JAMA：阶梯式护理干预能以较低的成本减轻体重

芝加哥–据6月27日刊《美国医学会杂志》JAMA上的一项研究披露，尽管在超重和肥胖的成年人中实施一项标准的行为性体重减轻干预措施在18个月中导致了平均体重的较大的减轻，但一项阶梯性的护理干预则导致了具有临床意义的体重减轻，而且其实施的成本较小。

“大多数的减肥计划在治疗的起初几周中强度很大，但随着时间的推移会变得强度减轻，而且在不考虑治疗成功或者失败的情况下与参与者维持着的一种固定的联系计划。高强度减肥计划成本高，并需要参与者承诺花大量的时间，这使得它们在许多情况下变得不切实际。一种替代的方式是阶梯式的治疗方法。它牵涉到起初的低强度的干预，并在在固定的时间点没有达到减肥里程碑时会增加其干预的强度。”

匹兹堡大学的John M. Jakicic， Ph.D.及其同事对一种阶梯性护理减肥干预（STEP）与一种标准性的行为减肥干预措施（SBWI）相比是否会导致更大幅度的体重减轻进行了检验。该临床试验包括了363名超重及肥胖的成年人（身体质量指数：25-<40； 年龄： 18-55岁， 33%为非白人， 83%为女性），他们被随机分派接受SBWI (n = 165) 或 STEP (n=198)。实验的参与者是在2008年5月至2010年2月间被招募的，而在2011年9月完成了对他们的数据的收集。所有的参与者都被安排进食一种低热卡饮食，指示其增加体力活动，并参加小组辅导，其时间从为期18个月的阶段中每周一次至每月一次。SBWI组被指派使用一种固定的计划。对STEP组来说，辅导的频度、类型和减肥策略可视相关于减肥目标而言的所观察到的体重减轻而每3个月进行1次修改。

在363名研究的参与者中， 260 (71.6%)人在该为期18个月的评估中提供了体重的检测数据。研究人员发现，与STEP组的-6.2公斤（13.7磅）相比，SBWI组在18个月时的体重减轻为-7.6公斤（16.8磅）。从基线水平至第18个月时的体重变化百分比在SBWI组为-8.1%，而在STEP组为-6.9%。

两组的参与者在静息心率、血压水平和健康程度上都有显著而且可比的改善。

文章的作者写道：“从付费者的角度看，STEP组的每位参与者的平均成本为358美元，而SBWI组为494美元。”从参与者的角度看，与SBWI组(863美元)相比，STEP组的成本也较低（427美元）。从社会的角度来看（即付费者与参与者的费用总和），STEP的平均成本为785美元。这一数字比SBWI的平均成本——估计为1，357美元——要显著降低。

doi:10.1001/jama.2012.6866
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Effect of a Stepped-Care Intervention Approach on Weight Loss in Adults

John M. Jakicic, PhD; Deborah F. Tate, PhD; Wei Lang, PhD; Kelli K. Davis, PhD; Kristen Polzien, PhD; Amy D. Rickman, PhD, RD, LDN; Karen Erickson, MPH, RD; Rebecca H. Neiberg, MS; Eric A. Finkelstein, PhD

Context Given the obesity epidemic, effective but resource-efficient weight loss treatments are needed. Stepped-treatment approaches customize interventions based on milestone completion and can be more effective while costing less to administer than conventional treatment approaches. Objective To determine whether a stepped-care weight loss intervention (STEP) compared with a standard behavioral weight loss intervention (SBWI) would result in greater weight loss. Design, Setting, and Participants A randomized clinical trial of 363 overweight and obese adults (body mass index: 25-<40; age: 18-55 years, 33% nonwhite, and 83% female) who were randomized to SBWI (n = 165) or STEP (n = 198) at 2 universities affiliated with academic medical centers in the United States (Step-Up Study). Participants were enrolled between May 2008 and February 2010 and data collection was completed by September 2011. Interventions All participants were placed on a low-calorie diet, prescribed increases in physical activity, and attended group counseling sessions ranging from weekly to monthly during an 18-month period. The SBWI group was assigned to a fixed program. Counseling frequency, type, and weight loss strategies could be modified every 3 months for the STEP group in response to observed weight loss as it related to weight loss goals. Main Outcome Measure Mean change in weight over 18 months. Additional outcomes included resting heart rate and blood pressure, waist circumference, body composition, fitness, physical activity, dietary intake, and cost of the program. Results Of the 363 participants randomized, 260 (71.6%) provided a measure of mean change in weight over 18 months. The 18-month intervention resulted in weight decreasing from 93.1 kg (95% CI, 91.0 to 95.2 kg) to 85.6 kg (95% CI, 83.4 to 87.7 kg) (P < .001) in the SBWI group and from 92.7 kg (95% CI, 90.8 to 94.6 kg) to 86.4 kg (95% CI, 84.5 to 88.4 kg) in the STEP group (P < .001). The percentage change in weight from baseline to 18 months was −8.1% (95% CI, −9.4% to −6.9%) in the SBWI group (P < .001) compared with −6.9% (95% CI, −8.0% to −5.8%) in the STEP group (P < .001). Although the between-group difference in 18-month weight loss was not statistically different (−1.3 kg [95% CI, −2.8 to 0.2 kg]; P = .09), there was a significant group × time interaction effect (P = .03). The cost per participant was $1357 (95% CI, $1272 to $1442) for the SBWI group vs $785 (95% CI, $739 to $830) for the STEP group (P < .001). Both groups had significant and comparable improvements in resting heart rate, blood pressure level, and fitness. Conclusions Among overweight and obese adults, the use of SBWI resulted in a greater mean weight loss than STEP over 18 months. Compared with SBWI, STEP resulted in clinically meaningful weight loss that cost less to implement. Trial Registration clinicaltrials.gov Identifier: NCT00714168