This pilot program included training instructors, implementing ESMMWL in North Carolina counties, and measuring participant changes in weight, waist circumference, health behaviors, and confidence in ability to engage in physical activity and healthful eating. Instructors delivered courses in their own county between January 2008 and June 2009. Start and end dates varied by instructor. The North Carolina State University institutional review board approved the study for the protection of human participants.

At the first meeting, participants recorded their sex, race or ethnicity, age, and goal of weight maintenance or loss. Participants were encouraged to set a goal of losing no more than 2 lb per week. Pairs of participants, guided by instructors, measured their height and beginning and ending waist circumference and weight. BMI was calculated by 1 author (K.J.). Participants who attended the last class and completed measurements and an evaluation questionnaire, provided by the instructor, were considered "completers." The 30-item questionnaire documented self-reported changes in mindfulness and the 12 eating and physical activity behaviors taught in ESMMWL. It was developed by the writing team and reviewed by an evaluation specialist (9). Using a 5-point Likert scale (very low to very high), participants rated their confidence in engaging in the behavior both before and after the program, and they reported whether changes were a result of program participation. Participants reported their past participation in weight management classes and satisfaction with the ESMMWL course and described their weight as a "lifelong struggle" or a new concern. Data were entered and analyzed by 2 authors (K.J., L.W.). Two summary confidence scores were calculated as measures of program effectiveness. The score for confidence in their ability to engage in physical activity was based on being physically active more or less than 30 minutes per day and participating in strength training, and possible scores ranged from 3 to 15. The score for confidence in their ability to follow healthful eating behaviors was based on responses for 8 distinct healthful eating practices, and possible scores ranged from 8 to 40. Change scores (before and after program) were calculated for BMI, weight, waist circumference, and the 2 confidence scores for comparisons by race and sex. Change in the confidence scores was compared for weight-loss status and history of weight struggle and course participation.

The variables used to describe program performance included the number of instructors who delivered a course compared with the number trained; the number, frequency, and length of classes taught, course location, fees charged, and incentives provided; and participants' satisfaction and instructor comments. A course was "delivered" if instructors returned participant data and the instructor summary form that documented the number, frequency, duration, and site of the classes, fee charged, use of incentives, number of participants enrolled and completed, and instructor feedback. In a follow-up telephone survey of all trained instructors conducted by an author (C.D.), plans for future course offerings were documented. Participant dropout rate was calculated on the basis of the number of participants who completed the measurements and questionnaire on the last class day compared with the number with initial measurements only. The course was made available to adults who wanted "to lose weight, maintain a healthy weight, or learn healthier lifestyle behaviors" (9,10). Fees for the course were established by the instructor, based on the instructor's perception of what the market could bear and, in some cases, factoring in a partial rebate-type incentive for participants who completed all or most of the classes. Instructors used various avenues to market the program, including local newspapers, e-mail to existing clients, or flyers at worksites. Participant characteristics were used to determine whether specific audiences (eg, African Americans vs whites, past participants in weight-loss program vs first-timers) met their goals, were more mindful, or experienced changed confidence in eating or physical activity behaviors.

Data were analyzed using SPSS version 16 (SPSS, Inc, Chicago, Illinois). Frequency distributions and descriptive statistics were used to summarize participants' responses. Independent-samples t tests and Pearson correlations were used to describe the bivariate relationships between BMI changes and participant characteristics and ESMMWL course characteristics to determine what audience might complete a weight management course using this approach. We conducted a multiple linear regression with change in BMI as the outcome variable and participant and course characteristics as independent variables.

Of the 1,162 participants who completed ESMMWL, most were white women. The mean age was 51.8 years. Participants identified an average weight-loss goal of 15.5 lb (range, 0-76 lb); 83% reported that they moved toward or attained their goal. Most completers (87%) lost weight; the average was 8.4 lb (range, 0.1-44 lb). The means for BMI, weight, waist circumference, confidence in ability to be physically active, and confidence in ability to eat healthfully improved significantly after participation (Table 1). Approximately 92% of participants reported an increase in confidence in their ability to eat healthfully, and 82% reported an increase in confidence in their ability to be physically active. Changes in BMI, weight, and waist circumference were significantly different by race (Table 2). Participants who gained weight had significantly smaller changes in confidence scores for physical activity and for healthful eating, on average, than those who lost weight (Table 3).

At the conclusion of their course, most participants reported changes in eating behaviors, physical activity, and mindfulness (Table 4). They also reported increased confidence in their ability to engage in these healthy behaviors.

Seventy-nine instructors (53 extension agents, 26 HPCs) delivered 101 ESMMWL courses in 48 counties between January 2008 and June 2009. An additional 26 instructors planned to teach in the near future. Fifty ESMMWL courses were delivered at worksites and the rest in community settings such as faith organizations. Instructors taught an average of 16 lessons (range, 8-19) in 15 weeks (range, 8-24); most met weekly (97%) for 1 hour (83%). An average of 24 participants enrolled in a course, and 54% completed it. Participants paid fees ranging from $5 to $150. Approximately 80% paid $25 or less. Instructors reported that they could charge a fee for ESMMWL that would be less expensive than a clinical consult for weight management or fees being charged by commercial weight-loss programs, worksites, or hospital wellness facilities in their communities. Incentive(s) including giveaways, money, and time off from work were offered in 55% of the courses.

Variables that were significantly related to change in BMI (incentives, cost, number of lessons attended, confidence to eat healthfully and be physically active, and weight-loss goal) were included in a linear regression model to identify independent predictors (Table 5). Larger improvements in BMI were associated with greater change in confidence in ability to eat healthfully, a larger weight-loss goal, a greater number of weeks participating, and higher cost of the program.

Approximately 60% of participants reported a lifelong struggle with their weight; this was the first weight-loss class for approximately 33% of participants. More African Americans than whites reported that this was their first course (χ ² = 14.22, P < .001). Preprogram BMI was highest among those who had struggled with their weight and been in courses before. Change in confidence in ability to eat healthfully was significant and was greatest among participants who had struggled with their weight most of their lives and who were taking their first course (Table 6).

Approximately 97% of completing participants said that ESMMWL met their expectations, and 99% said they would recommend the program to others. Most participants were satisfied or very satisfied with the quality of instructors' presentations, instructors' knowledge, program materials, and overall quality of the program.

Instructors responded positively to the ESMMWL magazine and PowerPoint presentations, noting they contained major concepts in a concise, easily understood, colorful, and visually appealing presentation. Some said handouts were needed in addition to the magazine. Instructors reported that it was difficult to engage participants for 19 weeks and the course could be shortened by deleting repetition and combining some topics. They found it difficult to motivate participants to complete the food and physical activity diary for the entire course. They stated that attendance varied because of work conflicts and personal issues.