Elsevier

Preventive Medicine

Volume 46, Issue 3, March 2008, Pages 238-246
Preventive Medicine

Transtheoretical Model-based multiple behavior intervention for weight management: Effectiveness on a population basis

https://doi.org/10.1016/j.ypmed.2007.09.010Get rights and content

Abstract

Background.

The increasing prevalence of overweight and obesity underscores the need for evidence-based, easily disseminable interventions for weight management that can be delivered on a population basis. The Transtheoretical Model (TTM) offers a promising theoretical framework for multiple behavior weight management interventions.

Methods.

Overweight or obese adults (BMI 25–39.9; n = 1277) were randomized to no-treatment control or home-based, stage-matched multiple behavior interventions for up to three behaviors related to weight management at 0, 3, 6, and 9 months. All participants were re-assessed at 6, 12, and 24 months.

Results.

Significant treatment effects were found for healthy eating (47.5% versus 34.3%), exercise (44.90% versus 38.10%), managing emotional distress (49.7% versus 30.30%), and untreated fruit and vegetable intake (48.5% versus 39.0%) progressing to Action/Maintenance at 24 months. The groups differed on weight lost at 24 months. Co-variation of behavior change occurred and was much more pronounced in the treatment group, where individuals progressing to Action/Maintenance for a single behavior were 2.5–5 times more likely to make progress on another behavior. The impact of the multiple behavior intervention was more than three times that of single behavior interventions.

Conclusions.

This study demonstrates the ability of TTM-based tailored feedback to improve healthy eating, exercise, managing emotional distress, and weight on a population basis. The treatment produced a high level of population impact that future multiple behavior interventions can seek to surpass.

Introduction

The increasing prevalence of overweight and obesity is associated with significant public health consequences (Adams et al., 2006, CDC, 2006, Flegal et al., 2002). A number of intensive, clinic-based treatment options for the treatment of obesity are available. Riebe et al. (2003), for example, examined the efficacy of a multiple behavior group-based, 6-month program based on the Transtheoretical Model of Behavior Change (TTM) that intervened on physical activity, nutrition, and behavior change. The participants (n = 144) demonstrated significant reductions in weight, percent of calories from fat, and caloric intake, as well as increases in VO2max, at the end of treatment (Riebe et al., 2003). While participants maintained reductions in weight and caloric intake and increases in weekly exercise minutes at 24 months, there was evidence of gradual loss of those improvements during the follow-up period. Furthermore, there were no differences on percent of calories from fat, and fruit and vegetable intake had declined from baseline (Riebe et al., 2005).

Consumers have expressed a desire for alternatives to clinic-based weight management interventions (Sherwood et al., 1998). Experts in the field (e.g., Perri, 1998) are calling for effectiveness studies of innovative and cost-effective strategies to improve long-term outcomes of clinic-based weight management programs. Easily disseminable interventions with sustained effectiveness delivered outside of clinic or group settings are needed. Home-based interventions offer a promising alternative. Individualized interventions are important for those not prepared to change multiple behaviors that are essential to managing weight (USDHHS, 2005).

Randomized trials of Internet-based weight management interventions (Tate et al., 2001, Tate et al., 2003) indicate that personalized guidance from counselors for those prepared to change can affect weight immediately post-treatment. Follow-up data, however, were unavailable to determine if the treatment effects were sustained. Glasgow et al. (2004) and Prochaska and Prochaska (in press) report that sustainable multiple behavior interventions are patient-centered, tailored, proactive, population-based, and ongoing.

Success of multiple behavior interventions based on the Transtheoretical Model (TTM) that fulfill the guidelines set forth by Glasgow et al. (2004) and Blue and Black (2005) (e.g., Prochaska et al., 2004, Prochaska et al., 2005) suggests that TTM offers a promising framework for multiple risk weight management interventions. The TTM is an integrative model of behavior change that incorporates process oriented variables to explain and predict how and when individuals change behaviors. In addition to the central organizing construct, stage of change, the TTM integrates several other behavior change constructs including decisional balance, processes of change, and self-efficacy (Prochaska et al., 2002). A randomized trial of TTM-based interventions for diabetes self-management indicated the intervention group was significantly more likely to move to Action and Maintenance (A/M) stages for self-monitoring of blood glucose and healthy eating (Jones et al., 2003). Prochaska et al. (2004) reported that home-based, TTM interventions outperformed usual care for smoking cessation, sun exposure, and dietary fat reduction. A second study demonstrated that TTM interventions had significant effects at 24 months on four behaviors: smoking, dietary fat, sun exposure, and mammography (Prochaska et al., 2005). Johnson et al. (2006) reported that, when paired with fully tailored interventions for lipid-lowering medication adherence, stage-matched interventions had significant effects on physical activity and dietary fat reduction.

The purpose of this study was to conduct the first randomized effectiveness trial with a one-year extended follow-up to examine the impact of fully tailored, home-based, TTM-based multiple behavior interventions targeting behaviors essential to healthy weight management in a population of overweight and obese adults. This study is among the first to examine the co-variation of multiple behavior changes involved in healthy weight management and the potential population impact of multiple behavior interventions for weight management.

Section snippets

Subjects

A sample of 1277 were recruited nationwide and randomized to treatment or control, with n = 1101 from large employers; n = 126 from Centerwatch.com, a website with clinical trial listings; and n = 46 who were ineligible for another study. Of the sample, 58.5% were recruited using proactive calls, and 41.5% were recruited reactively by emails or ads. Recruitment among those eligible was 79.6% (see Fig. 1 and Table 1).

Procedure

Participants completed baseline assessments by phone. At 3, 6, 9, 12, and 24 months,

Results

Table 2 presents the demographics and baseline stage distributions for the two groups.

Discussion

Individualized stage-matched, multiple behavior interventions had significant effects on progression to Action/Maintenance for healthy eating, exercise, managing emotional distress, and weight among those most at risk (i.e., those in pre-action) one year post-intervention. This is the first study to demonstrate the effectiveness of multiple behavior change home-based interventions targeting all of the behaviors involved in weight management in an overweight and obese sample. An unexpected and

Acknowledgments

This research was supported by Grant Number R44 HL070549 from the National Heart, Lung, and Blood Institute.

Financial disclosures: The authors affiliated with Pro-Change Behavior Systems, Inc. are employees of said company, which is currently licensing the programs described herein. Janice Prochaska, Ph.D. is the company's President and CEO.

References (38)

  • Design and methods for a clinical trial in the prevention of type 2 diabetes

    Diabetes Care

    (1999)
  • K.E. Evers et al.

    A randomized clinical trial of a population- and Transtheoretical Model based stress management intervention

    Health Psychol.

    (2006)
  • M. Fiore et al.

    Treating Tobacco Use and Dependence. USDHHS: Public Health Service

    (2000)
  • K.M. Flegal et al.

    Prevalence and trends in obesity among US adults, 1999–2000

    JAMA

    (2002)
  • O. Harel et al.

    Multiple imputation: review of theory, implementation and software

    Stat. Med.

    (2007)
  • S. Heshka et al.

    Weight loss with self-help compared with a structured commercial program

    JAMA

    (2003)
  • G. Godin et al.

    A simple method to assess exercise behavior in the community

    Can. J. Appl. Sport Sci.

    (1985)
  • S.S. Johnson et al.

    Transtheoretical Model intervention for adherence to lipid-lowering drugs

    Dis. Manag.

    (2006)
  • S.S. Johnson et al.

    Final Progress Report: Individualized Expert Systems for Weight Management, Grant Number R44 HL070549

    (2007)
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