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Original Article
Obesity
CLINICAL TRIALS AND INVESTIGATIONS
Using Synchronous Distance Education to Deliver a Weight
Loss Intervention: A Randomized Trial
Carolyn Dunn1, Olusola Olabode-Dada2, Lauren Whetstone3, Cathy Thomas2, Surabhi Aggarwal1, Kelly Nordby1,
Samuel Thompson2, Madison Johnson1, and Christine Allison4
Objective: To implement a randomized trial to evaluate the effectiveness of a weight loss program delivered
using synchronous distance education compared with a wait-list control group with 6-month follow-up.
Methods: Adults with a body mass index (BMI) 25 were randomized to the intervention (n 5 42) or waitlist control group (n 5 38). The intervention group participated in a synchronous, online, 15-week weight
loss program; weight loss was the primary outcome. Secondary measures included height, BMI, and
confidence in ability to be physically active and eat healthy. Assessments occurred at three and four time
points in the intervention and control group, respectively.
Results: Participants who completed the program lost significantly more weight (1.8 kg) than those in the
wait-list control group (0.25 kg) at week 15 [F(1,61) 5 6.19, P 5 0.02] and had a greater reduction in BMI
(0.71 vs. 0.14 kg/m2), [F(1,61) 5 7.45, P 5 0.01]. There were no significant differences between the intervention and the wait-list control groups for change in confidence in ability to be physically active or eat
healthy. Weight loss was maintained at 6 months.
Conclusions: Use of synchronous distance education is a promising approach for weight loss. The
results of this study will help to inform future research that employs Web-based interventions.
Obesity (2016) 24, 44–50. doi:10.1002/oby.21315
Introduction
Overweight and obesity are arguably the number one public health
issue of our time with 69% of adults with a body mass index (BMI)
25 (1). The primary concern related to overweight and obesity is
the health risks they pose. Overweight and obesity increase the risk
of chronic diseases, including heart disease, stroke, and type 2 diabetes. Overweight and obesity are associated with higher morbidity
and mortality rates and lower quality of life (2).
As a means to address this health epidemic, public health guidelines
have recommended strategies to help people achieve and maintain a
healthy weight (3,4). Suggested strategies include reduction in
caloric intake, an increase in physical activity, or a combination
(3,5). One approach to address obesity is the small-changes
approach (6,7). Making small lifestyle changes in diet and/or physical activity may prevent gradual weight gain. The use of evidencebased strategies, such as the small-changes approach, has the potential to reduce rates of overweight and obesity (6,7).
The need for greater access to weight loss programs has prompted
researchers to explore the use of the Internet, which could have a
wider reach (8). Several technologies have been tested including:
automated computer feedback, feedback through email from a health
coach, chat group sessions with a therapist, participant social support, use of health-related websites, online recordings, self-directed
computer programs, and submission of an electronic food and exercise diary (9). Computer-based interventions appear to produce
smaller weight losses and lower levels of weight maintenance when
compared with in-person interventions (4,9).
To best replicate the effects of face-to-face interventions, researchers
have found that computer-based weight loss programs must be structured and provide tailored feedback (10-13). There are a few studies
that used Web-based lessons delivered by a therapist (14,15), oneon-one coaching (11,12,14,16), and previously published work that
examines synchronous distance education combined with email
follow-up (13). Synchronous distance education shows promise as a
means to deliver health promotion programs (13).
1
Department of Youth, Family, and Community Sciences, North Carolina State University, Raleigh, North Carolina, USA. Correspondence: Carolyn Dunn
([email protected]) 2 North Carolina Division of Public Health, Department of Health and Human Services, Raleigh, North Carolina, USA
3
University of California, Nutrition Policy Institute, Nutrition Education and Obesity Prevention Research and Evaluation Unit, Berkeley, California, USA
4
NC State Health Plan for Teachers and State Employees, Raleigh, North Carolina, USA.
Funding agencies: Funding to offer Eat Smart, Move More, Weigh Less program to study participants was part of the funding that the NC State Health Plan for Teachers
and State Employees provides to offer the program to all its members. Funding to run the randomized control trial was provided by the Department of Youth, Family, and
Community Sciences, North Carolina State University.
Disclosure: The authors declare no conflict of interest.
Received: 13 April 2015; Accepted: 1 August 2015; Published online 6 December 2015. doi:10.1002/oby.21315
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Obesity | VOLUME 24 | NUMBER 1 | JANUARY 2016
www.obesityjournal.org
Original Article
Obesity
CLINICAL TRIALS AND INVESTIGATIONS
Synchronous distance education includes real time interaction with
an instructor and class participants as opposed to a taped session
where interaction is not possible. Synchronous distance education
virtually mimics the classroom experience (17). The authors’ prior
work (13) demonstrated greater weight loss with a web-based intervention using synchronous distance education technology as compared with face-to-face classes. Average weight loss at the end of
15-week program was 8.0 pounds (3.65 kg) versus 5.95 pounds
(2.7 kg) for Web-based and face-to-face groups, respectively. The
primary purpose of the current study was to examine the effectiveness of a 15-week weight loss program by comparing a sample of
adults with a BMI 25 who completed the program to a wait-list
control group, both of which expressed interest in losing weight.
The weight loss program used the small-changes approach delivered
through synchronous distance education to produce weight loss. The
second aim of the study was to investigate the maintenance of
weight loss at 6 months after completion of the weight loss program.
We were also interested in exploring differences among outcomes
for all participants before and after they completed the program, and
whether the number of classes attended was associated with any of
the outcome measures.
Methods
Participants
Eighty (69 female, 11 male) state employees covered by the North
Carolina State Health Plan for Teachers and State Employees were
recruited via email and phone from the registration lists of three
class cohorts of an online weight loss program offered between January and February 2013. Cohort 1 consisted of 14 classes with 230
participants, cohort 2 had six classes and 96 participants, and cohort
3 included 14 classes with 229 participants. Eligibility criteria
included: 18 years old; BMI 25; weekly access to a computer
with high-speed Internet; English language proficiency; and willingness to accept random group assignment. Participants were excluded
if they were currently enrolled in another weight management program, pregnant, had weight loss of 4.5 kg in the past year, were
taking medication known to affect body weight, someone in the
same household already enrolled in the study, had previously participated in the program, had surgery in the past 3 months or surgery
scheduled within the next 8 months, or had limited mobility.
Design
A randomized controlled trial (RCT) with weight loss intervention
and wait-list control group with 6-month follow-up was used. Eighty
individuals who met eligibility criteria were invited to meet in person with the project coordinator. The initial assessment included the
completion of a written informed consent, an online questionnaire of
physical activity and eating patterns, and measurements of height
and weight. Participants were also asked to sign an oath of confidentiality about their participation. Following the first meeting, study
participants were randomized, using a computerized random number
generator, to the intervention (n 5 42) or wait-list control group
(n 5 38) (Figure 1). Participants in the intervention group were seen
in-person at week 0, week 15, and 6 months. Participants in the
wait-list control group were seen at week 0, pre-intervention at
week 15, upon completion of the weight loss program (week 30)
and 6 months post-program completion. The 6-month time point
was 6 months from completion of the 15-week weight loss program
www.obesityjournal.org
Figure 1 Study design and participant numbers.
for the intervention and control groups. Participants received incentives to complete in-person measurements; $25 gift cards at all
assessments and $50 gift card at 6-month follow-up. Due to the
nature of the intervention, study staff and participants were not blind
to group assignment. Class instructors were not part of the study
staff and were blind to whether participants in their class were
enrolled in the study. Instructors did not know who in their class
was participating in the study. Instructors delivering the program
completed training to maintain program fidelity. Training consisted
of five modules on topics related to concepts used in the curriculum
as well multiple practice sessions using online delivery. Participant
data were collected between December 2012 and April 2014. The
study was reviewed and exempt from full review by the Institutional
Review Board of NC State University.
Intervention
Individuals randomized to the intervention group participated in Eat
Smart, Move More, Weigh Less Online (ESMMWL), a 15-week
weight loss program. Based on the Theory of Planned Behavior,
mindfulness, and small steps to change, the program consisted of
15 lessons that focused on eating and physical activity behaviors
that are evidence-based for weight loss (18). Topics covered
included eating fewer calories, preparing and eating more meals
Obesity | VOLUME 24 | NUMBER 1 | JANUARY 2016
45
Obesity
Synchronous Distance Education Weight Intervention Dunn et al.
at home, being physically active, and drinking fewer caloriecontaining beverages. Participants attended weekly, hour-long sessions with a trained instructor who provided information on each
topic. All instruction was delivered in a real-time online environment where the participants could see and chat with the instructor.
The instructor used best practice techniques for the online environment including engaging the learner in interaction with their fellow
classmates and instructor. The instructor could see when participants were logged into the session and could ask questions of specific participants to ensure engagement (see overview video at:
https://esmmweighless.com/how-it-works/). The instructor also
offered personalized support and answers to questions in-between
classes through email. Participants were encouraged to track their
progress through the ESMMWL weekly tracker that kept record of
each individual’s class goals, eating patterns, and physical activity
behaviors. Details about the ESMMWL program (18) and evaluation of the program both in person (19,20) and online (13) have
been published previously.
Wait-list control group
Participants assigned to the wait-list control group were not offered
intervention during the first 15 weeks following recruitment. Once
the second assessment (pre-intervention at week 15) was completed,
participants in the wait-list control group participated in ESMMWL.
Follow-up assessments
Participants in the intervention group were assessed at 15 weeks and 6
months after completion of the ESMMWL program. Data were collected in a private location and consisted of all measures assessed at
baseline except for height (i.e., weight, BMI, and a questionnaire of
physical activity and eating patterns). Follow-up assessments for those
in the wait-list control group were completed at 15 weeks after baseline
during which time they received no intervention, 15 weeks after they
completed the ESMMWL, and 6 months after program completion.
Sample size
Sample size was calculated based on an estimated weight loss difference of 22.7 kg between groups. For 80% power, a 5 0.05, and a
two-sided t-test, a sample size of 46 participants (23 per group) was
needed. We assumed a completion rate of 65%. Weight loss and
completion rate estimates were based on previous data from the
ESMMWL program (20). Individuals were excluded from the study
if they did not meet eligibility criteria, refused to participate, missed
recruitment window, or withdrew prior to randomization.
Outcome measures
The primary outcome was change in body weight and associated BMI.
Weight was measured without shoes in lightweight street clothing by
the project coordinator using a portable scale (Cardinal Detecto model
DR150/400; Cardinal, Webb City, MO) at each assessment. Height
was measured without shoes at baseline using a portable stadiometer
(Shorrboard model 420). Each participant’s BMI was calculated using
current weight and height measured at baseline (21).
Secondary outcomes consisted of confidence in ability to be physically active and eat healthy and was measured using a Web-based
questionnaire via SurveyMonkeyV at each data collection session.
Development of the questionnaire was described previously (18).
R
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Obesity | VOLUME 24 | NUMBER 1 | JANUARY 2016
Participants rated their confidence to engage in physical activity and
eating behaviors both before and after the program using a fivepoint Likert scale (not confident to very confident). Two summary
confidence scores were calculated. The score for confidence in participants’ ability to engage in physical activity was based on being
physically active at least 30 min/day, at least 60 min/day, at least 90
min/day, participating in strength training, and limiting daily screen
time with a possible score ranging from 5 to 25. The score for confidence in participants’ ability to follow healthful eating behaviors
was based on responses for nine distinct healthful eating practices,
with a possible score ranging from 9 to 45. The higher the value on
these two scales the greater the confidence of participants. Measures
of internal consistency for the confidence summary scores for online
classes were reported previously (13). Internal consistency for the
physical activity score, as measured by Cronbach’s alpha was 0.77
for confidence before the program and 0.78 for after; for the healthful eating score internal consistency was 0.85 for confidence before
the program and 0.83 for after.
In the same Web-based questionnaire, participants reported the
extent to which they engaged in 18 healthy eating and physical
activity behaviors on a scale from 1 (rarely or never) to 4 (usually/
always). After completion of ESMMWL they rated the extent to
which they engaged in these behaviors as a result of the program
using the same four-point scale.
In addition to the questions on confidence and healthy eating and
physical activity behaviors, participants reported their goals for the
program, progress toward goals, reasons for enrollment, past participation in weight management classes, satisfaction with the
ESMMWL course and perception of their struggle with weight as a
lifelong struggle or a new concern.
Statistical analysis
All analyses were performed using SPSS software (version 21; IBM
Corp, Armonk, NY). Means and frequency distributions were used
to describe the participant characteristics. Independent samples
t-tests and X2 tests were used to compare baseline measures for
intervention and wait-list control groups. Analyses of covariance,
adjusting for baseline measurements, were used to compare average
changes (from baseline to 15 weeks) in weight, BMI, and confidence in ability to eat healthfully and be physically active in the
intervention and wait-list control groups. Only data retrieved from
completers were included in this analysis. Completers were defined
as study participants who completed 10 of the 15 class sessions of
the ESMMWL program.
A repeated measures analysis of variance was conducted to examine
maintenance of weight loss at 6 months in participants in the intervention and wait-list control groups who completed at least 10 of
the 15 class sessions. The relationship between the number of
classes attended and change in weight, BMI, and healthy eating and
physical activity confidence was examined with Pearson correlation
coefficients.
Results
Baseline characteristics of intervention and control groups are presented
in Table 1. The majority of participants were female, Caucasian, and
www.obesityjournal.org
Original Article
Obesity
CLINICAL TRIALS AND INVESTIGATIONS
TABLE 1 Baseline characteristics of ESMMWL and control
group participants
ESMMWL
(n 5 28)
Control
(n 5 36)
P
value
Age, years, mean (SD)
47.6 (11.9)
Sex
Female, n (%)
22 (78.6)
Race, n (%)
African American
6 (21.4)
Caucasian
22 (78.6)
Other
0 (0.0)
Employment, n (%)
State agency
2 (7.2)
Public college, university,
9 (32.1)
or community college
Public school
16 (57.1)
Business
1 (3.6)
Education, n (%)
High school graduate
1 (3.6)
Some college, no degree
3 (10.7)
Associate’s degree
3 (10.7)
Bachelor’s degree
8 (28.6)
Master’s degree
11 (39.3)
Professional or doctorate degree
2 (7.1)
Annual household income, n (%)
$0-$25,000
0 (0.0)
$25,001-$50,000
6 (25.0)
$50,001-$75,000
11 (45.8)
$75,001-100,000
3 (12.5)
$100,001 or more
4 (16.7)
Preferred not to answer
4
Body weight (mean, SD)
Weight (kg)
101.3 (32.8)
BMI (kg/m2)
37.6 (10.6)
Confidence in
Ability to eat healthfully,
36.0 (6.9)
mean (SD)
Ability to engage in physical
15.1 (4.3)
activities, mean (SD)
48.2 (8.7)
0.81
32 (88.9)
0.31
0.47
11 (30.5)
23 (63.9)
2 (5.6)
0.61
3 (8.3)
9 (25.0)
24 (66.7)
0 (0.0)
0.69
1 (2.8)
1 (2.8)
5 (13.9)
9 (25.0)
19 (52.7)
1 (2.8)
0.45
1 (3.2)
8 (25.8)
7 (22.6)
4 (12.9)
11 (35.5)
5
92.6 (16.9)
33.7 (4.8)
0.21
0.08
34.1 (7.1)
0.18
13.5 (4.6)
0.30
employed full time. Over three-quarters completed at least a bachelor’s
degree and nearly three-quarters had household incomes greater than
$50,000. Baseline weight, BMI, and confidence scores were not significantly different for intervention and control participants.
Intervention versus wait-list control
Change in weight was compared between intervention group participants who completed at least 10 of the 15 classes in the ESMMWL
program and all control group participants. There were no statistically significant differences at baseline between those intervention
group participants who completed the program and those who did
not in terms of weight, BMI, age, or gender. Those who completed
ESMMWL lost significantly more weight than those in the wait-list
www.obesityjournal.org
control group, F(1,61) 5 6.19, P 5 0.02 and had a greater reduction
in BMI, F(1,61) 5 7.45, P 5 0.02 (Table 2). Similar results were
obtained using intention to treat analysis for weight loss. Participants
who completed ESMMWL lost an average of 1.76 kg, those in the
control group lost an average of 0.25 kg; F(1,71) 5 5.73, P 5 0.02.
There were no significant differences between the intervention group
and the control group for change in physical activity or healthy eating confidence (Table 2). Removing one outlying value from change
in physical activity confidence did not change the pattern of results.
Removing one outlying value from change in eating confidence
resulted in a lowering of the eating confidence score for the intervention group (from 1.1 to 0.4) and the difference between groups
remained non-significant.
All completers
The 48 participants in the intervention and wait-list control groups who
completed at least 10 of 15 ESMMWL class sessions lost an average of
1.34 kg at the end of their course. Weight loss was maintained at 6
months [repeated measures ANOVA with Greenhouse–Geisser correction for violation of sphericity, F(1.8,82.5) 5 7.81, P 5 0.001]. Pairwise
comparisons using Bonferroni correction showed significant weight loss
from pre-participation (99.1 kg) to post-participation (97.8 kg,
P 5 0.007) and maintenance of weight loss at 6 months (97.2 kg, no significant difference in weight from post-participation to 6 months).
Participants indicated the extent to which they engaged in 17 specific
healthy eating and physical activity behaviors before and after participation in ESMMWL using a scale ranging from 1 (rarely or never) to 4
(usually or always). Table 3 shows the average response before and after
participation for the 48 ESMMWL completers. An increase in healthy
behaviors was noted for 12 of the 17 behaviors. Weight loss and change
in BMI at completion of ESMMWL were associated with the number of
classes attended (r 5 0.36, P 5 0.01; r 5 0.39, P 5 0.006). The same
pattern emerged at 6-month follow-up (weight loss r 5 0.36, P 5 0.01;
BMI change r 5 0.42, P 5 0.003). Changes in eating and physical
activity confidence were not significantly correlated with the number of
classes attended neither immediately following completion of
ESMMWL nor at 6-month follow-up. Finally, those who lost weight
attended an average of 12.8 classes while those who did not lose weight
attended an average of 11.1 classes [t(1,46) 5 3.9, P < 0.001]. Discussion The primary aim of this study was to compare the weight loss of participants who were randomly assigned to complete a synchronous, online, 15-week weight loss program to those assigned to the wait-list control group. A wait-list control group was used as a comparison because it was necessary to identify individuals who were of a similar demographic background to those in the intervention group and also who self-selected as ready to engage in weight loss. The results of the current study show that those in the intervention group lost significantly more weight and had a significantly larger reduction in BMI than those in the wait-list control group. There were no significant differences between the intervention and wait-list control groups for any of the secondary outcome variables. There is also evidence to suggest that weight loss was maintained at 6 months among all participants (the intervention and control groups combined) who completed 10 of 15 classes. While there have been studies examining synchronous chat rooms led by a health professional (22-24), to the authors’ knowledge, Obesity | VOLUME 24 | NUMBER 1 | JANUARY 2016 47 Obesity Synchronous Distance Education Weight Intervention Dunn et al. ESMMWL program and at 6 months. Several other studies have also shown a dose–response effect where weight loss outcomes were improved with higher participation rates (25-30). TABLE 2 Change from baseline to 15 weeks (post-program) for ESMMWL and wait-list control group participants Characteristic Weight, kg BMI, kg/m2 Physical activity confidencea Eating confidenceb ESMMWL (n 5 28), mean (SD) Control group (n 5 36), mean (SD) P value 21.9 (3.0) 20.7 (1.2) 1.2 (5.03) 20.3 (2.3) 20.1 (0.9) 0.3 (3.99) 0.02 0.01 0.05 1.1 (6.16) 0.6 (4.77) 0.10 a Overall confidence in being physically active ranges from 5 being very low to 25 being very high on this aggregated scale. b Overall confidence in eating healthfully ranges from 9 being very low to 45 being very high on this aggregated scale. this study is the first RCT to examine the use of synchronous distance education paired with email follow up to produce weight loss among adults with a BMI 25. The average weight loss for the 48 participants who completed 10 out of 15 ESMMWL classes across the intervention and wait-list control groups was 1.34 kg. Among these same completers, there was a significant increase in 12 of the 17 healthy behaviors from pre- to post-participation in the ESMMWL program. Participants who lost weight attended significantly more classes than those who did not lose weight. Additionally, weight loss and change in BMI were found to have a significant, positive correlation with the number of classes attended immediately following completion of the The results from this study align with other RCTs showing that Web-based interventions can be effective in achieving weight loss (8,31), particularly, interventions with human feedback via email (11,12). This study is distinct because it utilizes synchronous distance education. Based on a qualitative review, there are five necessary components to make a technology-based weight loss intervention effective: self-monitoring, counselor feedback and communication, social support, use of a structured program, and the use of an individually tailored program (32). Similarly, a few systematic reviews have concluded that personalization, feedback, and adaptation are key components to Web-based interventions (8,31,33). The ESMMWL program used within this study incorporates all of these components, which aid in its ability to produce weight loss effects. While Web-based weight loss programs have been said to be less effective than in-person interventions (9), Harvey-Berino et al. (34) found that over half of the participants in the Web-based treatment group still lost a clinically significant amount of weight when compared with the in-person treatment group. Other RCT studies utilizing a Web-based intervention with human e-mail support, an automated counselor or chat rooms to impact weight loss have also produced losses of 4-7 kg, which is a clinically meaningful weight loss (35). A weight loss of 2.5-5.5 kg (or a loss of at least 5% of initial body weight) has been associated with increased health benefits such as reduced risk for type 2 diabetes and cardiovascular disease (4). The current study did not produce clinically significant weight loss but shows that synchronous distance education technology can be a promising approach for weight loss programs. TABLE 3 Behaviors attributed to program participation among those who completed ESMMWL Response at end of 15-week program Am physically active at least 30 minutes most days Am physically active at least 60 minutes most days Am physically active at least 90 minutes most days Include strength training in my physical activity routine at least two times per week East fewer calories Eat smaller portions Eat less fast food Drink fewer calorie-containing beverages Prepare and eat more meals at home Eat breakfast at least 5 days/week Eat 2-3 cups of vegetables most days Eat 11=2 to 2 cups of fruit most days Am mindful of getting physical activity each day Limit screen time (TV and computer) for myself Limit screen time (TV and computer) for my family Pack healthy lunches for myself Pack healthy lunches for my family Before ESMMWL (meana) After ESMMWL (meana) 2.1 1.5 1.2 1.4 2.9b 2.1b 1.5 2.4b 2.2 2.2 2.8 3.1 2.8 3.2 2.7 2.7 2.5 2.2 2.0 2.5 2.2 3.0b 3.2b 3.0 3.7b 3.2b 3.6 3.3b 3.2b 3.3b 2.8b 2.4 3.1b 2.8 a Mean on a scale from 1 “rarely or never” to 4 “usually or always.” P < 0.002. b 48 Obesity | VOLUME 24 | NUMBER 1 | JANUARY 2016 www.obesityjournal.org Original Article Obesity CLINICAL TRIALS AND INVESTIGATIONS This study also provides additional evidence to support the use of a small-changes approach to weight loss and weight maintenance. Currently, there are very few randomized studies in the literature that examine the small-changes approach to weight loss. Lutes et al. (36) conducted a RCT to examine small changes to nutrition and physical activity and found that the small changes group lost significantly more weight than the standard education and control groups. The small-changes approach is believed to be more suitable to people’s lifestyles, which has the potential to increase program participation, adherence, and long-term weight loss (37). The present study contributes to the literature in that it is a RCT that supports the use of a small-changes approach. Strengths of the study include: the use of a RCT design in order to compare the intervention and wait-list control groups, both of whom were motivated to lose weight; standardized protocols were used to obtain weight measurements at multiple time points rather than using self-reported weight; and the use of a real-time, synchronous distance education approach to weight loss. This approach provides participants with access to a live instructor regardless of their geographic location. Study limitations include the predominantly Caucasian female sample, self-reported confidence to engage in physical activity and eating behaviors as opposed to a measure to assess actual physical activity or eating behaviors, and follow-up beyond 6 months from completion of the weight management program. Also, the study population had a high average household income with a large percentage having education at bachelor’s level, which may limit the generalizability of study findings. Finally, a larger sample size may have shown clinically significant weight loss in the intervention group. A weight loss program using synchronous distance education has the capabilities of being interactive with a real-time, live instructor as one would have in a face-to-face course as well as being accessible to a large number of people regardless of geographic location. In order to make an impact on the obesity epidemic, it is necessary to replicate key components of in-person treatments and have a wide reach across the population. This study not only provides further evidence that Web-based interventions can be effective but also shows the efficacy of synchronous distance education and how it can produce weight loss among adults with a BMI 25.O Acknowledgments The authors would like to thank all study participants. The authors would also like to thank the following ESMMWL instructors: Greg Moore, Sara Morris, Tina Marie Mendieta, Christopher Minor, Marjorie Lanier, Adrienne Morton, and Meredith Fine. Finally, the authors would like to thank Megan Dean of the Mecklenburg County Health Department for providing office space to conduct assessments with participants. C 2015 The Obesity Society V References 1. Overweight and obesity statistics. National Institute of Health Web Site. Available from: http://win.niddk.nih.gov/publications/PDFs/stat904z.pdf 2. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. National Institutes of Health Web Site. Available from: http:// www.nhlbi.nih.gov/files/docs/guidelines/ob_gdlns.pdf 3. Baradel LA, Gillespie C, Kicklighter JR, Doucette MM, Penumetcha M, Blanck HM. Temporal changes in trying to lose weight and recommended weight-loss strategies among overweight and obese Americans, 1996-2003. 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