Weight Loss Maintenance in African American Women: A Systematic Review of the Behavioral Lifestyle Intervention Literature
Table 1
Behavioral lifestyle interventions reporting weight maintenance outcomes for african american women (1990–2011) ().
Author and year of publication
Quality ranking score†
Study design, setting, and length of trial
Participant characteristics††
Maintenance phase characteristics
Frequency, delivery, and dose (time), of maintenance components
Mean baseline weight (kg) (±SD/SE)
Weight change following intensive intervention phase mean (±SD/SE) weight (kg)
Weight change (kg) from baseline during maintenance phase follow-up (SD/SE)
Adherence to maintenance sessions/components retention (%)
Kumanyika et al. (2002)‡‡ [44] Trials of Nonpharmacologic Intervention in the Elderly (TONE)
11
Design: RCT
Setting: Academic Medical Centers
Length of Trial: Up to 34 month
(all overweight participants randomized to a weight loss treatment arm)
Weight loss/Sodium AAW: 21 CW: 43
Weight loss AAW: 25 CW: 50
Mean Age (y): AAW: 65.5 (±4.8) CW: 65.8 (±4.5)
Income: NDR
Education: College graduate: AAW: 25.6% CW: 41.8% Health status: Hypertensive BMI > 27.8 kg/m2
Formal Theoretical Framework: SCT
Cultural Adaptations: Yes, attention to cultural diversity, staff training, and printed materials
Duration of maintenance phase: 7–28 months (varied by participant)
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Didactic nutrition PA (self) Behavioral Modification Strategies (i) Self-monitoring of food intake, food-related behaviors, and PA (ii) Goal-setting Problem solving Relapse prevention [55]
Frequency, Delivery, and Dose: Months 7-8 Biweekly group or individual session Dose: 60 min (4 sessions total)
Months 9+ Monthly group or individual sessions Dose: 60 min (up to 17 sessions)
Monthly phone or mail-based contact (up to 17 contacts) [55]
Weight loss/Sodium AAW: 84.0 (±6.9) kg CW: 82.7 (±9.7) kg
Weight loss AAW: 82.9 (±9.3) kg CW: 82.3 (±9.0) kg
Weight loss/Sodium AAW: −3.9 (±3.6) kg CW: −3.9 (±3.9) kg
Weight loss AAW: −3.3 (±2.8) kg CW: −5.8 (±3.5) kg
12 month Fu Weight loss/Sodium AAW: −4.0 kg CW: −3.7 kg
Weight loss AAW: −3.9 kg CW: −5.9
18 month Fu Weight loss/Sodium AAW: −3.6 kg CW: −3.3 kg
Weight loss AAW: −3.8 kg CW: −5.0 kg
Proxy for end of trial (24 month Fu) Weight loss/Sodium AAW: −2.6 kg CW: −2.7 kg
Weight loss AAW: −3.5 kg CW: −4.6 kg
Adherence to maintenance sessions/components: NDR
Retention: Weight loss/Sodium AAW: 62% CW: 88%
Weight loss AAW: 48% CW: 66%
Kumanyika et al. (2005)‡ [3] Healthy Eating and Lifestyle Program (HELP)
11
Design: RCT
Setting: Academic Medical Center
Length of Trial: 15 or 21 months (cohort dependent)
AAW: ( AAW Phase 2 completers)
Group HELP maintenance AAW: Mean Age (y): 47.4 (±11.1) Education: >HS = 80%
Self-HELPmaintenance AAW: Mean Age (y): 46.2 (±8.6) Education: >HS = 61%
Clinic only AAW: Mean Age (y): 46.1 (±10.1) Education: >HS = 67%
Income: NDR
Health status: BMI 30–50 kg/m2 Medically cleared
Formal Theoretical Framework: SCT
Cultural Adaptations: Yes, study logo; adapted materials specific to AA; inclusion of AA interventionist
Duration of maintenance phase: 18 months (cohorts 1 and 2) 12 months (cohorts 3 and 4)
Criteria for entry into WL Maintenance Phase: Attended postphase 1 data collection
Components Targeted at WL Maintenance: Didactic Nutrition PA (self and occasional S weekend group walks) Behavioral Modification Strategies (i) Self-monitoring of food intake and PA (ii) Goal-setting (iii) Problem solving (iv) Relapse prevention
Frequency, Delivery, and Dose: Group HELP maintenance Months 7–9 biweekly group class Dose 60 min (6 total classes)
Months 10+ once monthly group class Dose: 60 min (8 classes total for cohorts 1 and 2; 3 classes total for cohorts 3 and 4) Group walking held occasionally Individualized nutrition, PA or behavioral consultations upon request 3 clinic visits (cohorts 1 and 2) 2 clinic visits (cohorts 3 and 4) Self -HELP Maintenance
Self-help kit (local restaurant and fitness guide, diaries, pedometer) 1 in-person group meeting Teams formed to promote peer support Once monthly call Group walking held occasionally 3 clinic visits (cohorts 1 and 2) 2 clinic visits (cohorts 3 and 4)
Clinic only 3 clinic visits (cohorts 1 and 2) 2 clinic visits (cohorts 3 and 4)
100.8 (±15.9) kg
Group HELP maintenance −1.6 kg (±3.3) kg
Self-HELP maintenance −2.0 (±4.1) kg
Clinic only −1.6 (±3.7) kg
12 month Fu NDR
End of Trial (12 or 18 month Fu depending on cohort) Group HELP maintenance −0.8 (±4.4) kg
Self-HELP maintenance −1.3 (±5.5) kg
Clinic only −1.4 (±5.7) kg
Adherence to maintenance sessions/components:
Group HELP Mean attendance 40% at biweekly classes Mean attendance 31% at monthly classes
Self-HELP 35–55% of participants were successfully reached for the monthly phone-based contact
Retention: 66% (all treatments)
Svetkey et al. (2008)‡‡ [56] Weight Loss Maintenance Trial (WLM) Post-intervention weight change crudely calculated from data presented in the manuscript
Mean Age (y): AAW: 53 (±9.0) CW: 57 (±9.0) [8] Income: AAW: 42% $60,000/y CW: 71% $60,000/y [8]
Education: College degree or higher: AAW: 56% CW: 72% [8] Health status: BMI 25–45 kg/m2 Hypertensive and/or dyslipidemic
Formal Theoretical Framework: SCT
Cultural Adaptations: Yes, Minority Implementation committee, AA cultural-training for all interventionists, cultural sensitivity training, development of specific strategies for enhancing intervention effectiveness for AA [57]
Duration of maintenance phase: 30 months
Criteria for entry into WL Maintenance Phase: 4 kg loss during IWL phase
Components Targeted at WL Maintenance: Continue calorie control/DASH diet pattern Didactic Nutrition PA (self, goal: 225 min/wk) Behavioral Modification Strategies (i) Self-monitoring, food intake, weight, and PA (ii) Problem-solving (iii) Goal-setting Relapse prevention MI
Frequency Delivery, and Dose: Self-directed maintenance One individual in-person session and printed materials
Technology maintenance Unlimited access to an interactive web-site Dose: encouraged to log on at least once per week
Personal contact maintenance Once monthly individual in-person or phone-based sessions Dose: 5–15 minutes and every 4th month 45–60 minutes (30 sessions total)
AAW: 94.8 (±15.2) kg CW: 89.5 (±15.2) kg
AAW: −7.1 kg CW: −8.0 kg
12 month Fu NDR
18 month Fu NDR
End of Trial (36 month Fu) Self-directed (based on adjusted values) AAW: −1.8 (se = 0.6) kg CW: −2.2 (se = 0.6) kg
Technology (based on adjusted values) AAW: −1.3 (se = 0.6) kg CW: −3.0 (se = 0.6) kg
Personal contact (based on adjusted values) AAW: −2.2 (se = 0.6) kg CW: −3.9 (se = 0.6) kg
Adherence to maintenance sessions/components:
Self-directed maintenance NA
Technology maintenance 77% logged on at least 1/week
Personal contact maintenance 91% of attendance at offered sessions
Self-report frequency weighing/week AAW: 3.0 (0.1) CW: 2.6 (0.1)
Personal contact maintenance 94% (all participants)
West et al. (2008) [11] Diabetes Prevention Program (DPP) Data reported for the IL arm only
11
Design: RCT
Setting: Academic Medical Centers
Length of Trial: 36 months
IL intervention arm AAW: 120 CW: 381
Age (y): AAW: 77.4% > 40 y CW: 75.6% > 40 y
Income: NDR
Education: NDR
Health status: Impaired glucose tolerance
Formal Theoretical Framework: SCT
Cultural Adaptations: Yes, case managers of same ethnic group, print materials tailored for ethnic group, literacy adaptations
Duration of Maintenance phase: 24 months
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Continued adherence to Fat and Calorie Control Didactic Nutrition PA (S and self: goal, 150 min/wk) Behavioral Modification Strategies (i) Self-monitoring food intake and PA (ii) Goal-setting Individual “Tool-box”
Frequency, Delivery, and Dose: At least one bimonthly individual, in-person session Dose: 15–45 minutes
Contacted at least once by phone in between sessions (However, coaches could meet with individuals as often as needed)
Group-based courses (3/year)
Maintenance campaigns to promote adherence (3-4/year) [59]
AAW: 82.0 (±14.8) kg CW: 95.1 (±21.2) kg
AAW: −4.7 (±5.1) kg CW: −7.5 (±5.6) kg
12 month Fu AAW: −4.4 ± 6.0 kg CW: −7.8 ± 7.4 kg
18 month Fu AAW: −3.9 ± 6.1 kg CW: −6.6 ± 8.2 kg
End of maintenance phase (36 month Fu) AAW: −2.1 ± 6.3 kg CW: −4.2 ± 7.5
Adherence to maintenance sessions/components: Mean 50.3 (±21.8) sessions (all IL participants) [58]
Retention: AAW: 64% CW: 69%
Kumanyika et al. (2009)‡ [50] Supporting Healthy Activity and Eating Right Everyday study (SHARE)
11
Design: RCT
Setting: Academic Medical Center
Length of Trial: 24 Months
Family High Support AAW: Mean Age (y): 47.3 (±7.3) Income: NDR Education: >HS = 86%
Family Low Support AAW: Mean Age (y): 50.2 (±8.2) Income: NDR Education: >HS = 77%
Individual High Support AAW: Mean Age (y): 48.2 (±7.7) Income: NDR Education: >HS = 83%
Individual Low Support AAW:
Mean Age (y): 46.8 (±6.6) Income: NDR Education: >HS = 71%
Health status: Healthy or medically cleared
Formal Theoretical Framework: NDR
Cultural Adaptations: Yes, AA program counselors, culturally-based content, community-based field trips
Duration of maintenance phase: 18 months
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Calorie control Didactic Nutrition PA (S and self, goal 180 min/wk) Behavioral Modification Strategies
Education: I: College graduate: 67% C: College graduate: 50%
Health status: Breast cancer survivors BMI 30–45 kg/m2
Formal Theoretical Framework: SCT
Cultural Adaptations: Yes, spirituality
Duration of maintenance phase: 12 months
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Calorie/Portion and Fat Control Didactic Nutrition PA (self, goal 150 min/wk) Behavioral Modification Strategies (i) Self-monitoring of food intake and activity Spirituality counseling (I only)
Frequency, Delivery, and Dose: I (spirituality and dietary counseling maintenance) Months 7–18 Dietary counseling, 1 individual in-person session at month 12, otherwise once monthly phone based sessions Dose: NDR (12 sessions total)
Months 7–9 Spirituality counseling Once weekly individual phone-based sessions (up to 12 sessions) ߙ Months 10–12 biweekly individual phone-based sessions (up to 6 sessions)
Months 13–18 Once monthly individual phone-based sessions (up to 6 sessions) Dose: 17–45 minutes/call
C (dietary counseling only maintenance) Months 7–18 Dietary Counseling, one individual in-person session at month 12, otherwise once monthly phone based sessions Dose: NDR (up to 12 sessions)
I and C: Months 7–18 once monthly mailed newsletter (12 newsletters)
I: 93.8 (±11.3) kg C: 94.9 (±14.8) kg
I: −1.0 (±6.5) kg C: −2.6 (±5.1) kg
12 month Fu NDR
End of Trial (18 month Fu) I: −0.7 kg C: −2.2 kg
Adherence to maintenance sessions/components: I (spirituality and dietary counseling maintenance) Spirituality counseling calls ranged from 2–26 completed per participant
Retention: 92% (all participants)
Kumanyika et al. (1991) [13] Hypertension Prevention Trial (HPT)
9
Design: RCT
Setting: Academic Medical Centers
Length of Trial: 36 months
(weight loss tx arms only) AAW: 28 CW:43
Age (y): 25–49 (all participants)
Income: NDR
Education: College graduate: 48% (all participants)
Health status: Healthy, normotensive
Formal Theoretical Framework: NDR
Cultural Adaptations: NDR
Duration of maintenance phase: 30 months
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Didactic Nutrition Behavioral Modification Strategies
Frequency Delivery, and Dose: Months 7–36 Bimonthly individual/group sessions Dose: NDR (15 sessions offered)
End of Trial (36 month Fu) AAW: +2.6 ± 4.7 kg CW: −1.2 ± 7.2 kg
Adherence to maintenance sessions/components: NDR
Retention: AAW: 93% CW: 93%
Kumanyika et al. (1991) [13] Trials of Hypertension (TOHP)
9
Design: RCT
Setting: Academic Medical Centers
Length of Trial: 18 months
(weight loss arms only) AAW: 33 CW: 48
Age (y): 30–54 (all participants)
Income: NDR
Education: College graduate: 50% (all participants)
Formal Theoretical Framework: NDR
Cultural Adaptations: NDR
Duration of maintenance phase: 12 months
Criteria for entry into WL Maintenance Phase: None Components Targeted at WL
Frequency, Delivery, and Dose: Varied by participant but could include one or a combination of: (a) monthly informal group sessions (b) group weigh-in (c) individual weigh-in (d) individual counseling Dose: NDR [64]
AAW: 79.9 (±10.0) kg CW: 79.7 (±10.8) kg
AAW: −1.9 (±3.5) kg CW: −4.9 (±4.8) kg
12 month Fu AAW: −1.1 ± 4.1 kg CW: −3.6 ± 5.2 kg
End of Trial (18 month Fu) AAW: −0.02 ± 4.1 kg CW: −2.5 ± 6.3 kg
Adherence to maintenance sessions/components: 90% participation (including make-up, all participants)
Retention: AAW: 97% CW: 100%
Stevens et al. (2001) [65] Trial of Hypertension Prevention II (TOHPII)
9
Design: RCT
Setting: Academic Medical Centers
Length of Trial: 36 months
I: 64 AAW C: 49 AAW
Mean Age (y): I: 43.4 (±6.1) (all participants) C: 43.3 (±6.1) (all participants)
Income: NDR and Education: NDR
Health Status: Systolic BP < 140 mmHg Diastolic BP 83–89 BMI: 24.4 to 37.4 kg/m2 (all women)
Formal Theoretical Framework: NDR
Cultural Adaptations: NDR
Duration of maintenance phase: 32 months
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Didactic Nutrition PA (SD) (30–45, four to five days per week) Behavioral Modification Strategies (i) Goal-setting (ii) Problem-solving (iii) Self-monitoring of food intake and PA
Formal Theoretical Framework: Social Ecological Model
Cultural Adaptations: Yes, trial specific to black women, chosen study site, AA instructors
Duration of maintenance period: 10 months
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Self-directed Free fitness club membership (I and C)
Frequency, Delivery, and Dose: No contact
I: 81.5 kg () C: 82.7 kg ()
I: +0.05 kg C: +0.3 kg
End of maintenance (12 month Fu)
I: +1.4 kg C: +1.02 kg
Adherence to maintenance sessions/components: NDR
Retention: I: 72% C: 72%
West et al. (2007) [14] Weight change crudely extrapolated from Figure 1 in the manuscript
9
Design: RCT
Setting: University
Length of Trial: 18 months
MI group AAW: 43 CW: 66
Attention control group AAW: 41 CW: 67
Mean Age (y): 53 ± 10 (all participants)
Education: College education or higher: 35% (all participants)
Income: NDR
Health Status: Type 2 Diabetes (no insulin use) BMI 27–50 kg/m2
Formal Theoretical Framework: NDR
Cultural Adaptations: NDR
Duration of maintenance phase: 12 months
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Calorie and fat control Didactic Nutrition PA (self, goal 150 min/wk) Behavioral Modification Strategies (i) Goal-setting (ii) Problem-solving (iii) Self-monitoring of food intake and PA (iv) Stimulus control (v) Relapse prevention MI or Attention Control sessions
Frequency, Delivery, and Dose: Months 7–12 Biweekly group sessions Dose: NDR (12 sessions total)
Months 7–12 Two individual MI or Attention Control sessions Dose: 45 minutes per session (5 sessions total)
Months 13–18 Once monthly group session Dose: NDR (6 sessions total)
MI group 97 (±17) kg (all participants)
Attention control group 97 (±15) kg (all participants)
MI group AAW: −3.4 kg CW: −5.3 kg
Attention control group AAW: −2.9 kg CW: −3.4 kg
12 month Fu MI group AAW: −2.9 kg CW: −5.9 kg
Attention control group AAW: −1.8 kg CW: −3.3 kg
End of maintenance phase (18 month Fu) MI group AAW: −1.9 kg CW: −4.4 kg
Attention control group AAW: −1.0 kg CW: −2.0 kg
Adherence to maintenance sessions/components:
Group sessions 7–12 months 57% attendance 13–18 months 48% attendance
Food diaries submitted 7–12 months 7 ± 9 diaries
13–18 months 5 ± 9 diaries
Retention: 93% (all participants)
Rickel et al. (2011)‡‡ [15] Treatment of Obesity in Underserved Rural Settings (TOURS)
Weight change crudely calculated from data presented in the manuscript
9
Design: RCT
Setting: Community, rural
Length of Trial: 18 months
AAW: 43 CW: 181
Mean Age (y): AAW: 58.0 (±0.9) CW: 60.1 (±0.5)
Income: AAW: <$50,000/y: 70% CW: <$50,000/y: 66%
Education: High school degree or less AAW: 28% WW: 39%
Health status: BMI > 30.0 kg/m2
Formal Theoretical Framework: NDR
Cultural Adaptations: Southern-focused
Duration of maintenance phase: 12 months
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Calorie control Didactic Nutrition PA (self, goal 30 min/day walking) Behavioral Modification Strategies (i) Problem solving (ii) Self-monitoring [68]
Frequency, Delivery, and Dose: All treatment groups received handouts describing how to use problem solving to deal with obstacles related to WL maintenance
Frequency, Delivery, and Dose: 2 in-person PCP visits Dose: 2-3 minutes devoted to discussing weight control (I and C)
I: AAW: 98.7 ± 16.4 kg CW: 76.2 ± 10.3 kg
C: AAW: 99.6 ± 14.3 kg CW: 100.9 ± 20.0 kg
I: AAW: −4.5 kg CW: −6.6 kg
C: AAW: +0.5 kg CW: +2.1 kg
End of trial (12 month Fu): I: AAW: −1.6 kg CW: −3.2 kg
C: AAW: −0.2 kg CW: −1.1 kg
Adherence to maintenance sessions/components: NDR
Retention: 94% (all participants)
Banks-Wallace (2007) [70] Weight change crudely calculated from Table 1 in the manuscript
5
Design UCT, pilot
Setting NDR
Duration of Trial: 18 months
AAW
Mean Age (y): 50.3
Income: 62% < $24,000
Education: Completed HS: 100%
Health status: Hypertensive
Formal Theoretical Framework: NDR
Cultural Adaptations: Yes, trial specific to AA women
Duration of Maintenance Phase: 6 months
Criteria for entry into WL Maintenance Phase: None
Components Targeted at WL Maintenance: Self-directed
Frequency, Delivery, and Dose: No contact
93.7 (±13.1) kg
−8.5 kg
End of trial (18 month Fu) +11.7 kg
Adherence to maintenance sessions/components: NDR
Retention: 71%
Total quality ranking score = [(Design: RCT = 4; pilot RCT = 3; nonrandomized controlled trial = 2; single group design = 1) + (Primary intervention focus on weight control: 1 = No; 2 = Yes) + (Inclusion of a formal maintenance program: 1 = No; 2 = Yes) + (Cultural Adaptations: 1 = no adaptations; 2 = limited to recruitment of AA participants; 3 = studies reporting adapting intervention-related content and other adaptations such as cultural sensitivity staff training)]. ††Data reported for AAW or CW only unless indicated otherwise. ‡Weight change by sex/ethnicity obtained from main study author for AAW completers only. ‡‡Intention to treat or multiple imputations analysis. AAW: african american women; BMI: body mass index; BP: blood pressure; C: control; CI: confidence interval; CW: caucasian women; DASH: dietary approaches to stop hypertension; FU: follow-up; HS: high school; I: intervention; IBW: ideal body weight; IL: intensive lifestyle; MI: motivational interviewing; NA: not applicable; NDR: no data reported; NRCT: non-randomized controlled trial; PA: physical activity; PCP: primary care physician; S: supervised; SD: standard deviation; SCT: social cognitive theory; SE: standard error; UCT: uncontrolled trial; WL: weight loss; Y: years.