Self-Management and Educational Support in Extremely Obese Patients Awaiting Bariatric Care (EVOLUTION)

Evaluating Self-Management and Educational Support in Extremely Obese Patients Awaiting Multidisciplinary Bariatric Care

Extreme obesity is present in 9% of the Canadian population. Extremely obese people have a high chance of developing health problems and dying early. Our national guidelines recommend that extremely obese individuals receive multidisciplinary treatment, meaning that a number of specialized care providers should be available to help administer obesity treatments to these patients.

The investigators oversee a large obesity program called the Weight Wise Obesity Program, which delivers multidisciplinary care at 5 sites in Alberta, Canada (Edmonton, Calgary, Grand Prairie, Medicine Hat, Red Deer). Wait times to enter the Weight Wise clinics range from a few months to three years depending on the site in Alberta. The investigators performed a survey of the patients on the wait list in Edmonton and discovered that they self- report extremely poor health and feel that the long wait times are partly responsible for this poor health. To try to support these patients as they wait for multidisciplinary care, the investigators designed a group based self-management intervention, consisting of Weight Wise Community Modules. Patients attend this program over three months to receive weight management education (diet, exercise, stress management, coping strategies).A web-based version of the modules is also available.

The investigators wish to determine if these modules delivered to patients prior to entering the clinic help to reduce weight, improve quality of life in the wait listed patients and also to see if going through the modules helps patients to be more ready for weight management when they reach the Weight Wise clinic. The investigators also wish to examine whether or not these modules are cost effective. If these modules are not useful, a more effective way to support wait listed patients will be sought.

Study Overview

• Status: Completed
• Conditions: Obesity
• Intervention / Treatment: Behavioral: Weight Wise Community Modules

Detailed Description

Background:

Extreme obesity (body mass index ≥ 35 kg/m2) affects 9% of Canadians; has tripled in prevalence in 3 decades; shortens life expectancy by 5-13 years; and is debilitating and costly. Current guidelines recommend that extremely obese patients receive treatment [consisting of intensive lifestyle modification ± bariatric (obesity) surgery] within a multidisciplinary bariatric setting. However, in Canada and other publicly funded health care settings, demand for multidisciplinary bariatric care far outstrips the capacity to provide it and so patients often face protracted, multiyear wait times. A recent study examining 150 patients on the Edmonton wait list (done at a time when the wait was several years in Edmonton) demonstrated that these patients self-report severely impaired health status (similar to those with diabetes or COPD) and strongly feel that prolonged wait times are a major contributor to their health impairments. To support these patients as they wait for more definitive management, our multidisciplinary team of clinicians, allied health professionals and decision makers have designed and implemented a Weight Wise Community Module (WWCM) program, consisting of a 3-month, 10-session group-based weight self-management intervention. In addition, a web-based version of the WWCM is now available. The WWCM program teaches self-management skills to improve diet, increase physical activity, reduce stress and increase self-efficacy - but it has not yet been evaluated. We are interested both in the outcomes after three months and after the patient has gone through the weight management clinic.The comparative clinical and cost-effectiveness of the in-person WWCM, web-based WWCM and usual care are not known.

Objectives:

To determine if an evidence-based weight-management program currently being delivered to adult (age 18 years or greater) extremely obese patients wait-listed for multidisciplinary bariatric (obesity) care in a population-based program improves clinical and humanistic outcomes, and is cost-effective.

Study Design:

This 9-month study will use a pragmatic, prospective, randomized, controlled design in which consenting extremely obese patients, newly wait listed for the Weight Wise Adult Clinic, will be randomly assigned one of three groups:

1. Weight Wise Community Modules delivered in person (9 modules delivered over 10 sessions).
2. Weight Wise Community Modules delivered on the web (13 modules, content is similar to the in-person modules)
3. Mailed Educational Pamphlets (including Canada's Guide to Health Living and tips on self-management strategies and improving readiness-to-change).

Each study arm will be comprised of 220 patients (660 total).Randomization will be performed independently of the research team by an independent organization, the EPICORE Centre.

Procedures:

Patients will be enrolled at the point of referral to each zonal program. They will have 3 months to complete the modules or review the mailed educational materials. After this, they will enter the weight management clinic in their zone. They will be followed by the study team for an additional six months while they are in the weight management clinic. Study outcomes assessments will occur at 3,6, and 9-months post randomization. If patients undergo bariatric surgery during the follow-up period, data will still be collected but they may need to be censored in the analysis.

• Study Type: Interventional
• Enrollment (Actual): 651
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Canada
  • Alberta
    • Edmonton, Alberta, Canada, T5H 3V9
      • Alberta Health Services, Edmonton Bariatric Speciality Clinic, Royal Alexandra Hospital
    • Red Deer, Alberta, Canada, T4N 4E7
      • Alberta Health Services, Bariatric Specialty Clinic, Red Deer Regional Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Body mass index (BMI) ≥ 35 kg/m2
2. Newly wait-listed for a provincial Weight Wise Adult Clinic
3. Adult age ≥ 18 years.

Exclusion Criteria:

1. Completed more than 4 Weight Wise Community Modules (web-based or group session) in previous 3 months
2. Pregnant female
3. Unable to read/write/comprehend English
4. Unable to access the web
5. Unable or unwilling to attend in-person module sessions
6. Untreated severe personality disorder, active psychosis, active substance dependence and/or major cognitive impairment
7. Participation in concurrent trial related to obesity management
8. Resides greater than 1 hour driving time to Weight Wise Clinic
9. Declined to participate.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Weight Wise Community Modules: Workshops; Groups workshops (10 in total) designed to improve weight management skills and enhance self-efficacy, delivered over 3 months, prior to entering a multidisciplinary bariatric care.	Behavioral: Weight Wise Community Modules; Program designed to educate patients regarding proper diet, exercise,and behavioural modification techniques with emphasis on increasing self-management, enhancing self-efficacy and identifying/overcoming barriers to success.
Active Comparator: Weight Wise Community Modules: Online; Online modules (13 in total) designed to improve weight management skills and enhance self-efficacy, delivered over 3 months, prior to entering a multidisciplinary bariatric care.	Behavioral: Weight Wise Community Modules; Program designed to educate patients regarding proper diet, exercise,and behavioural modification techniques with emphasis on increasing self-management, enhancing self-efficacy and identifying/overcoming barriers to success.
No Intervention: Educational Written Materials; Educational pamphlets about healthy living and tips on self-management strategies. Delivered by mail 3 months prior to entering a multidisciplinary bariatric care. This is minimal intervention and considered the control arm.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Proportion of patients achieving 5% weight loss	Current consensus guidelines endorse a 5% weight loss to achieve clinically meaningful health benefits after 6-12 months of intervention.	9 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinical outcomes: mean 9-month change in weight	kg	9 months
blood pressure	mm hg	9 months
total cholesterol	mmol/L	9 months
hemoglobin A1C		9 months
cardiovascular medications	number of medications	9 months
hypertension prevalence		9 mo
diabetes prevalence		9 mo
dyslipidemia prevalence		9 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
SF12 quality of life	total and domain scores	9 months
incremental cost-utility	$Cdn/QALY	9 months
Attrition rate from weight management clinic.		9 months
EQ5D	total score	9 mon
WEL self efficacy scale	total score	9 months
readiness to change	visual analogue score	9 months
PHQ-8 depression scale	total score	9 months

Collaborators and Investigators

• Sponsor: University of Alberta
• Collaborators: Canadian Institutes of Health Research (CIHR); Alberta Health services; Alberta Innovates Health Solutions
• Investigators: Principal Investigator: Raj Padwal, MD, MSc, General Internal Medicine and Clinical Pharmacology, University of Alberta

Publications and helpful links

General Publications

• Padwal RS, Sharma AM, Fradette M, Jelinski S, Klarenbach S, Edwards A, Majumdar SR. The evaluating self-management and educational support in severely obese patients awaiting multidisciplinary bariatric care (EVOLUTION) trial: rationale and design. BMC Health Serv Res. 2013 Aug 17;13:321. doi: 10.1186/1472-6963-13-321.
• Padwal RS, Klarenbach S, Sharma AM, Fradette M, Jelinski SE, Edwards A, Majumdar SR. The evaluating self-management and educational support in severely obese patients awaiting multidisciplinary bariatric care (EVOLUTION) trial: principal results. BMC Med. 2017 Mar 2;15(1):46. doi: 10.1186/s12916-017-0808-6.

Study record dates

Study Major Dates

• Study Start: March 1, 2013
• Primary Completion (Actual): March 1, 2016
• Study Completion (Actual): March 1, 2016

Study Registration Dates

• First Submitted: May 17, 2013
• First Submitted That Met QC Criteria: May 20, 2013
• First Posted (Estimate): May 22, 2013

Study Record Updates

• Last Update Posted (Actual): April 4, 2017
• Last Update Submitted That Met QC Criteria: March 30, 2017
• Last Verified: March 1, 2017

More Information

Terms related to this study

• Keywords: bariatrics, lifestyle and behavioral modification programs
• Other Study ID Numbers: CIHR 201200877