Doug Howard

Doug Howard, a biomedical research associate who lost 100 pounds over the course of about 2 years as part of the POWER Study of Johns Hopkins Pro Health, stands in his kitchen with a pair of pre-weight loss pants that he once wore. (Barbara Haddock Taylor, Baltimore Sun / November 30, 2011)

Baltimore resident Doug Howard lost 100 pounds taking part in a Johns Hopkins study that could change the way people approach the daunting task of dropping pounds and keeping them off.

For the two-year study, Howard, like other participants, was referred by his doctor. He then received coaching, both in person and over the phone. Another group, also referred by a doctor, received counseling over the phone but did not attend in-person sessions.

And here's the surprising part: In both groups, participants lost an average of 10 pounds and kept it off. A control group that received a number of weight-loss pamphlets and access to a noninteractive website, but got no phone or in-person support, lost less than 2 pounds on average.

"I think originally we thought the in-person group would do better," said Arlene Dalcin, a research associate on the project, which was mainly sponsored by the National Heart, Lung and Blood Institute. "In fact, there was no difference between in-person and remote. Each group lost a little more than 10 pounds and kept it off for two years."

The study indicates that counseling support is critical to weight-loss success, and also that getting the support over the phone can be just as effective as attending group or one-on-one counseling sessions. That could be good news for people who don't have the time or motivation for in-person sessions, or maybe don't want to step on a scale in a room full of people.

"In most weight-loss studies, there is a lot of emphasis on frequent, in-person counseling sessions, but from a logistical perspective, it's a disaster," said study leader Dr. Lawrence Appel, a professor of medicine and director of the Welch Center for Prevention, Epidemiology and Clinical Research at the Johns Hopkins University.

"Patients start off strong but then stop attending in-person sessions. That's why I like the telephone program. It is convenient to individuals and can be done anywhere. You could be living in rural South Dakota, and we could deliver this intervention. It removes some of the major logistical barriers."

Howard, 33 and 6 feet tall, had reached 280 pounds and was suffering from Type 2 diabetes when his doctor referred him to the study. He received support in the form of group and one-on-one counseling sessions, followed by a period of time when he received online information and regular phone calls from a counselor.

While in the study, Howard began exercising daily and changed his eating habits, limiting his intake to 1,800 calories a day. "I ate a lot more than that before," he said. "I had trouble feeling full, and it took me a while to find foods I liked that would fill me up."

For his research job, he used to pack a lunch of a peanut-butter-and-jelly sandwich, a single-serve bag of potato chips, a granola bar, a cup of pudding and a full-calorie soda. Now, he still packs the sandwich, but he takes carrots and a piece of fruit instead of chips, water instead of soda, and sugar-free pudding and reduced-sugar granola bar.

Eventually, his support took the form of a monthly phone call. "It was much easier to take a five-minute phone call" than to go to a meeting, he said.

Howard said he's good at following instructions, so once he was given the tools for managing his nutrition and exercise, he had no problem sticking with the program. Since leaving the study in February, he has kept the weight off and no longer takes medication for diabetes.

The study involved 415 people referred by physicians. Most were obese, and all were in the program for two years. For the first three months, participants not in the control group received weekly counseling, either in person or over the phone. Then the contact became less frequent, and participants in the in-person group switched to phone counseling only.

Participants in both groups also visited a website that let them enter their weight, daily calorie intake and number of minutes of exercise, and provided information on topics such as food substitutions or exercise tips. If a week went by without a log-in, participants would get automated reminders, and if they still didn't respond, they'd get letters and phone calls from their coaches and doctors.

Janelle Coughlin, a psychologist in the psychiatry department at Hopkins, helped develop the program, including the phone-coaching component. The coaches were trained to use a system called motivational interviewing that helps people work through the reasons they have been unable to lose weight in the past, she said.

The advice itself was not particularly earth-shattering. "The general concept of 'Move more, eat healthy and eat less' is similar across all the trials," said Gerald J. Jerome, an assistant professor in the department of kinesiology at Towson University working with the Hopkins team. "Taking a lifestyle approach, where you're increasing your exercise and self-monitoring with respect to the calories you're eating, isn't the sexiest, but it really is effective."

Coughlin said the phone counseling worked so well because the coaches were well-trained and "really knew their patients. They had relationships with them." Even participants who had never met their counselors in person got to know them over the two years of the study.

"I think that's one of the keys," she said. "If patients had just been using the Internet without that relationship, I don't think we would have had the same results."

Gwen Stewart, 60, of Ellicott City, lost 85 pounds on the program, though she's regained about 25, she said. Like Howard, she is no longer taking medication for diabetes.

She participated from September 2008 to September 2010 as a member of the group that received both in-person and over-the-phone coaching. She said she liked the group meetings but was able to stick with the program even when receiving phone support without in-person meetings. While in the program, she said, she cut out fried foods, ate more vegetables, and began walking and working out at the local Y.

"It was really a good program, and the best part of it, of course, was being able to get off the medications and not being in the diabetic range any longer," she said. "I think it was just the fact that you had someone who was looking at your progress and making sure you kept on track, and somebody would encourage you to keep going."