--- title: "paradoxical session attendance and weight loss relationships | Sutter Health" description: "Examining paradoxical session attendance and weight loss relationships in a clinic based lifestyle modification intervention" url: "https://www.sutterhealth.org/research/publications/paradoxical-session-attendance-weight-loss-relationships-1055312915" --- 1. [Home](https://www.sutterhealth.org/) / 2. [Research](https://www.sutterhealth.org/research) / 3. [Research publications](https://www.sutterhealth.org/research/publications) / 4. paradoxical session attendance and weight loss relationships # Examining paradoxical session attendance and weight loss relationships in a clinic based lifestyle modification intervention Kristen M. J. Azar, Sylvia Sudat, Qiwen Huang, Alice P. Pressman, Nina K. Szwerinski, Catherine Nasrallah, Elizabeth M. Venditti, & Robert J. Romanelli _Examining paradoxical session attendance and weight loss relationships in a clinic-based lifestyle modification intervention.Obes Sci Pract. 2023;_ 2023-07-04 ## Abstract Objective Evaluations of lifestyle modification interventions (LMIs), modeled after the Diabetes Prevention Program, have repeatedly shown a dose-response relationship between session attendance and weight loss. Despite this, not all participants had “average” weight loss experiences. Nearly one-third of LMI participants experienced unexpected, paradoxical outcomes (i.e., high attendance with little weight loss, and low attendance with clinically significant weight loss). Paradoxical weight-loss outcomes were characterized based on session attendance among participants in a group-based LMI in a real-world healthcare setting. This group-based LMI was delivered over 1 year to participants with the possibility of attending up to 25 sessions total. Methods LMI participants identified in 2010–2017 from electronic health records were characterized as having low (<75%) or high (≥75%) session attendance. Weight-loss outcomes were defined as expected (≥5%, high-attendance; <5%, low-attendance) or paradoxical (≥5%, low-attendance; <5%, high-attendance). Paradoxical-outcome-associated characteristics were identified using logistic regression. Results Among 1813 LMI participants, 1498 (82.6%) had low and 315 (17.4%) high session attendance; 555 (30.6%) had paradoxical outcomes, comprising 415 (74.8%) responders (≥5% weight-loss) and 140 (25.2%) non-responders (<5% weight-loss). Among participants with high session attendance, paradoxical non-responders were more likely to be female (odds ratio \[OR\]: 2.76; 95% confidence interval \[CI\]: 1.32, 5.77) and have type 2 diabetes (OR: 3.32; 95% CI: 1.01, 10.95). Among low-attendance participants, paradoxical responders were more likely to be non-Hispanic White and less likely to be non-Hispanic Black (OR: 0.35; 95% CI: 0.18, 0.69), non-Hispanic Asian (OR: 0.40; 95% CI: 0.22, 0.73), or Hispanic (OR: 0.53; 95% CI: 0.35, 0.80). Conclusions In a healthcare setting, nearly one-third of LMI participants experienced paradoxical outcomes. More research is needed to understand the facilitators and barriers to weight loss above and beyond session attendance. [PubMed abstract](https://doi.org/10.1002/osp4.696) ![Kristen M J Azar, RN, MSN, MPH](https://dyn.mktgcdn.com/p/rFmyR1kiX8JzE5-XNwup0gVC1GRaVTlH7oSDlG0Tr5A/fit=crop,gravity=auto,dpr=2,width=188,height=250,quality=100) Kristen M J Azar, RN, MSN, MPH Principal investigator [View profile](https://www.sutterhealth.org/research/investigators/kristen-m-j-azar-rn-msn-mph-1049680985) ![Sylvia Sudat, Ph.D.](https://dyn.mktgcdn.com/p/2AHRaDJwevdbwzC2ecrwY3nYIxbiqxd9NbpxBlI8Kpk/fit=crop,gravity=auto,dpr=2,width=188,height=250,quality=100) Sylvia Sudat, Ph.D. Principal investigator [View profile](https://www.sutterhealth.org/research/investigators/sylvia-sudat-phd-1049681027) ## Research topics - [Diabetes Type 2](https://www.sutterhealth.org/research-search-results?query=%22%5C%22Diabetes+Type+2%5C%22%22) - [Obesity](https://www.sutterhealth.org/research-search-results?query=%22%5C%22Obesity%5C%22%22) - [Diabetes, Insulin Resistance and Metabolic Syndrome](https://www.sutterhealth.org/research-search-results?query=%22%5C%22Diabetes%2C+Insulin+Resistance+and+Metabolic+Syndrome%5C%22%22) - [Prevention and Health Maintenance](https://www.sutterhealth.org/research-search-results?query=%22%5C%22Prevention+and+Health+Maintenance%5C%22%22) ## Related publications [View all publications](https://www.sutterhealth.org/research-search-results?verticalKey=research_publication) - Publication ### [Early weight loss and treatment response: data from a lifestyle change program in clinical practice.](https://www.sutterhealth.org/research/publications/early-wt-loss-and-tx-response-in-lifestyle-change-program-1055312721) Romanelli RJ, Sudat S, Huang Q, Pressman AR, Azar K. Am J Prev Med. pii: S0749-3797(19)30421-0. doi: 10.1016/j.amepre.2019.09.014. \[Epub ahead of print\] 2019 Dec 20 - Publication ### [Implementation of a group-based diabetes prevention program within a healthcare delivery system.](https://www.sutterhealth.org/research/publications/group-based-dm-prevention-in-healthcare-delivery-system-1055312659) Azar KMJ, Nasrallah C, Szwerinski NK, Petersen JJ, Halley MC, Greenwood D, Romanelli RJ. BMC Health Serv Res. 19(1):694. doi: 10.1186/s12913-019-4569-0. 2019 Oct 15 - Publication ### [Diabetes Prevention Program attendance is associated with improved patient activation: results from the Prediabetes Informed Decisions and Education (PRIDE) study.](https://www.sutterhealth.org/research/publications/diabetes-prevention-program-attendance-patient-activation-1055312692) Skrine Jeffers K, Castellon-Lopez Y, Grotts J, Mangione CM, Moin T, Tseng CH, Turk N, Frosch DL, Norris KC, Duke CC, Moreno G, Duru OK. Prev Med Rep. 16:100961. doi: 10.1016/j.pmedr.2019.100961. eCollection 2019 Dec. 2019 Jul 22 - Publication ### [Longitudinal weight outcomes from a behavioral lifestyle intervention in clinical practice.](https://www.sutterhealth.org/research/publications/weight-outcomes-from-behavioral-lifestyle-intervention-1055312674) Romanelli RJ, Huang HC, Chopra V, Ma J, Venditti EM, Sudat S, Greenwood DA, Pressman AR, Azar KMJ. Diabetes Educ. 145721719872553. doi: 10.1177/0145721719872553. \[Epub ahead of print\] 2019 Sep 03 - Publication ### [Diabetes prevention and weight loss with a fully automated behavioral intervention by email, web, and mobile phone: a randomized controlled trial among persons with prediabetes.](https://www.sutterhealth.org/research/publications/diabetes-prev-wt-loss-automated-beh-intervention-1055312953) Block G, Azar KM, Romanelli RJ, Block TJ, Hopkins D, Carpenter HA, Dolginsky MS, Hudes ML, Palaniappan LP, Block CH. J Med Internet Res. 17(10):e240. doi: 10.2196/jmir.4897. 2015 Oct 23 [View all publications](https://www.sutterhealth.org/research-search-results?verticalKey=research_publication) ```json {"@context":"https://schema.org","@type":"MedicalOrganization","name":"Sutter Health","@id":"https://www.sutterhealth.org/#medicalorganization","url":"https://www.sutterhealth.org","logo":"https://www.sutterhealth.org/static/images/sutter-health-logo.svg","address":{"@type":"PostalAddress","streetAddress":"2200 River Plaza Drive","addressLocality":"Sacramento","addressRegion":"CA","postalCode":"95833","addressCountry":"US"},"areaServed":{"@type":"AdministrativeArea","name":"California"},"sameAs":["https://www.facebook.com/SutterHealth","https://www.instagram.com/sutterhealth/","https://x.com/SutterHealth","https://www.youtube.com/sutterhealth","https://www.linkedin.com/company/sutter-health","https://en.wikipedia.org/wiki/Sutter_Health"]} ``` ```json {"@context":"https://schema.org","@type":"BreadcrumbList","@id":"https://www.sutterhealth.org/research/publications/paradoxical-session-attendance-weight-loss-relationships-1055312915#breadcrumblist","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https://www.sutterhealth.org/"},{"@type":"ListItem","position":2,"name":"Research","item":"https://www.sutterhealth.org/research"},{"@type":"ListItem","position":3,"name":"Research publications","item":"https://www.sutterhealth.org/research/publications"},{"@type":"ListItem","position":4,"name":"paradoxical session attendance and weight loss relationships"}]} ``` ```json {"@context":"https://schema.org","@type":"MedicalScholarlyArticle","@id":"https://www.sutterhealth.org/research/publications/paradoxical-session-attendance-weight-loss-relationships-1055312915#medicalscholarlyarticle","name":"Examining paradoxical session attendance and weight loss relationships in a clinic based lifestyle modification intervention","headline":"paradoxical session attendance and weight loss relationships","abstract":"Objective Evaluations of lifestyle modification interventions (LMIs), modeled after the Diabetes Prevention Program, have repeatedly shown a dose-response relationship between session attendance and weight loss. Despite this, not all participants had “average” weight loss experiences. Nearly one-third of LMI participants experienced unexpected, paradoxical outcomes (i.e., high attendance with little weight loss, and low attendance with clinically significant weight loss). Paradoxical weight-loss outcomes were characterized based on session attendance among participants in a group-based LMI in a real-world healthcare setting. This group-based LMI was delivered over 1 year to participants with the possibility of attending up to 25 sessions total. Methods LMI participants identified in 2010–2017 from electronic health records were characterized as having low (\u003c75%) or high (≥75%) session attendance. Weight-loss outcomes were defined as expected (≥5%, high-attendance; \u003c5%, low-attendance) or paradoxical (≥5%, low-attendance; \u003c5%, high-attendance). Paradoxical-outcome-associated characteristics were identified using logistic regression. Results Among 1813 LMI participants, 1498 (82.6%) had low and 315 (17.4%) high session attendance; 555 (30.6%) had paradoxical outcomes, comprising 415 (74.8%) responders (≥5% weight-loss) and 140 (25.2%) non-responders (\u003c5% weight-loss). Among participants with high session attendance, paradoxical non-responders were more likely to be female (odds ratio [OR]: 2.76; 95% confidence interval [CI]: 1.32, 5.77) and have type 2 diabetes (OR: 3.32; 95% CI: 1.01, 10.95). Among low-attendance participants, paradoxical responders were more likely to be non-Hispanic White and less likely to be non-Hispanic Black (OR: 0.35; 95% CI: 0.18, 0.69), non-Hispanic Asian (OR: 0.40; 95% CI: 0.22, 0.73), or Hispanic (OR: 0.53; 95% CI: 0.35, 0.80). Conclusions In a healthcare setting, nearly one-third of LMI participants experienced paradoxical outcomes. 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