A qualitative exploration of facilitators and barriers of adherence to time-restricted eating

Meanings that mothers of obese children attribute to eating habits: grounded theory

OBJECTIVE

To describe the meanings that mothers of obese children attribute to eating habits in Morelia, Michoacán, Mexico.

METHOD

Qualitative study, based on grounded theory and the premises of symbolic interactionism, conducted through semi-structured, individual, recorded and transcribed interviews, using intentional and theoretical sampling, with data analysis using the constant comparative method and the help of the ATLAS.ti software.

RESULTS

There were fourteen mothers as participants, with an average age of 36 years old, 50% in a stable union and 71% with paid work. The emerging categories were: 1. Mothers feeding based on their children's tastes, emotions and preferences; 2. Mothers compensating their children with food; 3. Mothers dealing with emotions; and 4. Mothers working and having to delegate childcare. Significant changes in eating habits were identified, since women, simultaneously exercising the roles of caregivers and providers, opt for quick and easy-to-prepare meals, which are most often ultra-processed food.

CONCLUSIONS

The meaning attributed to eating habits emerges from the social interaction that the mother establishes with her children and her partner, being constructed based on tastes and food preferences and interpreted as an act of love and care.

Time-Restricted Eating is a Feasible Dietary Strategy in the Treatment of Complicated Type 2 Diabetes: The RESET2 Pilot Study

OBJECTIVE

To investigate the feasibility of a 12-week time-restricted eating (TRE) intervention targeting people with overweight/obesity and complicated type 2 diabetes to inform the design of a 1-year randomized controlled trial.

METHODS

In this single-arm pilot study, 20 participants with overweight/obesity and complicated type 2 diabetes were recruited from the diabetes clinics at Hvidovre Hospital and Steno Diabetes Center Copenhagen in the Greater Copenhagen area, Denmark. Participants followed 8 weeks of strict 10-hour TRE, followed by a 4-week TRE period with individual adjustments and support options.

RESULTS

Nineteen participants completed the intervention. Median (quartile 1-quartile 3) adherence to the eating window across all 12 weeks was 94% (86-98). Mean (95% confidence interval) reductions in body weight of -2.0 kg (-2.9 to -1.1) and hemoglobin A1c of -0.4% (-0.6 to -0.1) were observed. Participants expressed that the individualized options added flexibility to the eating concept, enabled the maintenance of social life, and eased challenging times with TRE.

CONCLUSIONS AND IMPLICATIONS

Twelve weeks of TRE was feasible. Individualized adjustments and support may have the potential to facilitate the maintenance of long-term TRE.

Maintenance of time-restricted eating and high-intensity interval training in women with overweight/obesity 2 years after a randomized controlled trial

Time-restricted eating (TRE) and high-intensity interval training (HIIT) improve cardiometabolic health in individuals with overweight/obesity, with high adherence rates in supervised settings. Long-term maintenance of TRE and HIIT in real-world settings is unknown. In our previous TREHIIT trial, 131 women (body mass index (BMI) ≥ 27 kg/m2) were randomized to 7 weeks of TRE (eating window 10-h/day), HIIT (3 sessions/week), a combination (TREHIIT), or no intervention (CON). We investigated self-reported continuation of TRE and/or HIIT after 2 years. Fifty-nine participants (39.0 years (standard deviation (SD) 6.1), BMI 30.7 kg/m2 (SD 4.2)) attended the follow-up. Of those who completed the 7-week TRE or HIIT intervention, 46% maintained TRE and 45% continued HIIT for 2 years. There were no statistically significant (at p < .01) between-group differences in cardiometabolic outcomes, but non-significant lower body mass in HIIT (-4.2 kg, 95% confidence interval (CI), -7.7 to -0.7, p = .019) and visceral fat in TREHIIT (-18 cm2, CI, -33 to -4, p = .015) versus CON. After 2 years, HIIT and TREHIIT had ~ 4 kg lower fat mass and ~ 20 cm² lower visceral fat (both p < .001) compared with baseline. A short-term TRE and HIIT intervention may promote long-term lifestyle changes and health benefits. Future studies should collect objective adherence data to understand long-term maintenance of TRE and HIIT.

Intermittent Fasting: Implications for Obesity-Related Colorectal Tumorigenesis

Obesity is associated with metabolic and immune perturbations (ie, insulin resistance, increased inflammation, and oxidative stress), circadian rhythm dysregulation, and gut microbial changes that can promote colorectal tumorigenesis. Colorectal cancer (CRC) is the third most incident cancer in the United States. This narrative review examines the effects of intermittend fasting on factors influencing colon tumorigenesis, such as body weight, metabolic and immune markers, circadian rythm, and the gut microbiota in humans. Findings suggest that intermittent fasting regimens can lead to weight loss and shifts in metabolic markers, which could be preventive for CRC but effects on the gut microbiota composition and functions still remains elusive.

Time Restricted Eating: A Valuable Alternative to Calorie Restriction for Addressing Obesity?

PURPOSE OF REVIEW

In this review, we summarize the molecular effects of time-restricted eating (TRE) and its possible role in appetite regulation. We also discuss the potential clinical benefits of TRE in obesity.

RECENT FINDINGS

TRE is an emerging dietary approach consisting in limiting food intake to a specific window of time each day. The rationale behind this strategy is to restore the circadian misalignment, commonly seen in obesity. Preclinical studies have shown that restricting food intake only during the active phase of the day can positively influence several cellular functions including senescence, mitochondrial activity, inflammation, autophagy and nutrients' sensing pathways. Furthermore, TRE may play a role by modulating appetite and satiety hormones, though further research is needed to clarify its exact mechanisms. Clinical trials involving patients with obesity or type 2 diabetes suggest that TRE can be effective for weight loss, but its broader effects on improving other clinical outcomes, such as cardiovascular risk factors, remain less certain. The epidemic proportions of obesity cause urgency to find dietary, pharmacological and surgical interventions that can be effective in the medium and long term. According to its molecular effects, TRE can be an interesting alternative to caloric restriction in the treatment of obesity, but the considerable variability across clinical trials regarding population, intervention, and follow-up duration makes it difficult to reach definitive conclusions.

Navigating challenges and adherence in time-restricted eating: A qualitative study

AIMS

Adherence to any dietary approach is crucial for achieving long-term benefits. This qualitative study aims to explore the facilitators and barriers to adherence, and how individuals in community settings navigate time-restricted eating in their daily lives.

METHODS

Semi-structured, in-depth interviews were conducted with 21 participants who had practised time-restricted eating (confining the daily eating window to <10h a day; and excluding periodic fasting methods like the 5:2 approach or alternate day fasting) for periods ranging from 3 months to more than 5 years. A qualitative content analysis, underpinned by the Capability-Opportunity-Motivation-Behaviour Model, identified multiple facilitators, barriers, and strategies that evolved over the practice.

RESULTS

Key facilitators included the simplicity and versatility of time-restricted eating, maintaining a non-obsessive and non-dieting mindset, and having a supportive environment. Barriers included hunger and food cravings, an obsessive mindset during the initial stages, and conflicting schedules with social eating occasions, including holidays. Participants employed several coping strategies to successfully navigate adherence and reported confidence in maintaining time-restricted eating as a lifestyle that contributes to better health and weight management.

CONCLUSION

Our findings suggest that successful implementation of time-restricted eating in community settings requires flexibility and viewing it as more than a short-term weight loss tool. Guidelines are needed to help individuals and practitioners implement better practices and promote healthier behaviours.

Adherence and Retention in Early or Late Time-Restricted Eating: A Narrative Review of Randomized Controlled Trials

Time-restricted eating (TRE) is a form of intermittent fasting that involves reducing the time-period in which food is typically consumed daily. While TRE is known to induce health benefits, particularly for adults with obesity, there is currently debate about whether the time of day in which food is consumed also contributes to the health benefits of TRE. Early TRE (eTRE) and late TRE (lTRE) are subtypes of TRE that involve consuming food and caloric beverages either in the early or later part of the day. A growing body of literature indicates that eTRE may offer additional health benefits compared with lTRE. An important and unanswered question, however, is whether most adults can adhere to this type of eating pattern and whether adherence and retention differ between eTRE and lTRE. This narrative review compared adherence and retention in studies that implemented either eTRE or lTRE in adults for 8 weeks or longer. Five databases were searched, and 10 studies met our eligibility criteria. The key finding was that participants had high and comparable levels of adherence and retention in both eTRE and lTRE interventions. Specifically, the mean adherence rate was 81.4% for eTRE and 82.3% for lTRE, while the mean retention rate was 81% for eTRE and 85.8% for lTRE in eligible studies. Thus, the findings support the feasibility of both approaches. The lowest adherence and retention rates occurred in studies in which either eTRE or lTRE regimens were combined with other dietary interventions. Notably, the duration of the eating window did not seem to negatively affect adherence and retention rates for either eTRE or lTRE. More research is warranted to determine the influence of other factors, such as age and study location, on adherence to and retention of both eTRE and lTRE interventions.

Time-restricted feeding does not prevent adverse effects of palatable cafeteria diet on adiposity, cognition and gut microbiota in rats

Time-restricted feeding (TRF) is a popular dietary strategy whereby daily food intake is limited to a <12h window. As little is known about the effects of TRF on cognitive and behavioral measures, the present study examined the effects of time-restricted (8h/day; zeitgeber time [ZT]12-20) or continuous access to a high-fat, high-sugar cafeteria-style diet (Caf; Caf and Caf-TRF groups; n=12 adult male Sprague-Dawley rats) or standard chow (Chow and Chow-TRF groups) on short-term memory, anxiety-like behavior, adiposity and gut microbiota composition over 13-weeks with daily food intake measures. TRF significantly reduced daily energy intake in Caf- but not chow-fed groups. In Caf-fed groups, TRF reduced the proportion of energy derived from sugar while increasing that derived from protein. Caf diet significantly increased weight gain, adiposity and fasting glucose within 4 weeks; TRF partially reduced these effects. Caf diet increased anxiety-like behavior in the Elevated Plus Maze in week 3 but not week 12, and impaired hippocampal-dependent place recognition memory in week 11; neither measure was affected by TRF. Global microbiota composition differed markedly between chow and Caf groups, with a small effect of TRF in rats fed chow. In both chow and Caf diet groups, TRF reduced microbiota alpha diversity measures of Shannon diversity and evenness relative to continuous access. Results indicate only limited benefits of TRF access to an obesogenic diet under these conditions, suggesting that more severe time restriction may be required to offset adverse metabolic and cognitive effects when using highly palatable diets.

Development and feasibility testing of a time-restricted eating intervention for women living with overweight/obesity and HIV in a resource-limited setting of South Africa

BACKGROUND

Human Immunodeficiency Virus (HIV) and type 2 diabetes (T2D) are amongst the leading causes of death in South Africa. The preferred first-line anti-retroviral treatment contains dolutegravir (DTG), shown to increase body weight, may compound the already high rates of obesity and associated risk for T2D. South Africa has widespread food insecurity, making traditional dietary strategies difficult to implement. Time-restricted eating (TRE) may be an appropriate intervention in resource-limited communities.

METHODS

This article outlines the development and feasibility testing of a TRE intervention to inform the design of a TRE randomised controlled trial in women (20-45 years old) living with overweight/obesity and HIV, receiving DTG-based treatment from a resource-limited community in Cape Town, South Africa. Factors influencing TRE adoption were identified using the Capability, Opportunity, Motivation - Behaviour model and the Theoretical Domains Framework, combining in-depth interviews (IDIs) and focus group discussions. Participants from the IDIs went on to participate in a single arm 4-week TRE pilot trial where feasibility was explored in terms of reach, acceptability, applicability, and implementation integrity. An iterative, thematic analysis approach was employed to analyse the qualitative data.

RESULTS

Participants included 33 isiXhosa-speaking women (mean age 37.1 years, mean BMI 35.9 kg/m2). Thematic analysis identified psychological capability (knowledge of fasting), social influences (cultural preferences, family support), and reflective motivation (awareness of weight, health impact, motivation for TRE) as key factors influencing adoption of TRE for weight management. In a 4-week TRE pilot trial (n = 12), retention was 100%. Positive outcomes perceived included improved energy, appetite control and weight loss. TRE was perceived as acceptable, easy, and enjoyable. Family support facilitated adherence, while habitual and social eating and drinking practices were barriers. Compliance was high, aided by self-selected eating times, reminders, and weekly calls. Recommendations included the incorporation of dietary education sessions and text messages to provide additional support and reminders.

CONCLUSIONS

This study indicates that TRE is a feasible weight management strategy in women living with overweight/obesity and HIV, receiving DTG-based treatment in a resource-limited community. These findings will ensure that the forthcoming TRE randomised controlled trial is adapted and optimised to the local South African context.

Clinical potential of fasting in type 1 diabetes

Most adults with type 1 diabetes (T1DM) are either overweight or obese. As such, dietary management is recommended as an adjunct to insulin treatment to improve glycemic control and facilitate weight loss in these patients. Time-restricted eating (TRE) is a form of intermittent fasting that offers a simplified approach to treating obesity in T1DM. TRE typically involves restricting eating to 6 to 10 h per day, with water and medications allowed outside the eating window. This review examines the efficacy of TRE and other fasting protocols in improving weight and glycemic control in patients with obesity and T1DM. This review will also evaluate the safety of these regimens and provide advice to clinicians on implementing intermittent fasting in T1DM.

Differences in dietary acceptability, restraint, disinhibition, and hunger among African American participants randomized to either a vegan or omnivorous soul food diet

The Nutritious Eating with Soul study was a 24-month, randomized behavioral nutrition intervention among African American adults. This present study, which is a secondary analysis of the NEW Soul study, examined changes in dietary acceptability, restraint, disinhibition, and hunger. Participants (n = 159; 79% female, 74% with ≥ college degree, mean age 48.4 y) were randomized to either a soul food vegan (n = 77) or soul food omnivorous (n = 82) diet and participated in a two-year behavioral nutrition intervention. Questionnaires assessing dietary acceptability (Food Acceptability Questionnaire; FAQ) and dietary restraint, disinhibition, and hunger (Three-Factor Eating Questionnaire; TFEQ) were completed at baseline, 3, 6, 12, and 24 months. Mixed models were specified with main effects (group and time) and interaction effects (group by time) to estimate mean differences in FAQ and TFEQ scores using intent-to-treat analysis. After adjusting for employment, education, food security status, sex, and age, there were no differences in any of the FAQ items, total FAQ score, dietary restraint, disinhibition, and hunger at any timepoint except for one item of the FAQ at 12 months. Participants in the vegan group reported a greater increase in satisfaction after eating a meal than the omnivorous group (mean difference 0.80 ± 0.32, 95% CI 0.18, 1.42; P = 0.01). This is one of the first studies to examine differences in dietary acceptability, hunger, and other eating factors among African American adults randomized to either a vegan or omnivorous soul food diet. The findings highlight that plant-based eating styles are equally acceptable to omnivorous eating patterns and have similar changes in hunger, restraint, and disinhibition. These results suggest that plant-based eating styles can be an acceptable dietary pattern to recommend for cardiovascular disease prevention and may result in greater post-meal satisfaction.

Time-Restricted Eating and Its Metabolic Benefits

Newer management strategies are being evaluated to treat obesity, which continues to increase worldwide. After 12 h of fasting, the body switches from glucose to fat metabolism, regulating protein synthesis and autophagy. These cellular responses are central to the metabolic benefits of time-restricted eating (TRE), independent of calorie restriction and weight loss, and they have heightened interest in TRE regimens. Controversy remains, however, regarding the benefits of TRE regimens. We reviewed the current literature and concluded that TRE is equivalent to calorie restriction for weight loss and has positive effects for patients with diseases such as nonalcoholic fatty liver disease, cancer, and cardiovascular disease.

Type 2 Diabetes Mellitus and Sarcopenia as Comorbid Chronic Diseases in Older Adults: Established and Emerging Treatments and Therapies

Type 2 diabetes mellitus (T2DM) and sarcopenia (low skeletal muscle mass and function) share a bidirectional relationship. The prevalence of these diseases increases with age and they share common risk factors. Skeletal muscle fat infiltration, commonly referred to as myosteatosis, may be a major contributor to both T2DM and sarcopenia in older adults via independent effects on insulin resistance and muscle health. Many strategies to manage T2DM result in energy restriction and subsequent weight loss, and this can lead to significant declines in muscle mass in the absence of resistance exercise, which is also a first-line treatment for sarcopenia. In this review, we highlight recent evidence on established treatments and emerging therapies targeting weight loss and muscle mass and function improvements in older adults with, or at risk of, T2DM and/or sarcopenia. This includes dietary, physical activity and exercise interventions, new generation incretin-based agonists and myostatin-based antagonists, and endoscopic bariatric therapies. We also highlight how digital health technologies and health literacy interventions can increase uptake of, and adherence to, established and emerging treatments and therapies in older adults with T2DM and/or sarcopenia.

Feasibility of time-restricted eating in individuals with overweight, obesity, prediabetes, or type 2 diabetes: A systematic scoping review

OBJECTIVE

This systematic scoping review aimed to map and synthesize research on feasibility of time-restricted eating (TRE) in individuals with overweight, obesity, prediabetes, or type 2 diabetes, including recruitment rate, retention rate, safety, adherence, and participants' attitudes, experiences, and perspectives.

METHODS

The authors searched MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature from inception to November 22, 2022, supplemented by backward and forward citation search.

RESULTS

From 4219 identified records, 28 studies were included. In general, recruitment was easy and median retention rate was 95% among studies with <12 weeks duration and 89% among studies ≥12 weeks. Median (range) adherence to the target eating window for studies <12 and ≥12 weeks was 89% (75%-98%) and 81% (47%-93%), respectively. Variation in adherence among participants and studies was considerable, indicating that following TRE was difficult for some people and that intervention conditions influenced adherence. These findings were supported by qualitative data synthetized from seven studies, and determinants of adherence included calorie-free beverages outside the eating window, provision of support, and influence on the eating window. No serious adverse events were reported.

CONCLUSIONS

TRE is implementable, acceptable, and safe in populations with overweight, obesity, prediabetes, or type 2 diabetes, but it should be accompanied by support and options for individual adjustments.

Exploring Rates of Adherence and Barriers to Time-Restricted Eating

Whilst the treatment and prevention of overweight and obesity-related disease is managed by restricting daily energy intake, long-term adherence to dietary strategies appears unsustainable. Time-restricted eating (TRE) aims to position energy intake in an eating window under 12 h per day and offers an alternative behavioral intervention, which can aid weight management and improve cardiometabolic health. Adherence to previous TRE protocols is estimated at between 63 and 100%, although the accuracy of reporting is unclear. This study therefore aimed to provide an objective, subjective, and qualitative overview of adherence to a prescribed TRE protocol, and to identify any potential barriers affecting adherence. Adherence after 5 weeks of TRE was estimated at ~63% based on continuous glucose monitoring data when compared with time-stamped diet diaries. Subjective participant responses reported adherence at an average of ~61% per week. Barriers to adopting TRE, including work schedules, social events, and family life, were identified by participants during qualitative interviews. The findings of this study suggest that the development of personalized TRE protocols may help to navigate the barriers to adherence leading to improved health-related outcomes.

Designing a Co-created Intervention to Promote Motivation and Maintenance of Time-Restricted Eating in Individuals With Overweight and Type 2 Diabetes

OBJECTIVE

To design an appealing time-restricted eating (TRE) intervention by exploring behavioral and social mechanisms to improve TRE adoption and maintenance among people with type 2 diabetes (T2D) and overweight. Time-restricted eating is an intermittent fasting regimen suggested to improve glycemic control and body weight.

METHODS

Intervention development combined coherence theory and empirical data (workshops and semistructured interviews with the target group, their relatives, and health care professionals [HCPs]). Abductive analysis was applied.

RESULTS

The analysis suggested designing the TRE intervention in 2 phases: a short period with strict TRE, followed by a longer period focusing on adapting TRE to individual needs with support from HCPs, relatives, and peers. To reinforce TRE motivation and maintenance, HCPs should adopt a whole-person approach that focuses on participants' previous experiences.

CONCLUSIONS AND IMPLICATIONS

Important intervention elements to promote TRE adoption and maintenance are suggested to include a 2-phase design and support from professionals, family, and peers.

"Mars Bar and a Tin of Red Bull Kept Me and My Patients Alive": Exploring Barriers to Healthy Eating through Facebook Comments of Shiftworkers

The negative impact of an unhealthy diet on the shiftworker population has been well-documented. However, little evidence exists on the underlying reasons for unhealthy eating behaviours and the existing barriers to healthy eating withinshiftwork environments. This qualitative study investigated the dietary behaviours reported by shiftworkers through Facebook comments. Comments were collected if they were on public shiftworker-relevant posts pertaining to dietary news or dietary information on Facebook and were posted by self-identified shiftworkers, relatives of shiftworkers, or partners of shiftworkers. A thematic analysis of the 144 comments collected generated four categories that can be used to understand the motivations for eating behaviour on-shift: what shiftworkers eat, where food is sourced from, when food is eaten, and why certain foods are chosen. Results reveal motivations, attitudes, and both internal and external barriers to healthy eating behaviours, as well as similarities and differences across shiftwork industries. Recommendations for future research include further explorations on the link between scheduled eating (e.g., time-restricted eating) and shiftwork, the impact of a rotating shift arrangements on dietary health behaviours, and the impact of interpersonal relationships on shiftworker dietary choices. Understanding these motivations will inform strategies to promote healthy eating and help understand barriers for shiftworkers.

Early time-restricted eating affects weight, metabolic health, mood, and sleep in adherent completers: A secondary analysis

OBJECTIVE

Data are mixed on whether intermittent fasting improves weight loss and cardiometabolic health. Here, the effects of time-restricted eating (TRE) in participants who consistently adhered ≥5 d/wk every week were analyzed.

METHODS

Ninety patients aged 25 to 75 years old with obesity were randomized to early TRE (eTRE; 8-hour eating window from 07:00 to 15:00) or a control schedule (≥12-hour window) for 14 weeks. A per-protocol analysis of weight loss, body composition, cardiometabolic health, and other end points was performed.

RESULTS

Participants who adhered to eTRE ≥5 d/wk every week had greater improvements in body weight (-3.7 ± 1.2 kg; p = 0.003), body fat (-2.8 ± 1.3 kg; p = 0.04), heart rate (-7 ± 3 beats/min; p = 0.02), insulin resistance (-2.80 ± 1.36; p = 0.047), and glucose (-9 ± 5 mg/dL; p = 0.047) relative to adherers in the control group. They also experienced greater improvements in mood, including fatigue and anger; however, they self-reported sleeping less and taking longer to fall asleep.

CONCLUSIONS

For those who can consistently adhere at least 5 d/wk, eTRE is a valuable approach for improving body weight, body fat, cardiometabolic health, and mood. Further research is needed to determine whether eTRE's effects of shortening sleep but reducing fatigue are healthful or not.