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In Rural Setting, Weight Loss Therapy Best Delivered in Groups

Obese patients at rural primary care clinics lost more weight with a group intervention compared to individual visits with a clinician, a cluster-randomized trial showed.

In more than 1,400 obese patients followed for 2 years, mean weight loss was -4.4 kg (95% CI -5.5 to -3.4) for the group intervention and –2.6 kg (95% CI –3.6 to –1.5) for the individual visits. The mean difference in weight change was –1.9 kg (97.5% CI –3.5 to –0.2, P=0.01), said a research team led by Christie Befort, PhD, of the University of Kansas Medical Center in Kansas City.

A third group of patients participated in a group intervention via telephone conference call, and in this group mean weight loss was –3.9 kg (95% CI –5.0 to –2.9 kg), a mean difference in weight change of -1.4 kg compared with individual visits, which fell just short of statistical significance (97.5% CI –3.0 to 0.3 kg, P=0.06), Befort’s group reported in JAMA.

Reasons for the difference were likely the peer support and accountability that come with group interventions, the researchers speculated.

“To our knowledge, this was the first pragmatic trial comparing the Medicare reimbursable model with in-clinic group and telephone group visits,” they wrote, and was also the largest performed in local practices.

Notably, though, the proportion of patients achieving greater than 5% weight loss didn’t differ between groups. “Therefore, although the 24-month mean difference between in-clinic group and in-clinic individual visits was statistically significant, the absolute difference in weight loss of -1.9 kg was small in magnitude and may not represent a clinically important difference,” Befort’s team said.

Still, the study supports group interventions for patients in rural communities, where the prevalence of obesity is high but access to evidence-based weight management programs is low, they added.

The diet, physical activity, and behavioral recommendations were the same across all three study groups and based on the Look AHEAD lifestyle intervention. Participants received a calorie goal based on their weight and were instructed to consume a balanced diet with five or more fruit and vegetable servings per day. Portion control and optional use of protein shakes and frozen entrees were encouraged, but no food or scales were provided.

Participants were instructed to increase physical activity up to 225 minutes per week, to set weekly diet and physical activity goals, and to self-monitor daily with a physical activity monitor and commercial app or written log. Clinicians delivering the interventions were instructed to provide feedback to participants on logs. Intervention materials addressed problem-solving for overcoming barriers, including those common to rural environments.

The interventions were delivered at 36 participating primary care practices, which were randomized to provide one of the three delivery models to eligible patients: individual in-clinic visits following the frequency reimbursed by Medicare, group in-clinic visits, or group teleconference calls.

The trial included several pragmatic elements designed to make the findings generalizable to broader clinical practice: no particular types of practice were excluded, and patients were recruited through clinic registries and referrals rather than by research staff.

Furthermore, there were few exclusion criteria for patients. Participants were eligible if they were 20-75 years old, had a body mass index (BMI) of 30-45, lived in a rural location, and had at least one clinic visit in the last 18 months. No one was excluded specifically for recent weight loss or medications that affect weight. However, those with a history of bariatric surgery, pregnancy, myocardial infarction, stroke, or new cancer diagnosis in the last 6 months were considered ineligible.

Mean patient age was 54.7 and mean BMI was 36.7. The majority were white (96%) and female (77%).

Limitations of the study included lack of a control group not receiving any weight loss intervention. In addition, the study did not control for the different professional backgrounds or training of the clinicians delivering the interventions.


The study was funded by a Patient-Centered Outcomes Research Institute (PCORI) award.

Befort reported receiving grants from the National Institutes of Health and the MS Society.