How Obese Individuals Can Turn Small Amounts of Weight Loss Into Lasting Gains for Your Population

The problem of obesity has grown to unprecedented proportions. One out of three American adults is obese more than 78 million people, according to the most recent data from the CDC. Obesity is the biggest health risk facing our country today. In popular culture, the pervading sense is that a total solution is needed. Programs like The Biggest Loser, spokesmen like Jared for Subway and countless advertisements for myriad weight loss programs all hold up the ideal result of transforming from obese to bikini-ready in order to achieve success. The evidence is telling quite a different story. Small amounts of weight loss can have a dramatic impact, and they can be sustained over time.
The Costs of Obesity
A recently published study considered the cost of an obese person to an employer. It found that among more than 30,000 Mayo Clinic employees and retirees, health-related costs for obese workers over seven years averaged $1,850 per year higher than for normal-weight workers (The average for smokers was $1,275 per year higher than for nonsmokers ). These increased costs come from the higher risk of serious and costly health conditions, including high blood pressure and diabetes. Among the obese population, the prevalence of high cholesterol, depression, heart attack, and asthma is also higher than within the non-obese population. In total, the consequences of obesity result in $150 billion in healthcare costs in the US. The good news is that small changes can have a big impact on obesity-related health risks and costs. For obese individuals, achieving and sustaining a weight loss of just 5% of body weight delivers measurable and important health benefits. Small Loss, Big Impact The average American male is 510. Assuming he is at the threshold of obesity, he weighs 209 pounds. (Obesity in adults is defined as having a BMI of 30 or greater.) A five percent reduction in weight would mean a loss of only 11 pounds. That small loss may not have a large cosmetic impact it wont be the basis of a hit television series like The Biggest Loser but as the National Institutes of Health (NIH) points out, such reductions in weight have a significant impact on many comorbid conditions, including diabetes and hypertension.3 5% Weight Loss and Diabetes Medical costs for people with diabetes are more than two times higher than for people without diabetes. Weight reduction is an important step in reducing the prevalence of diabetes. In obese individuals, two separate randomized trials have demonstrated that a weight loss of approximately 5% reduces the incidence of diabetes by 58%.7,8 Improving control, reducing cardiovascular risk for individuals with diabetes Another trial assessed the effectiveness of an intensive lifestyle intervention on the incidence of cardiovascular disease in overweight and obese participants with type 2 diabetes. Fouryear results showed that the intervention group: Achieved a 6.2% average weight loss Experienced positive impacts on measures of glycemic control and cardiovascular disease risk, among them: -0.36% HbA1c, +3.7 mg/dl HDL, and -25.6 mg/ dl triglycerides.

Two Studies, Same 58% Reduction in Diabetes Risk

Study One Participants: > 3,200 nondiabetic individuals with a high risk for type 2 diabetes (mean BMI 34). Randomly Assigned Groups: (1) Lifestyle Modification Program following low-calorie, low-fat diet and 150 minutes/week of moderate intensity exercise with a goal of 7% weight loss; (2) Metformin Group, receiving a drug to control blood glucose levels; (3) Placebo Group. Results: The Lifestyle Modification Group lost an average of 5.6 kg (12.3 lbs) per participant and experienced a 58% reduced incidence of diabetes (4.8 cases of diabetes per 100 compared to 7.8 and 11.0 for Metformin and Placebo groups). Study Two Participants: 522 middle-aged, overweight subjects (mean BMI 31). Randomly Assigned Groups: (1) Lifestyle Intervention Group individualized counseling for weight reduction with focus on low-fat, high-fiber diet and increased physical activity; (2) Control Group. Results: The Lifestlye Intervention Group had a 58% reduction in the risk of diabetes. The low odds ratio for diabetes among those who lose at least 5% of their initial weight reveals the importance of even a relatively small reduction in weight in the prevention of diabetes.

5% Weight Loss and Hypertension A study of elderly participants with hypertension found an approximately 30% decrease in the need for antihypertensive medication through moderate reductions in weightan average loss of 3.5 kg (or 7.7 pounds) for obese participants. A study testing the effectiveness of weight loss, reduced sodium intake, and their combination in lowering systolic and diastolic blood pressure among overweight people with high-normal blood pressure found that all three approaches were effective: At six months, participants had an average 4.5 kg (9.9 lbs) weight loss and a 42% reduction in the incidence of hypertension.

Sustaining Gains
It is striking that despite rising awareness of and motivation to reverse the growth of obesity - Americans now spend an estimated $60 billion annually on weight loss - our country has

only grown fatter. The complete answer is complex, but it is clear that people want to lose weight: a recent Gallup survey found that the average adult has tried to lose weight more than five times. Without a question, weight loss is difficult for the individual to accomplish and most efforts are not designed to achieve sustained success. This challenge has attracted increasing interest from researchers, and one recent clinical trial shows promise for meaningfully achieving sustained weight loss in an obese population. A meta-analysis of 25 randomized, controlled trials associated a net weight reduction of 5.1 kg (11.2 lbs) with reductions in systolic blood pressure of -4.4 mm Hg and diastolic blood pressure of -3.6 mm Hgan estimated impact of approximately -1 mm Hg per kg of weight loss. A healthier diet has itself been shown to have a fast and beneficial impact on blood pressure. In the original Dietary Approaches to Stop Hypertension (DASH) trial, a diet rich in fruits, vegetables, and lowfat dairy products and reduced saturated and total fat lowered participant systolic blood pressure by 5.5 mm Hg and diastolic blood pressure by 3.0 mm Hg more than a control diet. The reduction in blood pressure began within two weeks and was maintained for the next six weeks of the study. A POWERful Approach to 5% Loss The NIHs National Heart, Lung, and Blood Institute funded independent research to assess and compare the effectiveness of weight loss interventions that could be used in primary care practices to help obese patients with one or more risk factors for cardiovascular disease. Results from two of these POWER trials (Practice Based Opportunities for Weight Reduction) appeared in the New England Journal of Medicine in November 2011. The POWER trial, developed by the Johns Hopkins University School of Medicine, compared two different types of behavioral interventions, both coupled with interactive web resources and physician support, with a Control Group: An In-Person Intervention Group that received inperson counseling, delivered by healthcare professionals with Johns Hopkins Medicine. The Remote Intervention Group received phone-based counseling, delivered by Healthways coaches trained by Johns Hopkins.

By comparison, the POWER-UP trial led by the University of Pennsylvania assessed the effectiveness of: A Usual Care program of quarterly primary care visits Brief Lifestyle Counseling (usual care plus monthly, brief visits with a medical assistant trained in obesity management) Enhanced Lifestyle Counseling (with the additional option of liquid meal replacements or weight loss medication)

Only the Enhanced Lifestyle Counseling groupwith liquid meals or medicationexperienced weight loss results comparable to those achieved in the Hopkins POWER trial. 3 Steps to 5%Without Medication For the FDA to approve a drug for use in weight loss, it must satisfy numerous criteriaincluding a standard of effectiveness demonstrated through clinical trials. Evidence of a 5% weight loss sustained over two years would meet such FDA standards. How did the Hopkins POWER trial achieve and sustain a 5% average weight loss with counseling, web, and physician support alone? Three critical elements underpinned the approach: Relationship between program participant and coach an emphasis on cultivating participant accountability and trust with the coach, whether the counseling occurred by phone or in person. Progressan orientation toward seeing and achieving positive progress through small, individualized goals. Focustools and reminders to keep awareness and motivation high.

Creating an effective coaching relationship Whether counseled by phone or in person, Hopkins POWER trial participants worked one on one with the same coach throughout the program and had the opportunity for regular, frequent contact.
1 to 6 Months Type of Contact Remote Intervention Phone In-Person Intervention Group Individual Phone 12 6 3 6.5 4 4 18 18 12 1 1 11 15 14 18 16 Recommended Actual (Median) 7 to 24 Months Recommended Actual (Median)

Both Intervention Groups achieved and sustained clinically significant weight loss over 24 months in obese medical patients. Nearly 40% of participants receiving intervention lost and maintained a loss of 5% or more of their initial body weight. Approximately 20% of participants experienced greater than a 10% weight reduction. Intervention Group participants overall: Lost an average of 5.2% of body weight at six months. Maintained a net average loss of 4.2% at 2 years.

Rather than following a standardized script, coaches trained in motivational interviewing techniques tailored each interaction to the participant. Participants also had one visit with their primary care physician in the first six months and in the last 18 months of the program. Building confidence through progress Beyond working toward an overall weight loss goal of 5% of body weight, coaches worked with participants to set small, achievable goals that would build a sense of accomplishment along the wayfor example, a one-pound weight loss over two weeks.

Sustaining interest and focus Beyond coaching contact, the web application, with learning modules and self-monitoring tools, helped participants maintain a consistent focus on the program. Participants were encouraged to log in on a weekly or more frequent basis to access educational content and to track their weight, caloric intake, and exercise. These tracking tools visually reflected participant progress and effort over time, further building confidence. The actual use of web resources by Hopkins POWER trial participants, both in the early and later stages of the program, underscores their importance.
1 to 6 Months Recommended Remote Support Web Log-In In-Person Support Web Log-In 26 20.5 72 35 26 23 72 35 Actual (Median) 7 to 24 Months Recommended Actual (Median)

Sources
Moriarty JP, Branda ME, Olsen KD, et al. The effects of incremental costs of smoking and obesity on health care costs among adults: a 7-year longitudinal study. J Occup Environ Med. 2012;54(3):286-91. 4 National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adultsThe evidence report. Obes Res 6(Suppl 2): 51S209S. 1998. 5 Gallup-Healthways Community Well-Being Survey Data 2010. 7 U.S. Department of Health & Human Services, National Diabetes Information Clearinghouse (NDIC). National Diabetes Statistics, 2011. Available at: http:// diabetes.niddk.nih.gov/dm/pubs/statistics/. Accessed May 11, 2012. 8 Knowler WC, Barrett-Connor E, Fowler SE et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002 Feb 7;346(6):393-403. 9 Tuomilehto J, Lindstrom J, Eriksson JG et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344:1343-1350. 10 Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med. 2010;170:1566-1575. 11 Whelton PK, Appel LJ, Espeland MA et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). JAMA. 1998;279:839-846 [Erratum JAMA 1998 Jun 24;279(24):1954]. 12 The Trials of Hypertension Prevention Collaborative Research Group. Effects of Weight Loss and Sodium Reduction Intervention on Blood Pressure and Hypertension Incidence in Overweight People With High-Normal Blood Pressure: The Trials of Hypertension Prevention, Phase II. Arch Intern Med. 1997;157:657667. 13 Neter JE, Stam BE, Kok FJ, Grobbee DE, Geleijnse JM. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension. 2003;42:878-884. 14 Appel LJ, Moore TJ, Obarzanek E et. al. A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. N Engl J Med 1997; 336:1117-1124. 15 Appel LJ, Clark JM, Yeh HC et al. Comparative Effectiveness of Weight Loss Interventions in Clinical Practice. N Eng J Med 2011; 365:1959-1968. 16 Wadden TA, Volger S, Sarwer DB et al. A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice. N Eng J Med 2011; 365:1969-1979. 17 Remote Interventions May Facilitate Weight Loss, JAMA. 2011;306(24):26602660. doi:10.1001/jama.2011.1852
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In announcing the results of the Hopkins POWER trial, lead researcher Lawrence J. Appel called out the scalable potential of the remote intervention: We believe the remote intervention consisting of phone counseling and the Internet has the possibility for widespread dissemination and could be applicable to other chronic conditions. Johns Hopkins Medicine and Healthways have developed Innergy as a commercially available version of the remote weight-loss intervention demonstrated in the Hopkins POWER trial. Participating organizations can expect Innergy to deliver an average of 5% or greater weight loss among participants, comparable to results achieved in the POWER trial. As demonstrated through numerous separate studies, that 5% weight loss will translate directly to reductions among participants in the risk for diabetes, cardiovascular disease, and hypertension. Projected savings in medical and Rx costs alone can generate a return on investment for Innergy customers ranging from 1.2 1.6 in the first two years of the program. For more information about how the science that powers Innergy can help you achieve lasting gains for your obese population, contact info@healthways.com.

Johns Hopkins faculty members and staff advise and collaborate with Healthways regarding the Innergy weight management program. Johns Hopkins receives financial compensation from Healthways in the form of royalties and fees for its contribution to the Innergy program.