1. Jennifer Pells, Ph.D. Clinical Director, Structure House Durham, NC

2.  Brief review of lifestyle-based (behavioral) weight maintenance  Describe intervention evaluated in this study (Structure House program)  Present preliminary results related to maintenance visits  Discussion and future directions  Consider new ways of thinking about weight loss maintenance and ongoing treatment

3.  Sustaining necessary behavioral changes (eating and physical activity), including self- monitoring  Metabolic adaptations to weight reduction that promote regain  Managing ‘obesogenic’ environment

4.  Most adults completing a standard behavioral weight management program will lose 5-10% of initial body weight  Most will regain ~1/3 of their lost weight within the first year after treatment and return to baseline weight within 3-5 years  Those who are successful at maintaining initial weight loss utilize a variety of strategies to limit dietary intake and increase physical activity  Those who maintain for 2-5 years have greatly increased likelihood of ongoing, long-term maintenance

6. Face-to-face and Internet- based maintenance programs reduced the risk of regaining 2.3 kg or more over and18-month maintenance period following successful weight loss. The face-to-face program was the only condition to reduce the amount of weight regained. Attendance at sessions and daily self-weighing predicted better outcomes.

7.  In general, body of research on maintenance and refinement of maintenance-focused interventions is insufficient  What are the most efficacious maintenance program protocols?  What degree of personalization might be needed to optimize longer-term outcomes (e.g., timing, duration, content of continuing care)?  Do effective maintenance programs differ based on initial treatment?

8.  Conduct preliminary analysis of self-initiated maintenance treatment (“return visits”) following initial residentially-based weight loss treatment  Describe pattern of return visits and associations between return visits and weight loss  Compare weight loss for individuals who completed return visits vs. no return visits

9. Residentially-based Multidisciplinary Behavioral/Cognitive- Behavioral Chronic disease/Lifelong Empirically-supported nutritional, fitness, & behavioral components Self-referred & self-pay 28-day average initial LOS

10.  Weight/BMI Males: 5.9% body wt reduction (average 19 lbs) Females: 5.1% body wt reduction (average 13 lbs)  Medical Triglycerides: 153 to 123 Total Cholesterol: 184 to 152(LDL: 105 to 83) Blood Pressure: 117/75 to 111/72  Psychosocial Improved Mood (Beck Depression Inventory; 0-63) : 17 to 5 Quality of Life (0-100) : 54 to 70

11.  981 cases analyzed from 2008-2013  70% female, 30% male; 95% Caucasian  Average age = 50 yrs  Average BMI = 42 (27-80)  274 had >1 return visit; 707 had 0 return visits  Outcomes evaluated at time of return visit or standardized 12- and 24- month follow-up

12.  Re-attend classes and groups  Participate in return-oriented clinical activities  Individualize treatment based on specific needs

13. Frequency of Return Visits (2008-2013; N = 274) Ave. number of days between visits Initial visit departure – 1st Return visit325 1st Return departure – 2nd Return visit265 2nd Return departure – 3rd Return visit284 3rd Return departure – 4th Return visit279 Duration of Return Visits (2008-2013; N = 274) Ave. duration of Return visits (range) Initial treatment visit28 days (6-167) 1st Return visit20 days (3-339) 2nd Return visit16 days (4-75) 3rd Return visit17 days (2-122) 4th Return visit15 days (4-32)

14. Return time frame (months) # of participants% weight loss from initial weight 0-3539.2% 3-65913.0% 6-94213.2% 9-124012.6% 12-152010.9% 15-18911.9% 18-2197.6% 21-24147.7% >24277.0%  No correlation between # of return visits and last-collected weight (r =.11)  Greater weight reduction when first return visit occurred within 12 months of initial treatment

19.  Additional treatment, in the form of “booster” sessions (return visits), can enhance weight loss following a residential obesity program  The majority of initial participants, however, did not return to treatment; thus, alternative effective maintenance interventions are likely needed  Longer-term outcomes in this study are consistent with previous studies: maintenance treatment can delay regain but we do not yet have adequate interventions to sustain weight loss/prevent regain  However, intensive initial treatment and critically- timed additional treatment offers promise

20.  Shift from linear weight loss  maintenance model to more dynamic model of sustaining weight loss, responding to small gains, combining intervention tools  Continuous support may not be necessary (or particularly effective); Critically-timed additional treatment, accessed as needed by individuals, may be more important  Positive note: maintaining weight loss becomes easier over time (typically after 2-5 years)  Majority of structured treatment may need to occur in this timeframe

21. jpells@structurehouse.com www.structurehouse.com