Group Lifestyle Balance Adapted for Individuals With Impaired Mobility: Outcomes for 6-Month RCT and Combined Groups at 12 Months

Published:November 04, 2020DOI:


      This study examines the feasibility and effectiveness of an intensive lifestyle intervention adapted for people with impaired mobility.

      Study design

      This was a randomized, wait-list controlled trial. The experimental group immediately received the 12-month weight loss program; the wait-list control group received it after a 6-month delay. Between-group comparisons were conducted for the 6-month RCT study design. Repeated measures were conducted for both groups combined after receiving the 12-month intervention. Data were collected August 2015–February 2017 and analyzed in 2017.


      A community-based sample received 23, group-based sessions via a mix of telephone and in-person sessions in a hospital-based setting. Participants with impaired mobility (n=66) were middle-aged (49.80 [SD=11.37] years), mostly White (66.7%), female (66.7%), and most commonly had spinal cord injury (47.0%).


      The 12-month intervention delivered 23 group-based sessions that promoted weight loss through reducing caloric intake and increasing physical activity.

      Main outcome measures

      Primary outcomes were effectiveness measured as change in weight and time spent in moderate physical activity. Feasibility was assessed in 12-month combined group analyses, measured as retention, attendance, and dietary self-monitoring.


      The 6-month RCT results showed that the immediate and delayed groups differed significantly (p<0.05) in weight (−1.66 [SD=4.42] kg loss vs 0.05 [SD=4.15] kg gain) and moderate physical activity (52.93 [SD=90.74] minutes/week increase vs −14.22 [SD=96.02] minutes/week decrease), accounting for baseline weight, time with disability, and age of onset. The 12-month results with groups combined demonstrated 74.2% retention and 77.7% core session attendance. Self-monitoring was higher in the delayed group (77.3%), who used a smartphone app, than the immediate group (47.3%), who mostly used paper trackers. Participants achieved significant 12-month weight loss of 3.31 (SD=10.13) kg (d=0.33) in mixed modeling analyses with groups combined yet did not significantly increase moderate physical activity.


      Group Lifestyle Balance Adapted for Individuals with Impaired Mobility is a feasible, effective approach to teach healthy lifestyle skills to individuals with mobility impairment, yielding modest weight loss and enhanced self-efficacy.

      Trial registration

      This study is registered at NCT03307187.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Courtney-Long EA
        • Carroll DD
        • Zhang QC
        • et al.
        Prevalence of disability and disability type among adults - United States, 2013.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 777-783
        • Taylor DM
        Americans with disabilities: 2014.
        U.S. Census Bureau, Washington, DCNovember 2018 (Published)
        • Froehlich-Grobe K
        • Lee J
        • Washburn RA
        Disparities in obesity and related conditions among Americans with disabilities.
        Am J Prev Med. 2013; 45: 83-90
        • Weil E
        • Wachterman M
        • McCarthy EP
        • et al.
        Obesity among adults with disabling conditions.
        JAMA. 2002; 288: 1265-1268
        • Carroll DD
        • Courtney-Long EA
        • Stevens AC
        • et al.
        Vital signs: disability and physical activity–United States, 2009‒2012.
        MMWR Morb Mortal Wkly Rep. 2014; 63 (Published August 22, 2020): 407-413
        • Grundy SM
        • Cleeman JI
        • Daniels SR
        • et al.
        Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute scientific statement.
        Circulation. 2005; 112: 2735-2752
        • Jensen MD
        • Ryan DH
        • Apovian CM
        • et al.
        2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society.
        J Am Coll Cardiol. 2014; 63: 2985-3023
        • Moyer VA
        • U.S. Preventive Services Task Force
        Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2012; 157: 373-378
        • U.S. Preventive Services Task Force
        Screening for obesity in adults: recommendations and rationale.
        Ann Intern Med. 2003; 139: 930-932
        • LeFevre ML
        • U.S. Preventive Services Task Force
        Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2014; 161: 587-593
        • Seiler N
        • Malcarney MB
        • Horton K
        • Dafflitto S
        Coverage of clinical preventive services under the Affordable Care Act: from law to access.
        Public Health Rep. 2014; 129: 526-532
        • Centers for Medicare and Medicaid Services
        Decision memo for intensive behavioral therapy for obesity (CAG-00423N).
        Centers for Medicare & Medicaid Services, Baltimore, MDNovember 29, 2011 (Published)
        • Centers for Medicare & Medicaid Services
        Medicare program; revisions to payment policies under the physician fee schedule and other revisions to Part B for CY 2018.
        Medicare Shared Savings Program requirements; and Medicare Diabetes Prevention Program, November 15, 2017 (Published)
        • Webb VL
        • Wadden TA.
        Intensive lifestyle intervention for obesity: principles, practices, and results.
        Gastroenterology. 2017; 152: 1752-1764
        • Campbell ML
        • Sheets D
        • Strong PS
        Secondary health conditions among middle-aged individuals with chronic physical disabilities: implications for unmet needs for services.
        Assist Technol. 1999; 11: 105-122
        • Rimmer JH
        • Rauworth A
        • Wang E
        • Heckerling PS
        • Gerber BS
        A randomized controlled trial to increase physical activity and reduce obesity in a predominantly African American group of women with mobility disabilities and severe obesity.
        Prev Med. 2009; 48: 473-479
        • Chen Y
        • Henson S
        • Jackson AB
        • Richards JS
        Obesity intervention in persons with spinal cord injury.
        Spinal Cord. 2006; 44: 82-91
        • Betts AC
        • Froehlich-Grobe K.
        Accessible weight loss: adapting a lifestyle intervention for adults with impaired mobility.
        Disabil Health J. 2017; 10: 139-144
        • Rimmer JH
        • Wang E
        • Pellegrini CA
        • Lullo C
        • Gerber BS
        Telehealth weight management intervention for adults with physical disabilities: a randomized controlled trial.
        Am J Phys Med Rehabil. 2013; 92: 1084-1094
        • Radomski M
        • Finkelstein M
        • Hagel S
        • Masemer S
        • Theis J
        • Thompson M
        A pilot wellness and weight management program for individuals with spinal cord injury: participants’ goals and outcomes.
        Top Spinal Cord Inj Rehabil. 2011; 17: 59-69
        • Nosek MA
        • Robinson-Whelen S
        • Ledoux TA
        • et al.
        A pilot test of the GoWoman weight management intervention for women with mobility impairments in the online virtual world of Second Life®.
        Disabil Rehabil. 2019; 41: 2718-2729
        • Littman AJ
        • Haselkorn JK
        • Arterburn DE
        • Boyko EJ
        Pilot randomized trial of a telephone-delivered physical activity and weight management intervention for individuals with lower extremity amputation.
        Disabil Health J. 2019; 12: 43-50
        • Reichard A
        • Saunders MD
        • Saunders RR
        • et al.
        A comparison of two weight management programs for adults with mobility impairments.
        Disabil Health J. 2015; 8: 61-69
        • National Center for Health Statistics
        • Centers for Disease Control and Prevention
        National Health and Nutrition Examination Survey 2013–2014 Data Documentation, Codebook, and Frequencies. Physical Functioning (PFQ_H).
        National Center for Health Statistics, CDC, Atlanta, GANovember 2016 (Accessed August 24, 2020)
        • National Institutes of Health
        Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults–the evidence report.
        Obes Res. 1998; 6 (Published August 24, 2020): 51S-209S
        • Buchholz AC
        • Bugaresti JM.
        A review of body mass index and waist circumference as markers of obesity and coronary heart disease risk in persons with chronic spinal cord injury.
        Spinal Cord. 2005; 43: 513-518
        • Wong CK
        • Wong RJ
        Standard and amputation-adjusted body mass index measures: comparison and relevance to functional measures, weight-related comorbidities, and dieting.
        Am J Phys Med Rehabil. 2017; 96: 912-915
        • BMI calculator for amputees
        Amputee Coalition.
        2017 (Published)
        • Wehmeyer ML
        The Arc's self-determination scale: procedural guidelines.
        Zarrow Center for Learning Enrichment, University of Oklahoma, Norman, OKAugust 1995 (Published)
        • Kramer MK
        • Vanderwood KK
        • Arena VC
        • et al.
        Evaluation of a Diabetes Prevention Program lifestyle intervention in older adults: a randomized controlled study in three senior/community centers of varying socioeconomic status.
        Diabetes Educ. 2018; 44: 118-129
        • Kramer MK
        • Kriska AM
        • Venditti EM
        • et al.
        Translating the Diabetes Prevention Program: a comprehensive model for prevention training and program delivery.
        Am J Prev Med. 2009; 37: 505-511
        • Venditti EM
        • Kramer MK.
        Necessary components for lifestyle modification interventions to reduce diabetes risk.
        Curr Diab Rep. 2012; 12: 138-146
        • Venditti EM
        • Kramer MK
        Diabetes Prevention Program community outreach: perspectives on lifestyle training and translation.
        Am J Prev Med. 2013; 44: S339-S345
        • Betts AC
        • Froehlich-Grobe K
        • Driver S
        • Carlton D
        • Kramer MK
        Reducing barriers to healthy weight: planned and responsive adaptations to a lifestyle intervention to serve people with impaired mobility.
        Disabil Health J. 2018; 11: 315-323
        • Driver S
        • Reynolds M
        • Woolsey A
        • et al.
        Impact of a community-based healthy lifestyle program on individuals with traumatic brain injury.
        J Head Trauma Rehabil. 2018; 33: E49-E58
        • Wardian JL
        • True MW
        • Sauerwein TJ
        • Watson NA
        • Hoover AM
        Evaluation of the Group Lifestyle Balance program in a military setting: an investment worth expanding.
        Mil Med. 2018; 183: e138-e143
        • O'Hara K
        • Stefancic A
        • Cabassa LJ
        Developing a peer-based healthy lifestyle program for people with serious mental illness in supportive housing.
        Transl Behav Med. 2017; 7: 793-803
        • Ma J
        • Yank V
        • Xiao L
        • et al.
        Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial.
        JAMA Intern Med. 2013; 173: 113-121
        • Taradash J
        • Kramer M
        • Molenaar D
        • Arena V
        • Vanderwood K
        • Kriska AM
        Recruitment for a Diabetes Prevention Program translation effort in a worksite setting.
        Contemp Clin Trials. 2015; 41: 204-210
        • Kramer MK
        • McWilliams JR
        • Chen HY
        • Siminerio LM
        A community-based diabetes prevention program: evaluation of the group lifestyle balance program delivered by diabetes educators.
        Diabetes Educ. 2011; 37: 659-668
        • Haskell WL
        • Lee IM
        • Pate RR
        • et al.
        Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association.
        Med Sci Sports Exerc. 2007; 39: 1423-1434
        • Craig CL
        • Marshall AL
        • Sjöström M
        • et al.
        International physical activity questionnaire: 12-country reliability and validity.
        Med Sci Sports Exerc. 2003; 35: 1381-1395
        • Becker H
        • Stuifenbergen A
        • Oh HS
        • Hall S
        Self-rated abilities for health practices: a health self-efficacy measure.
        Health Values. 1993; 17: 42-50
        • Bovaird JA
        Multilevel structural equation models for contextual factors.
        in: Little TD Bovaird JA Card NA Modeling Contextual Effects in Longitudinal Studies. Lawrence Erlbaum Associates, Inc., Mahwah, NJ2007: 149-182
        • Buchholz AC
        • McGillivray CF
        • Pencharz PB
        Differences in resting metabolic rate between paraplegic and able-bodied subjects are explained by differences in body composition.
        Am J Clin Nutr. 2003; 77: 371-378
        • Buchholz AC
        • Pencharz PB.
        Energy expenditure in chronic spinal cord injury.
        Curr Opin Clin Nutr Metab Care. 2004; 7: 635-639
        • Froehlich AK
        • Nary DE
        • White GW
        Identifying barriers to participation in physical activity for women with disabilities.
        Sci Psychosoc Process. 2002; 15: 21-29
        • Rimmer JH
        • Riley B
        • Wang E
        • Rauworth A
        Accessibility of health clubs for people with mobility disabilities and visual impairments.
        Am J Public Health. 2005; 95: 2022-2028
        • Rimmer JH
        • Wang E
        • Smith D
        Barriers associated with exercise and community access for individuals with stroke.
        J Rehabil Res Dev. 2008; 45: 315-322
        • Froehlich-Grobe K
        • Lollar D.
        Obesity and disability: time to act.
        Am J Prev Med. 2011; 41: 541-545
        • Katan MB
        • Ludwig DS
        Extra calories cause weight gain—but how much?.
        JAMA. 2010; 303: 65-66
        • Sheehan TJ
        • DuBrava S
        • DeChello LM
        • Fang Z
        Rates of weight change for black and white Americans over a twenty year period.
        Int J Obes Relat Metab Disord. 2003; 27: 498-504
        • Dutton GR
        • Kim Y
        • Jacobs Jr, DR
        • et al.
        25‐year weight gain in a racially balanced sample of U.S. adults: the CARDIA study.
        Obesity (Silver Spring). 2016; 24: 1962-1968
        • Osei‐Assibey G
        • Kyrou I
        • Adi Y
        • Kumar S
        • Matyka K
        Dietary and lifestyle interventions for weight management in adults from minority ethnic/non‐White groups: a systematic review.
        Obes Rev. 2010; 11: 769-776
        • Flegal KM
        • Carroll MD
        • Kit BK
        • Ogden CL
        Prevalence of obesity and trends in the distribution of body mass index among U.S. adults, 1999‒2010.
        JAMA. 2012; 307: 491-497
        • Svetkey LP
        • Erlinger TP
        • Vollmer WM
        • et al.
        Effect of lifestyle modifications on blood pressure by race, sex, hypertension status, and age.
        J Hum Hypertens. 2005; 19: 21-31
        • Radomski M
        • Finkelstein M
        • Hagel S
        • Masemer S
        • Theis J
        • Thompson M
        A pilot wellness and weight management program for individuals with spinal cord injury: participants’ goals and outcomes.
        Top Spinal Cord Inj Rehabil. 2011; 17 (Published August 24, 2020): 59-69
        • Rimmer JH
        • Wang E
        • Pellegrini CA
        • Lullo C
        • Gerber BS
        Telehealth weight management intervention for adults with physical disabilities: a randomized controlled trial.
        Am J Phys Med Rehabil. 2013; 92: 1084-1094
        • Betts AC
        • Froehlich-Grobe K.
        Accessible weight loss: adapting a lifestyle intervention for adults with impaired mobility.
        Disabil Health J. 2017; 10: 139-144