EFFICIENCY OF COMMUNITY BASED INTERVENTION PROGRAMME ON KEEPING LOWERED WEIGHT UČINKOVITOST INTERVENCIJSKEGA PROGRAMA ZA ZNIŽANJE TELESNE TEŽE V SKUPNOSTI Davorina Petek1, Nataša Kern2, Milena Kovač-Blaž3, Janko Kersnik4 Prispelo: 24. 8. 2010 - Sprejeto: 4. 1. 2011 Original scientific article UDC 613.24:614 Abstract Objective: To establish the effectiveness of community bas^d inteivention on loweiing a^nd sustaining v^eight. Methods: We peifoimed a longitudinal i^eti^ospective study in three pi^imaiy cai^e centi^es in Slovenia. 333 men a^ged 35 to 65 and women aged 45 to 70 with body mass index higher than 25 kg/m2 and high t^isk foi cat^dio^asculai diseases or with body mass index higher than 30 kg/m2 were included. The data for the analysis were extracted fi^om the foi^ms of National c^f^dio-^asculai disease p^ieven^ion pf^ogf^amme. Long-tef^m follow-up of theii weight wa^s p^i^oim^d 12 to 24 months aftei the inteivention. Results: The inclusion criteria fulfilled 250 (75%) participants. During the programme the participants' weight lowered by a mean 6.7 kg from 95.5±15.1 to 88.8±14.7 kg (7.1% of the entry body weight, 95% CI: -7.2 to -6.1 %). One to two years after the intervention 62.8% of the participants could not keep the weight they achieved during the intervention phase. Mean regain of the weight was 1.6 kg, (23% of the lost weight, 95% CI: 0.8 to 2.4 kg). Initial body weight of peop^le, who long-tei^m succeeded to k^^ep achieved weight wa^s highei than initial body weight of those people, who regained weight after the programme (t=3.490, P= 0.001) Gender and age did not show any statistically significant impact on long-term weight gain. Conclusions: The int^i^ention p^i^ogi^a^mme wa^s successful by the cr^iter^ia that weight i^eduction should t^e at least 5-10%. Majority of the participants could not sustain the reduced weight, but the mean weight gain was less than one fouith of the weight, lost in the int^i^ention pei^iod. Besides the intei^entions foi weight i^eduction also the long-tei^m p^io^ia^mmes foi sustaining the a^chieved weight loss ai^e ve^ impoitant. Key words: family practice, community medicine, cardiovascular diseases/prevention and control, body weight changes, follow-up study Izvirni znanstven članek UDK 613.24:614 Izvleček Izhodišča: Z raziskavo smo želeli oceniti, kakšna je dolgoročna učinkovitost v skupnosti izvedenega intervencijskega programa hujšanja. Metode: Dolgoročne rezultate intervencijskega programa delavnic za zdravo hujšanje v Gorenjski regiji smo ocenili z longitudinalno retrospektivno analizo. V raziskavo smo vključili 333 moških (35-65 let) in žensk (45-70 let) z indeksom telesne mase nad 25 kg/m2 in visokim tveganjem za bolezni srca in ožilja ali z indeksom telesne mase nad 30 kg/m2. Podatke smo pridobili iz obrazcev intervencijskega programa, dolgoročno uspešnost hujšanja pa smo ocenili po 12 do 24 mesecih. Rezultati: Vključitvena merila je izpolnjevalo 250 (75 %) udeležencev delavnic. Izmerjena telesna teža udeležencev je bila takoj po opravljenem programu v povprečju za 6,7 kg (95,5±15,1 kg do 88,8±14,7 kg) nižja glede na izhodiščno vreednost. Udeleženci delavnic so torej v povprečju izgubili 7,1 % začetne telesne teže (95-odstotni interval zaupanja (IZ): -7,2-6,1 %) Večina udeležencev (62,8 %) eno leto do dve leti po končanem programu ni uspela obdržati 1Department of Family Medicine, Medical School University of Ljubljana, Poljanski nasip 58, 1000 Ljubljana, Slovenia 2Primary Health Care Gorenjsko, Health Care Center Kranj, Gosposvetska ulica 12, 4000 Kranj, Slovenia 3Primary Health Care Center Ljubljana, Derčeva 5, 1000 Ljubljana, Slovenia 4Department of Family Medicine, Medical School University of Ljubljana, Poljanski nasip 58, 1000 Ljubljana, Slovenia and Department of Family Medicine, Medical School University of Maribor, Slomškov trg 15, 2000 Maribor, Slovenia Correspondence to: e-mail: davorina.petek@gmail.com doseženega znižanja telesne teže. Povprečni porast telesne teže je znašal 1,6 kg (23 %) izgubljene teže (95-odstotni IZ: 0,8-2,4 kg). Začetna telesna teža udeležencev delavnic, ki so dolgoročno uspeli obdržati znižano telesno težo, je bila višja kot začetna telesna teža tistih udeležencev, ki so se po programu spet zredili (t=3,490; p=0,001). Starost in spol nista statistično značilno vplivala na porast telesne teže eno leto do dve leti po zaključku programa. Zaključki: Glede na sprejeta merila (znižanje izhodiščne telesne teže za vsaj 5-10 %) zaključujemo, da je bil program zdravega hujšanja kratkoročno uspešen. V naslednjih 2 letih sicer večina udeležencev dosežene znižane telesne teže ni obdržala, vendar pa je njihova telesna teža v povprečju porastla za manj kot četrtino izgubljene telesne teže. Z našo raziskavo smo torej ugotovili, da je po začetni intervenciji smiselno in potrebno nadaljevati s programom za vzdrževanje znižane telesne teže. Ključne besede: družinska medicina, preventivni program, intervencija, zdravo hujšanje, spremljanje 1 Introduction Due to increasing incidence, obesity is becoming the major health problem in developed world [1]. In Europe, more than half of adults between age 35 and 65 are overweight or obese, defined by body mass index (BMI) 25 - 29.9 kg/m2 as overweight, BMI 30 - 39.9 kg/m^ as obese and BMI over 40 kg/m^ as extremely obese [2]. In Slovenia, 36.7% of people aged 25-64 are overweight and 15% are obese [3]. Other national studies showed that more than 40% of the Slovenian population had BMI over 25 kg/m^ [4,5]. The results of the National cardio-vascular disease prevention programme from 2008 are even worse - 73.2% of adults included in the programme had BMI over 25 kg/m^ [6]. Also, more men than women are obese in the early middle age group, but after age 45 there is no difference between the genders [5]. Regarding this huge and increasing prevalence and causal connection with other noncommunicable diseases several guidelines, programmes and methods to tackle obesity and reduce weight have been developed [7-9]. For long-term success in keeping reduced weight lifestyle changes are necessary. Different interventions have been successfully tested [10-12], but if we take into account growth of the problem, the interventions need to be widespread, easily accessible and community based, similar to other life style changes [13]. In Slovenia, a National intervention preventive programme for cardiovascular diseases was launched in 2001. It includes several health intervention programmes for healthy life-style, among them »Workshops for healthy weight reduction«. Every family physician in Slovenia is obliged to perform preventive programme for cardiovascular disease for his patients of specific age group (men between 35 and 65 years, women between 45 and 70 years). At the end cardiovascular risk assessment, based on Framingham risk assessment score is defined for each patient. After completing preventive health check-up, all people with BMI over 25 kg/m^ and high risks for cardiovascular disease or people with BMI over 30 kg/m^ are referred to the intervention parts of the programme, which are performed in larger Primary health care centres [14]. Activities of the preventive programme are regularly reported to the Ministry of Health and to National Health Insurance Company. Similar multifaceted three dimensional programmes are proven to be effective in several studies [15, 16]. The programmes are fully financially covered by the National Insurance Company. The main objective of the programme is 5-10% reduction of the starting body weight, which represents realistic goal and contributes to improvement of health indicators, especially if the reduced weight is sustained long-term [17-20]. In a systematic review of interventions of the adults in the practice based settings even smaller weight reduction was accepted as successful [11]. Also maintenance of the lost weight is very important in obesity management [21]. Only few reports on routine community based interventions for obesity are found in the literature. Majority of the interventions are part of clinical trials in hospital or primary care settings but regarding the increasing prevalence of obesity, which represents public health problem they need to be community based and oriented. We could not find any report on a nation-wide systematic intervention programme for body weight reduction. In this paper we analysed the effectiveness of community based programme in one region of Slovenia by the mean body weight loss during the intensive health style modification programme and by keeping lowered body weight of the participants 12-24 months after completion of such a programme. 2 Methods 2.1 Setting and study population We performed a cross sectional retrospective study in Primary Health Care Centre Gorenjsko, north-western part of the country, which covers population of 200.000 inhabitants. By the design of the National preventive programme for cardiovascular diseases men aged 35-65 and women aged 45-70 with BMI>25kg/m2 and high cardiovascular risk (20% or more, calculated by Framingham scale) or with BMI>30 kg/m2 were eligible for the intervention programme called the »Workshop for healthy weight reduction«. They were referred to the programme by their family physician after the preventive check up. In the study we included all the participants of this weight reduction programme from March 2003 to December 2004, who finished the programme at least one year earlier. 2.2 Description of the workshop The programme is organised as a series of meetings for the group of up to 20 participants and proceeds 16 times one hour per week. It is located in regional primary health care centres. The workshop is standardised by its content and type of providers. It consists of a combination of nutrition and physical activity curricula, including the use of behaviour cognitive techniques: setting of weight loss goal, low calorie diet with negative energy balance, based on self selected diet. It offers nutrition education, counselling and group sessions to help solving problems participants encounter during the programme. Physical activity is offered as guided aerobic exercise one hour per week. Life style modification is suggested (walking instead of driving, using stairs instead of elevators, increasing regular physical activity). Behaviour techniques include self monitornig, slow/ controlled eating, control of stimulus, behavioural substitution, behaviour change, advice and support for maintaining it with reinforcement of positive self-esteem. A general physician, a nurse educator - nutritionist and a physiotherapist are involved in the programme delivery. At the beginning of the programme each participant is examined for: body weight, body height, waist and wrist circumference, blood pressure. BMI is calculated. Body weight is measured by calibrated scale in people without shoes, lightly dressed. All the measurements are repeated at the end of the programme while body weight is checked every week. For all participants blood sugar and blood cholesterol values from the preventive check-up performed by the family doctor are recorded. According to the programme there was no organised intervention after the end of the workshop to keep the lowered weight. 2.3 Outcome measures We defined the effectiveness of the programme at expected 5-10% reduction of the beginning weight (or more) and sustained reduced weight for 12-24 months after finishing the programme. The success of the workshop was defined by the percentage of the weight loss and not by the statistical significance of the weight reduction, the same as in similar studies. We explored the long-term effectiveness set by Douketis, i.e. the programme is effective if the participants do not regain more than 3 kg [22]. 2.4 source of data Data about participants (age, inclusion and end of programme body weight, body height) were obtained from the database of Health Education Service in the Primary Health Care Centre Gorenjsko, which covers one administrative region in Slovenia. Information about body weight 12-24 months after the programme was not included in the database so we collected them by inviting the participants to their personal doctor, who reported the values to the research fellow. 2.5 statistical analysis We performed statistical analysis by SPSS for Windows software version 13.0 (SPSS Inc, Chicago, IL, USA). The data of weight were normally distributed what allowed us using mean values in analysis. The effectiveness of the workshop was measured by the mean body weight reduction/increase during the programme and one to two years after the programme. We report the results of selected statistical tests according to the measurement scales of the variables studied: t test of dependent samples to test the equality of means of inclusion body weight and body weight 1-2 years after the programme; t test of dependent samples of means for the difference of the weight gain according to gender. To test the effect of the age on weight gain Pearson's correlation coefficient and corresponding t-test was used. Significance of t test and correlation is determined at the 0.05 level for 2-tailed test. 3 Results The programme started 333 participants. 279 participants finished the workshop and were contacted one to two years after it. We could reach 250 participants, 19 were not available because they moved away or did not agree to participate. One person died in the time of the study. 25% of participants, who either did not finish the workshop or respond to our invitation for weight control 12-24 months after the intervention, were excluded from the analysis. Among 250 analysed participants 84% were women. Average age of all participants was 55.1±7.3 years, of women 55±7.2 years and of men 55.9±7.9 years. Mean body weight lowered at the end of the programme and slightly increased 12-24 months after the end of the programme. Details are shown in the Table 1. During the life style change programme participants on average lost 6.7±4.4 kg which represents 7.0% of the entry values. The 95% confidence interval for the mean decrease of the initial weight is -7.2 <^ - ^f< -6.1 where ^ is the mean initial weight and the final one (table 2). Regarding chosen values for the success of the programme being at least 5-10% reduction of the entry mean weight, the weight of the participants was successfully reduced during the programme. Table 1. Estimated average values of weight and BMI in participants of the weight reduction programme at the beginning, end and 12-24 months after the programme. Tabela 1. Povprečne vrednosti telesne teže in indeksa telesne mase (ITM) pri udeležencih delavnice zdravega hujšanja ob začetku delavnice, ob koncu delavnice ter 12-24 mesecev po zaključku programa. Variable Spremenljivka Weight and BMI1 Telesna teža in ITM1 Mean ± standard deviation in observed period Povprečje ± standardni odklon v opazovanem obdobju Beginning2 Začetek2 (n=250) End3 Konec3 (n=250) Long-term4 Dolgoročno4 (n=250) Weight (kg) Telesna teža (kg) 95,5±15,1 88,8±14,7 90,4±14,4 BMI1 (kg/m2) ITM1 (kg/m2) 35,3±4,5 32,9±4,6 33,5±4,4 Legend: 1body mass index 2 beginning of the workshop 3 end of the workshop 4 12-24 months after the end of the workshop Legenda: 1indeks telesne mase 2 začetek delavnice 3 konec delavnice 4 12-24 mesecev po koncu delavnice Table 2. Estimated mean differences of body weight in participants of the weight reduction programme in short term and long-term follow up. Tabela 2. Povprečna razlika v telesni teži pri udeležencih delavnice za zdravo hujšanje, ugotovljena s kratkoročnim in dolgoročnim spi^emljanjem. Difference of body weight and BMI1 Razlika v telesni teži in ITM1 Variable Spremenljivka Beginning-end2 Mean ±standard deviation 95% CI End-longterm3 Mean ±standard deviation 95% CI Začetek-konec2 Povprečje ± standardni odklon 95 % IZ Konec-dolgoročno3 Povprečje ± standardni odklon 95 % IZ Weight (kg) Telesna teža (kg) -6,7±4,4 -7,2-6,1 +1,6±6,3 0,8-2,4 BMI1 ITM1 (kg/m2) -2,5±1,6 -2,6-2,3 +0,6±2,3 0,3-0,9 Legend: 1body mass index ^difference between the beginning and end of the programme ^difference between end of the programme and 12-24 months after the programme Legenda: 1indeks telesne mase 2razlika med začetkom in koncem delavnice 3razlika med koncem delavnice in 12-24 mesecev po delavnici 12-24 months after the programme mean body weight of the participants increased by 23% of the weight lost during the intervention. Mean increase in body weight was 1.6 kg, 95% CI: (0.8 to 2.4 kg). 1-2 years after the course 93 (37.2%) participants managed to sustain or even further reduce body weight achieved at the end of the workshop. 157 (62.8%) participants regained some weight 1-2 years after the intervention. 60.4% of our participants were long-term successful in weight control by the Douketis standards regaining less than 3 kg. Inclusion body weight of the people, who succeeded to keep achieved weight or lowered it 1-2 years after the programme was higher than body weight of those people, who regained weight after the programme: Xi = 99.6, Xi = 92.8, t=3.490, P=0.001 where Xi = mean initial weight of participants who longterm sustained/reduced weight and Xi = mean initial weight of participants who longterm increased weight. We did not find statistically significant influence of participants' gender and age on the weight control in the next 1-2 years after the workshop ( Xm = 1.48, Xf = 1.62, t=0.129, P=0.898 where Xm = difference of weight means for men and Xf = difference of weight means for women. The correlation coefficient for age was r=-0,028, P=0,662). Figure 1. Mean body weight (kg) ±standard deviation at the beginning, at the end and 12-24 months after the end of the programme for healthy weight reduction. Slika 1. Povprečna telesna teža (kg) ± standardni odklon na začetku delavnice, na koncu delavnice in 12-24 mesecev po l