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Stead et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:87 DOI 10.1186/s12966-015-0240-2

RESEARCH

Open Access

Why are some people more successful at lifestyle change than others? Factors associated with successful weight loss in the BeWEL randomised controlled trial of adults at risk of colorectal cancer Martine Stead1*, Angela M. Craigie2, Maureen Macleod2, Jennifer McKell1, Stephen Caswell2, Robert J. C. Steele2 and Annie S. Anderson2

Abstract Background: The BeWEL (BodyWEight and physicaL activity) randomised controlled trial demonstrated that a weight management programme offered in the colorectal cancer screening setting was effective. However, the differential responses of participants to the programme were notable. This study aimed to explore the factors associated with success and to identify implications for future programme design. Methods: Analyses were conducted of quantitative data (n = 148) from the BeWEL intervention group to compare demographic and psychosocial characteristics and lifestyle changes in those who met and exceeded the target 7 % weight loss (‘super-achievers’) with those who achieved only ‘moderate’ or ‘low’ amounts of weight loss (2–7 % loss, or 25 kg/m2. The trial demonstrated sustained changes in body weight, physical activity, eating and drinking habits over a 12 month intervention programme delivered through three face-to-face visits with a counsellor and nine monthly telephone calls. Both groups lost significant weight, with the intervention group losing on average 3.50 kg (SD 4.91 kg, 95 % CI 2.70 to 4.30) and the control group losing 0.78 kg (SD 3.77 kg, 95 % CI 0.19 to 1.38) [9]. However, the significant group difference of 2.69 kg (95 % CI 1.70 to 3.67) highlights the overall success associated with the intervention programme and merits further investigation to examine the differential responses of participants to the programme. For example, only 33 (22 %) participants achieved the programme target of >7 % body weight loss [9]. While there is increasing evidence that carefully designed programmes can lead to successful weight loss [10], the reasons for the variation in outcomes found in such programmes are not well understood.

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A number of studies have attempted to shed some light on why some people are more successful at achieving or maintaining weight loss than others. For example, an online survey of participants in a commercial weight loss programme found that success was associated with various types of control over eating, such as greater dietary restraint, less tendency to eat to control mood and emotion, not skipping meals, not keeping snack foods in the house and eating takeaway foods less frequently [11]. Similarly, Fuglestad and colleagues’ [12] study of weight loss among individuals who had recently lost substantial weight on their own initiative found that greater regularity and control in eating was associated with greater recent weight loss and greater fruit and vegetable intake. However, neither study investigated the potential contribution of wider factors which might explain why some participants were better able to control their eating than others. A systematic review [13] of the factors reported in quantitative studies which were associated with successful participation in lifestyle behaviour change programmes (not solely focused on weight loss) found that the factors most consistently associated with uptake of lifestyle change related to support from family and friends, transport and other costs, and beliefs about the causes of illness and lifestyle change, with depression and anxiety also appearing influential. However, the review reported that many factors showed inconsistent patterns with respect to uptake and completion of lifestyle change programmes. Another review, this time focusing on factors identified in qualitative studies [14], found that the most commonly reported influences were those relating to social support (whether provided formally or informally), beliefs (about the self or the causes and management of poor health, and the value of maintaining lifestyle behaviours), and other psychological factors (including attitude, thinking and coping styles, and problem solving skills). The same review notes that influencing factors are interlinked, and that while the literature may help us to identify individual factors associated with successful lifestyle change, there is still a limited understanding of the nature of the relationships between factors and how they differ between individuals. Similarly, Dalle Grave and colleagues [10] state that despite some gains in insight, knowledge regarding predictors of weight loss remains incomplete. The current work aimed to explore the factors associated with success in weight loss in the BeWEL study by comparing, both quantitatively and qualitatively, those who succeeded in achieving more than 7 % weight loss with those who were less successful. The quantitative analysis examined the possible contribution of a range factors thought to be associated with weight loss, including sociodemographic and body weight characteristics, health perceptions, quality of life, self-efficacy and perceptions of

Stead et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:87

lifestyle, while the qualitative study enabled a more openended exploration of possible factors.

Methods Quantitative and qualitative methods were used to identify the factors associated with success in weight loss. Two approaches were used: a sub-group analysis of quantitative data for those participants who participated in the BeWEL intervention and completed follow-up measures, and qualitative interviews with a sample of 24 intervention participants who achieved varying levels of weight loss success. Recruitment

Recruitment for the BeWEL RCT took place in four Scottish NHS health board areas from November 2010 to May 2013. Participants aged 50 to 74 years who had taken part in the Scottish Bowel Screening programme and undergone polypectomy for adenoma were informed about the study in writing. Those indicating an interest in participating were telephone-screened by a research nurse for eligible criteria: BMI >25 kg/m2, able to undertake physical activity and provide informed consent, not pregnant and without insulin dependent diabetes mellitus or any cancer diagnosis. Eligible participants were then posted a more detailed information leaflet and invited to attend their local study centre to provide informed written consent and undergo baseline measures.

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Daily portions of fruit and vegetables were estimated using a modification of Cappuccio and colleagues’ twoitem questionnaire [20], which asked ‘How many pieces of fruit and vegetables (excluding potatoes) do you eat—of any sort—on a typical day?’, recording fruit and vegetable portions separately. Fruit and vegetable juices only counted as a maximum of one portion per day. Portion sizes were illustrated using show-cards as defined by the NHS Livewell Portion Size guidance [21]. Sugary drink intake (excluding diet, low-calorie drinks and fresh fruit juice) was self-reported using nine frequency categories whereas typical consumption of alcohol (on week days and weekends) was assessed using questions from the Alcohol Use Disorders Inventory Test (AUDIT) [22] questionnaire. Ethical approval was granted by NHS Tayside Committee on Medical Research Ethics (Ref 10/S1402/34). Randomisation

Following baseline measures, participants were randomised, 1:1, to parallel-groups using a permuted-block technique. Allocation was to either a control group (weight loss booklet) or a 12-month intervention group (three face-to-face visits with a counsellor and nine telephone calls, one per month).

Intervention Baseline and follow up measures

Socio-demographic data on age, gender, ethnicity, marital status, education, employment and postcode were recorded at baseline [15]. Objective measures recorded at baseline, three months and 12 months included height, weight, waist circumference, blood pressure, fasting blood samples and physical activity. Physical activity levels were measured objectively using a SenseWearTM armband (BodyMedia Inc. Pittsburgh, PA) worn on the upper arm for 7 days to provide participants’ daily step count, and time spent in sedentary, moderate (3 to 72) was based on intakes of substantial contributors to fat intake i.e. dairy foods, meat, processed meat, fish, fried foods, sweet and savoury snacks and fat spreads, and the unsaturated fat score (range 3–12) was based on the type of fats used.

The intervention protocol is described in full by Caswell and colleagues [23], but in brief targeted a 7 % reduction in body weight through diet, activity and behaviour change, including a personalised energy prescription (600kcals below that required for weight maintenance). Motivational interviewing techniques explored selfassessed confidence, ambivalence and personal values concerning weight. To assist change in both diet and physical activity, participants were encouraged to focus on one topic (diet or physical activity) during visit one, and the remaining topic on visit two, and were generally advised to begin with the topic where they had the strongest likelihood of success. Behaviour change techniques were employed including goal setting, identifying implementation intentions, self-monitoring of body weight (scales were provided) and counsellor feedback about reported diet, physical activity and weight change. The intervention was delivered in four NHS areas with one lifestyle counsellor in each area, and all counsellors received the same training to ensure consistency in delivery. The primary outcome was change in body weight at 12 months. Secondary outcomes included percentage weight loss, change in BMI and waist circumference, health behaviours (dietary and alcohol habits and physical activity) and self-reported psycho-social variables (self-efficacy and self-assessed health and quality of life).

Stead et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:87

Sub-group analysis of quantitative data

A sub-group analysis was undertaken of the intervention participants who completed the study to compare participants according to their percentage weight loss. Participants were divided into ‘super-achievers’ (≥7 % weight loss), ‘moderate-achievers’ (2–< 7 % weight loss) or ‘lowachievers’ (30 kg/m2) and 60 % (52 % males and 84 % females) reported having previously tried (80 % successfully) to lose weight (Table 1). When the three achievement groups were compared, no significant differences were found in their sociodemographic or body weight characteristics at baseline, nor their previous history of weight loss attempts (Table 1). In addition, no significant differences were found between NHS sites in baseline characteristics or weight loss outcomes, suggesting that ‘super-achievement’ was not explained by differences in implementation between the lifestyle counsellors allocated to each NHS site. Following the 12 month intervention, ‘super-achievers’ had lost an average of 10.2 kg (11.5 %) body weight, 3.5 BMI units, and 11.7 cm from their waist circumference.

Stead et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:87

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Table 1 Baseline socio-demographic and body weight characteristics of intervention participants who completed, by subsequent achievement category Super-achievers Moderate-achievers Low-achievers Between group differences

p-value

Mean or Odds Ratio (95%CI) n = 33

n = 58

n = 57

Super vs. moderate Super vs. low

Male gender: n (%)

22 (66.7)

44 (75.9)

44 (77.2)

0.6 (0.2, 1.6)

0.6 (0.2, 1.5)

0.51

Age (years): Mean (SD)

65.2 (SD 6.7)

63.7 (SD 6.5)

62.3 (SD 7.2)

1.5 (−1.4, 4.3)

2.9 (−0.2, 5.9)

0.15

1 (most deprived)

4 (12.1)

11 (19.0)

6 (10.5)

—

—

0.29

2

6 (18.2)

12 (20.7)

12 (21.1)

3

3 (9.1)

13 (22.4)

10 (17.5)

4

12 (36.4)

7 (12.1)

14 (24.6)

5 (least deprived)

8 (24.2)

15 (25.9)

15 (26.3)

SIMD quintiles: n (%)

In least deprived 5 SIMD deciles

21 (63.6)

29 (50.0)

37 (64.9)

1.8 (0.7, 4.2)

0.9 (0.4, 2.3)

0.22

Married/Cohabiting: n (%)

29 (87.9)

47 (81.0)

43 (75.4)

1.7 (0.5, 5.8)

2.4 (0.7, 7.9)

0.35

Retired: (%)

20 (60.6)

35 (60.3)

32 (56.1)

1.0 (0.4, 2.4)

1.2 (0.5, 2.9)

0.88

Baseline weight (kg): Mean (SD)

89.2 (12.1)

89.7 (16.1)

92.6 (15.5)

−0.4 (−6.8, 6.0)

−3.3 (−9.2, 2.5) 0.48

Baseline BMI (kg/m2): Mean (SD)

31.1 (3.4)

30.8 (4.9)

31.4 (4.9)

0.3 (−1.6, 2.2)

−0.3 (−2.0, 1.4) 0.78

Obesea at baseline: n (%)

19 (57.6)

26 (44.8)

27 (47.4)

1.7 (0.7, 4.0)

1.5 (0.6, 3.6)

Baseline waist circumference (cm): Mean (SD)

105.5 (9.2)

103.5 (11.2)

106.4 (11.8)

2.0 (−2.5, 6.6)

−0.8 (−5.3, 3.6) 0.37

Made previous attempt at weight loss: n (%)

24 (72.7)

31 (53.4)

34 (59.6)

2.3 (0.9, 5.8)

1.8 (0.7, 4.6)

0.20

Successful at previous weight loss attempts: n (%) 21 (87.5)

25 (80.6)

30 (88.2)

1.7 (0.4, 7.5)

0.9 (0.2, 4.6)

0.65

0.49

a

BMI > 30 kg/m2

In contrast, ‘moderate-achievers’ had lost 3.8 kg (4.2 %), 1.3 BMI units and 4.4 cm, and ‘low-achievers’ had gained 0.7 kg (0.8 %), 0.3 BMI units and lost 1.6 cm (Table 2). Lifestyle behaviours assessed at the end of the 12 month intervention period indicated that superachievers had increased their daily step count by 1878 ± 3556 steps per day, whereas moderate and low-achievers had reduced theirs (−109 ± 3335 and−372 ± 2118 steps per day, respectively, p < 0.01). A higher proportion of super-achievers also increased the number of portions of fruit and vegetables they reported consuming per day, but no other differences in fat or fibre scores, or in the proportions reducing their consumption of sugary drinks or alcohol between the groups, were identified. The majority (79 %) of participants had rated their current health as ‘good’ or better at baseline. However, while there were no significant differences in perceptions of current health, super-achievers were significantly less likely than the rest to report that their activities (e.g. stair climbing, moderate activity and general accomplishments) and work were affected by physical and emotional health (Table 3). Super-achievers were no different in how they had rated their self-efficacy, beliefs about their lifestyle risk and perceptions of their own lifestyle and bodyweight at baseline, with one exception: they were significantly

more likely to believe their diet was harmful to their health (Table 4). Qualitative study findings

Analysis across the sample, comparing super, moderate and low-achievers, found no clear patterns in relation to some key factors which previous studies have suggested may contribute to differences in success, such as family and social support, quality of relationship with counsellor and access to healthy food and opportunities for physical activity. Although having an involved and supportive spouse was important to some super-achievers, others, particularly female super-achievers, did well with either no partner to support them, or in the context of family indifference to their efforts. Similarly, although participants generally spoke positively about the counsellors, the depth and nature of the relationship varied, and there appeared not to be a consistent link between degree of weight loss achievement and relationship with the counsellor: for example, one super-achiever had requested extra contact with the counsellor during the 9-month telephone support period because he felt he needed this external prompting and validation to keep on track, while another superachiever could not even remember the counsellor’s name, and was satisfied with a much more arm’s length relationship. What seemed more important was that the individual was sufficiently driven to make changes for themselves

Mean (Standard Deviation)

P-value

Between group differences Mean or Odds Ratio (95%CI)

Super-achievers

Moderate-achiever

Low-achiever

(n = 33)

(n = 58)

(n = 57)

Super Vs Moderate

Super Vs Low

• Weight loss (kg)

−10.2 (4.3)

−3.8 (1.5)

• % body weight change

−11.5 (4.3)

−4.2 (1.4)

0.7 (2.4)

−6.4 (−7.8,−5.0)

−11.0 (−12.4,−9.6)