So I do have one disclosure,
we did a clinical trial that was successful.
It documented the effects of a remotely delivered intervention
and a company,
Healthways, is actually marketing it with Johns Hopkins,
so there's an institutional conflict of interest.
Okay, so I decided to approach this as sort of a top ten,
I guess that's David Letterman, but I don't watch late night
television, so I'm not even sure that's correct.
But, so I've done research on behavioral
strategies to improve cardiovascular health.
And often it really has focused on excess weight,
or either as the focus or as part of intervention.
So I thought I'd share with you ten, these are findings that I,
and most of them have come from our shop at Hopkins,
but others have been done elsewhere.
So the first thing I wanted to mention
was that age is probably a bit paradoxical
in that many people think that older aged people cannot
make lifestyle changes and quite frankly it's just the opposite.
That older aged individuals in our behavioral intervention
sites actually do much better than middle aged individuals.
This was the results of a clinical trial called TONE.
And, we randomized close to 800 people,
half to weight loss, and half to no weight loss.
And, what you see is the difference of about
four kilograms in weight loss between active and controls.
And they kept it off for two and
a half years without any evidence of recidivism.
Now this was a study just in overweight elderly individuals,
but we've actually done studies with middle-aged and older-aged.
And middle aged individuals like myself don't do as well as
older aged individuals.
And there are many possible reasons.
There could be physiologic reasons, but
the other thing is that they could be.
That individuals can focus more on their behaviors
that are needed for sustaining weight loss like exercise,
physical activity, and reduced calorie intake.
A second point I wanted to make is that
unfortunately there are major differences in the ability of
people to lose weight and actually sustain weight loss.
And a group of individuals that
unfortunately it doesn't do as well for African American women.
And this is, we found this in actually in most of our studies.
And the group that does well tend to be non-African
American men.
It might be they have less experiences with weight loss so
they're more successful in the first round.
But this was a clinical trial that enrolled
about 1,600 individuals and the group that
did the best were men who were not African-American.
Now I want to talk about weight regain, which popular now this
past week if you read the New York Times, including yesterday.
I'm not sure if there have been any questions about it, but
I'll cover that issue of regain among the Biggest Losers.
We have done a weight loss maintenance trial
where everybody got a weight loss intervention and then we
randomized people to different strategies to keep weight off.
And so phase one on this and I guess I'll use the pointer here.
Everybody got a weight loss intervention.
On average people lost eight kilograms and
then people were randomized.
This is the experience in the group didn't
get an active intervention.
You can see, regain over two and a half years.
But what is interesting is that it's partial regained,
it's not complete regained.
And that's actually a message that didn't come across in that
article, this stream of articles this past week.
Now, so
this was the headline from yesterday in the New York Times.
Why you can't lose weight on a diet?
It was actually a misleading title because
they actually experienced partial regain.
And so I just put on the right side here
the average weight loss at the end of the competition which was
quite substantial, 58 kilograms.
The weight regained over six years was 41.
And so, the average net weight loss that was sustained was
actually 17 kilograms, so they kept off about a third.
I think that there's actually been more hype to this than
the study warranted, and
actually was a pretty small sample size, 16 individuals.
We tested in that study the weight loss getting back to our
own trial two different interventions.
One that involved frequent personal contact and
in that intervention there was
modest effective monthly contact with trained interventionist.
But still there is a net reduction of about one and
a half kilograms beyond what the control group experienced.
We then actually published,
actually continued interventions.
This is a trial with about five years of intervention.
We re-randomized the people in the who got the monthly personal
contact.
And it turns out that continued intervention actually had so
significant impact.
So our sense is that, you've typically learned
after about two and a half years all the tools you need.
And continued intervention at that point's not likely to help,
even with monthly contact with an interventionist, which is
a fairly intensive intervention for over the long haul.
Now a lot of people are interested in technology.
We tested a web-based intervention on and
the intervention, despite having a lot of bells and whistles,
actually had no significant impact in terms of preventing
weight regain.
And this actually, by the way,
there are a lot of people that are interested in apps, and
combinations of apps and websites.
It was actually very, very little evidence that
those are a, effective in achieving weight loss and b,
effective in sustaining weight loss.
Unfortunately because I think there are a lot of people that
are very tech savvy.
Can write apps but unfortunately we don't have great evidence.
Six point types that emphasize different macro nutrients,
protein, carbohydrate, fat,
do not lead to different weight loss.
Now, there have been,
this is probably one of the most popular topics that is covered
in by individuals who report on weight loss.
But the best study that I know of was done by
a colleague of mine, Frank Sacks from Boston.
And he randomized people to four different diets and each diet,
one diet actually, I'm sorry let me, sorry about that.
The first diet was very high in carbohydrate.
That's the diet with the triangles and
then the fourth diet was had the least amount of carbohydrate,
that's this diet here.
And what you see is that basically all four diets led to
about five kilograms of weight loss on average.
And then over time there was weight regain.
But again, there was absolutely no difference in terms
of the extent of weight loss on high carb versus low carb diets.
And the importance of this study is that it was within the study
that people were randomized to these different diets.
Seventh and this hurts me quite a bit as a primary care doctor.
But, there is actually little evidence that
doctors are effective at
delivering behavioral weight loss interventions.
And I wish that weren't the case but, a colleague of mine,
Tom Wadden did a systematic review.
And he reached the conclusion there's little research on
primary care practitioners providing intensive counseling.
A range of trained interventionists who
provide such care by phone or in person could be considered.
And the reason why this is important is that,
actually about five years ago, CMS, Center for Medicare and
Medicaid Services, actually had this grand pronouncement
that there is grade a evidence.
When Tom Watt and I heard about this,
we go, wait a second, what evidence are they reviewing
because it's actually very weak evidence.
But they came up with that pronouncement and
decided that they would cover
weight loss interventions in the primary care setting.
For better or for worse,
CMS did not provide sufficient funding, and so almost no
primary care office actually offers those interventions.
So they basically didn't review the evidence correctly,
and they didn't provide enough funding to do it.
So I guess they maybe made the right decision with
underfunding it.
The one study that actually compared multiple strategies
to accomplish weight loss in patients of primary
care providers was done in England.
And this is a randomized trial with about seven
different groups.
The exercise group is the reference.
And if you look at these this is the extent of weight-loss within
each of the groups.
Weight Watchers was the best.
They had these other programs that I am not
as familiar with slimming down.
Rosemary Connelly sized down.
Note that physicians assisted by a nurse and physicians assisted
by a pharmacist had, were worse than control, okay?
So again, more bad news for primary care providers.
All right, eighth point.
Remote delivery of weight loss interventions can be as
effective as in person interventions.
This was a clinical trial that we published about
five years ago.
And it really just tested mode of delivery and
was I think quite important.
Because most people had thought that the way to deliver
interventions is actually have people get around a table,
schedule a meeting, and you have, weekly sessions.
Well there's huge logistic barriers to that,
I don't know about you, but if somebody told me.
You need to to participate in this program, to show up every
Monday and you have to show up for ten weeks in a row.
Huge barriers, so
we tested remote delivery vis-a-vis of telephone and
what was important was that the telephone based intervention.
Which is in the red line here was as effective as the in
person delivered intervention.
And so now a lot of people when they think about
either studies or even programs.
Such as the program I have the conflict on,
are really trying to implement remotely
delivered interventions using a multichannel approach.
Telephone plus computer and app.
Not app by itself, but app in combination with a provider.
Ninth point,
this is actually important and what I was showing you
in all of the previous studies is actually average weight loss.
What people don't realize is that the weight loss experienced
even within a group is actually substantial.
And, so, this is actually a frequency histogram.
So this shows the average might have been five kilograms, but
you have somebody who lost 40 and another person who lost 16.
And so those graphs that show very clean means or
averages really hide a lot of variability that occurs within
the active treatment group as well as the control group.
I was actually embarrassed when somebody
said we'd like to interview one of your participants for
a story that a television station was airing.
And the best person we could find on short notice was
somebody in the control group who actually lost weight.
And that happens actually quite a bit.
And you also have people in the active intervention group who
gain weight.
So there's a lot of variability that is sort of hidden
in the way we present our data.
And my tenth point sort of amplifies what Kim
was discussing which is prevention.
I quite frankly am sort of like Kim, dealing with people who
are overweight or obese and what I think is, we need to
really deal with the big culprit which is the toxic environment.
And so Kim pointed out portion size is a major reason but there
are many reasons and, quite frankly, we witnessed one today.
I didn't know about you but I do not eat brownies and
cookies in the middle of the afternoon, okay?
And so we provided those, and we're tempted.
You walk past them and wanna eat them.
But the reality is nobody needed any extra calories today.
Most of you, including myself,
have been sitting, I didn't get any physical activity today.
I probably need less than 2,000 calories to keep my weight.
And if I eat one of those cookies or brownies, that
probably got 10% of my calories just by sort of casually,
consuming something.
So, anyways, these are some of the,
I have about three of these slides.
I gave a talk in Iowa and so I went online and they had these
wonderful pictures from the Iowa State Fair and
this was deep fried butter, amazing.
I add those as lead ups to an unfortunate
state of the evidence that it is really difficult
to prove that the environment is causally related to obesity.
We can't do randomized trials where we assign people to
one community versus another and follow them for five years.
A PHD student working with me did
a systematic review of the literature on this topic and
the evidence is actually very weak even though most of us
who work in the obesity field believe that.
The environment and changes in the environment over the past
few years really is the causal problem.
So this was her conclusion, limited evidence for
the association between local food environment and obesity.
Still this needs to be interpreted cautiously because
of the low quality of available studies.
So I guess we'll take questions afterwards.
And look forward to your thoughts.