Weight Loss Maintenance in Rural Populations in the United States: Can Telemedicine Help?

Obesity is a public health crisis in the United States, with more than 40% of the population having obesity.¹ This is particularly troubling for underserved rural populations that often face numerous barriers to accessing health care and preventive services.² Examining how to best reach rural communities and engage them in weight loss and maintenance is of critical importance to improve the health of these populations.

In a randomized clinical trial, Perri and colleagues³ examined 2 potential strategies for weight-loss maintenance in rural populations in the southern United States. The primary outcome was the change in body weight from months 4 to 22. The study involved 3 phases. In phase 1 (months 1-4), all participants received a weight-loss intervention involving 16 weekly in-person group counseling sessions. In phase 2 (months 5-16), participants were randomized to 1 of 3 groups: individual telephone counseling, group telephone counseling, or an educational program with the same content used in telephone counseling. Each group received biweekly contacts for months 5 to 10 and monthly contacts for months 11 to 16. In phase 3 (months 17-22), participants were observed with no additional intervention contacts. Findings revealed that the individual telephone counseling group had significantly better weight loss maintenance than the educational program group, but no difference was found between group telephone counseling and the educational program.

This study provides several critical implications for researchers, clinicians, and health care policymakers. Despite the long-standing reported challenges in weight-loss maintenance, Perri et al³ demonstrated that it is possible to prevent weight regain with individual telephone counseling. More than half of the participants in the individual telephone counseling group maintained a weight loss of at least 5% at month 22, which is considered clinically significant. Almost one-third of participants had a weight loss of at least 10%. That such a low-cost intervention strategy can sustain clinically significant weight loss is promising, given the prevalence of obesity in rural communities and the lack of weight-loss programs and services. Although there has been rapid growth in telemedicine in the past few years, limited research has focused on improving obesity management in rural populations. This study serves as an important first step in understanding how to use telemedicine to best serve individuals in rural communities.

Perri and colleagues³ also reported that the intervention effect was partially mediated by greater adherence to caloric intake goals. During phase 1 of the study, all participants received training in completing food logs and a reference book to check caloric information. They were given the option of completing paper-and-pencil food logs or using smartphone-based self-monitoring apps. In phase 1, food logs were collected by health coaches at weekly in-person sessions. In phase 2, participants were instructed to return the food logs using prepaid envelopes. Findings revealed that participants in the individual telephone counseling group had greater adherence to self-monitoring and caloric goals than those in the other groups, which resulted in better long-term weight-loss maintenance. Self-monitoring of diet and physical activity and adherence to caloric intake goals have been advocated as cornerstones of weight-loss behavioral interventions.⁴ Tracking caloric intake can help individuals make informed dietary decisions, which is crucial for obesity management.⁴ The study by Perri et al³ provides further support regarding the importance of this mechanism for weight loss and weight-loss maintenance.

With these important findings in mind, several questions remain unanswered and warrant further investigation. First, it is unclear why there was no significant difference between the group telephone counseling and the educational program groups. The attendance rate for group telephone counseling, which used an audio-only format, was about 50%. It is possible that these group telephone sessions provided limited opportunity for building rapport, thereby discouraging participation. Our study team has been testing video conference-based group counseling for weight loss and other lifestyle behavioral changes.⁵ Such an approach may be more engaging because it allows for eye contact, viewing of facial expressions, and the ability to link participant identity with comments that are offered. Based on preliminary findings, participants demonstrated a 94% attendance rate during video conference-based group counseling sessions.⁶

Second, given the important role of self-monitoring and adherence to caloric goals, how can we best support individuals in these efforts? Mailing paper-and-pencil food logs can be very time-consuming and tedious. A recent study has reported that using smartphone-based self-monitoring apps can promote adherence to self-monitoring and caloric intake goals.⁷ The feedback from these apps is automated, real-time, and shows progress toward a caloric goal and macronutrient distributions. These features encourage individuals to remain vigilant about their dietary behaviors and make adjustments to the eating plan accordingly. Future studies need to examine strategies to promote smartphone-based self-monitoring apps among rural participants to improve obesity management.

Third, most of the study sample was composed of female participants. Yet, there is a substantial knowledge gap in understanding how to best reach and engage male adults in weight-loss efforts. Future studies need to explore how to recruit and help male participants to lose weight and prevent weight regain. Such research would be of benefit for obesity management in both rural and general populations.

Published: June 15, 2020. doi:10.1001/jamanetworkopen.2020.7134

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Hu L et al. JAMA Network Open.

Corresponding Author: Lu Hu, PhD, Department of Population Health, Center for Healthful Behavior Change, Grossman School of Medicine, New York University, 180 Madison Ave, 7th Floor, New York, NY 10016 (lu.hu@nyulangone.org).

Conflict of Interest Disclosures: Dr Hu was supported by the National Institute of Health grants U54MD000538-15, K99MD012811, and P30DK111022. No other disclosures were reported.