International Journal of Obesity (2013) 37, 468–472

& 2013 Macmillan Publishers Limited All rights reserved 0307-0565/13

www.nature.com/ijo

SHORT COMMUNICATION
Two-year outcomes of an adjunctive telephone coaching and
electronic contact intervention for adolescent weight-loss
maintenance: the Loozit randomized controlled trial
B Nguyen1, VA Shrewsbury1, J O’Connor1, KS Steinbeck2, AJ Hill3, S Shah4, MR Kohn5, S Torvaldsen6 and LA Baur1

This paper reports the final 24-month outcomes of a randomized controlled trial evaluating the effect of additional therapeutic
contact (ATC) as an adjunct to a community-based weight-management program for overweight and obese 13–16-year-olds.
ATC involved telephone coaching or short-message-service and/or email communication once per fortnight. Adolescents were
randomized to receive the Loozit group program—a two-phase behavioral lifestyle intervention with (n ¼ 73), or without (n ¼ 78),
ATC in Phase 2. Adolescents/parents separately attended seven weekly group sessions (Phase 1), followed by quarterly adolescent
sessions (Phase 2). Assessor-blinded, 24-month changes in anthropometry and metabolic health included primary outcomes body
mass index (BMI) z-score and waist:height ratio (WHtR). Secondary outcomes were self-reported psychosocial and lifestyle changes.
By 24 months, 17 adolescents had formally withdrawn. Relative to the Loozit program alone, ATC largely had no impact on
outcomes. Secondary pre-post assessment of the Loozit group program showed mean (95% CI) reductions in BMI z-score
( 0.13 ( 0.20,  0.06)) and WHtR ( 0.02 ( 0.03,  0.01)) in both arms, with several metabolic and psychosocial improvements.
Adjunctive ATC did not provide further benefits to the Loozit group program. We recommend that further work is needed to
optimize technological support for adolescents in weight-loss maintenance. Australian New Zealand Clinical Trials Registry Number
ACTRNO12606000175572.

International Journal of Obesity (2013) 37, 468–472; doi:10.1038/ijo.2012.74; published online 15 May 2012
Keywords: adolescent; randomized controlled trial; weight loss; weight maintenance; group therapy; cellular phone

INTRODUCTION (  0.12,  0.06)).3 At both 2 and 12 months, there were also

There are limited high-quality data on long-term outcomes
of adolescent obesity treatment, particularly low-intensity com-
munity-based programs that could be sustainably delivered in
typical healthcare systems.1 The Loozit group program is a
24-month behavioral lifestyle intervention specifically designed
to treat overweight and obese 13–16-year-olds in community
settings. The program involves seven weekly group sessions
(Phase 1) for adolescents and parents, followed by quarterly
adolescent booster group sessions for weight-loss maintenance
(Phase 2) between 2–24 months. The randomized controlled trial
(RCT) component, and novel aspect of this study, was the
evaluation of adjunctive additional therapeutic contact (ATC)
provided fortnightly to adolescents in one arm of the study, via
telephone coaching, short message service (SMS) and/or email
communication, in Phase 2. There are few, if any, community-
based adolescent weight-management RCTs that have such a long
weight-loss maintenance intervention or involve interactive
electronic contact.1
We have previously reported that Loozit group program
participants had a stabilization in overweight after 2 months,2
with greater reductions in overweight by 12 months (mean
(95% CI) change in body mass index (BMI) z-score (  0.09
improvements in most psychological outcomes, various metabolic
outcomes, and lifestyle behaviors.2,3 However, at 12 months,
ATC largely had no impact on outcome measures. The primary aim
of this paper was to evaluate the effectiveness of ATC provided as
an adjunct to this extended weight-loss maintenance intervention,
by reporting its impact on the final outcomes at 24 months.
A secondary aim was to report pre post outcomes of the Loozit
group program.
MATERIALS AND METHODS
Study design
Methods used in this paper replicate those in the 12-month outcomes
paper3 with further details published in the protocol.4 Recruitment
occurred from 2006 to 2009 mainly via media and schools.5 Eligible
participants were overweight and obese (BMI z-score: 1.0–2.5), but
otherwise healthy, 13–16-year-olds, who could attend group sessions
with a parent/carer, and had landline telephone and mobile phone and/or
email access. Randomization to the Loozit group program (‘G’-only) or
group program plus ATC (‘G þ ATC’), was stratified by sex, age and
intervention site, and occurred after informed written consent was
provided. This study is registered with the Australian New Zealand
Clinical Trials Registry (ACTRNO12606000175572) and was approved by

1
University of Sydney Clinical School, The Children’s Hospital at Westmead, Westmead, NSW, Australia; 2Academic Department of Adolescent Medicine, University of Sydney and
The Children’s Hospital at Westmead, Westmead, NSW, Australia; 3Academic Unit of Psychiatry & Behavioural Sciences, Institute of Health Sciences, Leeds University School of
Medicine, Leeds, UK; 4Primary Health Care Education and Research Unit, Sydney West Local Health District, Westmead, NSW, Australia; 5Department of Adolescent Medicine,
The Children0 s Hospital at Westmead, Westmead, NSW, Australia and 6School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia.
Correspondence: B Nguyen, University of Sydney Clinical School, The Children0 s Hospital at Westmead, Locked Bag 4001, Westmead, NSW-2145, Australia.
E-mail: binh.nguyenduy@health.nsw.gov.au
Received 30 November 2011; revised 4 April 2012; accepted 6 April 2012; published online 15 May 2012
 Table 1. Anthropometric and metabolic outcomes by treatment group and time over 24 months
a
Outcomes Assessment G-only group G þ ATC group Group effects between Time effects (24 Time effects (24 Time effects (24 months
baseline and 24 months minus months minus minus baseline) both
months (G þ ATC baseline) baseline) groups combined
minus G only) G only group G þ ATC group
Mean (s.d.) Mean (s.d.) Mean D (95% CI) Mean D (95% CI) Mean D (95% CI) Mean D (95% CI)

Anthropometry and BP
Height (cm) Baseline 163.3 (7.0) 164.6 (8.3) 1.3 (  1.2, 3.8) 5.5b (4.1, 7.0) 5.5b (4.3, 6.7) 5.5b (4.5, 6.4)
12 months 166.8 (7.8) 167.2 (8.7)
24 months 168.6 (9.2) 169.5 (9.0)
Weight (kg) Baseline 82.4 (12.4) 84.2 (16.3) 1.6 (  3.1, 6.2) 8.3b (5.4, 11.2) 6.4b (3.8, 9.0) 7.5b (5.6, 9.5)
12 months 85.9 (13.4) 88.1 (17.7)

& 2013 Macmillan Publishers Limited

24 months 90.7 (15.6) 88.6 (16.0)
BMI (kg m  2) Baseline 30.8 (3.5) 30.8 (4.2) 0.1 (  1.2, 1.3) 1.1b (0.2, 2.0) 0.4 (  0.5, 1.2) 0.8b (0.2, 1.4)
12 months 30.8 (3.8) 31.4 (4.8)
24 months 31.8 (4.5) 30.8 (4.6)
BMI z-score Baseline 2.02 (0.29) 2.03 (0.37)  0.01 (  0.11, 0.10)  0.09b (  0.17,  0.01)  0.17b (  0.29,  0.06)  0.13b (  0.20,  0.06)
12 months 1.94 (0.32) 1.97 (0.42)
24 months 1.93 (0.39) 1.83 (0.51)
Waist circumference (cm) Baseline 95.6 (9.8) 97.4 (12.0) 1.8 (  1.3, 4.9) 0.6 (  2.0, 3.1 )  0.3 (  3.4, 2.8) 0.2 (  1.7, 2.1)
12 months 95.1 (9.2) 96.3 (12.0)
24 months 96.4 (11.5) 95.9 (12.7)
WHtR Baseline 0.59 (0.06) 0.59 (0.06) 0.01 (  0.01, 0.02)  0.02 (  0.03, 0.00)  0.02b (  0.04, 0.00)  0.02b (  0.03,  0.01)
12 months 0.57 (0.05) 0.58 (0.06)
24 months 0.57 (0.06) 0.57 (0.07)
Systolic BP (mm Hg) Baseline 118 (12) 119 (13) 3 (0, 6)b,c 6b (2, 9) 2 (  2, 6) 4b (1, 7)
12 months 119 (10) 120 (13)
24 months 123 (12) 122 (13)
Diastolic BP (mm Hg) Baseline 60 (9) 60 (9) 1 (  1, 3) 2 (0, 5) 2 (  1, 4) 2b (0, 4)
12 months 60 (10) 61 (9)
24 months 62 (7) 62 (9)

Metabolic (Fasting)
Total cholesterol (mmol l  1) Baseline 4.4 (0.9) 4.4 (0.7) 0.0 (  0.2, 0.3)  0.2b (  0.4,  0.1)  0.1 (  0.3, 0.1)  0.2b (  0.3,  0.1)
12 months 4.3 (0.6) 4.4 (0.7)
24 months 4.2 (0.6) 4.2 (0.8)
LDL cholesterol (mmol l  1) Baseline 2.5 (0.7) 2.5 (0.7) 0.0 (  0.2, 0.2) 0.0 (  0.2, 0.1) 0.0 (  0.2, 0.2) 0.0 (  0.1, 0.1)
B Nguyen et al

12 months 2.5 (0.5) 2.6 (0.6)

24 months 2.5 (0.5) 2.5 (0.6)
HDL cholesterol (mmol l  1) Baseline 1.3 (0.3) 1.2 (0.4)  0.1 (  0.2, 0.0)  0.1b (  0.2, 0.0) 0.0 (  0.1, 0.1)  0.1b (  0.1, 0.0)
12 months 1.2 (0.2) 1.2 (0.3)
24 months 1.2 (0.3) 1.2 (0.3)
Triglycerides (mmol l  1)d Baseline 1.1 (0.7, 1.9)e 1.2 (0.7, 2.1)e 1.1 (0.9, 1.3) -0.9 (  1.0,  0.8)  0.8b (  1.0,  0.7)  0.9b (  1.0,  0.8)
12 months 1.0 (0.6, 1.8)e 1.1 (0.6, 2.0)e
24 months 1.0 (0.6, 1.6)e 1.0 (0.5, 2.1)e
Glucose (mmol l  1) Baseline 4.7 (0.4) 4.8 (0.5) 0.0 (  0.1, 0.1) 0.0 (  0.1, 0.2)  0.1 (  0.3, 0.1) 0.0 (  0.1, 0.1)
12 months 4.8 (0.3) 4.8 (0.5)
24 months 4.7 (0.5) 4.8 (0.6)
Insulin (mU l  1)d Baseline 16.0 (8.8, 29.1)e 20.1 (12.9, 31.2)e 1.2 (1.0, 1.3) 1.0 (0.9, 1.0) 0.9 (0.8, 1.0) 1.0 (0.9, 1.1)
12 months 17.0 (10.2, 28.2)e 19.3 (11.7, 31.8)e
24 months 15.6 (9.3, 26.3)e 17.6 (9.4, 33.1)e
ALT (U l  1)d Baseline 19 (11, 33)e 22 (14, 33)e 1 (1, 1) 1 (1, 1) 1 (1, 1) 1 (1, 1)
Two-year adolescent weight-loss maintenance

12 months 18 (12, 26)e 21 (14, 32)e

24 months 20 (11, 38)e 21 (12, 37)e

Abbreviations: ALT, alanine aminotransferase; BP, blood pressure; BMI, body mass index; CI, confidence interval; G-group only intervention; G þ ATC, group þ additional therapeutic contact intervention; HDL,
high-density lipoprotein; LDL, low-density lipoprotein; s.d., standard deviation; WHtR, waist:height ratio. aAll measured by blinded outcome assessors. bLinear mixed models (group, time); main effects of group
or time significant at P-value o0.05 (also marked in bold). No significant group-by-time interactions were found at 24 months for all listed variables. cThis finding was statistically significant at each time point
only after adjusting for sex and baseline age. dAs the baseline, 2-month, 12-month and 24-month data were not normally distributed, these variables were log transformed and then transformed back.
Geometric means are presented. eData presented as mean (mean minus s.d., mean plus s.d.). Mean minus s.d. and mean plus s.d. are not symmetrical around the mean because variables were log transformed
and transformed back.

International Journal of Obesity (2013) 468 – 472

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B Nguyen et al
470
Human Research Ethics Committees of The Children0 s Hospital at consistent with clinical practice guidelines.7 In Phase 2, ‘G þ ATC’
Westmead (CHW), Sydney West Local Health District, and the University adolescents were scheduled to receive ATC fortnightly (overall 14
of Sydney. telephone coaching sessions and 32 SMS and/or email messages).

Intervention
The Loozit group behavioral lifestyle intervention was conducted at a
community health center and CHW, Sydney, Australia, commencing
with 7  75-min weekly group sessions (Phase 1), held separately for
adolescents and parents/carers in both study arms. From 2–24 months
(Phase 2), the maintenance program involved 5  60-min quarterly
adolescent booster group sessions plus 12- and 24-month outcome
assessment sessions. Facilitated by trained dietitians, group sessions were
based upon a cognitive behavioral approach,6 and recommendations were
Measures
Primary outcomes were baseline to 24-month changes in BMI z-score8 and
waist:height ratio (WHtR). Secondary outcomes included changes in other
anthropometric and metabolic measures (Table 1) and self-reported
psychosocial and behavioral variables. Psychosocial well-being was
assessed using the Mental Health Inventory-5,9 sex-specific body
dissatisfaction scales,10 the MacArthur Scale of Subjective Social Status11
and the Harter Self Perception Profile for Adolescents.12 A 15-item food-
frequency questionnaire13 and eating behavior questions14 assessed

Assessed for eligibility (n=474)

Excluded (n=323)
Not meeting study criteria (n=225);
adolescent refused to participate (n=54);
unable to contact (n=26); other (n=18)
Randomised (n=151)

‘G’ intervention (n=78) ‘G+ATC’ intervention (n=73)

Baseline Baseline
Anthropometry/blood pressure (BP) assessment (n=78) Anthropometry/BP assessment (n=73)
Metabolic assessment (n=71) Metabolic assessment (n=64)

Between 0-2 months, 69 participants attended ≥ one Phase Between 0-2 months, 68 participants attended ≥ one Phase
1 group session and 9 did not (Reasons: cohort cancelled 1 group session and 5 did not (Reasons: cohort cancelled
[n=4]; found to be ineligible [n=1]; wanted one-to-one [n=4]; did not want to participate any longer [n=1])
support [n=2]; did not want to participate any longer [n=2])

2 months – end Phase 1 2 months – end Phase 1

Anthropometry/BP assessment (n=66) Anthropometry/BP assessment (n=64)a
Metabolic assessment (n=58) Metabolic assessment (n=53)
Formal withdrawals (n=3) Formal withdrawals (n=4)
Mother could not find childcare (n=1); did not want to Transport difficulties (n=2); difficult family situation (n=1);
participate any longer (n=2) post-baseline leg injury (n=1)

12 months 12 months
Anthropometry/BP assessment (n=50)b Anthropometry/BP assessment (n=57)b
Metabolic assessment (n=42) Metabolic assessment (n=44)
Formal withdrawals (n=0) Formal withdrawals (n=0)

24 months - end Phase 2 24 months - end Phase 2

Anthropometry/BP assessment (n=50)b Anthropometry/BP assessment (n=43)b
Metabolic assessment (n=39) Metabolic assessment (n=32)
Formal withdrawals (n=4)b Formal withdrawals (n=6)b
declined measurements due to: weight gain (n=1) or declined measurements due to: weight gain (n=3) or
program not helping (n=1); mother wanted to fear of not having done well (n=1); gradually withdrew
withdraw (n=1); adolescent did not want to attend from interventions (n=1); moved residence (n=1)
anymore (n=1)
Between 2-24 months, out of 64 participants continuing in
Between 2-24 months, out of 66 participants continuing the trial after Phase 1:
in the trial after Phase 1: 55 attended ≥ one booster session (median [range]: 3
49 attended ≥ one booster session (median [range]: 3 sessionsc [1 to 6d].
sessionsc [1 to 5d]). 64 were provided with ATC. The median [range]
number of telephone coaching sessions received was
12 [2 to 15d] and the number of SMS or email
messages sent was 31e [14 to 33d].

a One of these adolescents refused to have their anthropometry/blood pressure measured but continued in the study.
b The balance of adolescents who had their anthropometry/BP assessed at the previous time point did not attend this measurement session nor did they
formally withdraw from the study.
c Booster attendance was not significantly different between arms and declined from 69% to 31% between the first and final session.
d In some cohorts both arms started the Phase 1 intervention mid-school term and for this reason had an extra scheduled booster session, telephone
coaching session and SMS and/or email message above that specified in the study protocol. Some adolescents received less telephone coaching
sessions or SMS/email messages than specified in the protocol because they opted out of the ATC intervention or could not be contacted.
e The median [range] proportion of messages sent to adolescents that they replied to was 12% [0 to 55].

Figure 1. RCT participation from recruitment to 24 months.

International Journal of Obesity (2013) 468 – 472 & 2013 Macmillan Publishers Limited

dietary intake. The Children0 s Leisure Activities Study Survey measured
physical activity and sedentary behaviors.15 Adolescents and parents
anonymously completed program satisfaction questionnaires. Intervention
participation and reported adverse events were recorded.
Statistical analyses
Data were analyzed using SPSS, v.19 (SPSS Inc., Chicago, IL, USA) with
statistical significance accepted as Po0.05. Non-normally distributed
variables were log-transformed for analysis and are presented as back-
transformed data. Linear mixed models were used for all outcomes except
dietary variables that were dichotomized and analyzed with generalized
estimating equation models with a binomial distribution. Models used an
intention-to-treat approach with an unstructured covariance structure to
test for time (as repeated factor with levels: baseline, 2, 12 and 24 months)
and group effects. Group-by-time interactions were included if fixed effects
were significant. The least significant difference method was used for post
hoc comparisons. Base models were adjusted for additional significant
effects of sex and baseline age.
RESULTS
Participants
Figure 1 presents participation from recruitment to 24 months. Of
151 randomized adolescents, 9% did not receive any intervention,
and, by 24 months, a further 11% had formally withdrawn.
Twenty-four-month anthropometry/BP and metabolic outcomes
were assessed in 62% and 47% of adolescents, respectively.
Baseline anthropometry/BP and demographic characteristics were
not different between adolescents who formally withdrew and
those who did not, or adolescents with and without 24-month
follow-up. Booster session attendance declined from 69% to 31%
between the first and final session. The median (range) number of
telephone coaching sessions received and SMS/email messages
sent, respectively, was 12 (2 to 15) and 31 (14 to 33). Of
93 adolescents and 79 parents who completed satisfaction
questionnaires, respectively, 87% and 97%, responded they would
recommend the Loozit program to others. Adverse events
throughout the study included parent-reported disordered eating
(n ¼ 3) and poor body image (n ¼ 2), prescription drug overdose
(n ¼ 1) and a fractured ankle (n ¼ 1).
Effect of ATC
There were no statistically significant group effects or group-by-
time interactions indicating an effect of ATC for primary outcomes,
and very few for secondary outcomes at 24 months (Table 1).
Compared with the G-only group at each time point, the G þ ATC
group had a higher systolic BP (mean (95% CI) group difference:
3 mm Hg (0,6)), only after adjusting for sex and baseline age,
and lower perceived athletic competence (  0.22 (  0.44, 0.00)).
Accounting for significant group-by-time interactions did not
change 24-month outcomes except for the greater amount of
time spent using the computer in the G þ ATC group at 24 months
(2.3 h (1.0, 4.9)).
Pre-post assessment of the Loozit program
Anthropometry and metabolic health. Table 1 presents anthropo-
metric and metabolic outcomes by group and time. Time effects,
that is, baseline to 24-month changes, for both arms combined
are reported herein. At 24 months, there were statistically
significant reductions in BMI z-score, WHtR, total cholesterol,
HDL cholesterol and triglycerides, and increases in systolic
and diastolic BP. Adjusting for sex and baseline age had no
effect except the aforementioned group-by-time interaction for
systolic BP.
Psychosocial well-being and lifestyle behaviors. Improvements were
seen in: body shape satisfaction (mean: 0.43 (95% CI: 0.20, 0.65)),
subjective social status (1.26 (0.86, 1.66)), and except for close
& 2013 Macmillan Publishers Limited
Two-year adolescent weight-loss maintenance
B Nguyen et al
471
friendship, all Harter self-perception measures including global
self-worth (0.20 (0.09, 0.32)). Participants were more likely to
report less frequent consumption of high-fat meat products
(odds ratio: 0.22 (95% CI: 0.14, 0.36)), lunch every day (0.49 (0.30,
0.82)) and more likely to report never/rarely consuming fruit juice
(2.47 (1.59, 3.82)). Light-intensity physical activity reduced (mean:
 0.80 h (95% CI:  0.96,  0.64)) and total leisure activities
increased (1.2 h (1.0, 1.4)) including non-screen-based activities
(1.4 h (1.1, 1.7)). Adjusting for sex and baseline age had no effect
on these outcomes.
DISCUSSION
To our knowledge, this is the first community-based RCT in
adolescents investigating the potential impact of telephone
coaching combined with electronic communications on long-
term weight-management outcomes. As found at 12 months,3 the
ATC intervention did not have a significant impact on outcomes at
24 months or attendance at Phase 2 booster sessions. This finding
is surprising given the promising application of youth-friendly,
electronic technologies in weight-management interventions,16
and as a tool for behavior change.17 It is possible that ATC
provided once per fortnight in this RCT did not meet the threshold
for change. Daily SMS communications have since been found
acceptable to adolescents receiving obesity treatment18,19 but
weight outcomes were not evaluated.
The Loozit group program 24-month outcomes were similar to
those at 12 months.3 Between 12 and 24 months, adolescent
overweight (BMI z-score) reduced and previous reductions in
abdominal adiposity (WHtR) were sustained, despite the generally
poor long-term attendance at booster group sessions. Consistent
findings included reductions in total cholesterol, triglycerides,
consumption of high-fat meat products and lunch, and
improvements in most psychosocial outcomes. New findings at
24 months included increases in total and non-screen-based
leisure activities and BP (within normal range), and reductions in
HDL cholesterol and light physical activity. However, these results
reflect the expected secular increases in BP20 and sedentary
behaviors,21 and decreases in lunch intake21 and physical
activity.21
Absence of a ‘no treatment’ control group somewhat limits
interpretation of the group program0 s effectiveness but including
one would not have been ethical, given the intervention duration.
Another limitation was the increasing proportion of missing
outcome data (Figure 1), despite persistence in re-scheduling
missed measurement sessions.
The 24-month, Loozit group program has proved feasible to
deliver in a community setting with modest resources. However,
ATC provided no additional therapeutic benefit as a maintenance
adjunct to the Loozit program. These results highlight how
challenging long-term work with obese adolescents can be and
the need to identify strategies for further optimizing weight-
management outcomes and treatment engagement. We recom-
mend that future trials evaluate the health outcomes of adjunctive
ATC delivered at least once a week, and utilizing existing and
emerging youth-friendly technologies.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ACKNOWLEDGEMENTS
The Loozit RCT was funded by a University of Sydney Research & Development Grant
(2006); a bequest of the Estate of the late RT Hall (2006–08); Macquarie Bank
Foundation (2006–08); Financial Markets Foundation for Children (2007–08); and the
Heart Foundation of Australia Grant-in-Aid (2009–10). VAS was supported by an
Australian National Health and Medical Research Council Biomedical Postgraduate
International Journal of Obesity (2013) 468 – 472
 Two-year adolescent weight-loss maintenance
B Nguyen et al
472
Scholarship (#505009). The funding bodies did not have any input into the design
and conduct of the study; the collection, management, analysis, and interpretation of
the data; and the preparation, review or approval of this manuscript. We would like to
thank the participating adolescents and their parents/carers, as well as The Children0 s
Hospital at Westmead (CHW) Public Relations Department and local schools for
assisting with recruitment. We thank Dr Jennifer Peat and Dr Federica Barzi of the
Clinical Epidemiology Unit, CHW, for providing statistical advice. We would also like
to thank Anthea Lee, Kate Stevenson, Kristy McGregor, Michele Casey, Susie Burrell,
Kerryn Chisholm, Genevieve Dwyer, and Jessica Finlay for their contributions to
the study.
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