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International Journal of Obesity (2000) 24, 893±898 ß 2000 Macmillan Publishers Ltd All rights reserved 0307±0565/00 $15.00www.nature.com/ijo Effective long-term treatment of obesity: JD Latner1*, AJ Stunkard2, GT Wilson1, ML Jackson3, DS Zelitch3{ and E Labouvie1 1Department of Psychology, Rutgers University, Piscataway, NJ, USA; 2Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA; and 3Trevose Behavior Modi®cation Program, Trevose, PA, USA BACKGROUND: Despite the well-documented success of behavioral techniques in producing temporary weight loss, treatment is typically followed by weight regain. The maintenance of treatment effects may therefore be the greatest challenge in the long-term management of obesity, and continuous care may be necessary to achieve it.
OBJECTIVE: To describe the design and evaluate the effectiveness of the Trevose Behavior Modi®cation Program, a potentially widely replicable self-help weight loss program offering continuous care.
DESIGN: A description of the course of all subjects (n ˆ 171) who entered the Trevose program during 1992 and 1993.
SUBJECTS: One hundred and forty-six women aged 44.1Æ 11.7 y with a body mass index (BMI, kgam2) of 33.2Æ 4.4, and 25 men aged 49.0Æ 19.6 with a BMI of 35.1Æ 5.2 enrolled in the Trevose program during 1992 ± 1993.
RESULTS: Mean duration of treatment was 27.1 months, with 47.4% of members still in treatment at 2 y and 21.6% at 5 y. Mean intent-to-treat weight loss was 13.7Æ 0.5% of initial weight, or 12.8Æ 0.5 kg. As long as they remained in treatment, almost all participants lost at least 5% of their initial weight and at least 83% lost more than 10%. Members completing 2 y of treatment lost an average of 19.3% of their initial body weight (17.9 kg); at 5 y the loss was still 17.3% (15.7 kg). After leaving the program, subjects regained weight but remained 4.7% (4.5 kg) below their pretreatment CONCLUSION: A low-cost program offering treatment of inde®nite duration produced large long-term weight losses and may be suitable for widespread replication.
InternationalJournal of Obesity (2000) 24, 893±898 Keywords: weight loss; weight maintenance; continuing care; self help general population may be limited.4 Behavioral pro- grams for the control of obesity have potential for more widespread use, but evidence of their long-term The overarching problem in the treatment of obesity is effectiveness is also limited. In six studies with the consistency with which weight lost in treatment is follow-up periods of at least 4 y, the mean weight at regained. This problem has led to the view that follow-up was only 1.9 kg lower than at the beginning obesity is a chronic disorder which requires long- term treatment.1 The two forms of treatment are Two reports indicate that long-term weight losses pharmacologic and behavioral. In 1997, the appear- can be achieved. The ®rst report described a register ance of valvular heart disease in a signi®cant number of more than 1000 persons from all parts of the US of persons who took dexfen¯uramine in combination who maintained large weight losses for a period of with phentermine, after years of apparently safe use of years.11 These subjects reported that their success was DL-fen¯uramine, raised concern over the long-term due to continuing implementation of strategies that are use of any medication.2,3 The advent of two appar- core elements of behavioral treatment programs: self- ently safer medications, sibutramine and orlistat, pro- monitoring of food intake and physical activity, mises only modest weight losses, and their long term weekly weighing, better nutrition, and exercise. The safety and effectiveness still need to be established.
second report described the only program that con- Since medication for obesity must be administered by tinued treatment for as long as 4 y.12 In this Swedish physicians on an individual basis, its effect on the study of 104 severely obese (body mass index, BMI ˆ 41.5 y) persons (81 women and 26 men), 69% remained in treatment for 4 y and lost an average *Correspondence: JD Latner, Department of Psychology, Rutgers University, 152 Frelinghuysen Road, Piscataway, of 11.7 kg. During this time, behavioral measures were employed initially on a weekly basis and subse- quently less frequently. Any increase in weight led to {This work is dedicated to the memory of David Zelitch (1924 ± 1998), whose leadership and abilities through decades of reinstitution of more intensive outpatient therapy and, devotion have made the Trevose Behavior Modi®cation Program if that failed, to inpatient therapy. Ten to twelve year follow-up data indicated a maintenance of weight Received 21 June 1999; revised 9 November 1999; accepted These rare successes suggesting the importance of members. Thereafter the cumulative weight loss goals treatment duration are supported by a meta-analysis are 22% of the total goal for the second month, 30% that found that treatment duration was signi®cantly for the third month, and so forth until 90% of the goal correlated with weight loss after treatment and at is achieved. After the ®rst 5 weeks, absences may follow-up.14 Another study showed that 40 weeks of be excused, but only with 2 weeks advance notice.
treatment produced signi®cantly greater weight losses During vacations, members must mail a record of than did 20 weeks, both at 40 weeks (13.6 vs 6.4 kg) their weight to their group leader on the day of their and at 72 weeks (9.9 vs 4.6 kg) after the start of usual meeting. Failure to meet attendance or weight loss requirements during the ®rst 4 months results These studies suggest two causes of the poor long- in immediate dismissal from the program. After 4 term results of treatment of obesity. The ®rst is months, members who fail to meet a weight loss inadequate implementation (rather than inadequate requirement are given a grace period of one month techniques). The second is inadequate duration of (`drop-out') or 2 months (`parole') in which to lose treatment. We report here an effective behavioral the required weight, but once again, failure results in treatment program of long duration, with costs so low that it can be widely replicated and can serve as When members have reached, and maintained, their weight loss goal for 4 months, the requirement for attendance drops to two meetings a month and, after 8 months, to one meeting a month. After 12 months of successful maintenance, members are graduated to `independence level' and are not required to attend meetings. About 10% choose to continue regular The Trevose Behavior Modi®cation Program was attendance and they form the pool from which new begun in 1970 by David Zelitch, a formerly obese group leaders are chosen. Those who do not continue man, as a means of helping himself maintain his to attend must keep weight records and mail them in weight loss. The program now treats approximately to their group leader monthly. A weight gain of up to 1000 persons in its central location and in 63 smaller 10 pounds (above their weight when they reached satellite groups in Philadelphia and its surrounding `independence level') triggers an urgent request for areas. It is lay-directed and lay-administered, staffed the member to return for weekly meetings until the entirely by volunteers and it charges no fees. The extra weight is lost. If, however, the gain is greater Trevose Program has been operating in its present than 10 pounds, the members are not allowed to rejoin form for more than 25 y and has earned recognition by the program until their weight is no more than 10 other weight loss programs in the Philadelphia area pounds above their `independence level' weight.
for its willingness to accept all patients refused treat- This report describes the outcome of all subjects ment by them, usually for lack of funds.
enrolled in the Trevose program during the years Like most behavioral programs, the Trevose pro- 1992 ± 1993. Information on these individuals gram involves standard techniques, delivered in included gender, age on entry into the program, initial weekly 1 h meetings of groups of about 10 persons.
weight, BMI, weight loss goal and weights recorded It includes weigh-ins, self-monitoring of food intake monthly during treatment. Participant ¯ow during the and physical activity, measures to slow the rate of eating, and social support. Subjects are weighed at each of the weekly meetings on a balance-beam scale.
The ®rst step in the program is selection of the applicant's weight loss goal. Goals are derived from the 1959 tables of the Metropolitan Life Insurance Company16 and are subject to two constraints: they must be within the range of normal weight and no less than 20 nor more than 100 pounds less than the applicant's initial body weight. This latter constraint excludes very obese persons with their poorer prog- nosis as well as persons with solely cosmetic con- cerns. Once the overall goal is set, monthly weight loss goals are established, based on a cumulative Unlike most behavior therapy programs, attendance and achieving weight loss goals are strictly enforced.
A critical part of the program is a 5-week trial of treatment. During this time attendance is mandatory, as is the loss of 15% of the total weight loss goal; only those meeting these requirements are accepted as full Figure 1 Participant ¯ow during the study.
A total of 134 of 171 persons who were full women and 33 men) entered the 5-week trial which members of the 1992 ± 1993 cohort dropped out was completed by 171 (146 women and 25 men), who during the 5 y of membership in the program.
became full members. Ages of female and male full Reported current weight was obtained from 77 members were 44.1Æ 11.7 and 49.0Æ 10.6, respec- (58%) of these drop-outs through telephone contact, tively, and their BMIs were 33.2Æ 4.4 and 35.1Æ 5.2.
which took place an average of 47.1 months after they Mean duration of treatment was 27.1 months.
had left the program. This study was approved by the Figure 2 shows the percentage of full members con- Rutgers University Institutional Review Board.
tinuing in the program: 61.4% at 1 y, 47.4% at 2 y and Mean intent-to-treat weight loss for all full mem- bers was 13.7Æ 0.5% of initial weight or The most important aspect of this study is the long 12.8Æ 0.5 kg. (Percentage weight loss and kg of duration of treatment (Figure 2). There is no standard weight loss are quite similar for all measurements.) way of displaying the weight loss data of persons who The percentage of members who lost 5% and 10% of remain in a program for long, and varying, periods of their initial body weight is depicted in Table 1. As time. Accordingly, we devised a method, depicted in long as they were in the program, almost all partici- Figure 3, that shows the weight loss of participants pants lost at least 5% of their initial weight and at least who remained in the program for designated periods of time. The weight loss curves include subjects who Figure 3 illustrates this critical aspect of the Tre- reached the designated cut-off points (6, 12, 24, 30 vose program Ð the maintenance of weight losses of and 60 months). Weights of participants who persons as long as they remain in the program. It remained in the program beyond a cut-off point but depicts the weight losses of members who remained in did not reach the next cut-off point are shown until the the program for varying periods of time: 6, 12, 24, 36 earlier cut-off point (ie weights of members remaining and 60 months. The 61.4% of the full members who in the program between 36 and 59 months are remained in treatment at 1 y lost 18.5% of their depicted through the 36th month of participation).
original weight (17.1 kg), and the 47.4% who Regression analyses were used to estimate predic- remained at 2 y lost 19.3% of their original weight (17.9 kg). At 5 y, weight loss of members remaining in treatment averaged 17.3% of original weight (15.7 kg). The percentages are of all full members, Figure 1 shows the course of the 329 persons who applied to Trevose in 1992 ± 1993. Of these, 202 (169 Figure 3 Weight losses of full members who remained in the program for varying periods of time. The curves show the weight losses of members who completed varying durations of treatment: 6, 12, 24, 36 and 60 months. The percentages refer to the percent of all full members who reached these cut-off points.
For example, at 60 months, 22% were still in treatment and had lost 17% of their initial weight. This method of presentation is conservative, since it does not depict weight losses between cut- off points, for persons who remained in the program beyond one Figure 2 Decrease in the percent of members attending the cut-off point but did not reach the next cut-off point. The ®gure Trevose Behavior Modi®cation Program during the 5 y study does not include the 20% of full members who dropped out of period. 100% consists of full members who had completed the treatment during the ®rst 6 months. Numbers in the ®gure have 5 week trial period. See text for explanation.
Table 1 Mean weight loss of Trevose and Orlistat subjects at 6, 12, 24, 36, 48 and 60 months and those achieving weight losses of 5% or more and 10% or more of initial body weight excluding the 19.6% who dropped out at various times In the present study, the largest percent of weight during the ®rst 6 months and whose average weight loss, 20%, did not occur until 30 months of treatment, emphasizing again the advantages of long-term treat- Follow-up weights for the Trevose program were ment. By contrast, maximum weight loss in traditional obtained on 58% of members who had dropped out.
behavioral programs consistently occurs at 6 These members did not differ from those who were not contacted in terms of age, baseline weight or The high drop-out rate by the end of the ®fth year of weight losses at 1, 6, and 12 months of treatment.
treatment calls for caution in interpreting the results.
Their average net weight loss (weight below baseline Nevertheless, the drop-out rate at earlier points in values) 47.1 months after leaving the program was treatment is comparable to other treatment studies. It 4.7Æ 1.1% or 4.5Æ 2.3 kg. The length of follow-up may be helpful to compare the Trevose results with was not related to the size of the net weight loss.
those of a recent, large, 2 y controlled trial of the Three major predictors of weight loss, as deter- lipase inhibitor Orlistat.18 This study enrolled 1187 mined by regression analysis, accounted for 60% of persons who were somewhat heavier (BMI ˆ 36.5) the variance in weight loss in kg (F(3,162) ˆ 48.3; than the Trevose subjects (BMI of men ˆ 35.1, of P ` 0.001), and 47% of the variance in percentage women ˆ 33.2) and greater weight favors greater weight loss (F(3,162) ˆ 81.7; P ` 0.001). The predic- weight loss. After a 4 week placebo run-in period, tors were months in treatment (b ˆ 0.51; P ` 0.001), comparable to the Trevose 5-week trial period, all weight loss during the ®rst month (b ˆ 0.30; P ` .001) subjects received a diet, behavioral consultations and and initial BMI (b ˆ 0.27; P ` 0.001). The higher the either Orlistat or placebo. Subjects remaining in initial BMI, the greater the weight loss.
treatment were comparable in the two studies: at 1 y Trevose 62%, Orlistat 69%, placebo 57%; at 2 y, Trevose 47%, Orlistat (drug and placebo) 43%.
During the 2 y of treatment, Trevose subjects lost far more weight. Table 1 shows that at 1 y the mean weight loss for Trevose (19%) was twice that for Orlistat (9%) or placebo (6%). At 2 y the weight loss The Trevose Behavior Modi®cation Program is a for Trevose (19%) approached three times that for surprisingly effective weight control program, parti- Orlistat (8%) and placebo (6%). At 1 y, the percentage cularly when considered in the light of its minimal of subjects who lost at least 10% of their initial weight at Trevose was 97% compared to 39% for Orlistat and The results of the Trevose program are dif®cult to 25% for placebo. At 2 y 94% of Trevose subjects had compare with those of other programs because of its lost 10% of their initial weight compared to 34% for far greater duration of treatment. Thus, of the six Orlistat and 18% for placebo. The Orlistat study programs with follow-up periods of at least 4 y, terminated at two years, while weight losses of treatment averaged only 16.4 weeks in duration.5±10 Trevose subjects in treatment remained substantial Four-year follow-up of these programs showed an average net weight loss of 1.9 kg compared to 4.5 kg The self-help format of the Trevose program does for Trevose drop-outs contacted at follow-up. Weights not appear to be responsible for its success, which was for the Trevose subjects may be somewhat more far greater than that of two other self help programs reliable than those of the other six studies, since for obesity: Take Off Pounds Sensibly (TOPS)19 and they were obtained on a substantial proportion of Overeaters Anonymous.20 A study of 21 TOPS chap- subjects (58%) who were representative of those not ters in the Philadelphia area revealed that the average contacted. The representativeness of the subjects of member lost 6.8 kg but fewer persons remained in treatment than in Trevose: 53% survived for 1 y and 30% for 2 y.19 Overeaters Anonymous does not Second, one of the very few criteria for exclusion from Trevose is critical: no previous members are The content of the Trevose program does not seem accepted. Applicants learn at their ®rst encounter that different from that of most other behavioral weight this is a once in-a lifetime opportunity. As the Trevose control programs. What is different is its provision for Leaders' Manual makes clear, `this is a last chance treatment on a continuing basis. As noted above, behavior therapy appears effective as long it is used: Third, prospective candidates learn about Trevose at 2 y weight loss was 19% of initial weight and at 5 y primarily from satis®ed members who describe the expectations. They arrive highly motivated and know The behavior modi®cation component of the pro- gram contains no unique features. It relies on old- Fourth, the rules are in force from the beginning, fashioned behavior therapy; little has changed since it with the critical requirement that members complete was ®rst introduced in 1971 in the early days of the the 5-week trial of treatment and lose 15% of goal ®eld. At the time that one of the authors (AJS) and weight. This trial period is of great importance, for it Henry Jordan were helping David Zelitch implement introduces members to the practical aspects of the it at Trevose, it was tested in another setting: the 21 program and, particularly, its non-negotiable require- TOPS chapters in the Philadelphia area noted earlier.
As part of a larger controlled trial, the leaders of four Fifth, members know from the beginning that fail- TOPS chapters were taught the principles of behavior ure to meet attendance and weight loss goals is modi®cation and trained with the help of a behavioral grounds for dismissal. The message is, `We take this weight loss manual. Their results over a period of 12 work very seriously and expect that you will'.
weeks were compared with those of four matched These circumstances appear to be responsible for TOPS chapters that continued their standard pro- the successful implementation of the Trevose pro- gram. The behavioral program decreased drop-out gram Ð its simple and unambiguous contingencies: rate, both during treatment and at a 9-month follow- if members do not attend or if they fail to meet their up, to 41% compared to 67% for the standard weight loss goal, they are out and cannot come back.
program. Weight loss at the end of the behavioral No bargaining, no second chances. This implementa- program was 0.9 kg vs a gain of 0.3 kg in the standard tion and the opportunity for continuing care are the program.21 The difference between the results of the hallmarks of this successful program.
TOPS and the Trevose behavioral programs could not The time is ripe for replication and additional have been more striking, leading us to look beyond testing of the Trevose model on a large scale. Such the program's content for an explanation of its application, by both state and country health depart- ments, would have many bene®ts. It would bring low- It is, of course, possible that these results may be cost weight loss to large populations and would due to particular characteristics of the group examined facilitate studies of the mechanisms of the Trevose here. However, there are few restrictions on who can program that might further increase its effectiveness.
apply and the applicants do not appear to differ from the vast majority of persons seeking behavioral treat- ment for obesity. Even the predictors of weight loss in The authors are grateful to Theresa Chilton, Louise Trevose and other programs do not differ. The amount Fisher, Mildred Gamble, Sue Hirsch, and Arlene of weight lost during the ®rst month of treatment, the Robinson, volunteers at the Trevose Behavior Mod- duration of treatment and the initial BMI, highly i®cation Program, for their valuable administrative predictive in the Trevose program, are also predictive in other programs reported in the literature.22 How- ever, no other treatment program in the US has shown this level of long-term effectiveness, even in a speci®c population. These results provide preliminary support 1 Perri MG. The maintenance of treatment effects in the long- for the Trevose model of continuous care combined term management of obesity. Clin Psychol Sci Pract 1998; 5: with self-help and strict behavioral contingencies.
2 Connolly HM, Crary JL, McGoon MD, Hensrud DD, Edwards The effective elements of the Trevose program BS, Edwards WD, Schaff HV. Valvular heart disease asso- appear to be its model of continuing care and its ciated with fen¯uramine-phentermine. N Engl J Med 1997; First, the program tries to keep members in treat- 3 Devereux RB. Appetite suppressants and valvular heart dis- ease. N Engl J Med 1999; 339: 765 ± 767.
ment inde®nitely and helps to make this goal feasible.
4 Williamson DF. Pharmacotherapy for obesity. JAMA 1999; Obesity is presented as a life-long problem that requires life-long effort. There is no suggestion that, 5 Stunkard AJ, Penick SB. Behavior modi®cation in the treat- once the requisite behaviors are learned, the task is ment of obesity: the problem of maintaining weight loss. Arch completed; they must be practised inde®nitely. Suc- 6 Graham LE, Taylor CB, Hovell MF, Siegal W. Five-year cessful members are recruited to serve as role models follow-up to a behavioral weight-loss program. J Consult Clin 7 Stalonas PM, Perri MG, Kerzner AB. Do behavioral treat- 15 Perri MG, Nezu AM, Patti ET, McCann KL. Effect of length ments of obesity last? A ®ve-year follow-up investigation.
of treatment on weight loss. J Consult Clin Psychol 1989; 57: 8 Murphy JK, Bruce BK, Williamson DA. A comparison of 16 Metropolitan Life Insurance Company. New weight measured and self-reported weights in a 4-year follow-up of standards for men and women. Stat Bull Metrop Insur Co.
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therapy, and their combination: a ®ve-year perspective. Int J 18 Davidson MH, Hauptman J, DiGirolamo M, Foreyt JP, Halsted CH, Heber D, Heimburger DC, Lucas CP, Robbins 10 Wadden TA, Frey DL. A multicenter evaluation of a proprie- DC, Chung J, Heyms®eld SB. Weight control and risk factor tary weight loss program for the treatment of marked obesity: rediction in obese subjects treated for 2 y with Orlistat: a a ®ve-year follow-up. Int J Eat Disord 1997; 22: 203 ± 212.
randomized controlled trial. JAMA 1999; 281: 235 ± 242.
11 Klein ML, Wing RR, McGuire MT, Seagle HM, Hill JO. A 19 Garb JR, Stunkard AJ. Effectiveness of a self-help group in descriptive study of individuals successful at long-term main- obesity control. Arch Int Med 1974; 134: 716 ± 720.
tenance of substantial weight loss. Am J Clin Nutr 1997; 66: 20 Anonymous. Overeaters anonymous. JAMA 1984; 251: 12 Bjorvell H, Rossner S. Long term treatment of severe obesity: 21 Levitz LS, Stunkard AJ. A therapeutic coalition for obesity: four year follow up of results of combined behavioural behavior modi®cation and patient self-help. Am J Psychiat modi®cation programme. Br Med J 1985; 291: 379 ± 382.
13 Bjorvell H, Rossner S. A ten year follow-up of weight change 22 Wilson GT. Behavioral and psychological predictors of treat- in severely obese subjects treated in a behavioural modi®ca- ment outcome in obesity. In Allison DB, Pi-Sunyer FX (eds).
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Obesity treatment. New York: Plenum Press, 1995, pp 14 Bennett GA. Behavior therapy for obesity: a quantitative review of the effects of selected treatment characteristics on 23 Trevose Behavior Modi®cation Program. Leaders' manual, outcome. Behav Ther 1986; 17: 554 ± 562.

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