WEL) questionnaire, such as the ability to resist social pressure to eat unhealthy foods and the ability to engage in healthy activities, increased more for participants than for those receiving usual care, with these differences being statistically significant.3
Context of the InnovationThe program was implemented in three USAF military bases in San Antonio, TX—Lackland Air Force Base, Randolph Air Force Base, and Brooks City Base. At the time of the RCT, these bases served 17,000 active duty military personnel. As noted earlier, despite the fact that all personnel on these bases receive assistance with weight management as part of their regular medical care and support, many on the base remained at or above the weight limitations of USAF, and base leaders felt that their weight problems could have a negative impact on health care expenditures, productivity, and performance. Several clinical psychologists (also active duty military) with an interest in reducing the traditionally high dropout rates experienced in many face-to-face weight loss programs approached base leaders about the idea of testing an Internet-based program. Given the time pressures facing many active USAF personnel and resource constraints on the bases (e.g., available counselors), base leaders felt that this approach had significant potential, and agreed to test it.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Securing grant funding: A group of clinical psychologists wrote a proposal for grant funding to develop and test an Internet-based program based on LEARN, a face-to-face approach that had previously been found to be effective in multiple studies and populations.
- Developing Internet-based program: The psychologists took concepts from the LEARN manual to create a set of weekly modules that could be delivered through an interactive, Internet-based program.
- Orientation for researchers: As part of the RCT, researchers learned how to conduct specific aspects of the study, such as how to capture baseline information and to assess participants at various points during the trial.
- Training counselors: An expert on motivational interviewing conducted a 2-day workshop designed to teach the counselors how to interact effectively with participants. The session included lectures, role playing, and feedback and coaching based on the workshop leader's observations of the counselors' interactions with individual program participants.
Resources Used and Skills Needed
- Staffing: The program required two counselors who spent an average of 63 minutes with each participant during the 24-week trial.3
- Costs: The total costs to serve 227 participants over the 6-month period of the RCT were $11,178.40, or $49.24 per participant. Staff time totaled $3,185.08 ($14.03 per participant) while other direct costs totaled $7,993.32 ($35.21 per participant). The LEARN manuals represented the largest direct cost ($3,427, or just over $15 per participant), with other meaningful expenses being researcher orientation and travel, counselor training, Web site–related costs, supplies, postage, incentives, and photocopying.3 (More details on the costs of the program can be found in Rasu RS, Hunter CM, Peterson AL, et al. Economic evaluation of an Internet-based weight management program. Am J Manag Care. 2010;16(4):e98-e104. [PubMed])
Funding SourcesU.S. Department of Defense; U.S. Army Medical Research and Material Command; Peer Review Medical Research Program
Financial support for the RCT came from a grant funded by the U.S. Department of Defense, the U.S. Army Medical Research and Material Command, and the Peer Review Medical Research Program (grant #DAMD17-02-1-0180).
Tools and Other ResourcesMore information on LEARN is available at http://www.bestdietforme.com/Top60DietReviews/LEARN.htm.
Getting Started with This Innovation
- Leverage existing resources: Existing Web-based weight management programs may be available as a starting point for would-be adopters. These systems can then be customized to the local setting. (Such programs were not available when researchers developed this program.)
- Market potential to lose weight to those not significantly overweight: Some individuals may not be attracted to a program designed only to prevent weight gain, as their goal may be to lose weight. As a result, it is important to highlight the program's potential to help reduce weight slowly over time. That said, the program focuses on individuals who have not yet become very overweight or obese, as it is easier to avoid weight gain or to lose modest amounts of weight than to shed significant pounds.
- Design system to minimize input time: Some participants felt that the self-monitoring and reporting took too much time, which undermines the attraction of a Web-based program. Although these activities, particularly the self-monitoring and reporting of diet and physical activity, are critical to program success (including keeping participants motivated), efforts should be made to design the system to allow participants to enter the requisite information as efficiently as possible.
- Provide training on motivational interviewing: Because motivational interviewing can help participants make lasting lifestyle changes, counselors need to be skilled in using this approach.
Sustaining This Innovation
- Include counselor feedback: Participant ratings highlighted the feedback from counselors as the most useful part of the program, including both the written comments and the telephone calls. Such feedback keeps people motivated and engaged in the program.
- Use primary care physicians to market program, sustain interest: Primary care physicians can play an important role in getting individuals interested in this type of program, and in maintaining that interest over time. To that end, make physicians aware of the program, and encourage them to offer it to eligible patients and to ask those who participate about their progress at subsequent visits.
Additional Considerations and Lessons
- Consider broad expansion to other populations: Many populations outside of the military could be attracted to this Internet-based approach, including any time-pressed individual, those without easy access to nearby programs, and those who dislike face-to-face counseling.
Hunter CM, Peterson AL, Alvarez LM, et al. Weight management using the Internet: a randomized controlled trial. Am J Prev Med. 2008;34(2):119-26. [PubMed]
Robbins AS, Chao SY, Baumgartner N, et al. A low-intensity intervention to prevent annual weight gain in active duty Air Force members. Military Medicine. 2006;171(6):556-61. [PubMed]
Rasu RS, Hunter CM, Peterson AL, et al. Economic evaluation of an Internet-based weight management program. Am J Manag Care. 2010;16(4):e98-e104. [PubMed]
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Service Delivery Innovation Profile
Original publication: September 01, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 10, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.