THE COACH APPROACH

Obesity is associated with an increased risk of cancers of the esophagus, breast (post-menopausal), endometrium (the lining of the uterus), colon and rectum, kidney, pancreas, thyroid, gallbladder, and possibly other cancer types, according to the National Cancer Institute. Obesity also puts people at higher risk for coronary heart disease, stroke, high blood pressure, diabetes, and a number of other chronic diseases. According to the Centers for Disease Control and Prevention, 34.9% (78.6 million) of U.S. adults were defined as obese (body mass index of 30 or above) in 2011-2012, with a slightly higher percentage of obese women (35.5%) than men (32.2%) among those 20 years or older in 1999-2008.

THE COACH APPROACH is a cognitive-behavioral, one-on-one exercise support program with a group-based nutrition education component for sedentary obese women who want to lose weight. Originally developed and implemented in YMCAs with wellness centers, THE COACH APPROACH is based on principles of social cognitive and self-efficacy theory. The intervention aims to support adherence to a newly initiated exercise regimen by highlighting improvements in participants' mood and their incremental progress toward goals, pairing exercise regimens with reinforcing rather than punishing feelings, incorporating an array of self-management and self-regulatory skills, and facilitating social supports. The intervention targets both physiologic outcomes (e.g., body fat, body mass index, weight circumference, resting heart rate, blood pressure) and psychological outcomes (e.g., self-efficacy, physical self-concept, total mood disturbance, body areas satisfaction), as well as attendance at exercise sessions and exercise drop-out.

Participants meet individually with an exercise leader once a month for 6 months. Each of the six meetings follows the same format. The exercise leader administers a brief survey to assess the participant's (1) present ability to tolerate exercise-related discomfort, (2) existing social supports, and (3) self-management/self-regulatory abilities. A survey called the Personal Goal Profile is administered to help the participant set long-term exercise goals, broken down into process-oriented, short-term goals. The exercise leader then works with the participant to develop a customized exercise plan incorporating group exercise classes, cardiovascular and strength equipment, and other resources at the facility, depending on the individual's preferences. Participants are generally encouraged to set a goal of exercising three times per week and increase cardiovascular exercise to at least 30 minutes per session by the third month. However, each participant's exercise plan is customized to reflect individual preferences and ensure that the intensity and duration of each exercise can be realistically maintained, based on the individual's response to exertion. Once the exercise plan is set, a behavior contract is signed by both the participant and exercise leader to increase the participant's commitment to follow the plan. Each monthly meeting also includes training on a specific self-management/self-regulatory skill, such as cognitive restructuring, stimulus control, dissociation from discomfort, self-reward, and preparation strategies for dealing with barriers to exercise such as boredom, family responsibilities, and anxiety. At the end of each meeting, the participant receives a handout summarizing key points for the self-management skill discussed.

The participant's progress toward her exercise goals is graphed and reviewed at each meeting, using data collected by a computerized workout tracking system at the facility (FitLinxx). The goals and exercise plan may be modified at each meeting based on responses to the surveys administered during meetings as well as responses to three self-administered surveys completed between meetings. The self-report surveys assess (1) perceived level of exertion and (2) exercise-induced feelings associated with specific exercises and (3) the participant's general psychological state, including energy, fatigue, and stress levels. Feedback provided by the exercise leader to the participant focuses on any improvements made, even if minor, and emphasizes feelings of mastery and competence over physiologic changes (which may be slow in coming).

For the nutrition education component, participants attend six biweekly 1-hour sessions provided by a registered dietician. The small-group sessions follow a standardized curriculum called Cultivating Health, which includes a 49-page workbook. Topics include (1) understanding calories, carbohydrates, protein, and fats; (2) calculating caloric needs for weight loss; (3) using the food guide pyramid; (4) developing a plan for appropriate snacking; and (5) menu planning. Although the curriculum is focused on weight loss, no specific caloric or fat restrictions are imposed on participants.

Exercise leaders should have a national certification related to exercise or health science and/or a bachelor's degree in this area and must complete a 1-day COACH APPROACH training session and a minimum of 10 hours of supervised practice. An exercise leader supervisor/director is also required to provide ongoing oversight and corrective feedback to ensure fidelity. The supervisor/director is required to complete the standard COACH APPROACH exercise leader training plus 4 hours of specialized training, and additionally should have at least 2 years of experience managing professionals delivering exercise and/or health services.

-- 1-day training for exercise leaders
-- 4 hours of additional training for a supervisor/director overseeing the exercise leaders
-- Minimum of 10 hours of supervised practice for exercise leaders
-- 6 hours of meetings with each participant (a full-time exercise leader can typically work with 100-125 participants)
-- 60-90 minutes monthly per exercise leader dedicated to program fidelity/quality assurance
-- Twelve 1-hour Cultivating Health Nutrition information sessions for participants
-- 72 exercise sessions (3 per week over 6 months) at least 30 minutes in duration for participants (may be fewer or more based on individual adherence/compliance)

THE COACH APPROACH targets individuals who have not engaged in any regular exercise in the past year and want to lose weight.

THE COACH APPROACH was originally developed for use in YMCAs with wellness centers. It may be implemented in any setting that can provide the necessary supports (e.g., access to fitness equipment, group exercise classes, and areas for walking and running; an appropriate space for exercise leaders and dieticians to meet with participants on a monthly basis).

Materials required for implementation include:
-- THE COACH APPROACH Implementation Handbook
-- THE COACH APPROACH Training Slides
-- THE COACH APPROACH Training Notes
-- THE COACH APPROACH Timeline
-- THE COACH APPROACH Test
-- THE COACH APPROACH Desk Reference
-- Cultivating Health Weight Management Resource Guide
-- Cultivating Health Weight Management Workbook

For costs associated with this program, please contact: James J. Annesi. (See products page on the EBCCP website for contact information)

A 6-month, randomized controlled trial evaluated the effects of THE COACH APPROACH among 273 obese women who wanted to lose weight, targeting physiologic and psychologic outcomes such as waist circumference, body mass index (BMI), body-fat percentage, and total mood disturbance. Study recruitment occurred through newspaper advertisements and targeted obese women, aged 21-65 years, with a BMI of 30-45 kg/m² who had engaged in no regular physical exercise during the past year. Potential participants could not be pregnant or planning to become pregnant and could not be taking any medications for weight loss at study entry or for the duration of the study. A written statement from a physician regarding adequate physical health to participate in an exercise study was required in addition to a signed informed consent.

Participants had a mean age of 43.2 years (range of 22-65 years) with a mean BMI of 36.6 kg/m² (range of 30.0-44.9 kg/m²). Fifty percent of the participants were White, 44% were African American, and 6% were from other racial groups. Eighty-seven percent of participants were in the lower-middle to middle socioeconomic class.

Two hundred seventy-three women were randomized to one of three conditions at separate but similar YMCA wellness centers in the metropolitan Atlanta area. The conditions were exercise support meetings plus nutrition education sessions (THE COACH APPROACH full intervention), COACH APPROACH with exercise support meetings only (comparison), and typical YMCA wellness center practices (control). All study participants were assigned an initial meeting with an exercise leader. Control group participants were offered typical YMCA member-professional contacts, which consisted of instruction on how to complete specific exercises, their associated benefits, exercises completed, and monthly appointments to adjust exercise regimens. Nutrition and weight-loss information given to the control and comparison groups was restricted to a one-page summary of suggestions from the American College of Sports Medicine. For each of the three conditions, three physical exercise sessions per week were assigned, with the goal of increasing cardiovascular exercise to at least 30 minutes per session by the third month. One-on-one contact time with exercise leaders was similar across conditions. Assessments occurred in a private area at each YMCA at baseline and at week 24.

At each assessment, body-fat percentage was measured using Lange skinfold calipers at three sites (abdomen, ilium, and triceps), applying the Jackson-Pollock equation. BMI (weight in kilograms by height in meters squared) and waist circumference (in centimeters) were measured by a recently calibrated digital scale and a tape measure at each of the two assessments by the same data collector.

Total Mood Disturbance was measured by the 30-item version of the Profile of Mood States-Brief (POMS-B), which includes 6 subscales: Tension, Fatigue, Depression, Confusion, Anger, and Vigor. Each subscale consists of five items. Respondents rate their feelings over the preceding week on a 5-point Likert-type scale ranging from 0 (not at all) to 4 (extremely). A total score was calculated by subtracting the Vigor subscale score from the sum of the other subscale scores; the total score ranges from -20 to 100, with higher scores indicating greater mood disturbance.

There were no significant baseline differences among groups for any of the physiological or psychological outcome measures.

• Participants in THE COACH APPROACH full intervention and comparison groups had a larger decrease in body-fat percentage than participants in the control group from baseline to week 24 (-2.75%, -1.81%, and -0.12%, respectively, p<.001). The decrease in body-fat percentage from baseline to week 24 did not differ significantly between participants in THE COACH APPROACH full intervention and comparison groups.

• Participants in THE COACH APPROACH full intervention group had a larger decrease in BMI from baseline to week 24 than participants in the control group (-0.92 vs. -0.15 kg/m², p=.038). The decrease in participant BMI from baseline to week 24 did not differ significantly between THE COACH APPROACH full intervention and comparison groups (-0.92 vs. -0.73, n.s.).

• Participants in THE COACH APPROACH full intervention group had a larger decrease in waist circumference than participants in either the comparison or control groups from baseline to week 24 (-4.28, -2.05, and -1.03 cm, respectively, p<.001). The decrease in participant waist circumference from baseline to week 24 did not differ significantly between the comparison and control groups.

• Participants in THE COACH APPROACH full intervention group had a larger decrease in Total Mood Disturbance (TMD) score on the POMS-B from baseline to week 24 than participants in either the comparison or control groups (-10.23, -5.24, and -3.41, respectively, p<.001). TMD scores did not differ significantly between participants in the comparison and control groups.

Other Findings

• Participants in THE COACH APPROACH full intervention and comparison groups attended a higher percentage of the assigned number of exercise sessions than participants in the control group (50.97%, 43.16%, and 31.07%, respectively, p<.001). The percentage of exercise sessions attended during the study did not differ significantly between THE COACH APPROACH full intervention and comparison groups.