The treatment of obesity: what's new, what's recommended

A virtual reality intervention (Second Life) to improve weight maintenance: Rationale and design for an 18-month randomized trial

Despite the plethora of weight loss programs available in the US, the prevalence of overweight and obesity (BMI≥25kg/m(2)) among US adults continues to rise at least, in part, due to the high probability of weight regain following weight loss. Thus, the development and evaluation of novel interventions designed to improve weight maintenance are clearly needed. Virtual reality environments offer a promising platform for delivering weight maintenance interventions as they provide rapid feedback, learner experimentation, real-time personalized task selection and exploration. Utilizing virtual reality during weight maintenance allows individuals to engage in repeated experiential learning, practice skills, and participate in real-life scenarios without real-life repercussions, which may diminish weight regain. We will conduct an 18-month effectiveness trial (6 months weight loss, 12 months weight maintenance) in 202 overweight/obese adults (BMI 25-44.9kg/m(2)). Participants who achieve ≥5% weight loss following a 6month weight loss intervention delivered by phone conference call will be randomized to weight maintenance interventions delivered by conference call or conducted in a virtual environment (Second Life®). The primary aim of the study is to compare weight change during maintenance between the phone conference call and virtual groups. Secondarily, potential mediators of weight change including energy and macronutrient intake, physical activity, consumption of fruits and vegetables, self-efficacy for both physical activity and diet, and attendance and completion of experiential learning assignments will also be assessed.

Eating Motives and the Controversy over Dieting: Eating Less Than Needed versus Less Than Wanted

Anti-dieting sentiment has grown in recent years. Critics of restrained eating suggest that it evokes counter-regulatory responses that render it ineffective or even iatrogenic. However, restrained eaters are not in negative energy balance and overweight individuals show reduced eating problems when losing weight by dieting. A distinction is often drawn between physiological and psychological hunger, and neuroscience research has shown that there is a neurophysiological reality underlying this distinction. The brain has a homeostatic system (activated by energy deficits) and a hedonic system (activated by the presence of palatable food). The omnipresence of highly palatable food in the environment may chronically activate the hedonic appetite system, producing a need to actively restrain eating not just to lose weight but to avoid gaining it. Just as restricting energy intake below homeostatic needs produces physiological deprivation, restricting intake of palatable foods may produce "perceived deprivation" despite a state of energy balance. In summary, the motivation to eat more than one needs appears to be every bit as real, and perhaps every bit as powerful, as the motivation to eat when energy deprived.

Problem solving, treatment adherence, and weight-loss outcome among women participating in lifestyle treatment for obesity

OBJECTIVE

This study examined whether improvements in problem-solving abilities mediate the relation between treatment adherence and weight-loss outcome in the behavioral treatment of obesity.

METHOD

272 women (mean+/-SD age=59.4+/-6.2 years, BMI=36.5+/-4.8) participated in a 6-month lifestyle intervention for obesity. Body weight and problem-solving skills (as measured by the Social Problem Solving Inventory-Revised) were assessed pre- and posttreatment. The completion of self-monitoring logs during the intervention served as the marker of treatment adherence.

RESULTS

At posttreatment, participants lost 8.4+/-5.8 kg, an 8.8% reduction in body weight. Changes in weight were associated with increased problem-solving skills and with higher levels of treatment adherence. Improvements in problem-solving skills partially mediated the relation between treatment adherence and weight-loss outcome. Moreover, participants with weight reductions > or = 10% demonstrated significantly greater improvements in problem-solving skills than those with reductions <5%.

DISCUSSION

Improvements in problem-solving skills may enable participants to overcome barriers to adherence and thereby enhance treatment-induced weight losses.

Dieting: really harmful, merely ineffective or actually helpful?

Dieting has developed a negative reputation among many researchers and health care professionals. However, ‘dieting’ can refer to a variety of behavioural patterns that are associated with different effects on eating and body weight. The wisdom of dieting depends on what kind of dieting is involved, who is doing it, and why. Thus, depending on what one means by the term, dieting can be quite harmful, merely ineffective or actually beneficial. The present paper considers examples of all three. In particular, we argue that judgements about the desirability of dieting should consider the likely consequences to particular individuals of engaging in, or not engaging in, dieting behaviour.

Multiple types of dieting prospectively predict weight gain during the freshman year of college

The freshman year of college is a period of heightened risk for weight gain. This study examined measures of restrained eating, disinhibition, and emotional eating as predictors of weight gain during the freshman year. Using Lowe's multi-factorial model of dieting, it also examined three different types of dieting as predictors of weight gain. Sixty-nine females were assessed at three points during the school year. Weight gain during the freshman year averaged 2.1 kg. None of the traditional self-report measures of restraint, disinhibition, or emotional eating were predictive of weight gain. However, both a history of weight loss dieting and weight suppression (discrepancy between highest weight ever and current weight) predicted greater weight gain, and these effects appeared to be largely independent of one another. Individuals who said they were currently dieting to lose weight gained twice as much (5.0 kg) as former dieters (2.5 kg) and three times as much as never dieters (1.6 kg), but the import of this finding was unclear because there was only a small number of current dieters (N = 7). Overall the results indicate that specific subtypes of dieting predicts weight gain during the freshman year better than more global measures of restraint or overeating.

Effect of sibutramine and of cognitive-behavioural weight loss therapy in obesity and subclinical binge eating disorder

AIM

In this randomized, double-blind, placebo-controlled study, the effect of sibutramine and cognitive-behavioural weight loss (cognitive-BWL) treatment was assessed in obese subjects with and without subclinical binge eating disorder (sBED).

METHODS

Seventy-three obese participants were recruited from the community, 29 with and 44 without sBED. Subjects were randomly assigned to a 16-week treatment with either sibutramine or placebo while simultaneously participating in a cognitive-behavioural weight loss treatment.

RESULTS

Intent-to-treat analysis showed moderate weight loss after treatment in all subject groups. Treatment with BWL programs and sibutramine leads to a higher weight loss in all subjects compared with that in patients who had undergone BWL programs alone. Subjects with sBED significantly reduced their binge episodes during treatment, but with no augmenting effect of sibutramine.

DISCUSSION

Our results yield further evidence that sBED is associated with characteristics comparable with full-syndrome BED, significantly differing from those of obesity alone. These findings call for a systematic assessment of eating behaviour before starting obesity treatment.

Self-regulation of energy intake in the prevention and treatment of obesity: is it feasible?

The prevalence of obesity in developed countries has been steadily increasing. Comprehensive lifestyle change programs for the treatment of obesity have garnered considerable empirical support, but most weight lost in lifestyle interventions is regained within several years. The outcome of obesity prevention programs has also been disappointing. One reason for this state of affairs may be that most weight control programs are based on an assumption of equipotentiality of their intervention components. That is, obesity prevention and treatment programs consist of a multitude of behavioral, cognitive, nutritional, physical activity, and interpersonal techniques, all of which are assumed to be of roughly equal importance in weight control. However, there is considerable evidence that our evolutionary heritage has made most humans highly sensitive to the availability and nature of food in the environment. It therefore may be unrealistic to expect that enhancing self-regulatory skills will be sufficient to overcome the combined influence of our appetitive predispositions and the obesigenic environment. However, there is growing evidence that weight control interventions that focus on the availability, structure, composition, and portion size of foods in the diet improve long-term weight control. Concerted efforts to change the availability and nature of foods at both the individual and population level may hold considerable promise for the treatment and prevention of obesity.

Hip-Hop to Health Jr., an obesity prevention program for minority preschool children: baseline characteristics of participants

BACKGROUND

The prevalence of obesity in the United States is a significant public health problem. Many obesity-related risk factors are more prevalent in minority populations. Given the recalcitrant nature of weight loss interventions for adults, prevention of overweight and obesity has become a high priority. The present study reports baseline data from an obesity prevention intervention developed for minority preschool children.

METHODS

Hip-Hop to Health Jr. is a 5-year randomized controlled intervention that targets 3- to 5-year-old minority children enrolled in 24 Head Start programs. Our primary aim is to test the effect of the intervention on change in body mass index. Data were collected on sociodemographic, anthropometric, behavioral, and cognitive variables for the children and parents at baseline.

RESULTS

Participants included 416 black children, 337 black parents, 362 Latino children, and 309 Latino parents. Using body mass index for age and sex > or = the 95th percentile as the definition of overweight, 15% of the black children and 28% of the Latino children were overweight. More than 75% of the parents were either overweight or obese.

DISCUSSION

The development of interventions to effectively prevent or control obesity early in life is crucial. These data highlight the escalating problem of weight control in minority populations.

A review of psychosocial outcomes of surgery for morbid obesity

There is consistent evidence to support the notion that morbid obesity poses serious risks to physical health and has a substantial impact on psychosocial well-being. Researchers agree that bariatric surgery is currently the most viable option for successful weight loss and maintenance in the morbidly obese individual. The drastic, major weight loss and alleviation of medical risks that patients typically experience post-surgically are accompanied by psychosocial changes that appear to be equally remarkable. These psychosocial changes have yet to be studied as systematically or diligently as the physical changes and therefore remain to be fully understood. This paper (1) reviews the literature of psychosocial outcomes of obesity surgery for the past 36 years; (2) provides a critical assessment of the methodology utilized; and (3) suggests future research directions.

A community-based obesity prevention program for minority children: rationale and study design for Hip-Hop to Health Jr

BACKGROUND; The increasing prevalence of overweight among children in the United States presents a national health priority. Higher rates of overweight/obesity among minority women place their children at increased risk. Although increased rates of overweight are observed in 4- to 5-year-old children, they are not observed in 2- to 3-year-old children. Therefore, early prevention efforts incorporating families are critical.

METHODS

The primary aim of Hip-Hop to Health Jr. is to alter the trajectory toward overweight/obesity among preschool African-American and Latino children. This 5-year randomized intervention is conducted in 24 Head Start programs, where each site is randomized to either a 14-week dietary/physical activity intervention or a general health intervention.

RESULTS

This paper presents the rationale and design of the study. Efficacy of the intervention will be determined by weight change for the children and parent/caretaker. Secondary measures include reductions in dietary fat and increases in fiber, fruit/vegetable intake, and physical activity. Baseline data will be presented in future papers.

CONCLUSIONS

The problem of overweight/obesity is epidemic in the United States. Behaviors related to diet and physical activity are established early in life and modeled by family members. Early intervention efforts addressing the child and family are needed to prevent obesity later in life. This paper describes a comprehensive, family-oriented obesity prevention program for minority preschool children.

Effective diet and exercise treatments for overweight and recommendations for intervention

Traditional diet and exercise treatments for obesity have been ineffective in reducing the prevalence of overweight in the population. Treatment outcomes for overweight can be measured in terms of physical parameters (e.g. bodyweight, percentage body fat, body mass index), medical terms (e.g. blood pressure, blood glucose control, blood lipid levels), psychological terms (e.g. eating pathology, self-esteem, mood state) and behavioural terms (e.g. frequency of exercise, eating patterns, self healthcare). Regardless of the specific outcome measures used to define successful treatment, the desired outcome must be maintained for several years to be considered effective. Energy restrictive diets cause significant initial bodyweight loss, but are plagued with high dropout- and relapse-rate. Low-fat diets have met with minimal success for bodyweight control, but nonetheless can significantly lower blood lipid levels. High-protein/low-carbohydrate diets are claimed to be the most effective in reducing bodyweight, but there are no scientific data to support these claims. Persons on these types of diets are also at the greatest risk for metabolic adverse effects. Nondieting approaches and programmes that stress 'health at any size' have not been researched rigorously, but preliminary data show minimal bodyweight loss with significant improvements in psychological state, eating pathology and well-being. Exercise is the only variable that consistently shows effectiveness in physiological, medical, psychological and behavioural outcomes. A treatment programme that has the greatest potential for success, regardless of outcome measure, is a programme that consists of 4 key components. These components are: (i) pre-evaluation, where historical information is gathered and used to set programme goals, objectives and outcome measures; (ii) exercise, wherein enjoyable exercise is encouraged for health, bodyweight control and well being; (iii) a behavioural plan, which is based on patterns of eating and activity that will lead to the desired outcome measures; and (iv) a maintenance plan, that helps the individual develop skills for maintaining newly developed behaviours.

Focus on primary care: evaluation, management, and treatment of obesity in women

Obesity is the number one nutritional disorder in the developed world. It is now well recognized that obesity is a disease that represents a rapidly growing epidemic. It is often a lifelong problem that preferentially affects women. Modern science and medicine are just beginning to unravel the multifactorial pathophysiology of obesity. Current literature emphasizes the metabolic, hormonal, and behavioral interactions as well as genetic predisposition. This understanding has led to new recommendations for the management of the obese patient and to new pharmaceutical approaches for those at high risk. These risks include diabetes, cardiovascular disease, hypertension, gallbladder disease, and osteoarthritis. In addition, there are a number of reproductive health problems unique to obese women. Until recently, however, the evidence for benefit of weight loss was not clear. There are now numerous Category A data indicating significant benefit for weight loss as it affects multiple comorbidities It is, therefore, incumbent upon the providers of women's health care to assess patient risk and to offer resources, guidance, assistance, and reassurance to the overweight and obese patient as she embarks on a program of renewed health through weight loss.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to describe the classification of overweight and obesity, explain the pathophysiology of obesity, outline the evaluation and screening of the obese patient, and list potential therapeutic interventions for weight loss.

Lifestyle treatments in randomized clinical trials of pharmacotherapies for obesity

OBJECTIVE

This meta-analysis evaluated the types of lifestyle treatments used in published obesity drug studies and assessed their contribution to weight losses associated with pharmacological interventions.

RESEARCH METHODS AND PROCEDURES

Randomized, placebo-controlled, double-blind clinical trials of anti-obesity agents that are/were Food and Drug Administration-approved for the treatment of obesity (both prescription and over-the-counter), and drugs that are Food and Drug Administration-approved and are used off-label for obesity were included. Studies were located by computer searches of databases (e.g., Medline, PsychInfo) and reviewing tables of content/reference sections of journals, abstracts, previous reviews, past empirical studies, relevant book chapters, and recent issues of journals that regularly publish obesity research. In addition, a number of individuals who regularly publish in the obesity literature were asked to provide personal lists of obesity-drug studies. Based on the above criteria, a total of 108 randomized clinical trials were located.

RESULTS

Balanced-deficit diets, low-calorie diets, and self-monitoring were the most used lifestyle treatments in published obesity studies. They were incorporated into 40.7%, 25%, and 23.1% of pharmacotherapy studies, respectively. Physical activity and other behavioral or psychotherapeutic interventions rarely were used. A substantial portion of weight loss experienced by patients was attributable to both "placebo effects" and to the lifestyle treatments.

DISCUSSION

Obesity-pharmacotherapy trials do not use lifestyle treatments with the frequency expected based on the official positions of most professional organizations concerned with the comprehensive management of obesity.