Only one-fourth (26%) of all participants in the MOVE! group weight loss program attended six or more sessions during a six-month follow-up in 2008. More than 60% of all participants dropped out before the fourth session and 46% of the participants dropped out after attending just one treatment session.
Although high attrition is a common problem for weight management programs, MOVE! attrition rates appear to be higher than most. Tsai and Wadden  reported that attrition rates for nine weight loss programs ranged from 19% at 13 weeks to 56% at 26 weeks. All but two programs had less than 40% attrition during the initial phase that extended for 13 weeks or longer. Two programs with the highest attrition rates (45% and 56% at 26 weeks) offered on-site group counseling and 12 weeks of a very low calorie diet, respectively. Compared to these programs, an attrition rate of 74% before completing six visits represents a major challenge for achieving impact at the population level in the VA. Six of the 10 studies reviewed in Tsai and Wadden  were randomized controlled trials, whose initial screening and enrollment procedures may have functioned as a run-in process that screened out less motivated participants. The more selected sample in a controlled study than in a “take all comers” real world context might partially explain the much higher attrition in the MOVE! program than in other programs in the review. Nevertheless, regardless of whether the very high early attrition we observed is selective to the VA or a more general problem of real world obesity treatment programs, such attrition is clearly a barrier to optimal weight loss outcomes.
Because high attrition diminishes the effectiveness of weight management programs [1, 3–6], our analysis was focused on understanding factors that affect attrition. Older age, higher number of comorbidities, and higher BMI were all associated with greater retention, whereas male sex and non-Hispanic black race were associated with lower retention.
Previous research on factors that affect attrition from weight loss treatment is limited. Honas et al. (2003) examined data from a single medical weight management program and found that female sex, divorced status, African American race, and ages <50 were associated with higher attrition . Programs that promoted autonomous motivation  or used incentives  were found to increase retention, whereas high (or unrealistic) baseline weight loss expectations were found to increase attrition [2, 22]. Fabricatore and colleagues (2009) reported that younger age and baseline depressive symptoms are significantly associated with increased attrition from randomized clinical trials .
Our results were largely consistent with previous findings, except for marital status and comorbid depression which showed no significant association with attrition in our study (data not shown). Noticeably absent from the literature is information about how variations in accessibility, program features, and provider characteristics affect attrition. This is the first study to examine facility, program, and patient characteristics conjointly as potential factors affecting attrition in medical weight management programs.
A recent study of MOVE! best practices at 22 sites  identified the use of a standard curriculum and care delivered wholly or partly in a group-based format as one of two necessary (but not sufficient) factors for achieving larger patient weight loss outcomes. In the presence of these two necessary conditions, four combinations of conditions were determined to be sufficient for larger patient weight loss outcomes. These combinations included a design that required both individual and group-based care as well as a high staffing level. These findings parallel our findings that individual consultation and high staffing levels were both associated with retention.
Our results have several national and local policy implications. Geographic access is often a barrier to retention when MOVE! groups are held on-site. Electronic or telephone delivery of treatment offers potential solutions. Research on the effectiveness of Internet intervention has shown mixed results [1, 25–28] but obesity treatment delivery via telephone holds considerable promise . TeleMOVE!, a home telehealth version of MOVE! introduced in 2010, uses a home messaging device to provide 90-day cycles of daily, automated, interactive dialog with patients in response to data they transmit. A trained care coordinator monitors progress and intercedes with the patient as needed. TeleMOVE! can be used as an alternative channel of obesity treatment delivery to overcome geographic barriers to the program. However, its effectiveness has yet to be established.
Our findings suggest that more extensive use of individual consultation with specialists is warranted as an adjunct to group treatment early in the MOVE! program. Although we still do not clearly understand the extent to which effective obesity intervention requires in-person contact (or more specifically, which patients require it), our results as well as the “best practices” evaluation study  highlight the value of in-person contact and supplementing group sessions with individual consultation for both retention and outcomes.
Of the program factors we examined, regular on-site physical activity was the only strategy associated with increased retention. Currently, many sites do not have adequate resources for providing regular physical activity. According to the NCP Annual Report, 67% of facilities reported that indoor physical activities were barely or not at all sufficient for MOVE! program needs and 37% reported that outdoor physical activity facilities were insufficient.
Based on these results, we suggest that the VHA consider adopting a measure of MOVE! treatment retention as a facility performance or quality indicator. Current MOVE!-related measures focus on screening for obesity and participation in at least one treatment visit, but they do not recognize or reward facilities for better retention. In 2011, the VHA introduced retention as a pilot indicator of site performance. Future research should examine the effect of this indicator on attrition and, ultimately, on patient weight loss.
Major strengths of our study were its large sample and simultaneous modeling of individual, facility, and program characteristics associated with retention in an evidence-based group obesity treatment program. A limitation is that data for facility and program characteristics were drawn from the NCP Annual Report that is primarily used to monitor accountability within the healthcare system. This required report is completed by each facility’s MOVE! coordinator, and the fidelity with which facilities implemented each program strategy has not been validated. Also, because our study design was observational, causal inferences cannot be drawn.