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Dialing In: Effect of Telephonic Wellness Coaching on Weight Loss
Min Tao, PhD; Krishna Rangarajan, MS; Michael L. Paustian, PhD, MS; Elizabeth A. Wasilevich, PhD, MPH; and Darline K. El Reda, DrPH, MPH

Dialing In: Effect of Telephonic Wellness Coaching on Weight Loss

Min Tao, PhD; Krishna Rangarajan, MS; Michael L. Paustian, PhD, MS; Elizabeth A. Wasilevich, PhD, MPH; and Darline K. El Reda, DrPH, MPH
Small weight loss was reported by overweight/obese individuals targeted for telephonic wellness coaching in this large retrospective study using pre-post design.
In addition to our primary analyses among targeted members, we also conducted stratified analysis among wellness coaching program participants. We examined the average weight change stratified by: a) wellness coaching objective; b) the number of phone calls with the wellness coach; and c) the initial stage of change. Since wellness coaching participants could establish multiple goals upon program initiation, we applied a hierarchy to make these categories mutually exclusive. The hierarchy was: weight loss > physical activity > nutrition > smoking > others. Due to sample size concerns, the intensity of intervention (ie, number of phone calls the participant received) was dichotomized into 1 to 3 calls and 4 or more calls. Although the program is designed to consist of 4 calls, on rare occasions participants (<1%) may have had more than 4 calls with a health coach if additional coaching was requested by the participant. Participants who received 4 or more phone calls with health coaches were considered program completers. We used a paired t-test to determine whether weight changes were significant for each group between baseline and follow-up, with 95% confidence intervals (CIs) for weight changes were reported.

RESULTS

Demographic Characteristics for Study Population

Table 1
shows the characteristics of the study population. This population was well educated, with 70% of them having had at least some college education. The majority of the population was Caucasian; 55% of the population was male. The distributions of gender, race/ethnicity, and education were not different among the groups. More than 70% of respondents reported having motivation to lose weight in all study groups.

The average age was 45 years or above for all 3 groups, with the group targeted for other WCM programs having the highest average age (50 years). The groups were significantly different in their smoking and chronic disease status. Respondents targeted for other WCM programs had consistently higher rates of diabetes (40%) and asthma (27%) compared with respondents targeted for wellness coaching (12% and 9%, respectively). The group targeted for wellness coaching program had the highest prevalence of ever smoking (smoking sometime during their lifetime, may or may not smoke currently). As expected, the group not targeted for any programs had the fewest risk factors. Overall, the group targeted for wellness coaching was more similar to the group not targeted for any program than to the group targeted for other WCM programs.

Average Weight Change for Intervention and Control Groups

Table 2 provides the changes in self-reported weight between baseline and follow-up at 1 year by group, removing outliers using the 2 methodologies. After excluding 4% of individuals who reported a more than 18-kg (40-lb) weight change between baseline and follow-up, the average weight change was –0.44 kg (95% CI, –0.76 to –0.16) among respondents targeted for wellness coaching and –0.74 kg (95% CI, –1.06 to –0.15) specifically among wellness coaching participants. There was no statistically significant weight loss reported by either comparison group.

Table 3 shows the comparison of weight changes among the groups from the multivariable model. After excluding 4% of respondents who reported more than 18 kg (40 lb) weight changes, respondents targeted for wellness coaching reported –0.59 kg (95% CI, –0.88 to –0.30) more weight loss than respondents not targeted for any program. The unadjusted model and the full model adjusting for age, gender, education, and self-reported comorbidities yielded similar coefficient estimates for being targeted for wellness coaching. The respondents targeted for wellness coaching reported a 0.28-kg greater weight loss than the respondents targeted for other wellness programs, but the difference was not statistically significant.

Stratified Analysis Among Wellness Coaching Program Participants

Table 4 shows the results of average weight change stratified by participants’ goals, number of phone calls between the health coach and the participants, and the participants’ initial stage of changes. Based on the results of the paired t-test, individuals who set goals of weight loss and physical activity benefited most by losing 1.51 kg (P = .001) and 0.99 kg (P = .01), respectively with no significant weight change reported for participants that set other goals. Participants who started in the preparation stage report an average weight change of –1.43 kg (95% CI, –2.17 to –0.68) if they completed the 4 phone calls.

DISCUSSION

Overweight or obese health assessment respondents targeted for wellness coaching reported an average of .44 kg weight loss, .59 kg more weight loss than health assessment respondents not targeted for any wellness care management programs. Among wellness coaching participants, we observed that individuals who set goals of weight loss and physical activity reported significant weight loss while individuals who chose other health goals did not. Participants who started wellness coaching in the preparation stage and completed the 4-call program reported the most weight loss (–1.43 kg).

The strengths of this study are the large sample size and collection of program participation information among program participants that allowed stratified analysis using factors such as initial stage of change, wellness goals set, and program completion. It is interesting that among participants who began the program in the preparation stage, those who completed all 4 calls reported the most weight loss while those who did not complete the 4 calls reported no significant weight loss. Meanwhile, the weight loss reported by participants who started in the action stage did not differ by whether they completed the 4-call intervention or not. This suggests that if health coaches are able to increase the motivation preparation stage, and provide them necessary tools to act on, these individuals may benefit from the program while participants in other stages may realize little benefit from the program as it is currently designed. Interventions may need greater customization according to the participants’ initial stage of change to maximize program benefits for all participants.

These results should be interpreted conservatively, since this is a retrospective study with limited information collected for the study population. There are many additional unobserved factors could have had an impact on weight loss among program participants. For example, motivated participants might enroll in wellness or weight loss programs in addition to the employer-sponsored and health plan-administered wellness coaching programs. It is unclear whether these unobserved factors were distributed differentially among the groups and whether this impacts the comparison among the 3 groups. Despite the large sample size, another limitation of this study is the generalizability of the findings. Our study population includes commercially insured individuals with education levels higher than those of the general population. The findings may not be generalizable to minority, younger, or less educated populations. Using selfreported weight is another limitation of this study.

The respondents targeted for telephonic wellness coaching reported a small but significant weight loss. It is unclear whether weight loss can be sustained beyond 1 year and whether the small weight loss observed has meaningful longterm health benefits. Sustaining weight loss is a persistent issue in weight loss programs.32 We only identified 1 published study that followed telephonic weight loss program participants for up to 2 years, and that study reported no significant weight loss among telephonic coaching participants at 2 years compared with participants who received a mail intervention or usual care.33,34 It is worth noting that in this HealthPartners clinical trial, participants who received either phone, mail, or usual care were all highly motivated volunteers who responded to mail or a clinic poster about the trial. Because a major technique in telephonic wellness coaching is motivational interviewing, the benefit of intervention may be limited to participants who are already highly motivated. As shown in this study, wellness coaching participants who started in the preparation stage benefited significantly from the program. Participants who were already in the action stage reported weight loss, but showed no additional benefit from completing the program. Additional studies with different populations and additional settings are needed to fully address the impacts of telephonic wellness coaching on both short-term and long-term weight loss.

Research suggests that a moderate amount of weight loss has potential benefits for obese patients.35,36 But the amount of weight loss observed in this telephonic wellness coaching program is less than 1% of total body weight and among a healthier population. Future studies on telephonic wellness coaching and weight loss may need to also report details on nutritional and physical activity components of the programs that could be associated with weight loss and the sustainability of these behaviors. If the lifestyle changes adopted through wellness coaching result in a sustainable, small amount of weight loss, this may improve health outcomes in the long term.

Author Affiliations: Clinical Epidemiology and Biostatistics, Health Care Value, Blue Cross Blue Shield of Michigan (BCBSM).

Funding Source: None.

Author Disclosures: Drs Tao, Paustian, and El Reda all report being employed by BCBSM. Mr Rangarajan and Dr Wasilevich report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MT, KR, MLP, EAW, DKER); acquisition of data (MT, DKER); analysis and interpretation of data (MT, KR, MLP, DKER); drafting of the manuscript (MT, EAW, DKER); critical revision of the manuscript for important intellectual content (MT, MLP, EAW, DKER); statistical analysis (MT, KR); and supervision (MT, DKER).

Address correspondence to: Min Tao, PhD, Tower 500, Renaissance Ctr, Detroit, MI 48243. E-mail: mtao@bcbsm.com.
1. Centers for Disease Control and Prevention. Chronic disease prevention and health promotion: obesity. http://www.cdc.gov/chronicdisease/ resources/publications/aag/obesity.htm. Accessed January 2013.

2. Criqui MH, Mebane I, Wallace RB, Heiss G, Holdbrook MJ. Multivariate correlates of adult blood pressures in nine North American populations: the Lipid Research Clinics Prevalence Study. Prev Med. 1982;11(4):391-402.

3. Dyer AR, Elliott P. The INTERSALT study: relations of body mass index to blood pressure. INTERSALT Co-operative Research Group. J Hum Hypertens. 1989;3(5):299-308.

4. Stamler R, Stamler J, Riedlinger WF, Algera G, Roberts RH. Weight and blood pressure. Findings in hypertension screening of 1 million Americans. JAMA. 1978;240(15):1607-1610.

5. Haffner SM, Mitchell BD, Hazuda HP, Stern MP. Greater influence of central distribution of adipose tissue on incidence of noninsulin- dependent diabetes in women than men. Am J Clin Nutr. 1991;53(5):1312-1317.

6. Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med. 2001;345(11): 790-797.

7. Goran MI, Ball GD, Cruz ML. Obesity and risk of type 2 diabetes and cardiovascular disease in children and adolescents. J Clin Endocrinol Metab. 2003;88(4):1417-1427.

8. Kahn SE, Hull RL, Utzschneider KM. Mechanisms linking obesity to insulin resistance and type 2 diabetes. Nature. 2006;444(7121):840-846.

9. Health implications of obesity. National Institutes of Health Consensus Development Conference Statement. Ann Intern Med. 1985;103(6 pt 2):1073-1077.

10. Kurth T, Gaziano JM, Berger K, et al. Body mass index and the risk of stroke in men. Arch Intern Med. 2002;162(22):2557-2562.

11. Strazzullo P, D’Elia L, Cairella G, et al. Excess body weight and incidence of stroke: meta-analysis of prospective studies with 2 million participants. Stroke. 2010;41(5):e418-e426.

12. Rönmark E, Andersson C, Nystrom L, et al. Obesity increases the risk of incident asthma among adults. Eur Respir J. 2005;25(2):282-288.

13. Mandal S, Hart N. Respiratory complications of obesity. Clin Med. 2012;12(1):75-78.

14. Giovannucci E. Insulin and colon cancer. Cancer Causes Control. 1995;6(2):164-179.

15. Giovannucci E, Colditz GA, Stampfer MJ, Willett WC. Physical activity, obesity, and risk of colorectal adenoma in women (United States). Cancer Causes Control. 1996;7(2):253-263.

16. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A followup of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992;327(19):1350-1355.

17. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005; 293(15):1861-1867.

18. Flegal KM, Graubard BI, Williamson DF, Gail MH. Cause-specific excess deaths associated with underweight, overweight, and obesity. JAMA. 2007;298(17):2028-2037.

19. Manson JE, Stampfer MJ, Hennekens CH, Willett WC. Body weight and longevity. A reassessment. JAMA. 1987;257(3):353-358.

20. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Millwood). 2009;28(5):w822-w831.

21. Institute HS. Moving to an Evidence-Based Health Coaching Practice. http://infocus.healthsciences.org/InFocus_Moving_to_an_Evidence- Based_Health_Coaching_Practice.html. Accessed January 2013.

22. Lichtenstein E, Glasgow RE, Lando HA, Ossip-Klein DJ, Boles SM. Telephone counseling for smoking cessation: rationales and metaanalytic review of evidence. Health Educ Res. 1996;11(2):243-257.

23. Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 2006;19(3):CD002850.

24. Terry PE, Seaverson EL, Grossmeier J, Anderson DR. Effectiveness of a worksite telephone-based weight management program. Am J Health Promot. 2011;25(3):186-189.

25. Vanwormer JJ, Boucher JL, Pronk NP. Telephone-based counseling improves dietary fat, fruit, and vegetable consumption: a best-evidence synthesis. J Am Diet Assoc. 2006;106(9):1434-1444.

26. Hellerstedt WL, Jeffery RW. The effects of a telephone-based intervention on weight loss. Am J Health Promot. 1997;11(3):177-182.

27. van Wier MF, Ariëns GA, Dekkers JC, et al. Phone and e-mail counselling are effective for weight management in an overweight working population: a randomized controlled trial. BMC Public Health. 2009;9:6.

28. University of Michigan Health Resource Center. Health Risk Appraisal (HRA). http://www.hmrc.umich.edu/content.aspx?pageid=19 &fname=hra.txt. Accessed January 2013.

29. Johnson and Johnson Company, Wellness + Prevention Inc. Health Risk Assessment. http://www.healthmedia.com/products/digitalcoachingprograms/ succeed.htm. Accessed January 2013.

30. Tukey J. Exploratory data analysis Addison-Wesely; 1977.

31. SAS. SAS 9.2 Product Documentation. http://support.sas.com/documentation/ 92/index.html. Accessed January 2013.

32. Svetkey LP, Stevens VJ, Brantley PJ, et al. Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial. JAMA. 2008;299(10):1139-1148.

33. Jeffery RW, Sherwood NE, Brelje K, et al. Mail and phone interventions for weight loss in a managed-care setting: weigh-to-be one-year outcomes. Int J Obes Relat Metab Disord. 2003;27(12):1584-1592.

34. Sherwood NE, Jeffery RW, Pronk NP, et al. Mail and phone interventions for weight loss in a managed-care setting: weigh-to-be 2-year outcomes. Int J Obes (Lond). 2006;30(10):1565-1573.

35. Goldstein DJ. Beneficial health effects of modest weight loss. Int J Obes Relat Metab Disord. 1992;16(6):397-415.

36. Wing RR, Lang W, Wadden TA, et al. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care. 2011;34(7):1481-1486.
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