Keep It Off

Nearly half a million new cancer cases per year worldwide can be attributed to a high body mass index (BMI) according to the World Health Organization's (WHO) International Agency for Research on Cancer. Cancer due to overweight and obesity is more common in developed countries than in less developed countries. North America remains the most affected, with an estimated 111,000 obesity-related cancers in 2012, accounting for 23% of the total worldwide cancer burden linked to a high BMI. Cancers of the endometrium, colon, and breast account for almost three quarters (73%) of all cancers linked to a high BMI in women, while kidney and colon cancers account for two thirds (66%) of all cancers linked to a high BMI in men. Reducing overweight and obesity at the population level could have significant health benefits, including reducing the burden of cancer. The WHO's International Agency for Research on Cancer estimates that one quarter of all cancers attributed to overweight and obesity globally each year (118,000 cases) could have been prevented if the average BMI from 30 years ago had been maintained.

Keep It Off is a 2-year, telephone-based weight loss maintenance coaching intervention that targets adults who have intentionally lost at least 10% of their body weight during the past year. The program aims to help these adults maintain their weight loss over the 2-year period and beyond. The two-phase program includes a series of coaching calls; use of a 10-chapter course book on weight loss maintenance; and use of a log book for recording daily eating, physical activity, and weight. Throughout the intervention, participants report their weight weekly during scheduled coaching calls or by email.

The first phase of the program consists of 10 biweekly telephone coaching sessions to help participants appreciate the benefits of their achieved weight loss and develop key behaviors and skills necessary for weight loss maintenance. Each of the 20-minute calls in this phase focuses on a chapter from the Keep It Off Course Book. These chapters address weight loss history, physical activity, menu planning, strategies for successful weight management, problem solving, overcoming barriers to physical activity and healthy eating, relapse prevention, body image, and weight goals. After the first call, subsequent calls also include a review of the participant's weekly weight reports.  Participants are not given specific goals related to calorie and fat intake but are encouraged to self-monitor their dietary intake, calories, fat grams, and body weight to establish their optimal calorie range for weight maintenance. Participants are also encouraged to engage in 60 to 90 minutes of moderate to vigorous physical activity on most days. 

The program's second phase consists of eight monthly and then six bimonthly telephone coaching sessions, typically 10 to 15 minutes in length. During this phase, calls continue to include a review of weekly weight reports. In addition, in month 8, participants begin receiving bimonthly, tailored feedback letters with weight graphs. Three primary tailored letters are a "weight maintenance" letter for participants who are reporting their weight and maintaining their weight loss, a "weight gain" letter for participants who are reporting their weight but have gained weight, and a "no weight" letter for participants who are not reporting their weight. All letters provide positive feedback for continued participation in the intervention and efforts to maintain weight loss, regardless of current success. Accompanying each letter is a small incentive, such as a Keep It Off pen, sticky notes, or a refrigerator magnet, to encourage continued participation. 

In addition to receiving the regularly scheduled call for weight maintenance support, participants experiencing small weight gains of about 2 pounds over 4 weeks receive additional outreach coaching calls to discuss weight gain reversal strategies. The role of the coach during the outreach call is to engage the participant in problem solving to determine which Keep It Off Course Book chapter might be most helpful in reversing the weight gain. The coach studies recent participant reports of diet and activity to determine which components might be contributing to the weight gain, and an action plan is developed with one or two follow-up calls to help the participant stabilize his or her weight.

Two group sessions featuring outside guest speakers are scheduled for all Keep It Off participants and coaches during the course of the 2-year intervention, as are at least two motivational campaigns, such as a promotional weight maintenance for the holidays activity or a group walking event. 

Telephone coaches have a master's and/or bachelor's degree and expertise in nutrition, physical activity, weight loss, and behavior change methodology.  Coaches receive specialized training in implementing the program. Ongoing weekly supervision is recommended to review challenging cases and discuss potential solutions to problems that are encountered.

-- 8 hours for training Keep It Off telephone coaches
-- 96 hours (1 hour per week across 24 months) of ongoing supervision of interventionists, which is recommended to review challenging cases and discuss potential solutions to problems that are encountered
-- 200 minutes per participant for 10 biweekly telephone coaching calls, each about 20 minutes long
-- 140-210 minutes per participant for eight monthly and six bimonthly telephone coaching calls,  each about 10-15 minutes long
-- 30-90 minutes per participant for outreach coaching calls triggered by weight gain, each about 10-15 minutes long
-- 90 minutes per participant for nine bimonthly mailings averaging 10 minutes per mailing
-- 120 minutes over 2 years for two 1-hour group sessions featuring outside guest speakers
-- 60-120 minutes over 2 years for at least two group motivational campaigns

Keep It Off targets adults aged 19 to 70 years who have intentionally lost at least 10% of their body weight during the previous year.

Keep It Off was originally developed to be offered through a managed health care insurance plan. However, the Keep It Off intervention can be delivered by phone by any organization with a focus on health, including departments within health plans/systems and organizations and employer groups that contract with health plans to provide health and wellness coaching.

Materials required for implementation include:
-- Keep It Off Guided Protocol
-- Keep It Off Recruitment Protocol
-- Keep It Off Weight Reporting Protocol and Algorithm
-- Keep It Off Food and Activity Log
-- Keep It Off Course Book
-- Weight graph parameters
-- 36 weeks weight chart
-- Bimonthly Letter Templates

Materials recommended but not required include:
-- Walking Activity for Weight Maintenance
-- Weight Maintenance for the Holidays Activity

For costs associated with this program, please contact: Nancy E. Sherwood. (See products page on the EBCCP website for contact information.)

A 2-year, randomized controlled trial evaluated the effects of the Keep It Off weight loss maintenance intervention among 419 adult members of a managed care organization who had intentionally lost at least 10% of their body weight during the year prior to study entry. Targeted outcomes were weight change, weight maintenance, and daily caloric intake. Study recruitment occurred through several methods, including online and print newsletters at work sites with employees who had the managed care health plan and through the health plan's website advertisements. Eligible participants were those aged 19 to 70 years with a BMI of at least 20.5 kg/m² who were enrolled in the health plan for the past year and could provide documentation of their weight loss. Potential participants could not have a history of anorexia nervosa or bariatric surgery, serious comorbid medical conditions, cancer (except for skin cancer), congestive heart failure, or use of a phone-based weight loss program to achieve their recent weight loss, nor could they be current participants in another weight management study.

Four hundred nineteen participants were randomly assigned in blocks of 20 to either the Keep It Off intervention group or the self-directed comparison group. Participants in the self-directed group received the 10-chapter Keep It Off Course Book, a 1-month Keep It Off log book, and two telephone coaching sessions scheduled 2 weeks apart. During the coaching sessions, participants reviewed the course book and the instructions for self-monitoring their eating, physical activity, and weight in the log book.

Study participants had a mean age of 46.4 years, a mean baseline BMI of 28.4 kg/m², a mean baseline weight of 175.9 lbs, and a mean weight loss of 16.2% of their body weight prior to study entry. Seventy-seven percent of participants reported losing weight for health reasons, 82% were women, 91% were White, 5% were African American, 3% were Asian, and 1% were from other racial groups. Eighty-seven percent of participants were employed at least part time, and 64% had a college degree.

Assessments occurred at baseline and 6, 12, 18, and 24 months after baseline. At baseline and the 12- and 24-month follow-ups, weight and height were measured in person with participants in light clothing without shoes using a Seca 770 Medical Scale and a Seca 214 Portable Height Rod. At 6- and 18-month follow-ups, weight was self-reported by telephone. Weight change was assessed using the in-person measurements carried out at baseline and the 12- and 24-month follow-ups. Weight maintenance, a dichotomous measure ("Yes" or "No") defined as a weight gain of less than 2.5% of the baseline body weight, was based on all weight measurements (in person and self-reported) through follow-up. Self-reported daily calorie intake was measured at baseline and at the 12- and 24-month follow-ups with a web-based version of the National Cancer Institute's Diet History Questionnaire (DHQ).  The DHQ is a 36-page booklet that asks about the intake frequency and portion-size of 195 individual food and drink items, with additional queries about the specific forms in which foods are consumed.

There were no significant baseline differences between groups for any measured or demographic characteristics of study participants.

• Participants in the intervention group regained significantly less weight than participants in the comparison group from baseline to the 12-month follow-up (1.7 lbs vs. 5.3 lbs, p=.005) and baseline to the 24-month follow-up (6.8 lbs vs. 10.5 lbs, p=.028).

• A higher percentage of intervention group participants than comparison group participants maintained their baseline body weight across all follow-up assessments (p=.0002).

• Daily calorie intake was lower among intervention group participants than comparison group participants at the 24-month follow-up (1,429 kcal vs. 1,587 kcal, p=.015).