The Women on the Move Through Activity and Nutrition (WOMAN) study: final 48-month results

Epigenetic Regulation of Human Vascular Calcification

Vascular diseases present a significant threat to human health worldwide. Atherosclerosis is the most prevalent vascular disease, accounting for the majority of morbidity and mortality globally. Vascular calcification is a dynamic pathological process underlying the development of atherosclerotic plaques and involves the phenotypic transformation of vascular smooth muscle cells (VSMCs) into osteogenic cells. Specifically, the phenotypic switch in VSMCs often involves modifications in gene expression due to epigenetic changes, including DNA methylation, histone modification, and non-coding RNAs. Understanding the role of these epigenetic changes in regulating the pathophysiology of vascular calcification, along with the proteins and pathways that mediate these changes, will aid in identifying new therapeutic candidates to enhance vascular health. This review discusses a comprehensive range of epigenetic modifications and their implications for vascular health and the development of vascular calcification.

Interventions to Attenuate Cardiovascular Calcification Progression: A Systematic Review of Randomized Clinical Trials

BACKGROUND

Cardiovascular calcification, characterized by deposition of calcium phosphate in the arterial wall and heart valves, is associated with cardiovascular morbidity and mortality and is commonly seen in aging, diabetes, and chronic kidney disease. Whether evidence-based interventions could significantly attenuate cardiovascular calcification progression remains uncertain.

METHODS AND RESULTS

We conducted a systematic review of randomized controlled trials involving interventions, compared with placebo, another comparator, or standard of care, to attenuate cardiovascular calcification. Included clinical trials involved participants without chronic kidney disease, and the outcome was cardiovascular calcification measured using radiological methods. Quality of evidence was determined by the Cochrane risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations assessment. Forty-nine randomized controlled trials involving 9901 participants (median participants 104, median duration 12 months) were eligible for inclusion. Trials involving aged garlic extract (n=6 studies) consistently showed attenuation of cardiovascular calcification. Trials involving 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (n=14), other lipid-lowering agents (n=2), hormone replacement therapies (n=3), vitamin K (n=5), lifestyle measures (n=4), and omega-3 fatty acids (n=2) consistently showed no attenuation of cardiovascular calcification with these therapies. Trials involving antiresorptive (n=2), antihypertensive (n=2), antithrombotic (n=4), and hypoglycemic agents (n=3) showed mixed results. Singleton studies involving salsalate, folate with vitamin B6 and 12, and dalcetrapib showed no attenuation of cardiovascular calcification. Overall, Cochrane risk of bias was moderate, and the Grading of Recommendations, Assessment, Development, and Evaluations assessment for a majority of analyses was moderate certainty of evidence.

CONCLUSIONS

Currently, there are insufficient or conflicting data for interventions evaluated in clinical trials for mitigation of cardiovascular calcification. Therapy involving aged garlic extract appears most promising, but evaluable studies were small and of short duration.

Nutrition and Physical Activity Interventions Provided by Nutrition and Exercise Practitioners for the General Population: An Evidence-Based Practice Guideline From the Academy of Nutrition and Dietetics and American Council on Exercise

A nutritious diet and adequate physical activity vitally contribute to disease prevention, but most adults do not meet population-based dietary and physical activity recommendations. Qualified nutrition and exercise practitioners can address challenges to adopting healthy lifestyle behaviors by providing consistent, individualized, and evidence-based education and programming within their professional scopes of practice to improve client outcomes. The objective of this evidence-based practice guideline is to inform practice decisions for nutrition and exercise practitioners providing nutrition and physical activity interventions for adults who are healthy or have cardiometabolic risk factors, but no diagnosed disease. Evidence from a systematic review was translated to practice recommendations using an evidence-to-decision framework by an interdisciplinary team of nutrition and exercise practitioners and researchers. This evidence-based practice guideline does not provide specific dietary or physical activity recommendations but rather informs nutrition and exercise practitioners how they may utilize existing guidelines for the general population to individualize programming for a range of clients. This evidence-based practice guideline provides widely applicable recommendation statements and a detailed framework to help practitioners implement the recommendations into practice. Common barriers and facilitators encountered when delivering nutrition and physical activity interventions, such as adherence to professional scopes of practice; methods to support behavior change; and methods to support inclusion, diversity, equity, and access, are discussed. Nutrition and exercise practitioners can consistently provide individualized, practical, and evidence-based interventions by seeking to understand their clients' needs, circumstances, and values and by co-creating interventions with the client and their allied health team.

The Effect of Base Theory Educational Intervention on Health-Promoting Lifestyle in Women Susceptible to Cardiovascular Diseases: Application of the Theory of Planned Behavior

BACKGROUND

Cardiovascular diseases are the second leading cause of mortality, disability, and reduced productivity in women over 40 years and the first cause of mortality in women over 60 years. Therefore, the present study aimed to determine the effect of educational intervention based on theory of planned behavior (TPB) on health-promoting lifestyle in women susceptible to cardiovascular diseases.

METHODS

This quasiexperimental study was conducted on 200 women susceptible to cardiovascular diseases referred to health centers in Fasa city, Fars province, Iran. The available sampling was performed on women who referred to the centers and had a family record. In this study, two health-promoting lifestyle questionnaires consisting of 49 questions and the theory of planned behavior questionnaire consisting of 50 questions were used. The obtained data were analyzed by using the SPSS software version 24 in two stages before and six months after the educational intervention through paired t-test, independent t-test, chi-square test, and McNemar test.

RESULTS

The mean age of women in the experimental and control groups was 38.74 ± 9.22 and 39.14 ± 9.08 years, respectively. The results showed a significant increase in the experimental group after six months of intervention in terms of health-promoting lifestyle and constructs of the theory of planned behavior. Also, mean blood pressure, fasting blood sugar, and smoking of experimental group decreased six months after the educational intervention.

CONCLUSION

Considering the irreplaceable role of education in adopting healthy behaviors and the role of women in strengthening the family foundation, quality educational programs should be designed and regularly implemented by health care providers for women.

Long-Term Effect of Weight Regain Following Behavioral Weight Management Programs on Cardiometabolic Disease Incidence and Risk: Systematic Review and Meta-Analysis

BACKGROUND

Behavioral weight management programs (BWMPs) enhance weight loss in the short term, but longer term cardiometabolic effects are uncertain as weight is commonly regained. We assessed the impact of weight regain after BWMPs on cardiovascular risk factors, diabetes, and cardiovascular disease.

METHODS

Trial registries, 11 databases, and forward-citation searching (latest search, December 19) were used to identify articles published in English, from any geographical region. Randomized trials of BWMPs in adults with overweight/obesity reporting cardiometabolic outcomes at ≥12 months at and after program end were included. Differences between more intensive interventions and comparator groups were synthesized using mixed-effects, meta-regression, and time-to-event models to assess the impact of weight regain on cardiovascular disease incidence and risk.

RESULTS

One hundred twenty-four trials reporting on ≥1 cardiometabolic outcomes with a median follow-up of 28 (range, 11-360) months after program end were included. Median baseline participant body mass index was 33 kg/m2; median age was 51 years. Eight and 15 study arms (7889 and 4202 participants, respectively) examined the incidence of cardiovascular disease and type 2 diabetes, respectively, with imprecise evidence of a lower incidence for at least 5 years. Weight regain in BWMPs relative to comparators reduced these differences. One and 5 years after program end, total cholesterol/HDL (high-density lipoprotein) ratio was 1.5 points lower at both times (82 studies; 19 003 participants), systolic blood pressure was 1.5 mm mercury and 0.4 mm lower (84 studies; 30 836 participants), and HbA1c (%) 0.38 lower at both times (94 studies; 28 083 participants). Of the included studies, 22% were judged at high risk of bias; removing these did not meaningfully change results.

CONCLUSIONS

Despite weight regain, BWMPs reduce cardiometabolic risk factors with effects lasting at least 5 years after program end and dwindling with weight regain. Evidence that they reduce the incidence of cardiovascular disease or diabetes is less certain. Few studies followed participants for ≥5 years.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018105744.

A scoping review of behavior change techniques used to promote physical activity among women in midlife

Women in midlife experience health risks that could be mitigated by regular physical activity and reduced sedentary time, but this population rarely achieves physical activity levels that would protect their health. As a result, many behavioral interventions are designed to promote physical activity in this population, which are purportedly guided by theoretical models of health behavior (change) and activate an associated set of behavior change techniques (BCTs). The efficacy and effectiveness of these interventions appear to be limited, however, raising questions about their design and adaptation for women in midlife. Several aspects of these interventions are currently unclear. Specifically, which women they target (i.e., how "midlife" and "sedentary" or "inactive" are defined), which theoretical models or behavior BCTs are used, and how BCTs are activated in such interventions. A synthesis of this information would be useful as an initial step toward improving physical activity interventions for this at-risk group, and thus, represented the goal of the present scoping review. Eligibility required publication in a peer-reviewed journal in English between 2000 and 2021, inclusion of only women in midlife who did not have any medical or other restrictions on their physical activity (e.g., cancer diagnosis), and free-living physical activity or sedentary behavior as the target outcome (with associated assessment). Of the 4,410 initial results, 51 articles met inclusion criteria, and these described 36 unique interventions. More than half of the articles (59%) named an underlying theoretical model and interventions included an average of 3.76 identifiable BCTs (range 1-11). However, descriptions of many interventions were limited and did not provide enough detail to determine whether or how specific BCTs were activated. Interventions also used a wide range of inclusion criteria for age range and starting activity level, which has implications for targeting/tailoring and effectiveness, and many interventions focused on marginalized populations (e.g., women from racial/ethnic minority backgrounds, those un- or under-insured). The present review identifies some strengths and highlights important limitations of existing literature, as well as key opportunities for advancing the design and potential utility of physical activity interventions for women in midlife.

Systematic review registration

https://osf.io/g8tuc.

Nutrition and Physical Exercise in Women

While the benefits of nutrition and physical exercise are commonly studied separately, their concomitant integration has the potential to produce greater benefits in women than strategies focusing only on one or the other [...]

Comparative Effectiveness of Behavioral Interventions for Cardiovascular Risk Reduction in Latinos: A Systematic Review

BACKGROUND

Latinos, the fastest growing ethnic minority group in the United States, are at a high risk for cardiovascular disease (CVD). However, little is known about effective strategies to reduce CVD risk in this population.

OBJECTIVE

The aim of this study was to systematically review and synthesize evidence from randomized controlled trials that examined the effectiveness of behavioral interventions to reduce CVD risk in Latinos living in the United States.

METHODS

Four electronic databases were searched for relevant peer-reviewed English- and Spanish-language articles published between January 1, 2000, and December 31, 2019. Four reviewers independently completed article screening, data abstraction, and quality appraisal. At least 2 reviewers completed data abstraction and quality appraisal for each article, and a third reviewer was assigned to settle disagreements. Data on study characteristics and outcomes were abstracted.

RESULTS

We retrieved 1939 articles. After applying inclusion/exclusion criteria, 17 articles were included. Most interventions were led by community health workers (n = 10); 2 family-based interventions were identified. None of the included studies was nurse led. Behavioral factors were assessed across all included studies, whereas only 4 studies reported on psychosocial outcomes. Improvements were observed in dietary habits and psychosocial outcomes. Findings for physical activity and biological outcomes were mixed. We identified no differences in outcomes based on intervention modalities used or the role of those who led the interventions.

CONCLUSION

Existing evidence is mixed. Future research should assess the effectiveness of understudied treatment modalities (including nurse-led, mobile health, and family-based interventions) in reducing CVD risk in Latinos.

A systematic review of inequalities in the uptake of, adherence to, and effectiveness of behavioral weight management interventions in adults

The extent to which behavioral weight management interventions affect health inequalities is uncertain, as is whether trials of these interventions directly consider inequalities. We conducted a systematic review, synthesizing evidence on how different aspects of inequality impact uptake, adherence, and effectiveness in trials of behavioral weight management interventions. We included (cluster-) randomized controlled trials of primary care-applicable behavioral weight management interventions in adults with overweight or obesity published prior to March 2020. Data about trial uptake, intervention adherence, attrition, and weight change by PROGRESS-Plus criteria (place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic status, social capital, plus other discriminating factors) were extracted. Data were synthesized narratively and summarized in harvest plots. We identified 91 behavioral weight loss interventions and 12 behavioral weight loss maintenance interventions. Fifty-six of the 103 trials considered inequalities in relation to at least one of intervention or trial uptake (n = 15), intervention adherence (n = 15), trial attrition (n = 32), or weight outcome (n = 34). Most trials found no inequalities gradient. If a gradient was observed for trial uptake, intervention adherence, and trial attrition, those considered "more advantaged" did best. Alternative methods of data synthesis that enable data to be pooled and increase statistical power may enhance understanding of inequalities in behavioral weight management interventions.

Impact of Nutrition and Physical Activity Interventions Provided by Nutrition and Exercise Practitioners for the Adult General Population: A Systematic Review and Meta-Analysis

Healthy dietary intake and physical activity reduce the risk of non-communicable diseases. This systematic review and meta-analysis aimed to examine the effect of interventions including both nutrition and physical activity provided by nutrition and exercise practitioners for adults in the general population (those without diagnosed disease). The MEDLINE, CINAHL, Cochrane Central, Cochrane Database of Systematic Reviews and SportDiscus databases were searched for randomized controlled trials (RCTs) published from 2010 until April 2021. Outcomes included physical activity, fruit and vegetable intake, waist circumference, percent weight loss, quality of life (QoL) and adverse events. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods were used to synthesize and grade evidence. Meta-analyses were stratified according to participant health status. The database search identified 11,205 articles, and 31 RCTs were included. Interventions increased physical activity amount [standardized mean difference (SMD) (95% CI): 0.25 (0.08, 0.43)] (low certainty evidence); increased vegetable intake [SMD (95% CI): 0.14 (0.05, 0.23)] (moderate certainty evidence); reduced waist circumference [MD (95% CI): -2.16 cm (-2.96, -1.36)] (high certainty evidence); and increased likelihood of achieving 5% weight loss for adults with overweight and obesity [relative risk (95% CI): 2.37 (1.76, 3.19)] (high certainty evidence). Very low and low certainty evidence described little-to-no effect on QoL or adverse events. Nutrition and exercise practitioners play key roles in facilitating positive lifestyle behaviors to reduce cardiometabolic disease risk in adults.

Nutrition and physical activity interventions for the general population with and without cardiometabolic risk: a scoping review

OBJECTIVE

The objective of this scoping review was to examine the research question: In the adults with or without cardiometabolic risk, what is the availability of literature examining interventions to improve or maintain nutrition and physical activity-related outcomes? Sub-topics included: (1) behaviour counseling or coaching from a dietitian/nutritionist or exercise practitioner, (2) mobile applications to improve nutrition and physical activity and (3) nutritional ergogenic aids.

DESIGN

The current study is a scoping review. A literature search of the Medline Complete, CINAHL Complete, Cochrane Database of Systematic Reviews and other databases was conducted to identify articles published in the English language from January 2005 until May 2020. Data were synthesised using bubble charts and heat maps.

SETTING

Out-patient, community and workplace.

PARTICIPANTS

Adults with or without cardiometabolic risk factors living in economically developed countries.

RESULTS

Searches resulted in 19 474 unique articles and 170 articles were included in this scoping review, including one guideline, thirty systematic reviews (SR), 134 randomised controlled trials and five non-randomised trials. Mobile applications (n 37) as well as ergogenic aids (n 87) have been addressed in several recent studies, including SR. While primary research has examined the effect of individual-level nutrition and physical activity counseling or coaching from a dietitian/nutritionist and/or exercise practitioner (n 48), interventions provided by these practitioners have not been recently synthesised in SR.

CONCLUSION

SR of behaviour counseling or coaching provided by a dietitian/nutritionist and/or exercise practitioner are needed and can inform practice for practitioners working with individuals who are healthy or have cardiometabolic risk.

Long-term effects (> 24 months) of multiple lifestyle intervention on major cardiovascular risk factors among high-risk subjects: a meta-analysis

Background

The evidence of the long-term effects of multiple lifestyle intervention on cardiovascular risk is uncertain. We aimed to summarize the evidence from randomized clinical trials examining the efficacy of lifestyle intervention on major cardiovascular risk factors in subjects at high cardiovascular risk.

Methods

Eligible trials investigated the impact of lifestyle intervention versus usual care with minimum 24 months follow-up, reporting more than one major cardiovascular risk factor. A literature search updated April 15, 2020 identified 12 eligible studies. The results from individual trials were combined, using fixed and random effect models, using the standardized mean difference (SMD) to estimate effect sizes. Small-study effect was evaluated, and heterogeneity between studies examined, by subgroup and meta-regression analyses, considering patient- and study-level variables.

Results

Small-study effect was not identified. Lifestyle intervention reduced systolic blood pressure modestly with an estimated SMD of − 0.13, 95% confidence interval (CI): − 0.21 to − 0.04, with moderate heterogeneity (I² = 59%), corresponding to a mean difference of approximately 2 mmHg (MD = − 1.86, 95% CI − 3.14 to − 0.57, p = 0.0046). This effect disappeared in the subgroup of trials judged at low risk of bias (SMD = 0.02, 95% CI − 0.08 to 0.11). For the outcome total cholesterol SMD was − 0.06, 95% CI − 0.13 to 0.00, with no heterogeneity (I² = 0%), indicating no effect of the intervention.

Conclusion

Lifestyle intervention resulted in only a modest effect on systolic blood pressure and no effect on total cholesterol after 24 months. Further lifestyle trials should consider the challenge of maintaining larger long-term benefits to ensure impact on cardiovascular outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01989-5.

Traditional Risk Factors are Causally Related to Carotid Intima-Media Thickness Progression: Inferences from Observational Cohort Studies and Interventional Trials

In the present review, associations between traditional vascular risk factors (VRFs) and carotid intimamedial thickness progression (C-IMTp) as well as the effects of therapies for VRFs control on C-IMTp were appraised to infer causality between each VRF and C-IMTp. Cohort studies indicate that smoking, binge drinking, fatness, diabetes, hypertension and hypercholesterolemia are associated with accelerated C-IMTp. An exception is physical activity, with mixed data. Interventions for the control of obesity, diabetes, hypertension and hypercholesterolemia decelerate C-IMTp. Conversely, scarce information is available regarding the effect of smoking cessation, stop of excessive alcohol intake and management of the metabolic syndrome. Altogether, these data support a causative role of several traditional VRFs on C-IMTp. Shortcomings in study design and/or ultrasonographic protocols may account for most negative studies, which underlines the importance of careful consideration of methodological aspects in investigations using C-IMTp as the outcome.

Tackling reporting issues and variation in behavioural weight management interventions: Design and piloting of the standardized reporting of adult behavioural weight management interventions to aid evaluation (STAR-LITE) template

In the United Kingdom, the National Institute for Health and Care Excellence make recommendations to guide the local-level selection and implementation of adult behavioural weight management interventions (BWMIs) which lack specificity. The reporting of BWMIs is generally poorly detailed, resulting in difficulties when comparing effectiveness, quality and appropriateness for participants. This non-standardized reporting makes meta-analysis of intervention data impossible, resulting in vague guidance based on weak evidence, reinforcing the urgent need for consistency and detail within BWMI description. STAR-LITE - a 4-section, 119-item standardized adult BWMI reporting template - was developed and tested using a two-phase process. After initial design, the template was piloted using adult behavioural weight management RCTs and currently implemented UK BWMI mapping information to further refine the template and examine current reporting and variance. Overall, reporting quality of weight management RCTs was poor, and large variance across different components of real-world BWMIs was observed. Non-specific guidance and wide variation in adult BWMIs are likely linked to inadequate RCT reporting quality and the inability to perform reliable comparisons of data. Future use of STAR-LITE would facilitate the consistent, detailed reporting of adult BWMIs, supporting their evaluation and comparison, to ultimately inform effective policy and improve weight management practice.

Evaluating the impact of HBM-based education on exercise among health care workers: the usage of mobile applications in Iran

BACKGROUND

Mechanical life made us witness the growing increase of chronic diseases despite the prominent scientific developments in the field of health, treatment and control. The aim of this study was to evaluate the impact of educational intervention based on Health Belief Model (HBM) using mobile applications (Telegram messenger) on doing exercise among the health care workers of Ilam university of medical sciences in 2017.

METHODS

In this interventional study, 114 people working in Ilam University of medical sciences participated in two groups of intervention and control (employed at two different cities) after providing the informed consent form. HBM-ISCS questionnaire was used to collect the required data and its reliability was approved using Cronbach's alpha. Descriptive statistics, chi square, t test, repeated measures ANOVA (RMANOVA) and structural equation model (SEM) were used.

RESULTS

Half of the participants were men, 58.77% of them were undergraduate. The mean and SD of their age was 37.61 ± 4.88 years. Based on the results of the repeated measures analysis of variance test (before and after the intervention) in the intervention group, there were significant difference in all of the HBM constructs (perceived barriers was excepted), daily and weekly exercises, blood biochemical markers of the participants (P > 0.05). The above changes were not significant in the control group (P ≥ 0.05).

CONCLUSION

Exercise is closely related to the beliefs of people, so implementing educational interventions based on Telegram messenger with emphasis on health beliefs and using HBM can lead to have exercise. Therefore, this application can be a suitable tool to deliver trainings, especially when holding in-person classes is difficult.

Behavioral and Pharmacotherapy Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Overweight and obesity have been associated with adverse health effects.

OBJECTIVE

To systematically review evidence on benefits and harms of behavioral and pharmacotherapy weight loss and weight loss maintenance interventions in adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed Publisher-Supplied Records, PsycINFO, and the Cochrane Central Register of Controlled Trials for studies published through June 6, 2017; ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials through August 2017; and ongoing surveillance in targeted publications through March 23, 2018. Studies from previous reviews were reevaluated for inclusion.

STUDY SELECTION

Randomized clinical trials (RCTs) focusing on weight loss or weight loss maintenance in adults.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted by one reviewer and confirmed by another. Random-effects meta-analyses were conducted for weight loss outcomes in behavior-based interventions.

MAIN OUTCOMES AND MEASURES

Health outcomes, weight loss or weight loss maintenance, reduction in obesity-related conditions, and adverse events.

RESULTS

A total of 122 RCTs (N = 62 533) and 2 observational studies (N = 209 993) were identified. Compared with controls, participants in behavior-based interventions had greater mean weight loss at 12 to 18 months (-2.39 kg [95% CI, -2.86 to -1.93]; 67 studies [n = 22065]) and less weight regain (-1.59 kg [95% CI, -2.38 to -0.79]; 8 studies [n = 1408]). Studies of medication-based weight loss and maintenance interventions also reported greater weight loss or less weight regain in intervention compared with placebo groups at 12 to 18 months (range, -0.6 to -5.8 kg; no meta-analysis). Participants with prediabetes in weight loss interventions had a lower risk of developing diabetes compared with controls (relative risk, 0.67 [95% CI, 0.51 to 0.89]). There was no evidence of other benefits, but most health outcomes such as mortality, cardiovascular disease, and cancer were infrequently reported. Small improvements in quality of life in some medication trials were noted but were of unclear clinical significance. There was no evidence of harm such as cardiovascular disease from behavior-based interventions; higher rates of adverse events were associated with higher dropout rates in medication groups than in placebo groups.

CONCLUSIONS AND RELEVANCE

Behavior-based weight loss interventions with or without weight loss medications were associated with more weight loss and a lower risk of developing diabetes than control conditions. Weight loss medications, but not behavior-based interventions, were associated with higher rates of harms. Long-term weight and health outcomes data, as well as data on important subgroups, were limited.

Weight management programmes: Re-analysis of a systematic review to identify pathways to effectiveness

Background

Previous systematic reviews of weight management programmes (WMPs) have not been able to account for heterogeneity of effectiveness within programmes using top‐down behavioural change taxonomies. This could be due to overlapping causal pathways to effectiveness (or lack of effectiveness) in these complex interventions. Qualitative comparative analysis (QCA) can help identify these overlapping pathways.

Methods

Using trials of adult WMPs with dietary and physical activity components identified from a previous systematic review, we selected the 10 most and 10 least effective interventions by amount of weight loss at 12 months compared to minimal treatment. Using intervention components suggested by synthesis of studies of programme user views, we labelled interventions as to the presence of these components and, using qualitative comparative analysis, developed pathways of component combinations that created the conditions sufficient for interventions to be most effective and least effective.

Results

Informed by the synthesis of views studies, we constructed 3 truth tables relating to quality of the user‐provider relationship; perceived high need for guidance from providers; and quality of the relationship between peers in weight management programmes. We found effective interventions were characterized by opportunities to develop supportive relationships with providers or peers, directive provider‐led goal setting and components perceived to foster self‐regulation.

Conclusions

Although QCA is an inductive method, this innovative approach has enabled the identification of potentially critical aspects of WMPs, such as the nature of relationships within them, which were previously not considered to be as important as more concrete content such as dietary focus.

Effect of lifestyle interventions on cardiovascular risk factors among adults without impaired glucose tolerance or diabetes: A systematic review and meta-analysis

Structured lifestyle interventions can reduce diabetes incidence and cardiovascular disease (CVD) risk among persons with impaired glucose tolerance (IGT), but it is unclear whether they should be implemented among persons without IGT. We conducted a systematic review and meta-analyses to assess the effectiveness of lifestyle interventions on CVD risk among adults without IGT or diabetes. We systematically searched MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Library, and PsychInfo databases, from inception to May 4, 2016. We selected randomized controlled trials of lifestyle interventions, involving physical activity (PA), dietary (D), or combined strategies (PA+D) with follow-up duration ≥12 months. We excluded all studies that included individuals with IGT, confirmed by 2-hours oral glucose tolerance test (75g), but included all other studies recruiting populations with different glycemic levels. We stratified studies by baseline glycemic levels: (1) low-range group with mean fasting plasma glucose (FPG) <5.5mmol/L or glycated hemoglobin (A1C) <5.5%, and (2) high-range group with FPG ≥5.5mmol/L or A1C ≥5.5%, and synthesized data using random-effects models. Primary outcomes in this review included systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), and triglycerides (TG). Totally 79 studies met inclusion criteria. Compared to usual care (UC), lifestyle interventions achieved significant improvements in SBP (-2.16mmHg[95%CI, -2.93, -1.39]), DBP (-1.83mmHg[-2.34, -1.31]), TC (-0.10mmol/L[-0.15, -0.05]), LDL-C (-0.09mmol/L[-0.13, -0.04]), HDL-C (0.03mmol/L[0.01, 0.04]), and TG (-0.08mmol/L[-0.14, -0.03]). Similar effects were observed among both low-and high-range study groups except for TC and TG. Similar effects also appeared in SBP and DBP categories regardless of follow-up duration. PA+D interventions had larger improvement effects on CVD risk factors than PA alone interventions. In adults without IGT or diabetes, lifestyle interventions resulted in significant improvements in SBP, DBP, TC, LDL-C, HDL-C, and TG, and might further reduce CVD risk.

Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses

PURPOSE

This systematic review aims to explain the heterogeneity in results of interventions to promote physical activity and healthy eating for overweight and obese adults, by exploring the differential effects of behaviour change techniques (BCTs) and other intervention characteristics.

METHODS

The inclusion criteria specified RCTs with ≥ 12 weeks' duration, from January 2007 to October 2014, for adults (mean age ≥ 40 years, mean BMI ≥ 30). Primary outcomes were measures of healthy diet or physical activity. Two reviewers rated study quality, coded the BCTs, and collected outcome results at short (≤6 months) and long term (≥12 months). Meta-analyses and meta-regressions were used to estimate effect sizes (ES), heterogeneity indices (I²) and regression coefficients.

RESULTS

We included 48 studies containing a total of 82 outcome reports. The 32 long term reports had an overall ES = 0.24 with 95% confidence interval (CI): 0.15 to 0.33 and I² = 59.4%. The 50 short term reports had an ES = 0.37 with 95% CI: 0.26 to 0.48, and I² = 71.3%. The number of BCTs unique to the intervention group, and the BCTs goal setting and self-monitoring of behaviour predicted the effect at short and long term. The total number of BCTs in both intervention arms and using the BCTs goal setting of outcome, feedback on outcome of behaviour, implementing graded tasks, and adding objects to the environment, e.g. using a step counter, significantly predicted the effect at long term. Setting a goal for change; and the presence of reporting bias independently explained 58.8% of inter-study variation at short term. Autonomy supportive and person-centred methods as in Motivational Interviewing, the BCTs goal setting of behaviour, and receiving feedback on the outcome of behaviour, explained all of the between study variations in effects at long term.

CONCLUSION

There are similarities, but also differences in effective BCTs promoting change in healthy eating and physical activity and BCTs supporting maintenance of change. The results support the use of goal setting and self-monitoring of behaviour when counselling overweight and obese adults. Several other BCTs as well as the use of a person-centred and autonomy supportive counselling approach seem important in order to maintain behaviour over time.

TRIAL REGISTRATION

PROSPERO CRD42015020624.

Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses

Purpose

This systematic review aims to explain the heterogeneity in results of interventions to promote physical activity and healthy eating for overweight and obese adults, by exploring the differential effects of behaviour change techniques (BCTs) and other intervention characteristics.

Methods

The inclusion criteria specified RCTs with ≥ 12 weeks’ duration, from January 2007 to October 2014, for adults (mean age ≥ 40 years, mean BMI ≥ 30). Primary outcomes were measures of healthy diet or physical activity. Two reviewers rated study quality, coded the BCTs, and collected outcome results at short (≤6 months) and long term (≥12 months). Meta-analyses and meta-regressions were used to estimate effect sizes (ES), heterogeneity indices (I²) and regression coefficients.

Results

We included 48 studies containing a total of 82 outcome reports. The 32 long term reports had an overall ES = 0.24 with 95% confidence interval (CI): 0.15 to 0.33 and I² = 59.4%. The 50 short term reports had an ES = 0.37 with 95% CI: 0.26 to 0.48, and I² = 71.3%. The number of BCTs unique to the intervention group, and the BCTs goal setting and self-monitoring of behaviour predicted the effect at short and long term. The total number of BCTs in both intervention arms and using the BCTs goal setting of outcome, feedback on outcome of behaviour, implementing graded tasks, and adding objects to the environment, e.g. using a step counter, significantly predicted the effect at long term. Setting a goal for change; and the presence of reporting bias independently explained 58.8% of inter-study variation at short term. Autonomy supportive and person-centred methods as in Motivational Interviewing, the BCTs goal setting of behaviour, and receiving feedback on the outcome of behaviour, explained all of the between study variations in effects at long term.

Conclusion

There are similarities, but also differences in effective BCTs promoting change in healthy eating and physical activity and BCTs supporting maintenance of change. The results support the use of goal setting and self-monitoring of behaviour when counselling overweight and obese adults. Several other BCTs as well as the use of a person-centred and autonomy supportive counselling approach seem important in order to maintain behaviour over time.

Trial Registration

PROSPERO CRD42015020624

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0494-y) contains supplementary material, which is available to authorized users.

Weight Loss and Coronary Heart Disease: Sensitivity Analysis for Unmeasured Confounding by Undiagnosed Disease

BACKGROUND

Evidence for the effect of weight loss on coronary heart disease (CHD) or mortality has been mixed. The effect estimates can be confounded due to undiagnosed diseases that may affect weight loss.

METHODS

We used data from the Nurses' Health Study to estimate the 26-year risk of CHD under several hypothetical weight loss strategies. We applied the parametric g-formula and implemented a novel sensitivity analysis for unmeasured confounding due to undiagnosed disease by imposing a lag time for the effect of weight loss on chronic disease. Several sensitivity analyses were conducted.

RESULTS

The estimated 26-year risk of CHD did not change under weight loss strategies using lag times from 0 to 18 years. For a 6-year lag time, the risk ratios of CHD for weight loss compared with no weight loss ranged from 1.00 (0.99, 1.02) to 1.02 (0.99, 1.05) for different degrees of weight loss with and without restricting the weight loss strategy to participants with no major chronic disease. Similarly, no protective effect of weight loss was estimated for mortality risk. In contrast, we estimated a protective effect of weight loss on risk of type 2 diabetes.

CONCLUSION

We estimated that maintaining or losing weight after becoming overweight or obese does not reduce the risk of CHD or death in this cohort of middle-age US women. Unmeasured confounding, measurement error, and model misspecification are possible explanations but these did not prevent us from estimating a beneficial effect of weight loss on diabetes.

Effect of lifestyle interventions on glucose regulation among adults without impaired glucose tolerance or diabetes: A systematic review and meta-analysis

This study systematically assessed the effectiveness of lifestyle interventions on glycemic indicators among adults (⩾18years) without IGT or diabetes. Randomized controlled trials using physical activity (PA), diet (D), or their combined strategies (PA+D) with follow-up ⩾12months were systematically searched from multiple electronic-databases between inception and May 4, 2016. Outcome measures included fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), fasting insulin (FI), homeostasis model assessment-estimated insulin resistance (HOMA-IR), and bodyweight. Included studies were divided into low-range (FPG <5.5mmol/L or HbA1c <5.5%) and high-range (FPG ⩾5.5mmol/L or HbA1c ⩾5.5%) groups according to baseline glycemic levels. Seventy-nine studies met inclusion criteria. Random-effect models demonstrated that compared with usual care, lifestyle interventions achieved significant reductions in FPG (-0.14mmol/L [95%CI, -0.19, -0.10]), HbA1c (-0.06% [-0.09, -0.03]), FI (%change: -15.18% [-20.01, -10.35]), HOMA-IR (%change: -22.82% [-29.14, -16.51]), and bodyweight (%change: -3.99% [-4.69, -3.29]). The same effect sizes in FPG reduction (0.07) appeared among both low-range and high-range groups. Similar effects were observed among all groups regardless of lengths of follow-up. D and PA+D interventions had larger effects on glucose reduction than PA alone. Lifestyle interventions significantly improved FPG, HbA1c, FI, HOMA-IR, and bodyweight among adults without IGT or diabetes, and might reduce progression of hyperglycemia to type 2 diabetes mellitus.

Impact of Self-Preference Community Fitness Interventions in High-Risk African Americans

African Americans have a high prevalence of obesity and physical inactivity, but few interventions have been successful in the long term. We describe a 1-year intervention program to increase physical activity and reduce cardiometabolic risk. Interventions incorporated the premise that self-selection into flexible venues and varying exercise modalities would result in improvement in fitness and risk factors. Results of this single-group pretest/posttest observational study show 1-year overall group reductions in body weight and body mass index and cardiometabolic factors including high-sensitivity C-reactive protein, and increases in dual-energy x-ray absorptiometry-derived absolute and percent lean mass and lean-fat ratio, and decreased fat mass.

Weight change among people randomized to minimal intervention control groups in weight loss trials

OBJECTIVE

Evidence on the effectiveness of behavioral weight management programs often comes from uncontrolled program evaluations. These frequently make the assumption that, without intervention, people will gain weight. The aim of this study was to use data from minimal intervention control groups in randomized controlled trials to examine the evidence for this assumption and the effect of frequency of weighing on weight change.

METHODS

Data were extracted from minimal intervention control arms in a systematic review of multicomponent behavioral weight management programs. Two reviewers classified control arms into three categories based on intensity of minimal intervention and calculated 12-month mean weight change using baseline observation carried forward. Meta-regression was conducted in STATA v12.

RESULTS

Thirty studies met the inclusion criteria, twenty-nine of which had usable data, representing 5,963 participants allocated to control arms. Control arms were categorized according to intensity, as offering leaflets only, a single session of advice, or more than one session of advice from someone without specialist skills in supporting weight loss. Mean weight change at 12 months across all categories was -0.8 kg (95% CI -1.1 to -0.4). In an unadjusted model, increasing intensity by moving up a category was associated with an additional weight loss of -0.53 kg (95% CI -0.96 to -0.09). Also in an unadjusted model, each additional weigh-in was associated with a weight change of -0.42 kg (95% CI -0.81 to -0.03). However, when both variables were placed in the same model, neither intervention category nor number of weigh-ins was associated with weight change.

CONCLUSIONS

Uncontrolled evaluations of weight loss programs should assume that, in the absence of intervention, their population would weigh up to a kilogram on average less than baseline at the end of the first year of follow-up.

Aortic flow propagation velocity, epicardial fat thickness, and osteoprotegerin level to predict subclinical atherosclerosis in patients with nonalcoholic fatty liver disease

Objective:

Nonalcoholic fatty liver disease is the most common cause of liver dysfunction in Western countries and an independent risk factor for atherosclerotic heart disease. Appropriate noninvasive parameters are lacking for optimal risk stratification of cardiovascular disease in these patients. We evaluated several recently discovered noninvasive parameters for atherosclerosis in patients with nonalcoholic fatty liver disease: epicardial fat thickness, aortic flow propagation velocity, and osteoprotegerin level.

Methods:

Forty-one patients (27 men and 14 women; mean age, 37.9±8.9 years) with nonalcoholic fatty liver disease and 37 control subjects (17 men and 20 women; mean age, 34.5±8.6 years) were enrolled in this observational case-control study. Patients with nonalcoholic fatty liver disease diagnosed at a gastroenterology outpatient clinic were included. Patients with cardiac pathology other than hypertension were excluded. Epicardial fat thickness and aortic flow propagation velocity were measured by echocardiography. The serum concentration of osteoprotegerin was measured using a commercial enzyme-linked immunosorbent assay kit.

Results:

Nonalcoholic fatty liver disease patients exhibited a significantly lower aortic flow propagation velocity (155.17±30.00 vs. 179.00±18.14 cm/s, p=0.000) and significantly higher epicardial fat thickness (0.51±0.25 vs. 0.29±0.09 cm, p=0.000) than control subjects. Osteoprotegerin levels were higher, but not significant, in patients with nonalcoholic fatty liver disease (28.0±13.0 vs. 25.2±10.8 pg/mL, p=0.244). Binary logistic regression analysis showed that aortic flow propagation velocity (OR, –0.973; 95% CI, 0.947–0.999) and waist circumference (OR, –1.191; 95% CI, 1.088–1.303) were independent predictors of nonalcoholic fatty liver disease.

Conclusion:

In this study, epicardial fat thickness and osteoprotegerin level were higher and aortic flow propagation velocity was lower in patients with nonalcoholic fatty liver disease. Early detection of abnormal epicardial fat thickness and aortic flow propagation velocity may warrant a search for undetected cardiovascular disease in patients with nonalcoholic fatty liver disease. (Anatol J Cardiol 2016; 16: 974-9)

Knowledge, Attitudes, and Practices on Lifestyle and Cardiovascular Risk Factors Among Metabolic Syndrome Patients in an Urban Tertiary Care Institute in Sri Lanka

Metabolic syndrome (MetS) is a significant predictor of cardiovascular diseases (CVDs). A pretested questionnaire was used to assess knowledge, attitudes, and practice (KAP) of CVD and its risks among Sri Lankan urban adults (35-55 years) with MetS. KAP scores were predefined as high, moderate, and low. Of the participants (n = 423), 13% were males and 87% were females. Attitudes scores were high among this population, though their knowledge and practices scores on CVD risk factors were moderate. Participants with high mean knowledge scores had significantly lower waist circumference (WC) and showed a trend toward reduced fasting blood glucose levels. Participants with high practice scores had significantly lower BMI and WC, which signify that better knowledge and practices are associated with decrease in CVD risk markers in these patients. The study reveals that urban MetS patients have a moderate knowledge and practice score, though their attitude score is high regarding CVD risk factors.

Lipoprotein particles and size, total and high molecular weight adiponectin, and leptin in relation to incident coronary heart disease among severely obese postmenopausal women: The Women's Health Initiative Observational Study

Background

We hypothesized that higher concentrations of LDL particles (LDL-P) and leptin, and lower concentrations of HDL particles (HDL-P), and total and high molecular weight (HMW) adiponectin, would predict incident coronary heart disease (CHD) among severely obese postmenopausal women.

Methods

In a case–cohort study nested in the Women's Health Initiative Observational Study, we sampled 677 of the 1852 white or black women with body mass index (BMI) ≥ 40 kg/m² and no prevalent cardiovascular disease (CVD), including all 124 cases of incident CHD over mean 5.0 year follow-up. Biomarkers were assayed on stored blood samples.

Results

In multivariable-adjusted weighted Cox models, higher baseline levels of total and small LDL-P, and lower levels of total and medium HDL-P, and smaller mean HDL-P size were significantly associated with incident CHD. In contrast, large HDL-P levels were inversely associated with CHD only for women without diabetes, and higher total and HMW adiponectin levels and lower leptin levels were associated with CHD only for women with diabetes. Higher total LDL-P and lower HDL-P were associated with CHD risk independently of confounders including CV risk factors and other lipoprotein measures, with adjusted HR (95% CIs) of 1.55 (1.28, 1.88) and 0.70 (0.57, 0.85), respectively, and similar results for medium HDL-P.

Conclusions

Higher CHD risk among severely obese postmenopausal women is strongly associated with modifiable concentrations of LDL-P and HDL-P, independent of diabetes, smoking, hypertension, physical activity, BMI and waist circumference.

General significance

Severely obese postmenopausal women should be considered high risk candidates for lipid lowering therapy.

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CHD risk is ~ 2-fold higher for severely obese postmenopausal women (BMI ≥ 40 kg/m²).

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Baseline risk factors were measured among 677 severely obese postmenopausal women.

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5-year CHD risk related to higher LDL particles, lower total, medium HDL particles.

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Paradoxical or no relations of adiponectin (total, HMW) and leptin with CHD risk

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Clinical implications: Statins reduce LDL particles and increase HDL particles.

Effectiveness of a physical activity and weight loss intervention for middle-aged women: healthy bodies, healthy hearts randomized trial

BACKGROUND

Physical inactivity is a significant risk factor for cardiovascular disease and remains highly prevalent in middle-aged women.

OBJECTIVE

We hypothesized that an interventionist-led (IL), primary-care-based physical activity (PA) and weight loss intervention would increase PA levels and decrease weight to a greater degree than a self-guided (SG) program.

DESIGN

We conducted a randomized trial.

PARTICIPANTS

Ninety-nine inactive women aged 45-65 years and with BMI ≥ 25 kg/m(2) were recruited from three primary care clinics.

INTERVENTIONS

The interventionist-led (IL) group (n = 49) had 12 weekly sessions of 30 min discussions with 30 min of moderate-intensity PA. The self-guided (SG) group (n = 50) received a manual for independent use.

MAIN MEASURES

Assessments were conducted at 0, 3, and 12 months; PA and weight were primary outcomes. Weight was measured with a standardized protocol. Leisure PA levels were assessed using the Modifiable Activity Questionnaire. Differences in changes by group were analyzed with a t-test or Wilcoxon rank-sum test. Mixed models were used to analyze differences in changes of outcomes by group, using an intention-to-treat principle.

KEY RESULTS

Data from 98 women were available for analysis. At baseline, mean (SD) age was 53.9 (5.4) years and 37 % were black. Mean weight was 92.3 (17.7) kg and mean BMI was 34.7 (5.9) kg/m(2). Median PA level was 2.8 metabolic equivalent hours per week (MET-hour/week) (IQR 0.0, 12.0). At 3 months, IL women had a significantly greater increase in PA levels (7.5 vs. 1.9 MET-hour/week; p = 0.02) than SG women; there was no significant difference in weight change. At 12 months, the difference between groups was no longer significant (4.7 vs. 0.7 MET-hour/week; p = 0.38). Mixed model analysis showed a significant (p = 0.048) difference in PA change between groups at 3 months only.

CONCLUSIONS

The IL intervention was successful in increasing the physical activity levels of obese, inactive middle-aged women in the short-term. No significant changes in weight were observed.

Long-term weight status in regainers after weight loss by lifestyle intervention: status and challenges

After having participated in a weight loss trial, most participants do not stabilise the obtained weight loss but return to their initial weight. The aim of this review is to describe the main determinants of continued low weight status after weight loss, and the effectiveness of physical activity (PA), energy restriction and macronutrient composition of the diet for low long-term weight regain. Studies with intervention periods of at least 3 months duration of weight reduction measures and a follow-up at least 2 years after the intervention period were considered as eligible for the review. Owing to limited data, the studies describing the role of PA in weight management were eligible with a follow-up of 1 year only. It appears that a diet with self-regulation of dietary intake seems to be given a prominent role in the strategy of successful long-term weight loss among the obese. This measure could be combined with behaviour therapy and PA and tailored to the individual situation. However, considering available evidence it is difficult to conclude regarding unambiguous measures and to recommend a specific dietary intervention. Nevertheless, interventions should be effective in promoting intrinsic motivation and self-efficacy. The harmonisation and standardisation of data collection in the follow-up period of long-term weight loss studies is a major challenge.

Effect of behavioural techniques and delivery mode on effectiveness of weight management: systematic review, meta-analysis and meta-regression

A systematic review, meta-analysis and meta-regression were conducted to evaluate the effectiveness of behavioural weight management programmes and examine how programme characteristics affect mean weight loss. Randomized controlled trials of multicomponent behavioural weight management programmes in overweight and obese adults were included. References were obtained through systematic searches of electronic databases (conducted November 2012), screening reference lists and contacting experts. Two reviewers extracted data and evaluated risk of bias. Thirty-seven studies, representing over 16,000 participants, were included. The pooled mean difference in weight loss at 12 months was -2.8 kg (95% confidence interval [CI] -3.6 to -2.1, P < 0.001). I(2) indicated that 93% of the variability in outcome was due to differences in programme effectiveness. Meta-analysis showed no evidence that supervised physical activity sessions (mean difference 1.1 kg, 95% CI -2.65 to 4.79, P = 0.08), more frequent contact (mean difference -0.3 kg, 95% CI -0.7 to 0.2, P = 0.25) or in-person contact (mean difference 0.0 kg, 95% CI -1.8 to 1.8, P = 0.06) were related to programme effectiveness at 12 months. In meta-regression, calorie counting (-3.3 kg, 95% CI -4.6 to -2.0, P = 0.027), contact with a dietitian (-1.5 kg, 95% CI -2.9 to -0.2, P < 0.001) and use of behaviour change techniques that compare participants' behaviour with others (-1.5 kg, 95% CI -2.9 to -0.1, P = 0.032) were associated with greater weight loss. There was no evidence that other programme characteristics were associated with programme effectiveness. Most but not all behavioural weight management programmes are effective. Programmes that support participants to count calories or include a dietitian may be more effective, but the programme characteristics explaining success are mainly unknown.

The association between carotid intima media thickness and individual dietary components and patterns

AIMS

To review: 1) the correlation between individual dietary components and carotid intima media thickness (cIMT); 2) the relationship between dietary patterns and cIMT; 3) the effect of dietary interventions on cIMT progression.

DATA SYNTHESIS

An electronic search for epidemiological and intervention trials investigating the association between dietary components or patterns of intake and cIMT was performed in PUBMED, EMBASE and the Cochrane Library. Epidemiological data shows that a higher intake of fruit, wholegrains and soluble fibre and lower consumption of saturated fat in favour of polyunsaturated fat is associated with lower cIMT. In people at high risk of cardiovascular disease >93 g/day of fruit is associated with lower cIMT. Lower cIMT has also been observed when >0.79 serves/day of wholegrains and >25 g/day of fibre, predominately in the soluble form is consumed. Saturated fat is positively associated with cIMT, for every 10 g/day increase in saturated fat cIMT is 0.03 mm greater. Olive oil is inversely associated with cIMT, with a benefit seen when >34 g/day is consumed. While there are many epidemiological studies exploring the association between dietary intake and cIMT there are few intervention studies. Intervention studies show that a Mediterranean diet may reduce cIMT progression, especially in those with a higher cIMT.

CONCLUSIONS

A Mediterranean style dietary pattern, which is high in fruits, wholegrains, fibre and olive oil and low in saturated fat, may reduce carotid atherosclerosis development and progression. However further research from randomised controlled trials is required to understand the association between diet and cIMT and the underlying mechanisms.

Healthy strategies for successful weight loss and weight maintenance: a systematic review

The rates of overweight and obesity are rising in Canada and worldwide, and there is a need for effective methods for weight loss and weight maintenance to empower individuals to make changes. The purpose of this systematic review was to examine the evidence available for successful diet strategies for weight loss and weight maintenance among adults. A search was conducted of the following databases: CAB Abstracts, Central Register of Controlled Trials, EMBASE, MEDLINE, Food Science and Technology Abstracts, and Web of Knowledge. The studies investigated had participants who were overweight or obese and between 18 and 65 years of age. A successful study was defined as one that reported an intervention that created ≥5% weight loss from baseline and a maintenance phase during which the ≥5% weight loss was maintained from baseline to 12 months. After exclusions, the search resulted in 67 papers. Overall, for significant safe weight loss, an energy deficit was required, which was commonly achieved by reduced fat intake. Increased dietary fibre was also a component of 21% of successful interventions. Physical activity was included in 88% of successful interventions, and behaviour training such as self-monitoring was part of 92% of successful interventions. The same combination of energy and fat restriction, regular physical activity, and behavioural strategies was also required for successful weight maintenance. This review confirmed previous knowledge about weight loss and weight maintenance in adults. A comprehensive approach, including reduced dietary intake, regular physical activity, and behavioural strategies, is warranted and is supported by the research evidence.

Short- and long-term eating habit modification predicts weight change in overweight, postmenopausal women: results from the WOMAN study

BACKGROUND

Standard behavioral obesity treatment produces poor long-term results. Focusing on healthy eating behaviors rather than energy intake may be an alternative strategy. In addition, important behaviors might differ for short- vs long-term weight control.

OBJECTIVE

Our aim was to describe and compare associations between changes in eating behaviors and weight after 6 and 48 months.

DESIGN

We performed secondary analysis of data collected during a randomized weight-loss intervention trial with 48-month follow-up.

PARTICIPANTS

We studied 481 overweight and obese postmenopausal women enrolled in the Women on the Move through Activity and Nutrition (WOMAN) Study.

MAIN OUTCOME MEASURES

We measured changes in weight from baseline to 6 and 48 months.

STATISTICAL ANALYSES PERFORMED

Linear regression models were used to examine the associations between 6- and 48-month changes in eating habits assessed by the Conner Diet Habit Survey and changes in weight. Analyses were conducted in the combined study population and stratified by randomization group.

RESULTS

At 6 months in the combined population, weight loss was independently associated with decreased desserts (P<0.001), restaurant eating (P=0.042), sugar-sweetened beverages (P=0.009), and fried foods (P<0.001), and increased fish consumption (P=0.003). Results were similar in intervention participants; only reduced desserts and fried foods associated with weight loss in controls. At 48 months in the combined population, weight loss was again associated with decreased desserts (P=0.003) and sugar-sweetened beverages (P=0.011), but also decreased meats/cheeses (P=0.024) and increased fruits/vegetables (P<0.001). Decreased meats/cheeses predicted weight loss in intervention participants; desserts, sugar-sweetened beverages, and fruits/vegetables were independently associated in controls.

CONCLUSIONS

Changes in eating behaviors were associated with weight change, although important behaviors differed for short- and long-term weight change and by randomization group. Future studies should determine whether interventions targeting these behaviors could improve long-term obesity treatment outcomes.

Hormone therapy, estrogen metabolism, and risk of breast cancer in the Women's Health Initiative Hormone Therapy Trial

BACKGROUND

In the Women's Health Initiative Hormone Trials (WHI-HT), breast cancer risk was increased with estrogen plus progestin (E+P) but not with unopposed estrogen (E-alone). We hypothesized that E+P would preferentially metabolize to 16α-hydroxyestrone (16α-OHE1) rather than 2-hydroxyestrone (2-OHE1), and that breast cancer risk would be associated with baseline and 1 year changes in estrogen metabolites: positively for 16α-OHE1 levels and negatively for levels of 2-OHE-1 and the 2:16 ratio.

METHODS

In a prospective case-control study nested in the WHI-HT, 845 confirmed breast cancer cases were matched to 1,690 controls by age and ethnicity. Using stored serum, 2-OHE1 and 16α-OHE1 levels were measured by enzyme immunoassay at baseline, and for those randomized to active treatment (n = 1,259), at 1 year.

RESULTS

The 1-year increase in 16α-OHE1 was greater with E+P than E-alone (median 55.5 pg/mL vs. 43.5 pg/mL, P < 0.001), but both increased 2-OHE1 by ∼300 pg/mL. Breast cancer risk was modestly associated with higher baseline levels of 2-OHE1 and the 2:16 ratio, and for estrogen receptor+/progesterone+ cases only, higher baseline 16α-OHE1 levels. For those randomized to active treatment, breast cancer risk was associated with greater increase in 2-OHE-1 and the 2:16 ratio, but associations were not significant.

CONCLUSIONS

Although E+P modestly increased 16α-OHE1 more than E-alone, increase in 16α-OHE1 was not associated with breast cancer.

IMPACT

Study results do not explain differences between the WHI E+P and WHI E-alone breast cancer results but metabolism of oral HT, which may explain smaller than expected increase in breast cancer compared with endogenous estrogens.

High-density lipoprotein cholesterol and particle concentrations, carotid atherosclerosis, and coronary events: MESA (multi-ethnic study of atherosclerosis)

OBJECTIVES

The purpose of this study was to evaluate independent associations of high-density lipoprotein cholesterol (HDL-C) and particle (HDL-P) concentrations with carotid intima-media thickness (cIMT) and incident coronary heart disease (CHD).

BACKGROUND

HDL-C is inversely related to CHD, and also to triglycerides, low-density lipoprotein particles (LDL-P), and related metabolic risk. HDL-P associations with CHD may be partially independent of these factors.

METHODS

In a multiethnic study of 5,598 men and women ages 45 to 84 years old, without baseline CHD, excluding subjects on lipid-lowering medications, triglycerides >400 mg/dl, or missing values, we evaluated associations of HDL-C and nuclear magnetic resonance spectroscopy-measured HDL-P with cIMT and incident CHD (myocardial infarction, CHD death, and angina, n = 227 events; mean 6.0 years follow-up). All models were adjusted for age, sex, ethnicity, hypertension, and smoking.

RESULTS

HDL-C and HDL-P correlated with each other (ρ = 0.69) and LDL-P (ρ = -0.38, -0.25, respectively, p < 0.05 for all). For (1 SD) higher HDL-C (15 mg/dl) or HDL-P (6.64 μmol/l), cIMT differences were - 26.1 (95% confidence interval [CI]: -34.7 to -17.4) μm and -30.1 (95% CI: -38.8 to - 21.4) μm, and CHD hazard ratios were 0.74 (95% CI: 0.63 to 0.88) and 0.70 (95% CI: 0.59 to 0.82), respectively. Adjusted for each other and LDL-P, HDL-C was no longer associated with cIMT (2.3; 95% CI: - 9.5 to 14.2 μm) or CHD (0.97; 95% CI: 0.77 to 1.22), but HDL-P remained independently associated with cIMT (-22.2; 95% CI: - 33.8 to -10.6 μm) and CHD (0.75; 95% CI: 0.61 to 0.93). Interactions by sex, ethnicity, diabetes, and high-sensitivity C-reactive protein were not significant.

CONCLUSIONS

Adjusting for each other and LDL-P substantially attenuated associations of HDL-C, but not HDL-P, with cIMT and CHD. Potential confounding by related lipids or lipoproteins should be carefully considered when evaluating HDL-related risk.