Audiotranscript

Behavior Change to Prevent Chronic Disease: Psychology in Action

Presented by Elizabeth Venditti, PhD

3/6/19

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Good afternoon. Welcome to the COPE March professional webinar entitled "Behavior Change to Prevent Chronic Disease: Psychology in Action".

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We're so glad you've joined us. We have about 448 health professionals registered for this webinar today and we're really thrilled that you've joined us.

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My name is Lisa Diewald and I'm the program manager for the MacDonald Center for Obesity Prevention and Education at Villanova University's M. Louise Fitzpatrick College of Nursing.

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I have the pleasure of being the moderator for today's webinar. Villanova is home to the first college of nursing in the country to have a center devoted exclusively to obesity prevention and education.

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As the bottom of the slide illustrates, COPE's goals are to enhance nursing education and topics related to nutrition, obesity prevention and health promotion strategies,

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to provide continuing education programs such as this webinar on obesity and obesity-related diseases for health professionals and educators, and finally to participate in research to expand and improve evidence-based approaches for obesity prevention and education in the community.

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Before we begin the presentation, I would just like to remind our listeners that PDFs of today's PowerPoint slides are posted on the COPE website at Villanova.edu/COPE. After going to COPE's website, simply click on the webinar description page for this month's webinar.

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Please use the question and answer section on your screen to submit questions for our speaker. All questions will be answered at the end of the webinar and we will leave about 10 minutes for questions. The expected length of the webinar is one hour.

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The session will be recorded and placed on the COPE website within the next week.

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If you use your phone to call into the webinar today and want CE credit for attending the webinar, please take a moment after the session to email us at COPE@villanova.edu and provide your name so that we can send your CE certificate.

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The objectives for today's webinar are to discuss key components of evidence-based lifestyle interventions,

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to describe the efficacy trials and translational research contributing to current public health science (specifically related to obesity management and diabetes prevention) in high risk groups,

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and finally, to identify challenges that remain in the field to improve translational and public health.

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Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation.

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Villanova University College of Nursing continuing education COPE is a continuing professional education CPE accredited provider with the Commission on dietetic registration, as well as an approved provider with the American College of Sports Medicine.

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Our webinar this month awards one contact hour for nurses and one CPEU for dietitians and DTRs. The suggested CDR learning need codes are 5370, 6010, 6020 and 5190.

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Next I have the privilege of introducing our speaker for today's webinar.

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Elizabeth Venditti, PhD is an associate professor of psychiatry and epidemiology at the University of Pittsburgh School of Medicine.

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She earned her PhD in clinical psychology from University of Pittsburgh Kenneth P Dietrich School of Arts and Sciences and has extensive experience in the development,

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training, implementation and investigation of long term behavioral weight management protocols for individual and group lifestyle interventions.

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She is the principal investigator for the DPP outcomes study, phase three, as well as a co-investigator on several other behavioral medicine and public health trials.

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Dr. Venditti is an author on numerous publications focusing on obesity, diabetes prevention and health psychology, and is the recipient of the Pitt Innovator Award from University of Pittsburgh's Innovation Institute.

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While we are preparing for Dr Venditti's presentation to begin, I just wanted to mention that neither the planners, nor the presenter of this program have any disclosures to report.

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Accredited status does not imply endorsement by Villanova University, COPE or the American Nurses credentialing center

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of any commercial products or medical nutrition advice displayed in conjunction with an activity. And with that, I welcome Dr. Elizabeth Venditti to our COPE webinar program and I will turn things over to her for the presentation.

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Thank you so much for that lovely introduction and good afternoon all.

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Do I have control now Lisa?

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Yes, you should have control of the mouse.

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Okay, let me click on it.

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Ah, OK. Alright. So the title of my talk is Behavior Change to Prevent Chronic Disease: Psychology in Action

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And a rough outline for what I'm hoping to convey today is a little bit about the rationale for behavior change interventions and obesity and diabetes prevention in adults- so the why.

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Some fundamental intervention components- the what, and the evidence base from some major randomized trials and translational effectiveness studies.

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And then to end with implications for integrated clinical practice. I'm aware that this is a large group of

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health coaches, dietitians, nurses who are embedded in a variety of settings- specialty clinics, primary care and of course

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what I'm going to be speaking about today- your role is integral to all of these things and so I want to be able to talk about the implications for what we've learned from science and psychology and behavior change.

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So first, and I will focus largely on the obesity to diabetes trajectory, but of course, obesity is associated with many chronic conditions. So you can sub in whatever is most important.

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We know that over 30 million individuals, about 10% of the US population, have a diagnosis of diabetes and what you know everyone I think is increasingly aware of is that there are 84 million with pre- but most people don't know that because they're not necessarily screening

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or getting risk tests done. About one out of three people will develop diabetes in their lifetime. And of course it is highly prevalent or most prevalent in African Americans, Hispanics, American Indian, Alaska Native,

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Native Hawaiian and Pacific Islanders. So in some ways, you know, we're at the tip of the iceberg. Awareness is increasing and certainly in your practice, you are going to be working with people on that spectrum of at risk, pre-, early and clinically diagnosed diabetes.

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It's costly. The driving force is type two, which accounts for the vast majority of all diabetes cases and about one out of seven total health care dollars is spent treating diabetes

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and its complications. So we're talking billions of dollars. So, prevention of obesity, prevention of diabetes is certainly something that everybody in this field wants to be thinking about.

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So the rationale, then becomes, if we are going to treat obesity to diabetes and other chronic conditions,

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why are we bothering with lifestyle behavior change? Well, I'm a health psychologist and so I know why I'm bothering with it because I believe these behaviors are incredibly important.

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But should we- here's the provocative question I like to start talks with- can specialized, personalized precision medicine help us all?

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We know that genetic, physiologic and psychosocial factors are incredibly complex and we need to address individual vulnerability. And behavior changes is hard. It's challenging

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But the food in the activity environment is potent in shaping habits in animals and people. I like to think of it as the final common pathway. So we have all of this immense variability and responsivity

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to the interventions that are out there right now. But the final common pathway is we do move around and we eat and we try to self regulate and so

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it's in our best interest to try to grab on to those behavioral pathways. And the bargain, the benefit of course

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is that if people do grab on to these behavioral pathways and learn how to take charge of what's around them a little bit better than they have in the past, it can impact their energy balance behaviors, it can influence a wide variety of mental and physical outcomes.

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So this, of course, the theoretical background is social learning. Bandura is, you know, the father of it all, he's actually still in his 90s and writing about some of these things.

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That lifestyle self management- managing our own behavior is actually good medicine. It's good health care.

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Because the person, the environment and the way we think about ourselves

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acting in the environment really has a lot to do with whether we develop healthier or unhealthier behaviors. And in all of these programs the primary focus

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is on building our own capacity to self-regulate in changing environments, changing families, changing cultures, sometimes toxic environments. And our job is to help

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the individual or the group or the family or the parent and the child try to self regulate in these environments. So the emphasis is on social learning. There's always a context, it's not the individual in isolation.

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How they think and behave, the norms, the social support that they receive for living a healthier lifestyle and the social ecology- that's getting into stuff I'm not going to talk about in this

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presentation, but that's sort of how the world makes it harder or easier to take charge of what's around you. So I recommend this 2004 article by Bandura "Health Promotion by Social Cognitive Means."

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It's kind of utopian but it's a good read and I recommend it.

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So one thing I'm often asked when I do trainings and presentations is if lifestyle intervention is good medicine, what's the minimally effective dose? And you know the subtext of that is, what can I pay for, what will people do,

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what will have an insurance plan pay for? And one of the things I try to say is

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that in any good evidence-based intervention, like an obesity management program or a diabetes prevention program,

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in roughly the first half of those sessions, so let's just take a 16 session core curriculum as an example, in those first 8 sessions

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you are really teaching the thing I just talked about- capacity for self-management. Capacity for self-management of your diet,

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of your nutrition, of your activity, of your weight and your energy balance and the environment around you. And in those sessions we always begin with goals-

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weight goals, activity goals, calories and fat goals and, you know, depending on the empirical science they can be higher, they can be lower.

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We ask people to become more self aware through self monitoring. The means of self monitoring change, but we're always trying to create that awareness. And then we teach core behavioral skills for self control. We teach the psychology of self control.

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Then in the second half of the program we start to talk about barriers. We start to talk about the thousand things that are likely to get in the way.

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And the kinds of psychological and behavioral skills that are likely to be required if you're going to be at this for a lifetime.

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And a lot of that involves trial and error problem solving. Problem solving is very important

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to obesity self management. We teach it in our programs- we may not do enough with it is my own thought and there's more and more research looking into how to better problem solving interventions. And then how do you apply those to personal barriers for healthy eating and activity.

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So the minimum effective dose somewhere in the realm of 10 to 12 to 16 sessions and what's going to get paid for is an emerging question.

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I'm not going to go into every little component of the multicomponent lifestyle intervention here, but it's important for you to remember that even, you know, the National Diabetes Prevention Program, that is, you know, receiving widespread

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public health support happily right now began with a multicomponent behavioral obesity lifestyle intervention with the idea that if you want to decrease weight

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and adiposity, so that you can decrease someone's risk for diabetes, that's what you see in the center of the slide,

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you have to start at the top with commitment to a program-setting goals and self monitoring. And as you allow your eyes to go clockwise around the circle, you can see that the first half of the session, so basically from midnight to six, you're looking at

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the basic behavioral skills that I talked about. And then the remainder of that as you continue to go clockwise is problem solving, managing thoughts, preventing relapse, enhancing motivation, managing stress,

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getting social support. Sometimes I get the question

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"in my population in the group I work with, it's all about their stress. Maybe I should start with stress first?" If the goal is weight control

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you want to start with the basic behaviors. First let people run into their barriers like stress and then talk about the stress. We tend to view these multicomponent programs as something that should be done in a sequence and in order.

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So a lot of you I think probably know about the diabetes prevention program. I'm going to just-

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and I'm seeing some questions come up and I think I will- shall I answer some of these now, Lisa, or should I wait til the end?

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I think we'll probably wait till the end.

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Okay, yes. I'm just- I just want to acknowledge that

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some of the folks out there are asking questions. So hold that question and I will try to answer it at the end.

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In the DPP which is an exemplar, as I said, of an evidence-based intervention,

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what made it novel when it was designed in the late 90s, was it started with a very specific set of goals, two goals as a matter of fact. It was we already knew that weight loss and physical activity were important for

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reducing glucose impairment, but we came out and we said 7% weight loss, 150 minutes of activity, mostly walking per week- set your eye on that prize.

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It's when we started talking about case managers as being coaches, lifestyle coaches, to facilitate that self management and problem solving skill.

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The highly structured core curriculum sequence was introduced, and again a gold standard is 16 sessions over the first six months with some form of less frequent but regular contact falling core program delivery.

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The maintenance intervention, which is probably not sustainable or reimbursable,

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was a required in-person contact every two months, at least with interim phone and mail contact.

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The reason I say it's not sustainable or reimbursable is that the original DPP trial delivered approximately 50 sessions, and you can see the standard deviation there 21.8 over a little under three years. That is a lot of touch, a lot of contact and

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presently is not likely something to be reimbursed. There were supplemental group classes, there were motivational campaigns and boosters because the other thing

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we have to grapple with when we're doing long term case management is once you've given someone a fundamental program, you don't just repeat it over and over again. Attendance decreases, weight response is not the same. So the very long term treatments are a question for research.

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So some of the evidence- again I keep kind of emphasizing this idea that if you're, let's say you're doing an NDP P right now or another type of evidence-based obesity intervention, it comes from really a very robust history since the 1970s.

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I list there Wadden Thomas A. You could Google that anywhere-multiple reviews and PubMed

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about the history of behavioral weight management. There's a very robust, long history of these evidence-based interventions and basically they show that,

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give me your most motivated, you know, most engaged patient or participant- that individual can lose 10% at six months. So, for example, 10 kilograms in a 200 pound individual.

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If you continue to have a longer duration contact, say monthly for a year, you will have better weight loss but regain will always be the norm.

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And maintenance contacts and moderate to high levels of physical activity will slow that rate of

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regain so you often see people describing the check. And what we're trying to do in these programs is simply suppress

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the rate of regain. But regain is evident and about 25% of participants will actually stay fairly weight stable but on average regain is the norm.

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So a lot of multi-site

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randomized control trials show that, you know, it's not really 10% because we have less engaged patients who are not attending and so on, that you might get somewhere in that 4-8% average weight loss or a five kilogram weight loss

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somewhere between one and three years. So I think it's still an optimistic picture and that people can lose weight. They do regain

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but it's not the case that everybody goes way back up over baseline, which is I think sometimes a counterpoint that's delivered

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in research. But what about non responders?

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We all know that we have individuals who engage and do well, but we also have individuals who don't. And I think that this is the future of some of the science in these evidence-based programs that if somebody is not responding

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more of the same is not likely better. So let's say by the first two months of a behavioral lifestyle intervention somebody lost nothing or in fact gained more weight.

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It's a pretty good likelihood that the intervention is not working for them. Now, that doesn't mean you boot them out of your programs, but there are some late bloomers. But it's not so likely, on average, that they're going to respond. So, for example,

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Unick et. al, did a study in 2014- it was actually on look ahead data that showed that those individuals who achieved greater than or equal to 2% of weight loss, two months

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into a program really predicted the likelihood of a 10% weight loss at one year.

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15% of those individuals who didn't reach the 2% actually did go on. So it's not that there aren't late bloomers at all, but they're definitely the rare group.

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So what do we do? What do we do for the non-responder? I just want to mention, I'm not going to talk about this a lot.

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It's not the point of the presentation, but there is something that NIH is supporting called the science of behavior change

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and the idea is if what we need to do to help non-responders

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and help them build capacity is that we have to focus on what is common in the interventions- the interventions that I'm speaking about today.

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But what needs to be individualized so goes back to this personalized medicine idea.

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And if you're interested in it, I urge you to kind of look up some of the research that comes from the NIH science of behavior change. A lot of it involves target engagement mechanisms,

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neurobehavioral functions where you're sort of giving somebody a treatment, you're engaging them in some tasks and in some cases actually brain imaging.

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And we assume that if we see some change over the course of treatment, we don't know exactly what the mechanism is but something is being engaged and it's important.

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The kind of work we do in terms of delivering evidence-based intervention, the last point here under the examples is this idea of stepped care. So if an individual is not doing well in a basic DPP,

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you know, do they need augmentation with motivational interviewing? Do they need to have an adaptive intervention approach that involves food provision? These are the kinds of things that scientists are looking at.

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I'm just showing you there is a behavioral task called delayed discounting, which sets up trials, whereby you,

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you know, you press buttons to say whether you want rewards more now versus later. And

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the rewards change in value and they do trials of these kinds of tasks and if you deliver an intervention and somebody changes their capacity to be able to delay reward, then you know we've engaged something in that individual.

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So I'm going to go now to the evidence. I'm going to quickly just do a few slides on the DPP. I think most of you know that it was a large trial. It's already the late 1990s that this trial began.

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Many sites across the country. And the goal was to prevent or delay the development of type 2 diabetes in persons with impaired glucose tolerance.

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The reason is that there is a very long period of glucose intolerance that precedes the development of diabetes. We have screening tests available and we know that interventions can address modifiable risk factors.

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So what are those factors? Those individual characteristics that we are engaging with when we are using our evidence-based interventions.

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It's the obesity, the overweight and the obesity, its body fat distribution, its physical inactivity and it's rising fasting

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glucose levels and 2 hour glucose levels. These are the things that if we can deliver interventions that will affect those components, the likelihood of delaying or preventing type 2 all together is much higher.

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So the design- it was a three group randomized control trial (lifestyle, metformin, placebo), standardized protocol across clinics, expert staff training and data quality control.

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Who was in this trial? It was individuals over the age of 25 and they had to have a 2 hour glucose tolerance test. Of course we're more familiar with using Hgb A1c- most of the people we get do not get a glucose tolerance test.

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BMI was greater than 24 and in Asian Americans 22. And the goal is to recruit at least 50% of the sample from high risk racial ethnic groups.

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This is the screening funnel. You can see that thousands of individuals were screened to get down to the 3,000 individuals in a 3 arm study. About 1,000 individuals in each of the metformin, placebo and lifestyle arms. Of course, in clinical practice

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we don't always have the beauty of not treating the individuals who are at step one or step two.

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So one of the things we always say when we present the evidence base of the DPP is it was a highly defined group. These are the folks on the brink of diabetes and of course you all in practice are seeing individuals just before, just after and advanced.

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But the evidence that I'm pointing to is for this specific group of individuals.

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Importantly, this has been stated many times, prior to this trial there were some studies done in China and in Finland, white European, there was really very much of an emphasis on bringing in the disproportionately affected groups and we were pretty successful in doing that.

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The circle that you see

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to the left is actually the age groups. We worked very hard to get that 20% of individuals over the age of 60 because that is when you are really age-wise at highest risk for diabetes type 2 onset.

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And then on the right wheel you see that we were able to get about 45% from the high-risk ethnic groups, the largest of those slices being black Americans.

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Random assignment of those eligible participants- 1,000 in a group. And this is the slide that many of you have seen. This is 2002 so that's 17 years ago

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already that this data came out. So what you see here is the cumulative incidence of diabetes on the Y axis, you see the years of randomization on the X axis.

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The blue line is the lifestyle intervention, the yellow line is the metformin intervention and the green line is the placebo intervention. And essentially what this slide is showing you was that lifestyle intervention, that 2.8 years, 50 plus sessions that I described to you earlier,

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was the most effective and significantly more effective than either metformin or placebo in reducing the onset of diabetes over that 2.8 year period.

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Metformin, of course, was also effective, just not quite as effective as the lifestyle but also significantly more effective than placebo. And the rates that you see cited is that it was a 31% risk reduction by metformin, which by the way is completely respectable.

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And I'm here to talk about lifestyle but that was a perfectly respectable risk reduction compared to placebo. I think what was very exciting

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is the 58%

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reduction with a lifestyle intervention.

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The weight changes, or changes you've seen before, you get about a little less than seven kilogram weight difference at 6 months, which is maintained pretty nicely in the first year.

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And the

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long term maintenance up to the 2.8 years-the regain, the checkmark that I told you about is evident, although you can see it suppressed for a good long time.

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You will also note in looking at this mean weight change that metformin gives you a nice little couple kilogram weight loss- a decent bang for the buck.

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And what some people point out is "wow that placebo group hardly changed at all". That may in part be to the fact that this is a group of highly monitored individuals who are essentially having health checks every quarter.

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The leisure physical activity changed. Activity is probably, in some ways, the more poorly understood element of the DPP. It wasn't one group got a weight

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reduction and one group got a activity. It was a multi-component treatment. So we can't really pull things apart. But indeed, we know that during the course of that intervention, the lifestyle

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did in fact increase the number of hours per week of leisure physical activity, whereas metformin and placebo essentially overlapped one another.

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And this is the slide that I always enjoy. I've been presenting this for dozens of years, but it still gives me a thrill every time.

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Which is that, and especially if you tend to be interested in mind body kinds of concepts and interventions, is that

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year by year, the lifestyle intervention and the metformin intervention were able to reduce fasting plasma glucose. One being

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a talk therapy essentially, you know, a coaching therapy, the other being a cardio metabolic drug. And you can see that the fasting plasma glucose outcomes were nearly identical over that period. So it's

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always interesting to me that there's more than one way to skin a cat, so to speak.

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And of course, what was exciting was that the lifestyle intervention, talk therapy, a coaching therapy could be that potent.

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So back to weight loss,

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I think it's pretty well understood in the diabetes world

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that

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the weight loss is the dominant determinant of reduced diabetes risk, particularly in that first six months to one year.

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Every kilogram of weight loss- this is from a pretty often cited, pretty classic paper by Hamman et al, 2006, the reference is below,

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that for every kilogram of weight loss, you achieve a 16% reduction in diabetes risk. So kilogram for kilogram, even though I'm saying if you don't get some weight loss early on,

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you're not likely to get it later on with more sessions, but kilogram for kilogram you do get reduced glucose and reduced diabetes risk.

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And it does appear that it was the lower percent of calories from fat that predicted the weight loss.

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Increased physical activity predicts weight loss maintenance over time. I'm not telling you anything that you haven't heard before.

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And it was independently associated with decreased diabetes risk among those who weren't at the 7% weight loss goal. But in terms of the biggest bang it is the reduction in BMI, the reduction in body fat that appears to suppress the glucose

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and make people more insulin sensitive. And then as time goes on, of course, the activity becomes critical to maintaining that lower body weight.

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What was the decrease in calories? We aimed for a 500 decrease a day in order for the individual to lose a pound or two a week. Those of you, you're mostly dietitians, this was all based on Harris Benedict

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and the typical equations that we compute for weight loss. But participants saw none of this- they saw four categories based on body weight

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and they got a weight goal, they got a calorie goal and they got a fat gram goal.

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And you were in one of four categories and of course the people who were over 200 pounds, get more calories and more fat grams, the individuals who were lower get less. It's not fair but that's the laws of physics.

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And we found that individuals were successful in decreasing by about 450 calories a day.

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Sometimes when I'm in sessions I quote this paper and I say to participants, "if I were to tell you where would those 450 calories come from if you are going to shave them out of your daily calorie intake", everyone

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to a person is able to say, "well, it's less alcohol, it's less dessert, it's less Starbucks." They're able to wrap their minds around what it means to reduce a certain number of calories per day.

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We also found that the DPP group did do this by reducing their percent of calories from fat. So they decreased by about 6.6% of their total calories. So on average,

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they moved from 34% of their total calories from fat to under that 30% marker to 27.5. So this was not a no fat, non-fat, fat phobic kind of program. It was a modest, or what's called a prudent fat reduction, and the group was successful in doing that.

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We continue to learn from the DPP. What happened in the DPP is something you don't often want to do in a clinical trial, which is that you

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finish the trial and then you treat your control group and your comparison group. But because the lifestyle was so successful at a fixed point in time, the entire

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DPP cohort, all three randomized treatment arms, was offered a 16 session group DPP very much like what you see in the end DPP today. And from that moment on, there is a longitudinal study called the DPP Outcomes Study- we continue to follow this cohort. It's actually year 26 and

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we continued from about 2002 to about 2015 to continue to offer some lifestyle intervention to all. I will tell you that only about 20% of people at any given time attended those meetings.

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And this is what weight change looks like over a 10 year period. This is from Lancet, 2009. This is DPP cohort and you can see that roughly around year five from baseline, year five into year six

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the weight change in the lifestyle arm in blue begins to converge with that of the metformin group that stayed remarkably stable at that couple kilo weight loss over time.

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And that the placebo group also stayed fairly stable over a decade.

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I'm not going to pause here, although this is sometimes a good discussion slide for, you know, what would you give people? Should we just give people the pill? Do we bother with the lifestyle? Back to my original question, why bother with lifestyle?

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Well, here's one of the reasons we bother with lifestyle- even though there was slow and steady weight great gain, not all the way back up to baseline, but to the similar weight loss

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level or status of the metformin group, the lifestyle group over the decade of DPP and the outcome study continue to have a

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lower incidence of diabetes. So you can see here that in blue the lifestyle group's continued cumulative incidence is suppressed, even though they began to regain weight. They have a lot of years at a lower BMI and thus they kick the can of diabetes down the road.

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I will tell you that these rates, obviously come together

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as we move out to 15 years because we've basically seen the treatment effect.

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Okay, so

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I want to mention that the longer term studies of the DPP

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show that all three groups had decreased blood pressure, cholesterol and triglycerides, including the placebo arm, but the lifestyle participants continue to have significantly lower blood pressure and lipid levels than the other participants with use of

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less medicine. So again, medicines can be costly. Some are cheap, some are not. But lifestyle participants are able to achieve some of the same ends with less use of medicines.

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I also want to point out that there are very much age differences in responsivity. In a pure intent to treat model everybody in that original slide I showed you

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indicated that the lifestyle group did better than metformin. Both of them did better than placebo. In terms of weight, however, the youngest portion of the lifestyle cohort actually regained weight more quickly. I think there is an understanding that

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we may not be doing as good a job in our evidence-based interventions working with younger individuals. And this certainly shows you that all three groups

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regain at a much higher rate and more quickly- the lifestyle, the metformin and the placebo. Middle-age group looks a little bit more like that first slide that I showed you

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and this is very interesting to me. Individuals who are over 60, so these are individuals who are at the exact same glucose levels at the start as the middle-aged group and the younger group

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were able to sustain their weight losses much, much better. Again, this is a great point for discussion- why did these older folks maintain weight loss much better? They were also

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much more likely to have a cumulative reduction in diabetes. So one of the things I'm going to talk about at the end of this presentation, and which I need to quickly get to is

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working with older adults, working with the individual over 60 we can potentially get a very big health bang for these interventions. So we continue to learn from the DPP

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and stay posted.

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So efforts to translate the DPP lifestyle program are expanding very rapidly.

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I think you all know about this. It's been in the Y, there's an NDPP I'm sure some of you are running NDPPs in your communities, Indian Health Service has a DPP, state health departments

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are doing the DPP, VAMC has MOVE and a DPP, there are faith-based and primary care based and employer-based and military-based interventions. So the good news is

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this data that I've just described to you published 17 years ago has made its way into medical treatment and is being paid for- reimbursement is now available as of April 2018.

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CMS Medicare is still the classroom-based intervention that

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is being reimbursed, although they're beginning to look at web-based coaching, that's actively going on there. I fully suspect that in the next year or two there will be new CMS

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decisions about using these evidence-based programs and combinations of classroom and online. Other payers are following suit and Medicaid is developing their own models for use of these evidence-based programs, the year long program.

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I just want to cover a couple of them.

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This is encouraging to me-the initial results of the NDPP by Ely et al. This was in Diabetes Care in October of 2017. They wanted to basically look at the first four years of implementation of the NDPP.

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They studied 14,747 men and women 18 and older who enrolled in a year long program and received

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16 in the first six months, 6 in the last six months. And here's what they found. And this was

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country-wide, many different settings. A lot of them were the wise and the curriculum was probably the mostly the 2012 curriculum that the CDC has on their website.

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Median attendance was about 14 sessions. So, people didn't necessarily stay the whole year. In fact, median days in the program is 19 weeks- that goes to show you that

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much happens in the first six months and attendance tapers. The average percent weight loss was 4.2% (median 3.1%). That's actually for a sample size that big, really, really encouraging.

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About 35% achieved the 5% weight loss goal and 41.8% the 150 minute goal.

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I'm going to tell you a little bit about some of the research that I'm doing in about three minutes because I see we have eight comments here so I want to leave time for questions.

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I recently completed something called the Pitt Retiree Study. I work within one of the recognized CDC curriculum called group lifestyle balance.

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And what I did in this study was I worked with 322 adults 65 to 80 and I think that

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I mentioned to you that you can get a big bang in this age group for all kinds of reasons that we can probably understand.

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I saw them for 12 sessions in person

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and at four months from baseline these individuals randomized into one of two groups. Group phone calls, so eight half hour phone calls for once a month for the next eight months and a newsletter control.

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And then the primary outcome was weight change at 12 months. So essentially 12 in-person sessions plus eight 30 minute phone calls.

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I did community based screening- individuals to come into the program has to have at least a 27 BMI plus additional risk and I went to the places where I was likely to find 65 to 80 year olds. You'll see them there.

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And here's what I found at month 12- that paper is being prepared now- was that the phone group,

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that group that had 12 in-person sessions but the remaining sessions by phone, was able to lose 7.5% with a standard deviation of 5.5 and the newsletter group lost 5.8%. These are the one year data. And that between group difference is significant.

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So phone calls was an effective means of sustaining and promoting weight loss over the course of the full year and I did find slightly more favorable changes in activity, physical function, lipids, waist and blood pressure.

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And both groups showed modest physical and mental health related quality of life benefits.

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So I think that it was a successful trial. So go back to our original question-is lifestyle self management good medicine? Cartoon here says the mind body problem, "get up", "no".

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This of course is what we still must contend with. And I want to end by saying that the Pitt Retirees who began the program with mild depressive symptoms, that's the column

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mild depressive symptoms present, were about 24% of them had that actually were able to lose the same amount of weight compared to those who had no depressive symptoms and their mood improved. So I think my point is that

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we can deal with both mind and body in these programs and that the overall health benefit is significant.

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And with that, the implications for practice is that mind, body, health, in fact, is just health. I think it's all the whole person.

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That manualized (scalable) interventions are the foundation and are available, but that increasingly, we may need adaptive or stepped care intervention for non-responders

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and that teams of multi-disciplinary professionals (mind and body experts) all play a critical role in the delivery of these programs.

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So, thank you. Thank you for listening. I realized I kind of speed raced through the end of that, but I'd love to hear your questions.

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Okay. Thank you, Dr Venditti we'll get to a couple questions in just a minute or two. Just a couple housekeeping tips.

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I do want to remind everyone who has completed the webinar that you will be emailed a link to the evaluation within a week, the email will be sent to the email address you use to register for the webinar.

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The evaluation will expire in three weeks so try to complete it as soon as possible to ensure you receive your CE

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certificate quickly.

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Once the evaluation is completed, we will send you a CE certificate separately within the next two business days.

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Remember also if you phoned into the webinar today please email us at cope@villanova.edu and provide your name so that we can provide you with your CE certificate.

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We do have an upcoming continuing education webinar coming up, it's actually going to be on a Friday this time, Friday, May 17, we are pleased to be

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welcoming Dr. Monica Aggarwal from the Integrative Cardiology and Prevention Center at the University of Florida to present on the role of nutrition in chronic disease, which kind of dovetails very nicely with what we've been talking about today in terms of the behavioral aspects.

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Okay, Dr. Venditti thank you. This was super helpful in outlining to us some

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long-term effects, actually pretty long-term effects of lifestyle change on diabetes prevention and chronic disease prevention. We do have a few questions. I know you're aware of a few of them. I wanted to just

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kind of see if we could add answer one that we had- you referred to campaigns and boosters early on in your presentation, as far as I don't know if that was a retention mechanism but the listeners want to know what campaigns are boosters, what does that mean,

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so could we operationalize that in-

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For sure. So campaigns or boosters were essentially something that you do

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when you are working with individuals over a long period of time. So I think what I outlined for you today is that the core intervention, where you work to get your sort of induction of behavior change and the teaching of the basic self management skills,

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that happens in six months. Then you bring people to a year, which is the point at which you often see your best weight loss results.

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And then the question becomes, what do we do for an encore? Because, you know, you're not just going to cycle people back through

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the same fundamental teaching principles. First of all, people don't come because you've already told them that. And in fact, the most common thing you'll hear at about 18 months into a program is, I know what to do, I just need to do it.

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And then what we typically do if we are still actively engaged with that group of participants, if we're following them in a clinic or in a research protocol, is set up four to six week campaigns.

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We focus on we would like for you to retool your behavioral skills and lose five pounds over the next 10 weeks or four weeks or five weeks.

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And set some goals, reengage people in the behaviors, the self monitoring and they get a small incentive. So it's not unlike in the university there are weight races that happened in January- that's a campaign. Or

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"steps move it" has a steps campaign where you focus over a brief, actionable period of time. You have smart goals, you see what you achieve and you get a small reward for achieving it. That's a campaign.

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Okay, thank you.

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I think participants, definitely, whether it's an individual program or whether it's a group program they appreciate boosters. They appreciate ways to stay motivated and I think the DPP has shown that this has certainly been successful.

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And some of it is really about reengaging the participant in the behaviors that they do- putting it back on the front burner and so on. Somebody, a question did pop up

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on my screen. I just wanted to say, real quickly. Somebody wanted to know if the Pitt Retiree study I did was with individuals with diabetes. No one had diabetes in that study, it was just individuals who are overweight and had additional cardio- metabolic risk factors.

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Okay, another question, how can the DPP programming all the data that we have and all the programming that we have as a result of it, incorporate some recent trends in intuitive eating

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as far as a holistic approach to eating and health management? Do you see that happening, or do you see ways that

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they could be melded together?

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I think

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that fits in a little bit to some of what I was saying about science of behavior change. So, for example,

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I think the way evidence-based interventions work is, the public health approach, is you identify high-risk people,

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you give pretty much the letter of the law behavior change package,

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and you see what kind of outcome you get. I think in science behavior change, they're saying, look, at eight weeks if somebody's not moving with this program then we really need to think about who are those individuals?

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Maybe those are individuals who need an intuitive eating program. Maybe those are individuals who need an acceptance-based type of therapy.

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One size probably does not fit all. Public health, of course, the goal is to give the best known programming to all who appear that they might benefit, but then those who are not responders, we need to think about other ways of incorporating other strategies and skills.

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Okay. And finally, we have time for one more question. And a question we get perennially and I think it's great to just kind of get your feedback on it-

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when you are delivering a group intervention, and it's a long-term group intervention, how do you handle group members who are very engaged, but perhaps overbearing in the group session? How do you level the playing field?

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Right, how to manage challenging group participants. I

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give whole presentations on this so let me see if I can give you my thumbnail sketch.

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One thing I want to tell you is that this is something that Dr. Tom Waton, who's a psychologist in Philadelphia and premier obesity researcher, has written a lot about. And in fact, I think he wrote a whole manual for Look Ahead

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of managing difficult group participants and a lot of it is about remaining in the driver's seat

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and learning how to firmly but gently

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ask an individual that you'll speak with them more following the group that you want to hear from others. You want to share, you know, the talking stick, so to speak.

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So it's a really good question. And it's something that I think group interventionists just get better with over time- how to stay in the driver's seat and, you know, draw out the people who aren't saying as much and kind of quiet.

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You know, there are different ways to

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try to engage those who are not as talkative, and try to subdue, politely subdue, and a lot of times I always say, I use the shuffle the papers like,

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you know, Jim that was a great- you know, I understand what you have to say but I want to hear from others, or we've got to move on or we won't cover the material in the session.

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Okay, great. Thank you. I think the visual just of the talking stick and the driver's seat

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are both super helpful. Thank you, Dr. Venditti, I can't

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thank you enough for this very informative and practical presentation.

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With that, I believe we're out of time for today. I just like to encourage

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participants to please go to the COPE website, sign up for upcoming webinars. Please look out for the evaluation email if you need a CE certificate. We are introducing closed captioning

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for recordings of our webinars so you will notice in the next week that Dr. Venditti's

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presentation will be available as an audio transcript, as well as a closed captioned version on our website. So thank you, Dr Venditti again

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for your wonderful presentation. We are pleased to be providing these free webinars- we welcome your input so feel free to give us your feedback on your evaluation. Thank you very much and have a great day everyone.

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Bye bye.

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Bye bye.