Mood changes in behavioral weight loss programs

Diet, Obesity, and Depression: A Systematic Review

BACKGROUND

Obesity and depression co-occur in a significant proportion of the population. Mechanisms linking the two disorders include the immune and the endocrine system, psychological and social mechanisms. The aim of this systematic review was to ascertain whether weight loss through dietary interventions has the additional effect of ameliorating depressive symptoms in obese patients.

METHODS

We systematically searched three databases (Pubmed, Medline, Embase) for longitudinal clinical trials testing a dietary intervention in people with obesity and depression or symptoms of depression.

RESULTS

Twenty-four longitudinal clinical studies met the eligibility criteria with a total of 3244 included patients. Seventeen studies examined the effects of calorie-restricted diets and eight studies examined dietary supplements (two studies examined both). Only three studies examined people with a diagnosis of both obesity and depression. The majority of studies showed that interventions using a calorie-restricted diet resulted in decreases in depression scores, with effect sizes between ≈0.2 and ≈0.6. The results were less clear for dietary supplements.

CONCLUSIONS

People with obesity and depression appear to be a specific subgroup of depressed patients in which calorie-restricted diets might constitute a promising personalized treatment approach. The reduction of depressive symptoms may be related to immunoendocrine and psychosocial mechanisms.

Enhancing employee wellness: Translating an effective community behavioral weight-loss treatment to the worksite

BACKGROUND

As rates of obesity continue to rise in the USA, there is a need for effective treatments for excess adiposity. Behavioral weight-loss interventions can produce clinically meaningful weight reduction through life-style modifications. However, few studies have evaluated the effectiveness of high-intensity behavioral weight-loss interventions at worksites.

AIM

The present research investigated the effectiveness of a previously validated behavioral weight-loss intervention in a Hawai'i worksite.

METHODS

Thirty-six participants were recruited from the employee population of a local employer. Participants received six months of group behavioral weight-loss treatment from trained providers. Anthropomorphic, physiological, psychological, and behavioral assessments were collected pre and post treatment. Select physiological and behavioral assessments were collected every four sessions.

RESULTS

Sixty-one percent of participants adhered to treatment, and 78% of participants completed treatment. From pre to post treatment, results found that participants achieved clinically significant improvements in weight, body mass index (BMI), and waist circumference, with accompanying physiological, psychological, and behavioral improvements (F(12, 2)=101.379, p=0.010, partial η²=0.998). Analyses revealed that participants also achieved significant changes in weight, BMI, and waist circumference across time points, as well as improvements in specific eating habits.

CONCLUSIONS

The present study demonstrated the efficacy of a worksite behavioral weight-loss program. The present intervention produced clinically significant weight losses for a large proportion of participants, accompanied by significant improvements in physiological, behavioral, and psychological outcomes. This research is promising for the ongoing implementation of behavioral weight-loss approaches.

Changes in Cognitive Function Following Bariatric Surgery: a Systematic Review

Increased body mass is directly associated with reduced cognitive function. The aim of this study was to systematically review the effect of bariatric weight loss surgery on cognitive function. A comprehensive and unrestricted literature search was conducted using the following databases: MEDLINE, EMBASE, PubMed, Scopus, Web of Sciences, and the Cochrane Library. A total of 414 publications were identified, of which 18 were included in the final review. Cognitive function as measured by a number of different assessment tools was shown to improve following surgically induced weight loss in most studies. Significant and rapid weight loss resulting from bariatric surgery is associated with prompt and sustained improvements in cognitive function including memory, executive function, and cognitive control.

The Heterogeneity of Obesity: Fitting Treatments To Individuals - Republished Article

Body weight is regulated by a complex interaction of biological, behavioral, and cultural factors. The population as a whole is at risk for obesity because of increased intake of dietary fat, the consumption of calories in fewer meals per day, striking accessibility to palatable foods, and decreased physical activity. This risk may become a reality in individuals with certain biological predispositions (genetic tendency, low metabolic rate, increased fat cell number), specific eating patterns, and susceptibility to the extreme cultural pressure to be lean. These factors must be considered in establishing goals for treatment, which fall into medical and psychosocial categories. This includes defining a "reasonable" as opposed to "ideal" weight. A three-stage process is proposed for identifying the best treatment for an individual. This involves a classification decision, a stepped care decision, and then a matching decision. Criteria are provided for a comprehensive assessment of the overweight individual, and treatment options are reviewed for programs of varying intensity, cost, and risk.

Relation of Dieting in College and High School Students to Symptoms Associated with Semi-starvation

Dieting and concern with weight were found to be associated with psychological and neurological symptoms observed in cases of severe semi-starvation. College students of both sexes ( n 292) and high school females ( n121) rated themselves on dietary restraint and psychological and physical symptoms that were prevalent in men after 24 weeks in the Minnesota semi-starvation experiment of 1944–5. Apprehension, irritability, and moodiness were associated with a high concern with restraint. Blank spells, hunger pain, concern for health, and social withdrawal were associated with a history of restraint. Depression, lower self-esteem, eating behavior patterns, apathy, and decreased motivation were associated with both restraint parameters. Our results suggest that normal dieting may be more closely related to psychological and health risks associated with chronic semi-starvation than is commonly believed.

The impact on utilities of differences in body weight among Canadian patients with type 2 diabetes

OBJECTIVE

The objective of this study was to estimate utility values for hypothetical health states that describe differences in weight and quality of life associated with type 2 diabetes mellitus (DM) from Canadians with type 2 DM. The impact on utility values was examined separately for participants with a body mass index (BMI) of 18 to less than 25 kg/m(2) ('healthy'), 25 to less than 30 ('overweight'), and 30 or more ('obese').

METHODS

The health state descriptions were modified from a published diabetes utility study. Health states included a base-case type 2 DM health state (at participants' current weight), and six health states where the weight and attendant quality of life impact varied (base case ±3%, ±5%, and ±7% weight). Utilities were elicited using the time trade-off technique. Linear regression modeling was used to estimate the utility increment or decrement associated with a one unit difference in BMI.

RESULTS

Among 96 participants, the mean age was 55 years and 51% were men. The mean BMI was 32 kg/m(2) and 84% wanted to lose weight. The mean (SD) utility for the base-case state was 0.911 (0.013). Mean utilities (utility decrements) were 0.907 (-0.004), 0.865 (-0.046) and 0.806 (-0.105) for the health states describing an increased weight of 3%, 5% and 7%, respectively; and 0.923 (+0.012), 0.940 (+0.029) and 0.949 (+0.038) for the health states describing a decreased weight of 3%, 5% and 7%, respectively. For every increase of 1 kg/m(2) BMI there was an associated decrease in utility of 0.0472 (95% CI: 0.0375, 0.0569) and for every decrease of 1 kg/m(2) BMI there was an associated increase in utility of 0.0171 (95% CI: 0.0103, 0.0238).

CONCLUSIONS

The preferences of Canadian patients with type 2 DM for diabetes-related health states varied according to the weight, and quality of life impact, associated with that health state. Increased weight had a greater effect on utilities than decreased weight.

Lifestyle modification in the management of obesity: achievements and challenges

Lifestyle modification therapy for overweight and obese patients combines specific recommendations on diet and exercise with behavioral and cognitive procedures and strategies. In completers it produces a mean weight loss of 8-10 % in about 30 weeks of treatment. However, two main issues still to be resolved are how to improve dissemination of this approach, and how to help patients maintain the healthy behavioral changes and avoid weight gain in the long term. In recent years, several strategies for promoting and maintaining lifestyle modification have been evaluated, and promising results have been achieved by individualising the treatment, delivering the intervention by phone and internet or in a community setting, and combining lifestyle modification programs with residential treatment and bariatric surgery. These new strategies raise optimistic expectations for the effective management of obesity through lifestyle modification.

Major factors for facilitating change in behavioral strategies to reduce obesity

It is very unlikely that our obesity-promoting environment will change in the near future. It is therefore mandatory to improve our knowledge of the main factors associated with successful adoption of obesity-reducing behaviors. This may help design more powerful procedures and strategies to facilitate the adoption of healthy lifestyles in a "toxic" environment favoring the development of a positive energy balance. The aim of this review is to describe the main factors associated with successful adoption of obesity-reducing behaviors and to describe the most recent development, limits, and outcomes of lifestyle modification programs. The evidence regarding predictors of weight loss and weight loss maintenance remains largely incomplete. It is necessary to develop strategies matching treatments to patients' needs to improve successful weight loss and its maintenance. How to detect and how to address these needs is a continuous, challenging, research problem.

Influence of body mass index on the choice of therapy for depression and follow-up care

OBJECTIVE

Overweight and obese patients commonly suffer from depression and choice of depression therapy may alter weight. We conducted a cohort study to investigate whether obesity is associated with treatment choices for depression; and whether obesity is associated with appropriate duration of depression treatment and receipt of follow-up visits.

DESIGN AND METHODS

Adults with a diagnosis of depression between January 1, 2006 and March 31, 2010 who had 1+ new episodes of an antidepressant medication and/or psychotherapy were eligible. Medication use, encounters, diagnoses, height, and weight were collected from health plan databases. We modeled receipt of the different therapies (medication and psychotherapy) by BMI and BMI trajectory during the 9-months prior to initiation of therapy using logistic regression models that accommodated correlation within provider and adjusted for covariates. We modeled BMI via a restricted cubic spline. Fluoxetine was the reference treatment option in the medication models.

RESULTS

Lower BMI was associated with greater use of mirtazapine, and a declining BMI prior to treatment was associated with greater odds of initiating mirtazapine and paroxetine. Higher BMI was associated with greater odds of initiating bupropion even after adjustment for smoking status. Obese patients were less likely to receive psychotherapy and less likely to receive appropriate duration (180-days) of depression treatment compared to normal weight subjects.

CONCLUSIONS

Our study provides evidence that BMI is considered when choosing therapy but associations were weak. Our results should prompt discussion about recommending and choosing depression treatment plans that optimize depression care and weight management concurrently. Differences in care and follow-up by BMI warrant additional research.

Association between change in depression and change in weight among women enrolled in weight loss treatment

OBJECTIVE

To examine the association between improvement in depression and loss of weight among women with depressive symptoms entering a behavioral weight loss program.

METHODS

Women aged 40 to 65 with body mass index (BMI) of 30 or more and co-occurring symptoms of depression were identified by a population-based survey. A total of 203 of these women were enrolled in one of two behavioral treatment programs: one focused on weight loss and another on both weight loss and depression. Both programs included up to 26 group sessions over 12 months. Assessments at baseline, 6 months, 12 months and 24 months included measurement of weight, depressive symptoms, self-reported physical activity and estimated caloric intake (via food frequency questionnaire).

RESULTS

Over the first 6 months, women with a decrease in depression score were more likely to lose 5 kg or more than women without a significant decrease in depression (38% vs. 22%, odds ratio=2.20, 95% CI=1.09 to 4.44). Over the same period, improvement in depression was associated with increase in physical activity but not with change in caloric intake. Change in depression and change in weight were not significantly associated over later intervals (between 6 and 12 months or between 12 and 24 months).

CONCLUSIONS

Among women with co-occurring obesity and depression, short-term improvement in depression is associated with weight loss.

Change in body image and psychological well-being during behavioral obesity treatment: Associations with weight loss and maintenance

This study reports on outcomes from a behavioral obesity treatment program, evaluating if treatment-related changes in body image and psychological well-being are predictors of weight change during treatment and after follow-up. Participants were 142 overweight/obese women (BMI=30.2+/-3.7kg/m(2); age=38.3+/-5.8 years) participants in a behavioral treatment program consisting of a 4-month treatment period and a 12-month follow-up. Psychosocial variables improved during treatment and these changes were correlated with 4-month weight reduction. Short-term changes in body size dissatisfaction (p=.002) and mood (p=.003) predicted long-term weight loss. Additional results suggest that there might be a predictive role of short-term changes in body size dissatisfaction and self-esteem on long-term weight loss after accounting for initial weight change (p<.028). We conclude that, along with weight changes, cognitive and affect-related processes influenced during obesity treatment may be related long-term success, in some cases independently of initial weight loss.

Deficits in psychological well-being and quality-of-life in minor depression: implications for DSM-V

OBJECTIVE

To examine deficits in psychological well-being (PWB) and quality-of-life (QOL) in minor depressive disorder (Min D).

METHOD

Ninety-three subjects entering a treatment study for Min D were assessed using the QOL, Enjoyment and satisfaction questionnaire (Q-LES-Q), and the Psychological Well-Being Scale (PWBS). Scores were compared with major depressive disorder (MDD) and normative community samples.

RESULTS

Even though subjects had mild depressive severity, Q-LES-Q total scores for the Min D sample averaged nearly two standard deviations below the community norm. Almost 40% of Min D cases had Q-LES-Q scores in the lowest 1% of the population. Responses to most Q-LES-Q items were closer to subjects with MDD than to community norms. Mean standardized PWB scores were extremely low for subscales of Environmental Mastery and Self-Acceptance, low for Purpose in Life and Positive Relations with others, but within the normal range for Personal Growth and Autonomy. QOL and PWB measures had low correlations with depressive symptom severity, and scores were similar in the presence or absence of a prior history of MDD.

CONCLUSIONS

Mild depressive symptoms with Min D are associated with major deficits in QOL and PWB measures of environmental mastery and poor self-acceptance. Our findings suggest that diminished QOL and PWB may be intrinsic cognitive aspects of Min D with or without a history of MDD. It may be unnecessary in the DSM IV-TR to exclude the diagnosis of Min D if a subject has had a past episode of MDD. Minor depression exists along a continuum of depression. Deficits in psychological well-being and quality-of-life in minor depression are severe. No difference in these measures if minor depression existed with or without a history of major depression.

Long-term effects of provided low and high glycemic load low energy diets on mood and cognition

Energy-restricted low glycemic load diets are being used increasingly for weight loss. However, the long-term effects of such regimens on mood and cognitive performance are not known. We assessed the effects of low glycemic load (LG) and high glycemic load (HG) energy-restricted diets on mood and cognitive performance during 6 months of a randomized controlled trial when all food was provided. Subjects were 42 healthy overweight adults (age 35+/-5 years; BMI 27.8+/-1.6 kg/m(2)) with a mean weight loss of 8.7+/-5.0% that did not differ significantly by diet randomization. Mood was assessed by using the Profile of Mood States (POMS) questionnaire. Cognitive performance was assessed by using computerized tests of simple reaction time, vigilance, learning, short-term memory and attention, and language-based logical reasoning. Worsening mood outcome over time was observed in the HG diet group compared to the LG for the depression subscale of POMS (p=0.009 after including hunger as a covariate). There was no significant change over time in any cognitive performance values. These findings suggest a negative effect of an HG weight loss diet on sub-clinical depression but, in contrast to a previous suggestion, provide no support for differential effects of LG versus HD diets on cognitive performance.

Changes in symptoms of depression with weight loss: results of a randomized trial

Recent studies of rimonabant have re-awakened interest in the possible adverse psychiatric effects of weight loss, as well as of weight loss medications. This study examined changes in symptoms of depression in 194 obese participants (age = 43.7 +/- 10.2 years; BMI = 37.6 +/- 4.1 kg/m(2)) in a 1-year randomized trial of lifestyle modification and medication. Participants were assigned to (i) sibutramine alone; (ii) lifestyle modification alone; (iii) sibutramine plus lifestyle modification (i.e., combined therapy); or (iv) sibutramine plus brief therapy. Participants completed the Beck Depression Inventory-II (BDI-II) at baseline and weeks 6, 10, 18, 26, 40, and 52. At 1 year, participants in combined therapy lost the most weight and those in sibutramine alone the least (12.1 +/- 8.8% vs. 5.5 +/- 6.5%; P < 0.01). Mean BDI-II scores across all participants declined from 8.1 +/- 6.9 to 6.2 +/- 7.7 at 1 year (P < 0.001), with no significant differences among groups. Despite this favorable change, 13.9% of participants (across the four groups) reported potentially discernible increases (>or= 5 points on the BDI-II) in symptoms of depression at week 52. They lost significantly less weight than participants in the rest of the sample (5.4 +/- 7.8% vs. 9.0 +/- 7.8%, respectively; P < 0.03). The baseline prevalence of suicidal ideation was 3.6%. Seven new cases of suicidal ideation were observed during the year, with three in lifestyle modification alone. Further research is needed to identify characteristics of obese patients at risk of negative mood changes (and suicidal ideation) in response to behavioral and pharmacologic therapies.

Weight loss to treat urinary incontinence in overweight and obese women

BACKGROUND

Obesity is an established and modifiable risk factor for urinary incontinence, but conclusive evidence for a beneficial effect of weight loss on urinary incontinence is lacking.

METHODS

We randomly assigned 338 overweight and obese women with at least 10 urinary-incontinence episodes per week to an intensive 6-month weight-loss program that included diet, exercise, and behavior modification (226 patients) or to a structured education program (112 patients).

RESULTS

The mean (+/-SD) age of the participants was 53+/-11 years. The body-mass index (BMI) (the weight in kilograms divided by the square of the height in meters) and the weekly number of incontinence episodes as recorded in a 7-day diary of voiding were similar in the intervention group and the control group at baseline (BMI, 36+/-6 and 36+/-5, respectively; incontinence episodes, 24+/-18 and 24+/-16, respectively). The women in the intervention group had a mean weight loss of 8.0% (7.8 kg), as compared with 1.6% (1.5 kg) in the control group (P<0.001). After 6 months, the mean weekly number of incontinence episodes decreased by 47% in the intervention group, as compared with 28% in the control group (P=0.01). As compared with the control group, the intervention group had a greater decrease in the frequency of stress-incontinence episodes (P=0.02), but not of urge-incontinence episodes (P=0.14). A higher proportion of the intervention group than of the control group had a clinically relevant reduction of 70% or more in the frequency of all incontinence episodes (P<0.001), stress-incontinence episodes (P=0.009), and urge-incontinence episodes (P=0.04).

CONCLUSIONS

A 6-month behavioral intervention targeting weight loss reduced the frequency of self-reported urinary-incontinence episodes among overweight and obese women as compared with a control group. A decrease in urinary incontinence may be another benefit among the extensive health improvements associated with moderate weight reduction. (ClinicalTrials.gov number, NCT00091988.)

Weight-loss maintenance in successful weight losers: surgical vs non-surgical methods

OBJECTIVE

As large weight losses are rarely achieved through any method except bariatric surgery, there have been no studies comparing individuals who initially lost large amounts of weight through bariatric surgery or non-surgical means. The National Weight Control Registry (NWCR) provides a resource for making such unique comparisons. This study compared the amount of weight regain, behaviors and psychological characteristics in NWCR participants who were equally successful in losing and maintaining large amounts of weight through either bariatric surgery or non-surgical methods.

DESIGN

Surgical participants (n=105) were matched with two non-surgical participants (n=210) on gender, entry weight, maximum weight loss and weight-maintenance duration, and compared prospectively over 1 year.

RESULTS

Participants in the surgical and non-surgical groups reported having lost approximately 56 kg and keeping > or =13.6 kg off for 5.5+/-7.1 years. Both groups gained small but significant amounts of weight from registry entry to 1 year (P=0.034), but did not significantly differ in magnitude of weight regain (1.8+/-7.5 and 1.7+/-7.0 kg for surgical and non-surgical groups, respectively; P=0.369). Surgical participants reported less physical activity, more fast food and fat consumption, less dietary restraint, and higher depression and stress at entry and 1 year. Higher levels of disinhibition at entry and increased disinhibition over 1 year were related to weight regain in both groups.

CONCLUSIONS

Despite marked behavioral differences between the groups, significant differences in weight regain were not observed. The findings suggest that weight-loss maintenance comparable with that after bariatric surgery can be accomplished through non-surgical methods with more intensive behavioral efforts. Increased susceptibility to cues that trigger overeating may increase risk of weight regain regardless of initial weight-loss method.

Low- and high-carbohydrate weight-loss diets have similar effects on mood but not cognitive performance

BACKGROUND

Low-carbohydrate diets are often used to promote weight loss, but their effects on psychological function are largely unknown.

OBJECTIVE

We compared the effects of a low-carbohydrate, high-fat (LCHF) diet with a conventional high-carbohydrate, low-fat (HCLF) diet on mood and cognitive function.

DESIGN

Ninety-three overweight or obese participants [x +/- SEM age: 50.2 +/- 0.8 y; body mass index (in kg/m2): 33.6 +/- 0.4] were randomly assigned to an energy-restricted ( approximately 6-7 MJ, 30% deficit), planned isocaloric LCHF diet or an HCLF diet for 8 wk. Body weight and psychological well-being were measured by using the Profile of Mood States, Beck Depression Inventory, and Spielberger State Anxiety Inventory instruments at baseline and fortnightly. Cognitive functioning (working memory and speed of processing) was assessed at baseline and week 8.

RESULTS

The LCHF diet resulted in significantly greater weight loss than did the HCLF diet (7.8 +/- 0.4 and 6.4 +/- 0.4 kg, respectively; P = 0.04). Both groups showed improvements in psychological well-being (P < 0.01 for time), with the greatest effect occurring during the first 2 wk, but there was no significant difference between groups. There were no significant between-group differences in working memory (P = 0.68), but there was a significant time x diet interaction for speed of processing (P = 0.04), so that this measure improved less in the LCHF than in the HCLF diet group.

CONCLUSIONS

Both dietary patterns significantly reduced body weight and were associated with improvements in mood. There was some evidence for a smaller improvement in cognitive functioning with the LCHF diet with respect to speed of processing, but further studies are required to determine the replicability of this finding.

Weight loss treatment and psychological well-being: a review and meta-analysis

Research suggests that weight loss treatment generally benefits psychological well-being but these effects have never been quantitatively reviewed. A meta-analysis of 117 weight loss treatment tests showed that weight loss treatment was associated with lowered depression and increased self-esteem. Treatment type moderated treatment effects on depression and self-esteem. Actual weight loss moderated treatment effects on self-esteem but not depression; only treatments that produced actual weight loss predicted increased self-esteem whereas improvements in depression were independent of weight loss. The clinical implications of the findings and the possible causal relationships among weight, depression and self-esteem are discussed.

Changes in obesity-related attitudes in women seeking weight reduction

OBJECTIVE

To examine changes in obesity-related attitudes in a sample of obese women who participated in either dieting or non-dieting interventions.

RESEARCH METHODS AND PROCEDURES

A total of 123 obese women were randomly assigned to one of three weight control programs: meal replacement diet, balanced deficit diet, or a non-dieting program. (The first two groups were combined as a single dieting condition.) Participants completed questionnaires (at baseline, Week 20, and Week 40) to assess beliefs and attitudes about obesity, along with measures of self-esteem, depression, and body image.

RESULTS

At Weeks 20 and 40, participants in the non-dieting condition reported significantly less negativity about obesity than those in the dieting group. Women in the dieting condition did not report an increase in negative attitudes toward obesity, despite losing significantly more weight than non-dieting participants. Both groups experienced improvements in self-esteem, body image, and depressive symptoms. Improvement in self-esteem was associated with a reduction in negativity about obesity and with improvements in body image.

DISCUSSION

The non-dieting program produced greater reductions in negative attitudes toward obesity than the dieting intervention. Dieting (with successful weight loss), however, did not result in greater negativity toward obesity. Non-dieting programs seem to be useful in obese women for improving self-esteem, body image, and internalized negative attitudes about obesity.

Behavior Therapy and Cognitive-Behavioral Therapy of Obesity: Is There a Difference?

Current practice guidelines for management of overweight and obesity recommend a program of diet, exercise, and behavior therapy for all persons with a body mass index (calculated as kg/m(2)) of at least 30 (and those with body mass index > or =25 plus two weight-related comorbidities). In this tripartite treatment--often referred to as lifestyle modification--behavior therapy provides a structure that facilitates meeting goals for energy intake and expenditure. Although standard behavior therapy reliably induces mean weight losses of approximately 10% of initial weight, these reductions are difficult to maintain. Some authors argue that a shift in focus from behavior change to cognitive change will improve long-term results of lifestyle modification programs. This review describes, in detail, the standard behavioral treatment of obesity and compares it with an alternative treatment model that is based in a cognitive conceptualization of weight control. A review of the literature suggests that the differences between standard behavior therapy and cognitive-behavioral therapy of obesity lie more in their underlying theories than in their implementation. Empirical comparisons of the long-term effects of these approaches are needed.

Psychopathology and obesity

Obesity has historically been linked to emotional factors by clinicians and the lay public alike. Early psychiatric studies reinforced the popular perception that psychopathology is common among the overweight and plays an important role in the development of obesity. This notion has been challenged by recent investigations which suggest that psychological disturbances are more likely to be the consequences than the causes of obesity. Emotional difficulties faced by the obese may be largely attributable to an entrenched cultural contempt for the obese and a pervasive preoccupation with thinness.

Psychobiological impact of a progressive weight loss program in obese men

Psychobiological effects associated with a progressive body weight loss may help to improve the understanding of psychological barriers to weight loss. We hypothesized that a moderate body weight loss (about 10% of initial body weight) is accompanied with some negative psychological impact. Four questionnaires [SF-36 Health Survey, Three-Factor Eating Questionnaire (TFEQ), Beck Depression Inventory (BDI) and Pittsburgh Sleep Quality Index (PSQI)] were administered at each phase of a body weight loss program that consisted of a supervised diet and exercise clinical intervention to 11 obese men (mean BMI = 33.4 kg/m(2), mean age = 38 yr). The three phases investigated were: 1) at the beginning of the intervention (baseline); 2) after 5 +/- 1 kg body weight loss (Phase 1); and 3) after 10 +/- 1 kg body weight loss (Phase 2). Using the SF-36 Health Survey, physical and mental health were shown to be significantly improved at Phase 1 (p < 0.05). The TFEQ showed that cognitive dietary restraint increased (p < 0.001), and both disinhibition (p < 0.05) and susceptibility to hunger (p < 0.05) were significantly reduced at both Phase 1 and 2 compared to baseline. Depression as measured by the BDI significantly increased at Phase 2 (p < 0.05) compared to baseline and Phase 1. However, the mean BDI scores observed remained below the cut-off point for likely clinical significance. Finally, the PSQI showed that sleep quality was significantly improved at Phase 1 compared to baseline (p < 0.01). Altogether, these results suggest that a substantial improvement in the psychobiological profile occurs with a 5-kg weight loss (Phase 1) but that with additional weight loss (Phase 2) a small, but significant increase in depression occurred and seems to be associated with the increase in rigid restraint of eating. However, prospective studies with a larger sample are needed to confirm and deepen these results.

Personality-related characteristics in restricting versus binging and purging eating disordered patients

The current study sought to examine differences in personality-related characteristics between restricting anorexia nervosa (RAN), binging/purging anorexia (BPAN), and purging bulimia nervosa (BN) patients. Scores on the Temperament and Character Inventory (TCI) and on the Dutch Eating Behaviour Questionnaire (DEBQ) were compared for 166 RAN, 78 BPAN, and 151 BN patients. Bingers/purgers showed a higher score for restrained, external and emotional eating and a lower score for a subscale of "self-directedness" compared to patients who never binge and purge. Personality differences were most marked between RAN and BN patients, while personality characteristics of BPAN patients tended to be similar to those of BN patients. BN patients showed higher scores on "novelty seeking" and the subscales "exploratory excitability," "impulsivity," and "extravagance," and lower scores on "self-directedness," compared to restricting patients. Moreover RAN patients also showed higher scores on subscales of character dimensions, compared to BN patients. The higher the scores on novelty seeking, the lower the scores on several character scales, which has important implications for the reinforcement of behavior and the treatment of eating disorders.

Obesity and health-related quality of life: a cross-sectional analysis of the US population

OBJECTIVE

To examine the relationship between body mass index (BMI) and health-related quality-of-life (HRQL), in the presence of dietary controls and/or exercise in a national sample in the United States.

METHODS

BMI and its association with HRQL domains (physical, mental and activity limitations) were examined using the Centers' for Disease Control and Prevention's 2000 Behavioral Risk Factor Surveillence System (BRFSS) data, after adjusting for various sociodemographic factors, self-reported health-status, and diet/exercise behavior.

RESULTS

Based on World Health Organization's (WHO) classification of obesity, the study sample (N=182 372) included approximately 43.7% nonoverweight, 36% overweight, 14% obese, and 7% severely obese respondents. Exercise and dietary modifications were used by 17.5% of overweight, 15.2% of obese, and 12.5% of severely obese individuals. Logistic regression results using nonoverweight BMI as the reference category showed that severely obese (OR=1.87, 95% CI 1.64-2.12) and obese (OR=1.21, 95% CI 1.09-1.33) were more likely to experience greater than 14 unhealthy days affecting the physical health domain. Severely obese (OR=1.41, 95% CI 1.26-1.59) and obese (OR=1.17, 95% CI 1.07-1.28) were also more likely to experience greater than 14 unhealthy days affecting the mental health domain. Similarly, severely obese (OR=1.73, 95% CI 1.50-1.99) and obese (OR=1.22, 95% CI 1.08-1.37) were more likely to experience greater than 14 days with activity limitations. Exercise and dietary controls were associated with better HRQL across all three domains.

CONCLUSION

The study highlights the relationship between BMI and HRQL in the United States. The study also underlines the positive correlation of exercise and dietary modifications with HRQL.

Men gain additional psychological benefits by adding exercise to a weight-loss program

OBJECTIVE

Adding exercise to a comprehensive weight-loss program might not only attenuate any psychological distress associated with weight-loss attempts but also may provide psychological benefits. This study examined whether a diet-plus-exercise weight-loss program improved psychological outcomes more than a diet-only weight-loss program or an assessment-only control group.

RESEARCH METHODS AND PROCEDURES

This study was part of a larger 1-year randomized weight-loss trial examining the effects of diet and exercise on cardiovascular disease risk factors in 264 overweight adults. Psychological measures specific to weight control (e.g., cognitive restraint, disinhibition, hunger, and body dissatisfaction) as well as traditional measures of psychological distress (e.g., symptoms of depression, anxiety, and stress) were obtained at baseline and 1 year.

RESULTS

Men and women in either weight-loss program reported greater restraint, less disinhibition, and less hunger at 1 year than those in no program. Men in the diet-plus-exercise program experienced additional increases in restraint and decreases in hunger than did men in the diet-only program. Women in the diet-plus-exercise program did not experience additional psychological benefits specific to weight control than those in the diet-only program, despite increases in aerobic capacity.

DISCUSSION

The pattern seen for overweight men in the diet-plus-exercise program at 1 year-greater restraint, less disinhibition, and less hunger-is similar to the pattern seen in successful weight maintainers. These results underscore the need for innovative strategies that will enhance and sustain the pattern of psychological benefits specific to weight control associated with successful weight loss, especially for overweight women.

A case-control study of successful maintenance of a substantial weight loss: individuals who lost weight through surgery versus those who lost weight through non-surgical means

OBJECTIVE

To determine if method of weight loss (surgery; non-surgery) is associated with current levels of psychosocial functioning or current weight maintenance behaviors in individuals who have lost large amounts of weight.

DESIGN

Subjects were 67 cases and 67 controls selected from the National Weight Control Registry, a longitudinal study of individuals successful at long-term maintenance of weight loss. Cases had initially lost weight through bariatric surgery while controls had lost weight through non-surgical means. The current psychosocial functioning and weight maintenance behaviors of cases and controls were assessed and compared.

RESULTS

Cases and controls were matched on gender, current weight and total weight loss. Surgical cases reported significantly higher fat intake and lower physical activity levels. There were no differences in cases' and controls' reports of the impact of weight loss on other areas of their lives, neither were there differences on measures of depression or binge-eating.

CONCLUSIONS

Reported improvement in psychosocial functioning did not depend upon how weight was initially lost, but cases and controls appear to be using very different behaviors to maintain their weight losses.

Functional status and emotional well-being, dietary intake, and physical activity of severely obese subjects

OBJECTIVE

Analyze functional status and emotional well-being, energy and nutrient intake, and physical activity in sibling pairs raised together in the same family.

DESIGN

One sibling classified as severely obese (body mass index > or = 35) and the other sibling as normal weight (body mass index < or = 27).

SUBJECTS

From January 1994 through December 1996 at the Cardiovascular Genetics Research Clinic of the University of Utah School of Medicine, 145 sibling pairs (n = 290) were selected from a population-based, family history database or a hospital-based, very-low-energy weight-loss program.

STATISTICAL ANALYSIS PERFORMED

Repeated-measures analysis of variance tested for differences between severely obese and normal-weight siblings.

RESULTS

All functional status and emotional well-being scores (poorer perceived health) were significantly lower in severely obese siblings compared with normal-weight siblings. The severely obese siblings had a higher percentage dietary fat intake (3% higher) and total energy intake (more than 350 kcal higher), and lower weight-adjusted total energy intake (almost 10 kcal/kg lower) and activity energy expenditure (3.5 kcal/kg lower), compared with normal-weight siblings. Thus, environmental influences such as energy and nutrient intake and physical activity are highly related to severe obesity.

APPLICATIONS

Previously shared environment of severely obese and normal-weight siblings raises questions about whether strong environmental influences or genetic predisposition account for the differences in sibling weight. When counseling individuals or families with a history of severe obesity, dietetics practitioners should be familiar with the potential for strong genetic factors and related environmental influences. In addition, dietitians should be prepared to offer a flexible approach to physical exercise as well as provide additional behavioral support.

The psychological ramifications of weight management

It has long been believed that food restriction leads to psychological disturbances, including depression, preoccupation with food, and binge eating. However, recent studies suggest that comprehensive weight loss programs that incorporate behavioral treatment, diet change, and encouragement of physical activity in fact can improve the psychological state, including mood. A study conducted on subjects participating in the Weight Watchers program demonstrated positive psychological changes and improved quality of life. These changes may help motivate overweight people to maintain the physical activity and nutritional practices necessary to lose and maintain weight. Programs that include group support, like Weight Watchers, have been associated with psychological benefits independent of the amount of weight lost. Furthermore, dieters who regain lost weight do not appear to experience adverse psychological consequences. The development or exacerbation of bulimia has been linked by some authors to strict dieting, but more moderate weight control programs do not appear to produce disordered eating and may help reduce binge eating among overweight people. Individuals who successfully lose and maintain weight have been shown to experience improved mood, self-confidence, and quality of life. Additionally, decreasing levels of psychological and behavioral symptoms have been associated with increasing duration of weight loss maintenance. It can be concluded that quality of life and other psychological measures improve in individuals on comprehensive weight management programs.

Improved psychological well-being, quality of life, and health practices in moderately overweight women participating in a 12-week structured weight loss program

OBJECTIVE

To study the effects of a 12-week weight loss strategy involving increased physical activity, self-selected hypocaloric diet, and group support on psychological well-being, quality of life, and health practices in moderately obese women.

METHODS

Eighty women aged 20-49 years weighing between 20-50% above 1983 Metropolitan Life Insurance Tables were randomly assigned to a weight loss intervention (6279 kJ/week of physical activity, 33,258-41,462 kJ/week diet and weekly meetings) or served as controls. Subjects were tested pre and post 12-weeks.

RESULTS

The intervention group lost significant (p<0.001) body weight (kg) and body fat (%) compared to controls (-6.07+/-4.01 kg vs. 1.31+/-1.28 kg; 36.8%-32.5% vs. 36.2%-36.0%). Intervention subjects vs. controls achieved significant improvements (p<0.001) in body cathexis (X Change 18.6+/-16.7 vs. 0.7+/-8.6) and estimation of ability to achieve physical fitness (X Change 8.1+/-7.1 vs. 0.9+/-5.9). Various quality of life indices also improved (p<0.01) in the intervention group compared to controls (physical function: X Change 13.5.2+/-16.7 vs. 1.4+/-9.5; vitality: X change 21.7+/-17.9 vs. 2.9+/-20.8; mental health: X change 10.4+/-16.0 vs. 2.3+/-10.1). Similarly, physical activity levels also improved significantly (p<0.0001) in the intervention group (4.4+/-2.3 vs. 0.6+/-1.3; on NASA 0-7 scale).

CONCLUSIONS

Practical weight loss practices such as increased activity, self-selected hypocaloric diet, and group support are effective for weight loss and yield significant health and psychological benefits in moderately obese females.

Weight loss and psychopathology: a three-cluster MMPI typology

The present study investigated the effects of a treatment, including diet, exercise, and psychoeducational groups, on the severity of the psychopathology of obese subjects. The 120 subjects (60 male and 60 female), aged 20 to 50 years, were hospitalised for about two months. The mean Body Mass Index (BMI) at the start was 40.9 (SD = 5.3) and at the end 34.3 (SD = 5.5). The MMPI and clinical interview were administered to the subjects. The aims of the study were to see if there was change between the beginning and the end of treatment and to individuate groups of subjects homogeneous for the severity of the psychopathology at the start of treatment and to relate the severity to changes, whether worsening or improving, at the end of treatment. A multivariate analysis of variance showed significant change in scores on the psychological variables after treatment. Cluster analysis divided the patients into three groups with different severity of psychopathology. There were significant decreases on Hypochondriasis, Depression, and Social Introversion. Scores of the subjects with the most severe psychopathological traits changed most.

Depressive symptoms in overweight and obese older adults: a test of the "jolly fat" hypothesis

The association between body weight and depressive symptoms in older adults was examined in a population-based study of 2,245 noninstitutionalized men and women aged 50 to 89 years living in Rancho Bernardo, California, U.S.A. The prevalence of Beck Depression Inventory scores > or = 13 was inversely associated with body weight in men, but not in women. Overweight and obese 50- to 69-yr-old women were more depressed than women with a body mass index below 25 kg/m2, but the difference was only marginally significant (p = 0.09). When age, health status and medication use were controlled, the odds of being depressed were 0.34 (p = 0.004) in overweight men and 0.28 (p = 0.09) in obese men, compared to men with a body mass index below 25 kg/m2. In this cohort, depression in men was inversely associated with body weight, supporting the "Jolly Fat" hypothesis. The likelihood that more stigma is attached to excessive weight in women than men may account for the lack of an inverse association between weight and depression in women.

Assessing Impact of Weight on Quality of Life

This paper is a preliminary report on the development of a new instrument, the Impact of Weight on Quality of Life (IWQOL) questionnaire, that assesses the effects of weight on various areas of life. We conducted two studies utilizing subjects in treatment for obesity at Duke University Diet and Fitness Center. The first study describes item development, assesses reliability, and compares pre- and post-treatment scores on the IWQOL. In the second study we examined the effects of body mass index (BMI), gender, and age on subjects' perceptions of impact of weight on quality of life. Results indicate adequate psychometric properties with test-retest reliabilities averaging .75 for single items, and .89 for scales. Scale internal consistency averaged .87. Post-treatment scores differed significantly from pre-treatment scores on all scales, indicating that treatment produced positive changes in impact of weight on quality of life. The results of the second study indicate that the impact of weight generally worsened as the patients' size increased. However for women there was no association between BMI and impact of weight on Self-Esteem and Sexual Life. Even at the lowest BMI tertile studied, women reported that weight had a substantial impact in these areas. There were also significant gender differences, with women showing greater impact of weight on Self-Esteem and Sexual Life compared with men. The impact of age was a bit surprising, with some areas showing positive changes and others showing no change.

Behavioural and psychosocial aspects of obesity and its treatment

This chapter emphasized new directions being pursued in the behavioural treatment of obesity. Behavioural weight-loss programmes are being strengthened by their increased emphasis on low fat intake and exercise, by more direct intervention on behavioural antecedents and consequences of eating, by the use of very low calorie diets (VLCDs) and by the adoption of a chronic disease model and the concomitant lengthening of treatment programmes. With these approaches, initial weight losses of 10-20 kg can be achieved, and maintenance of weight losses of 5-10 kg can be expected. Treatments may also be strengthened by the identification of subgroups of the obese. Recently, progress has been made in this area with the description of a subgroup of the obese who have severe problems with binge eating. Binge eating disorder has been proposed as a new diagnostic category for DSM-IV. From 20 to 45% of the obese who present for treatment suffer from such problems. Obese binge eaters have worse mood and more psychopathology than obese people who do not binge eat, and are more likely to drop out of behavioural weight-control treatments. Although binge eaters may regain weight faster than non-binge eaters, both short- and long-term weight loss of binge eaters and non-binge eaters appear quite similar. Treatments have been identified that show promise in ameliorating binge eating for these patients, but these treatments have not produced weight loss. Although there has recently been concern about the possible negative effects of dieting on mood state, participation in behavioural weight-loss programmes is not associated with worsening mood in obese patients. No psychological variables have distinguished obese from non-obese individuals. Nonetheless, there is substantial prejudice against the obese. Awareness of this prejudice can lead to more sensitive and appropriate treatments for the problem of obesity.

The influence of weight reduction and exercise regimes upon the personality profiles of overweight males

In the present study, the MMPI was used to detect personality changes in 53 overweight, yet otherwise healthy, males who were participating in either a weight reduction or an aerobic exercise conditioning program. Analysis of pre- and post-intervention scores revealed that only the participants in the aerobic conditioning group demonstrated the predicted desirable psychological changes. More specifically, this group displayed significant clinically desirable changes on the Hs, PD, and HEA scores. Similar to the weight loss participants, a demographically matched nonintervention comparison group showed none of these desirable changes and actually yielded a significant increase on the D scale. However, when compared to this "normal" group, both intervention programs showed statistically significant differences on at least two MMPI scales.

Psychological features of obesity

The study of obesity from a variety of psychological perspectives has been exciting and inventive, although we still do not understand fully the role of psychological variables in the etiology of obesity. Many of the factors thought to be of etiologic significance--field dependence, lack of impulse control, inability to delay gratification, or a maladaptive eating style--have not been supported by experimental evidence. Other factors once thought to be of importance as causes of obesity, depression and dysphoria, for example, appear, instead, to be consequences of being obese and may serve to maintain and intensify weight-related problems. Dieting behavior in response to weight concerns appears, perversely, to be implicated in increasing overweight and adiposity. Finally, arousability in response to food cues in the environment may play a causal role in some obesities.

Dieting and depression: a critical review

Investigations of affective changes during weight reduction have produced sharply conflicting results. Studies conducted through the 1950s and 1960s indicated that weight reduction was accompanied by a high incidence of affective disturbance ranging from simple dysphoria to clinical depression and psychosis. More recently, studies of behavioral programs have suggested that weight reduction may actually improve mood. A critical and systematic review of the literature revealed that the conflicting evidence is best explained by differences in mood assessment. The method of mood assessment consistently predicted the affective changes observed in previous reports. Other variables previously thought to influence affective response to weight reduction, including duration of treatment and weight loss, did not independently predict outcome.

Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with type II diabetes?

Self-monitoring of blood glucose levels is currently being recommended for obese patients with type II diabetes to improve weight loss and glycemic control. To determine whether self-monitoring of blood glucose levels improves dietary compliance in these patients, 50 obese patients with type II diabetes were randomly assigned either to a standard behavioral weight control program or to a weight control program that included self-monitoring of blood glucose levels and focused on the weight-blood glucose relationship. Both groups lost significant amounts of weight and maintained their losses for at least one year; reductions in medication could be made for 70 percent of patients. These data suggest that the behavioral weight control used in this study may be of benefit to patients with type II diabetes. However, there was no evidence that the addition of self-monitoring of blood glucose levels to the treatment program improved the outcome in terms of weight loss, reduction in medication, dietary compliance, or mood state.