Short and long-term lifestyle coaching approaches used to address diverse participant barriers to weight loss and physical activity adherence

International Journal of Behavioral Nutrition and Physical Activity Short and long-term lifestyle coaching approaches used to address diverse participant barriers to weight loss and physical activity adherence Elizabeth M Venditti 0 1 Judith Wylie-Rosett Linda M Delahanty Lisa Mele 1 Mary A Hoskin Sharon L Edelstein 1 0 Western Psychiatric Institute and Clinic, University of Pittsburgh Medical School , 3811 O'Hara Street, Pittsburgh, PA 15213 , USA 1 George Washington University Biostatistics Center , 6110 Executive Boulevard, Suite 750, Rockville, MD 20852 , USA Background: Individual barriers to weight loss and physical activity goals in the Diabetes Prevention Program, a randomized trial with 3.2 years average treatment duration, have not been previously reported. Evaluating barriers and the lifestyle coaching approaches used to improve adherence in a large, diverse participant cohort can inform dissemination efforts. Methods: Lifestyle coaches documented barriers and approaches after each session (mean session attendance = 50.3 21.8). Subjects were 1076 intensive lifestyle participants (mean age = 50.6 years; mean BMI = 33.9 kg/m2; 68% female, 48% non-Caucasian). Barriers and approaches used to improve adherence were ranked by the percentage of the cohort for whom they applied. Barrier groupings were also analyzed in relation to baseline demographic characteristics. Results: Top weight loss barriers reported were problems with self-monitoring (58%); social cues (58%); holidays (54%); low activity (48%); and internal cues (thought/mood) (44%). Top activity barriers were holidays (51%); time management (50%); internal cues (30%); illness (29%), and motivation (26%). The percentage of the cohort having any type of barrier increased over the long-term intervention period. A majority of the weight loss barriers were significantly associated with younger age, greater obesity, and non-Caucasian race/ethnicity (p-values vary). Physical activity barriers, particularly thought and mood cues, social cues and time management, physical injury or illness and access/weather, were most significantly associated with being female and obese (p < 0.001 for all). Lifestyle coaches used problem-solving with most participants (75% short-term; > 90% long term) and regularly reviewed self-monitoring skills. More costly approaches were used infrequently during the first 16 sessions (10%) but increased over 3.2 years. Conclusion: Behavioral problem solving approaches have short and long term dissemination potential for many kinds of participant barriers. Given minimal resources, increased attention to training lifestyle coaches in the consistent use of these approaches appears warranted. Lifestyle intervention; Diabetes prevention; Barriers; Behavioral approaches; Problem-solving; Toolbox strategies - Background The Diabetes Prevention Program (DPP) demonstrated that diabetes incidence was reduced 58% with lifestyle intervention and 31% in the metformin compared to the placebo treatment group [1]. Approximately half of the lifestyle group reached a 7% weight loss goal and threequarters met the 150 minute weekly physical activity goal by the end of 16 sessions; 37% and 67% of the cohort remained at weight and activity goals, respectively, after an average 3.2 years. Other reports have discussed variables associated with behavioral success [2-4], the relative impact of weight loss and physical activity on diabetes incidence [5] and key intervention features [6]. Because lifestyle intervention was successful, a groupfacilitated program was implemented in all treatment arms, providing a model for cost-effective diabetes prevention translation [7]. However, the kinds of barriers DPP participants faced or the individualized approaches lifestyle coaches used to facilitate adherence have not been explored. Examining these data may inform groupbased training and dissemination efforts currently underway. The original DPP lifestyle intervention was highly resourced, but some of the coaching strategies may be translatable to group-facilitated approaches. The cost-effectiveness of the original DPP treatments [8-10] has been addressed and a burgeoning dissemination literature demonstrates that standardized adaptations are feasible and effective in producing weight losses of roughly 3-7%, with decreased cardio-metabolic risk, at least in the short term [11-30]. The Centers for Disease Control (CDC) National Diabetes Prevention Program (NDPP) and others have focused on training a competent workforce to implement DPP-adapted interventions with fidelity, and build infrastructure to sustain group based diabetes prevention programs [26,31]. Similarly, the IMAGE project has established common primary prevention training standards and practice guidelines in Europe [32,33]. Nonetheless, skepticism remains regarding long-term effectiveness of behavioral interventions for maintaining population level changes in eating, activity and weight to reduce diabetes incidence [34,35]. Criticisms that such programs require significant time, costly skilled labor and additional products, or that adherence is unpredictable, have been answered in part by the early success of DPP dissemination efforts [13-30]. Nonetheless, understanding adherence barriers among a large ethnically diverse participant group, and the specific methods (referred to as toolbox approaches) used by lifestyle coaches have implications for translation. It is not possible to discriminate the effectiveness of single strategies in a multi-component behavioral intervention, but quantifying commonly used coaching approaches adds to our knowledge of how best to translate a known effective intervention to the community at large. Problem-solving is central to obesity interventions [36-40]. Explicit guidance in this area distinguishes behavior modification from educational approaches or brief dietary consultation. Problem solving is a behavior change method used in conjunction with other approaches such as goal setting, self-monitoring and feedback, behavioral prompts and rehearsal, cognitive coaching, and reinforcement for goal achievement [37]. Lifestyle coaches frequently employ such techniques when interacting with participants and utilize five problem-solving steps including: [1] positive orientation; [2] problem definition/behavior chains; [3] generating alternatives; [4] setting achievable goals and [5] trial and error implementation. Despite the important role of this approach, few prospective studies have been conducted. Perri and colleagues [38-40] have demonstrated that extended programs for obese women, using problem solving for self-management, are associated with better outcomes compared to standard behavior therapies or education-only interventions. Murawski et al. [40] found that participants with 10% weight reductions demonstrated significantly greater improvement on a self-report measure of problem-solving skill than those with < 5% reduc (...truncated)