We performed a systematic review of the behavioral lifestyle intervention trials conducted in the United States published between 1990 and 2011 that included a maintenance phase of at least six months, to identify intervention features that promote weight loss maintenance in African American women. Seventeen studies met the inclusion criteria. Generally, African American women lost less weight during the intensive weight loss phase and maintained a lower % of their weight loss compared to Caucasian women. The majority of studies failed to describe the specific strategies used in the delivery of the maintenance intervention, adherence to those strategies, and did not incorporate a maintenance phase process evaluation making it difficult to identify intervention characteristics associated with better weight loss maintenance. However, the inclusion of cultural adaptations, particularly in studies with a mixed ethnicity/race sample, resulted in less % weight regain for African American women. Studies with a formal maintenance intervention and weight management as the primary intervention focus reported more positive weight maintenance outcomes for African American women. Nonetheless, our results present both the difficulty in weight loss and maintenance experienced by African American women in behavioral lifestyle interventions.
Overweight (body mass index (BMI) 25.0–29.9 kg/m2) and obesity (BMI ≥ 30 kg/m2) are global public health problems [
The most common approach to obesity treatment includes lifestyle interventions that target both diet and physical activity (PA) and some form of behavioral self-management [
The challenge of maintaining weight loss is well documented [
Minorities, including AA women, are largely underrepresented in the behavioral lifestyle intervention literature, however, two systematic reviews addressing obesity treatment in minority populations were recently published [
The systematic review focused on the behavioral lifestyle intervention literature published between 1990 and 2011. The year 1990 was chosen as a starting point because “Healthy People 2000,” which was the first comprehensive preventive health agenda for the US population, established specific goals for reducing the prevalence of overweight and obesity [
Randomized and nonrandomized studies were included in the review if they met the following criteria: (1) English language papers published in peer-reviewed journals, (2) behavioral lifestyle interventions with a maintenance phase of at least six months (both formal maintenance programs and non-contact periods) in which weight was reported as an outcome, (3) studies conducted in the US (due to potential country-specific differences in weight management practices) [
Figure
Article search results.
For each of the 17 studies, the primary author (L. M. Tussing-Humphreys) extracted the following data, using a standardized form, which are presented in Tables
Behavioral lifestyle interventions reporting weight maintenance outcomes for african american women (1990–2011) (
Author and year of publication | Quality ranking score† | Study design, setting, and length of trial | Participant characteristics†† | Maintenance phase characteristics | Frequency, delivery, and dose (time), of maintenance components | Mean baseline weight (kg) (±SD/SE) | Weight change following intensive intervention phase |
Weight change (kg) from baseline during maintenance phase follow-up (SD/SE) | Adherence to maintenance sessions/components |
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Kumanyika et al. (2002)‡‡ [ |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
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Adherence to maintenance sessions/components: NDR |
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Kumanyika et al. (2005)‡ |
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Design: |
AAW: |
Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
100.8 (±15.9) kg |
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Adherence to maintenance sessions/components: |
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Svetkey et al. (2008)‡‡ [ |
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Design: |
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Formal Theoretical Framework: SCT |
Frequency Delivery, and Dose: |
AAW: 94.8 (±15.2) kg |
AAW: −7.1 kg |
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Adherence to maintenance sessions/components: |
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West et al. (2008) [ |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
AAW: 82.0 (±14.8) kg |
AAW: −4.7 (±5.1) kg |
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Adherence to maintenance sessions/components: |
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Kumanyika et al. (2009)‡ |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
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|
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Adherence to maintenance sessions/components: |
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Fitzgibbon et al. (2010) |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
I: 104.3 (±15.6) kg |
I: −3.0 (±4.9) kg |
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Adherence to maintenance sessions/components: |
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Martin et al. (2008)‡‡ [ |
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Design: |
I: 68 AAW |
Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
I: 101.2 (±20.6) kg |
I: −1.4 kg |
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Adherence to maintenance sessions/components: |
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Djuric et al. (2009) |
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Design: |
I ( |
Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
I: 93.8 (±11.3) kg |
I: −1.0 (±6.5) kg |
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Adherence to maintenance sessions/components: |
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Kumanyika et al. (1991) |
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Design: |
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Formal Theoretical Framework: |
Frequency Delivery, and Dose: |
AAW: 77.2 (±9.9) kg |
AAW: −2.6 (±3.9) kg |
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Adherence to maintenance sessions/components: |
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Kumanyika et al. (1991) |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
AAW: 79.9 (±10.0) kg |
AAW: −1.9 (±3.5) kg |
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Adherence to maintenance sessions/components: |
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Stevens et al. (2001) |
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Design: |
I: 64 AAW |
Formal Theoretical Framework: |
Frequency, Delivery, and Dose: [ |
I: 84.1 (±11.9) kg (all women) |
I: AAW: −2.1 (CI: −3.0 to −1.3) kg |
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Adherence to maintenance sessions/components: |
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Yancey et al. (2006) |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
I: 81.5 kg ( |
I: +0.05 kg |
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Adherence to maintenance sessions/components: |
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West et al. (2007) |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
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Adherence to maintenance sessions/components: |
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Rickel et al. (2011)‡‡ |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
AAW: 99.9 (±2.6) kg |
AAW: −6.8 (±0.80) kg |
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Adherence to maintenance sessions/components: |
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McNabb et al. (1993) [ |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
I: 93.5 (±17.8) kg |
I: −4.1 kg |
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Adherence to maintenance sessions/components: |
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Tsai et al. (2010)‡ [ |
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Design: |
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Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
I: AAW: |
I: AAW: −4.5 kg |
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Adherence to maintenance sessions/components: |
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Banks-Wallace (2007) |
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Design |
|
Formal Theoretical Framework: |
Frequency, Delivery, and Dose: |
93.7 (±13.1) kg | −8.5 kg |
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Adherence to maintenance sessions/components: |
††Data reported for AAW or CW only unless indicated otherwise.
‡Weight change by sex/ethnicity obtained from main study author for AAW completers only.
‡‡Intention to treat or multiple imputations analysis.
AAW: african american women; BMI: body mass index; BP: blood pressure; C: control; CI: confidence interval; CW: caucasian women; DASH: dietary approaches to stop hypertension; FU: follow-up; HS: high school; I: intervention; IBW: ideal body weight; IL: intensive lifestyle; MI: motivational interviewing; NA: not applicable; NDR: no data reported; NRCT: non-randomized controlled trial; PA: physical activity; PCP: primary care physician; S: supervised; SD: standard deviation; SCT: social cognitive theory; SE: standard error; UCT: uncontrolled trial; WL: weight loss; Y: years.
Quality Rankings, Total Quality Score, Maintenance Phase Characteristics, and % Weight Loss Regained at Follow-up for African American Woman Enrolled in US Behavioral Lifestyle Interventions, 1990–2011 (
Author | Year | Maintenance |
Study |
Primary focus on weight control | Formal maintenance program | Cultural adaptations | Total quality |
Maintenance format | Frequency of maintenance sessions | % Weight regain 12 M† | % Weight regain 18 M† | % Weight regain |
|
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Kumanyika et al. [ |
2002 | Weight Loss/Sodium Reduction | 4 | 2 | 2 | 3 | 11 | Group and individual sessions | Biweekly then monthly | AAW: 0% |
AAW: 7% |
AAW: 33% | |
Kumanyika et al. [ |
2002 | Weight loss | 4 | 2 | 2 | 3 | 11 | Group and individual sessions | Biweekly then monthly | AAW: 0% |
AAW: 0% |
AAW: 0% | |
Kumanyika et al. [ |
2005 | Group HELP | 4 | 2 | 2 | 3 | 11 | Group | Biweekly then monthly | 49% | |||
Kumanyika et al. [ |
2005 | Self HELP | 4 | 2 | 2 | 3 | 11 | Self-directed, 1 group session, some staff phone support | Infrequent | 35% | |||
Kumanyika et al. [ |
2005 | Clinic only | 4 | 2 | 2 | 3 | 11 | 2-3 clinic visits only | Semi-annually | 12% | |||
Svetkey et al. [ |
2008 | Personal Contact | 4 | 2 | 2 | 3 | 11 | Individual session | Monthly | AAW: 66% | |||
Svetkey et al. [ |
2008 | Internet | 4 | 2 | 2 | 3 | 11 | Web-based | Weekly login | AAW: 80% | |||
Svetkey et al. [ |
2008 | Self | 4 | 2 | 2 | 3 | 11 | No contact | NA | AAW: 77% | |||
West et al. [ |
2008 | IL | 4 | 2 | 2 | 3 | 11 | Individual | At least monthly | AAW: 6% |
AAW: 17% |
AAW: 55% | |
Kumanyika et al. [ |
2009 | Family High Support | 4 | 2 | 2 | 3 | 11 | Group and individual sessions | Biweekly then monthly | 0% | 6% | 41% | |
Kumanyika et al. [ |
2009 | Family Low Support | 4 | 2 | 2 | 3 | 11 | Group and individual sessions | Biweekly then monthly | 0% | 0% | 40% | |
Kumanyika et al. [ |
2009 | Individual High Support | 4 | 2 | 2 | 3 | 11 | Group and individual sessions | Biweekly then monthly | 0% | 5% | 71% | |
Kumanyika et al. [ |
2009 | Individual Low Support | 4 | 2 | 2 | 3 | 11 | Group and individual sessions | Biweekly then monthly | 35% | 12% | 6% | |
Fitzgibbon et al. [ |
2010 | Intervention | 4 | 2 | 2 | 3 | 11 | Group and individual session | Twice weekly, weekly, then monthly | 33% | |||
Martin et al. [ |
2008 | Intervention | 4 | 2 | 1 | 3 | 10 | No contact | NA | 0% | 64% | ||
Djuric et al. [ |
2009 | Diet and Spirituality | 3 | 2 | 2 | 3 | 10 | Individual sessions | Weekly then biweekly | 30% | |||
Djuric et al. [ |
2009 | Diet only | 3 | 2 | 2 | 3 | 10 | Individual sessions | Monthly | 15% |
|||
Kumanyika et al. [ |
1991 | Weight loss treatment arms | 4 | 2 | 2 | 1 | 9 | Group and individual sessions | Bimonthly | AAW: 46% |
AAW: 88% |
AAW: 215% | |
Kumanyika et al. [ |
1991 | Weight loss treatments arms | 4 | 2 | 2 | 1 | 9 | Group and individual sessions | Monthly | AAW: 42% |
AAW: 89% |
||
Stevens et al. [ |
2001 | Intervention | 4 | 2 | 2 | 1 | 9 | Group and individual session/mail and phone-based contact | Biweekly then monthly | AAW: 81% |
AAW: 123% | ||
Yancey et al. [ |
2006 | Intervention | 4 | 1 | 1 | 3 | 9 | No contact, free gym membership | NA | NA | |||
West et al. [ |
2007 | MI | 4 | 2 | 2 | 1 | 9 | Group and individual sessions | Biweekly then monthly | AAW: 15% |
AAW: 44% |
||
West et al. [ |
2007 | Attention control | 4 | 2 | 2 | 1 | 9 | Group and individual sessions | Biweekly then monthly | AAW: 34% |
AAW: 66% |
||
Rickel et al. [ |
2011 | Extended |
4 | 2 | 2 | 1 | 9 | Individual sessions | Biweekly | AAW: 28% |
|||
Rickel et al. [ |
2011 | Self | 4 | 2 | 2 | 1 | 9 | Newsletter only | Biweekly | AAW: 19% |
|||
McNabb et al. [ |
1993 | Intervention | 2 | 2 | 1 | 2 | 7 | No contact | NA | 0% | |||
Tsai et al. |
2010 | Intervention | 3 | 2 | 1 | 1 | 7 | Two visits with PCP | Quarterly | AAW: 64% |
|||
Banks-Wallace [ |
2007 | Intervention | 1 | 1 | 1 | 2 | 5 | No contact | NA | 138% |
†% Weight change at follow-up time-points crudely calculated from data provided in the manuscripts.
††Svetkey et al., 2008 [
‡No weight loss achieved during intensive intervention phase, therefore, no weight regain to report.
AAW: African American Women; CW: Caucasian Women; IL: Intensive Lifestyle; M: Month; NA: Not Applicable; PCP: Primary Care Provider.
To address study quality, we adapted the ranking system developed by Whitt-Glover and Kumanyika [
The 17 studies are ranked alphabetically according to date published and study quality which ranged between 5 and a maximum of 11 points (Tables
Thirteen of the 17 studies were RCTs. The interventions were implemented in various settings including academic medical centers [
The sample sizes varied significantly across the studies ranging from 21 to 2921 participants. The multi-institution RCTs [
The majority of the studies (16 of 17) enrolled AA women with mean ages between 40 to 60 years old. All of the studies recruited overweight and obese individuals although their health status varied. Participants in the TONE trial [
Eight studies utilized a formal theoretical framework in the design of the intervention. [
Across the 17 studies, weight changes for AA women following the intensive intervention phase ranged from +0.5 to −8.5 kg. In the studies enrolling both AA and Caucasian women [
The duration of the maintenance phase ranged from 6 to 30 months. Only, two studies [
Common features of the maintenance interventions included some combination of didactic nutrition and PA sessions [
The frequency of contact and delivery of the maintenance interventions was diverse. Participants in seven studies [
Participants, enrolled in four of the multi-institution RCTs, reported modest to excellent adherence to maintenance sessions [
The majority of studies, with a formal maintenance intervention, did not report adherence to specific maintenance activities such as self-monitoring of weight, dietary intake, or PA [
The percentage of participants available for final assessment varied. Five of the eight studies [
Table
At 18-month follow-up, % weight regain for AA women in studies with the highest quality ranking (11 points), enrolling only AA women [
The highest ranking studies (11 points), enrolling both AA and Caucasian women [
This paper reports on a systematic review of the behavioral lifestyle intervention literature published between 1990 and 2011 that reported weight outcomes, included a maintenance phase of at least six months, and enrolled or specifically targeted AA women. Only 17 studies met the inclusion criteria, underscoring the limited research in this area. The studies reviewed differed in design, duration, and intensity of the maintenance interventions, sample size, and attrition rates, which led to the inevitable challenge of cross-study comparisons.
Generally, AA women lost less weight during the intensive weight loss phase and maintained a lower % of their weight loss compared to Caucasian women in the behavioral lifestyle interventions reviewed [
The most remarkable finding was that the majority of studies failed to describe the specific strategies used in the delivery of the maintenance intervention, adherence to those strategies, and did not incorporate a maintenance phase process evaluation making it difficult to identify intervention characteristics associated with better weight control. Also, many of the studies did not report a distinction between what similar or different behaviors were performed during the active and maintenance phase of the intervention. This may be due to the fact that often, the active intervention phase does not lead to sufficient weight losses to warrant an active maintenance phase. Other than the WLM trial [
Despite this significant caveat, we attempted to identify design components that influence the effectiveness of behavioral lifestyle interventions designed to promote weight maintenance specific to AA women. Findings suggest that inclusion of cultural adaptations may result in more favorable weight maintenance outcomes for AA women and is consistent with the existing literature [
Not surprising, inclusion of a formal maintenance program was largely associated with lower % weight regain for both AA and Caucasian women [
African American and Caucasian women were more successful with weight maintenance when study participants were recruited for this purpose. It may be that AA women recruited for interventions where weight loss was secondary (e.g., walking intervention, sodium reduction) [
Some limitations in our study deserve mention. We included RCTs, pilot RCTs, and nonrandomized controlled and single group design trials. The small sample sizes of the nonrandomized trials and higher attrition rates in several of the studies may have introduced selection bias [
Overall, our synthesis of the literature shows that AA women struggle unduly with both weight loss and maintenance. All of the studies reviewed focused specifically on individual behavior change strategies. It may be that the inherent biology and social and environmental constraints of AA women, unfavorably impacts their adoption of these behaviors [
In terms of AA women’s socioenvironment, several factors may hinder their adoption of behaviors shown to positively impact weight control. These factors include socioeconomic status [
The emergence of system-oriented and multilevel research will provide greater insight into the relational complexity of individual- and population-level factors affecting weight management [
The authors have no conflict of interests to disclose.
L. M. Tussing-Humphreys’ effort was supported by the US Department of Agriculture, Agricultural Research Service Project 6401–53000-001-00D and the University of Illinois at Chicago Department of Medicine and University of Illinois Cancer Center. M. L. Fitzgibbon’s effort was supported by the NIH research projects 5R25CA057699, P50CA106743, and P60 MD003424. A. Kong’s effort was supported by 5R25CA057699 from the National Cancer Institute. The authors would like to thank Guadalupe Compean and Sarah Olender for their technical assistance and Dr. Jessica Thomson and Dalia Lovera for their very helpful and constructive comments on an earlier draft of this paper.