Evaluation of a Weight Management Programme for Overweight Women
TITLE: Evaluation of a weight management programme for overweight
STUDENT: Alison Bradshaw
SUPERVISOR: Dr. Caroline Horwath, Department of Human Nutrition
The Dunedin Women's Wellness Programme was conducted during July-September 2002 to address the issue of overweight. Three different "non dieting" programmes provided strategies to help women achieve and maintain a healthy comfortable weight without feeling deprived of food or quality of life. Another 115 women will participate in 2003, after which time the effects of the three different programmes can be compared. This report focuses on programme 1, which takes a mind-body approach. Since programme 1 started, 78% of participants noticed changes in their eating patterns, 15% had decreased their medications and 46% reported positive health changes.
In New Zealand overweight and obesity account for over $135 million a year in health care costs (1). The 1997 NZ National Nutrition Survey (2) results indicate that nearly half of all New Zealand women are overweight or obese. The rise in overweight and obesity is of great health concern since they are established risk factors for diabetes, cardiovascular disease, gall bladder disease and some cancers. It would appear that the traditional weight-loss approach, that is, food restriction through dieting, is an obvious solution to the problem of overweight and obesity. Unfortunately, although many women have been on a diet at some time in their life (3), weight lost by dieting is invariably regained over a period of time (1). In response to the failure of traditional weight reducing diets and restrictive eating plans, new perspectives for long term weight management are emerging, and are being labelled "non-dieting" approaches. (4).
Non-dieting approaches encourage "the adoption of 'healthy', 'normal' or 'natural' eating, i.e. eating which is autonomous, regulated by body hunger and satiety signals, and free of negative affect and inappropriate attitudes to food" (3). The Dunedin Women's Wellness Programme, consisting of three different 10 week weight-management programmes for women, is based on the non-dieting philosophy. The programmes were conducted during July - September 2002 in the Department of Human Nutrition. They provide a variety of strategies to help women achieve and maintain a healthy comfortable weight without feeling deprived of food or quality of life. The objective of all three Women's Wellness Programmes is to promote long-term maintenance of healthy lifestyle habits and a healthy body weight amongst overweight Otago women who also have other cardiovascular risk factors.
Programme one takes a mind-body approach aimed at enhancing feelings of wellbeing, relaxation and the ability to cope with stress. Key intervention components include training in different techniques to elicit the relaxation response and cognitive restructuring. Programme two focuses on the development of healthy food and physical activity patterns based on Bandura's Social Cognitive Theory (5). Programmes one and two involve weekly group meetings (2 hours duration) for ten weeks. Programme Three is a mail-delivered programme with the same content as Programme Two. Participants completed the l0-week programmes at the end of Sept 2002.
The summer project involved collating end-of-programme reactions and comments from the participants in Programme One, analysing transcripts from focus group interviews evaluating all three programmes, and conducting the 4-month follow-up of participants (which included a clinic visit and completion of a mailed questionnaire).
The methodology of the Summer Research Project was three-fold.
1. Statistical analysis and description of the end-of-programme results for programme 1. (Mind body approach). Using the SPSS statistical package, frequencies and descriptive statistics were produced. The data come from questions on: reactions to the programme (specific components of the programme and aspects of the session format); changes in eating patterns, medications, health and other aspects of life since the start of the programme; perceived effectiveness of the programme and how it compared with expectations; and involvement in new activities (see Appendix for questions). The questionnaire addresses many other areas that cannot be analysed until the 2003 cohort has completed the programme. These include eating restraint and perceptions of the benefits and barriers of reducing dietary fat intake and increasing exercise levels.
2. Qualitative analysis of focus group interviews (end of the 10- week programme) from all three programmes, using the long-table approach (6). This involved exploration of women's reactions and suggestions for improvement to the programmes, as well as their experiences with the different approaches. Six focus groups were conducted, two for each of the three programmes. The tapes were transcribed by an assistant employed by the Women' Wellness Programme. The analysis was transcript-based, and used 'unabridged transcripts of the focus groups as a basis for analysis. The "Long-Table Approach" (6) was used as the analysis strategy, because it allows the identification of themes and the categorisation of results. A hard copy of the transcript was cut into quotes that were placed under question or theme headings. Questions that the summer student asked herself after reading each quote were: "Did the participant answer the question that was asked?" "Does the comment answer a different question in the focus group?" "Does the comment say something of importance about the topic?" and "Is it like something that has been said earlier?" (6). Attention was paid to frequency, specificity, emotion and extensiveness of the quotes. A descriptive summary of the responses for each programme group provided an overview that allowed themes to become clearer. When the 2003 intake of 119 women have completed the programme and also participated in focus groups, the final qualitative comparisons of the three programmes will be possible.
3. Organization and execution of a 4-month follow-up of participants in the three programmes. This involved: a) finalising questions in the 4-month self-completed mail questionnaire b) printing the self-completed mail questionnaire; c) sending 111 participants in the 3 different programmes a letter informing them of the imminent 4-month follow-up; d) phoning participants to schedule their clinic appointment; e) sending out mail questionnaire to all scheduled participants; f) conducting clinic appointments: blood pressure (taken twice, with 7 minutes between measures) and weight were measured, mail questionnaires were collected and checked for completeness, and three further validated questionnaires were administered: SCL-90-R (measure of psychological distress); medical symptoms (Harvard questionnaire) and Lifestyle Profile II (Harvard questionnaire).
1. STATISTICALANAYSIS OFEND-OF-PROGRAMME 1 EVALUATION BOOKS
Several open-ended questions explored participants' experiences in programme 1. Since the programme started, 78% of participants noticed changes in their eating patterns. Eating changes included less "non-hungry" eating (eating when not physically hungry), fewer snacks throughout the day, and a greater awareness of what they are eating, how much they are eating, and whether they actually want to eat anything. Reductions in prescribed or over the counter medicines were indicated by 15% of participants. These included a halving of hypertensive medicine (n =1), less Panadol, Voltaren and/or Disprin (n =2), decreased dose of antidepressant (n =1) and using Mylanta less frequently (n =1). 46% of participants noted changes in their health as a result of taking part in the programme. The changes in health included fewer headaches (n =4), decreased blood pressure (n =1), fewer mouth ulcers (n =1) and less heart burn (n =1). When asked "have you noticed any other changes in your life as a result of taking part in the programme", 65% of participants answered "Yes." Changes in life that had occurred included feeling better about oneself, not holding onto negative thoughts, feeling better about one's body, feeling more at ease, more relaxed, and changing the way one reacts to stress - more able to reason and think things through.
Participants generally perceived the programme to be effective. Three participants noted that they had better mental health and wellness, but their weight had not decreased. Two participants were too busy to participate fully, and of 21 responses, only two women said that the programme had not been effective. Participants were asked how the programme compared with their expectations. Of 21 participants who responded, 6 said that the programme exceeded their expectations or found that it compared very well with their expectations (n = 3). Others didn't
know what to expect or had no expectations (n = 4), were sceptical at first and then starting seeing it working for them (n = 3), expected a miracle programme but now feel less worried about their weight (n = 1), The programme failed to meet 4 women's expectations - one said there was too much homework, another thought it was too slow, one had thought it would be more stimulating and the fourth expected a strict diet/exercise programme.
Participants rated the sessions on distorted thinking as the most valuable aspect of the programme (Table 1). Other valuable aspects were the food and nutrition topics and the cooking demonstration. The least valuable aspect of the programme was the homework activities (Table 1). Following the completion of the programme, participants continued to regularly use the relaxation tapes (n = 11), relaxation techniques (n = 7) and emotional freedom technique (n = 3). Common themes emerged in response to the question "what did you enjoy most about the programme?" These included group discussions, support from within the group, support from the psychotherapist present in each session, relaxation practice, meditation and the tapes that were given out each week.
2. 4-MONTH FOLLOW-UP RESULTS
Of 111 participants in the 3 programmes (30 in each of programme 1 and 2, and 51 in Programme 3), 17 had formally withdrawn by the time of follow up; however, these participants were invited to visit the Nutrition Department for a follow-up appointment. Seventy-two participants attended their clinic visit (65% follow-up rate). Reasons for not attending the clinic visit included: withdrawn from programme and didn't want to come in (n = 3), were too busy (n = 9), were out of the country or had moved to a different city (n = 3), felt that they had filled in enough questionnaires already and didn't want to come in again (n = 11), disliked measurement of waist/hip circumference at previous clinic visit (n =1), were sick or in hospital (n =2), had sick relatives (n = 1), had moved and not updated their contact details (n = 2), did not reply to phone messages (n = 3), or no showed/rescheduled repeatedly and I didn't want to annoy her (n = 4). Each appointment took approximately 45 minutes.
Another 115 women will complete the Women's Wellness Programme in 2003, to increase the statistical power of the study. After the second intake of participants has completed the study, it will be possible to determine which of the three programmes is most effective in promoting lifestyle change, wellness and weight loss. For the purposes of this summer research project, it was possible to perform statistical analysis on the Programme One participants' end-of-programme evaluation questionnaires. The evaluation questionnaires and physical measurements from the three programmes cannot be compared because only the combined 2002 and 2003 cohorts afford the randomised trial adequate statistical power. Furthermore, in a randomised controlled trial, one cannot take premature looks at incomplete data comparing the different arms of the trial comparisons can only be made once all the data is collected.
Results from the end-of-programme evaluations indicate that Programme One was perceived to be valuable by the participants and helped them change their eating patterns. Unfortunately many participants could not put maximal effort into the programme for various reasons, and thus found it difficult to keep up with the homework. The results may reflect the lack of time and effort that participants could put into the Women's Wellness Programme; for example, only 15% of participants reported decreased medication use. Nonetheless, many women did gain benefit from this mind-body approach to weight management, and learnt relaxation techniques, changed their eating patterns and started to address their cognitive distortions.
The 4-month follow-up results illustrate how difficult it is to retain participants once a programme is finished, a finding reported by other similar studies (7-9). Many women did not like the idea of coming in to the clinic to be weighed. As the results indicate, a number of women did not enjoy filling out the questionnaires, and thus declined to be involved in the 4-month follow up. Some women attended the fortnightly continuing sessions, and this appeared to be a good way to keep their motivation up - they were also more likely to attend the 4-month follow-up appointment.
When a non-dieting approach is taken to weight management, the following questions can arise, as Foreyt and Goodrick (10) capture: "How does one convince participants that restrictive dieting is counterproductive to their goal of losing weight?" "Is there a non-dieting approach that can b used?" and "Will participants believe that such an approach can work?" The Women's Wellness programme 1 has encouraged and helped participants to question the notion of dieting, and has provided overweight/obese Dunedin women with 'a healthier, more holistic approach to weight management and lifestyle change.
This Summer Research Project was kindly funded by The Otago Diabetes Research Trust. Dr.
Caroline Horwath, from the Department of Human Nutrition, provided supervision and support.
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