Predictors of programme adherence and weight loss in women in an obesity programme using meal replacements

Predictors of attrition from a weight loss program. A study of adult patients with obesity in a community setting

PURPOSE

Obesity unit attrition is frequent and contributes to treatment failure. Many studies evaluating attrition predictors were part of randomized trials, and different terminology and criteria were used in the engagement field. We aimed to investigate the factors potentially implicated in early (< 12 weeks) and late (> 12 weeks) attrition from an obesity unit in a community setting METHODS: This was a retrospective cohort study of 250 patients with obesity who were followed-up at our obesity unit. Our program included at least 6 meetings in 12 months. Sociodemographic and anthropometric data, and psychometric questionnaires were collected from all participants.

RESULTS

One-hundred thirty-four (53.6%) participants dropped out. Those individuals showed lower BMI, lower overall health status, and increased depression scores. In a multiple regression model, BMI (inversely; OR = 0.90; 95%CI 0.84-0.96) and depression score (directly, OR = 1.05; 1.00-1.10) were associated with attrition risk. Early dropouts (n = 47) had lower weights, smaller waist circumferences and worse mental health scores than late dropouts (n = 87) and more frequently lived alone. When compared to completers, early dropouts had lower weights, BMIs, waist circumferences, overall health and mental status scores, increased depression scores and percentage of individuals living alone. In a multiple regression, lower BMI (OR = 0.83; 0.75-0.92), lower mental status score (OR = 3.17; 1.17-8.59) and living alone (OR = 2.25; 1.02-4.97) were associated with early attrition risk.

CONCLUSION

Lower BMI and increased depression score were associated with attrition. Early attrition was associated with lower weight, decreased mental well-being, and living alone. Individuals with these characteristics might need tailored approaches to enhance their engagement.

LEVEL OF EVIDENCE

Level V, retrospective descriptive study.

Intermediate weight changes and follow-up of dietetic treatment in primary health care: an observational study

BACKGROUND

Primary health care data have shown that most patients who were treated for overweight or obesity by a dietitian did not accomplish the recommended treatment period. It is hypothesised that a slow rate of weight loss might discourage patients from continuing dietetic treatment. This study evaluated intermediate weight changes during regular dietetic treatment in Dutch primary health care, and examined whether weight losses at previous consultations were associated with attendance at follow-up consultations.

METHODS

This observational study was based on real life practice data of overweight and obese patients during the period 2013-2017, derived from Dutch dietetic practices that participated in the Nivel Primary Care Database. Multilevel regression analyses were conducted to estimate the mean changes in body mass index (BMI) during six consecutive consultations and to calculate odds ratios for the association of weight change at previous consultations with attendance at follow-up consultations.

RESULTS

The total study population consisted of 25,588 overweight or obese patients, with a mean initial BMI of 32.7 kg/m². The BMI decreased between consecutive consultations, with the highest weight losses between the first and second consultation. After six consultations, a mean weight loss of - 1.5 kg/m² was estimated. Patients who lost weight between the two previous consultations were more likely to attend the next consultation than patients who did not lose weight or gained weight.

CONCLUSIONS

Body mass index decreased during consecutive consultations, and intermediate weight losses were associated with a higher attendance at follow-up consultations during dietetic treatment in overweight patients. Dietitians should therefore focus on discussing intermediate weight loss expectations with their patients.

A systematic review of UK-based long-term nonsurgical interventions for people with severe obesity (BMI ≥35 kg m-2 )

Introduction

The aim of this project was to systematically review UK evidence on the effectiveness of long‐term (≥12 months) weight management services (WMSs) for weight loss and weight maintenance for adults (≥16 years) with severe obesity (body mass index ≥35 kg m⁻²), who would generally be eligible for Tier 3 services.

Methods

Four data sources were searched from 1999 to October 2018.

Results

Our searches identified 20 studies, mostly noncomparative studies: 10 primary care interventions, nine in secondary care specialist weight management clinics and one commercial setting intervention. A programme including a phase of low energy formula diet (810–833 kcal day⁻¹) showed the largest mean (SD) weight change at 12 months of –12.4 (11.4) kg for complete cases, with 25.3% dropout. Limitations or differences in evaluation and reporting (particularly for denominators), unclear dropout rates, and differences between participant groups in terms of comorbidities and psychological characteristics, made comparisons between WMSs and inferences challenging.

Conclusions

There is a persistent and clear need for guidance on long‐term weight data collection and reporting methods to allow comparisons across studies and services for participants with severe obesity. Data could also include quality of life, clinical outcomes, adverse events, costs and economic outcomes. A randomised trial comparison of National Health Service Tier 3 services with commercial WMSs would be of value.

Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation

BACKGROUND

Adults with severe obesity [body mass index (BMI) of ≥ 35 kg/m2] have an increased risk of comorbidities and psychological, social and economic consequences.

OBJECTIVES

Systematically review bariatric surgery, weight-management programmes (WMPs) and orlistat pharmacotherapy for adults with severe obesity, and evaluate the feasibility, acceptability, clinical effectiveness and cost-effectiveness of treatment.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials and the NHS Economic Evaluation Database were searched (last searched in May 2017).

REVIEW METHODS

Four systematic reviews evaluated clinical effectiveness, cost-effectiveness and qualitative evidence for adults with a BMI of ≥ 35 kg/m2. Data from meta-analyses populated a microsimulation model predicting costs, outcomes and cost-effectiveness of Roux-en-Y gastric bypass (RYGB) surgery and the most effective lifestyle WMPs over a 30-year time horizon from a NHS perspective, compared with current UK population obesity trends. Interventions were cost-effective if the additional cost of achieving a quality-adjusted life-year is < £20,000-30,000.

RESULTS

A total of 131 randomised controlled trials (RCTs), 26 UK studies, 33 qualitative studies and 46 cost-effectiveness studies were included. From RCTs, RYGB produced the greatest long-term weight change [-20.23 kg, 95% confidence interval (CI) -23.75 to -16.71 kg, at 60 months]. WMPs with very low-calorie diets (VLCDs) produced the greatest weight loss at 12 months compared with no WMPs. Adding a VLCD to a WMP gave an additional mean weight change of -4.41 kg (95% CI -5.93 to -2.88 kg) at 12 months. The intensive Look AHEAD WMP produced mean long-term weight loss of 6% in people with type 2 diabetes mellitus (at a median of 9.6 years). The microsimulation model found that WMPs were generally cost-effective compared with population obesity trends. Long-term WMP weight regain was very uncertain, apart from Look AHEAD. The addition of a VLCD to a WMP was not cost-effective compared with a WMP alone. RYGB was cost-effective compared with no surgery and WMPs, but the model did not replicate long-term cost savings found in previous studies. Qualitative data suggested that participants could be attracted to take part in WMPs through endorsement by their health-care provider or through perceiving innovative activities, with WMPs being delivered to groups. Features improving long-term weight loss included having group support, additional behavioural support, a physical activity programme to attend, a prescribed calorie diet or a calorie deficit.

LIMITATIONS

Reviewed studies often lacked generalisability to UK settings in terms of participants and resources for implementation, and usually lacked long-term follow-up (particularly for complications for surgery), leading to unrealistic weight regain assumptions. The views of potential and actual users of services were rarely reported to contribute to service design. This study may have failed to identify unpublished UK evaluations. Dual, blinded numerical data extraction was not undertaken.

CONCLUSIONS

Roux-en-Y gastric bypass was costly to deliver, but it was the most cost-effective intervention. Adding a VLCD to a WMP was not cost-effective compared with a WMP alone. Most WMPs were cost-effective compared with current population obesity trends.

FUTURE WORK

Improved reporting of WMPs is needed to allow replication, translation and further research. Qualitative research is needed with adults who are potential users of, or who fail to engage with or drop out from, WMPs. RCTs and economic evaluations in UK settings (e.g. Tier 3, commercial programmes or primary care) should evaluate VLCDs with long-term follow-up (≥ 5 years). Decision models should incorporate relevant costs, disease states and evidence-based weight regain assumptions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016040190.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit and Health Economics Research Unit are core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.

A path model analysis on predictors of dropout (at 6 and 12 months) during the weight loss interventions in endocrinology outpatient division

INTRODUCTION

This study aimed to identify the dropout rate at 6 and 12 months from the first outpatient visit, and to analyze dropout risk factors among the following areas: biochemical examinations, anthropometric measures, psychological tests, personal data, and life attitude such as smoking, physical activity, and pathologies.

METHODS

This is a retrospective longitudinal observational study. Patients undergo an outpatient endocrinology visit, which includes collecting biographical data, anthropometric measurements, physical and pathological history, psychological tests, and biochemical examinations.

RESULTS

The sample consists of 913 subjects (682 women and 231 men), with an average age of 50.88 years (±15.80) for the total sample, with a BMI of 33.11 ± 5.65 kg/m². 51.9% of the patients abandoned therapy at 6 months after their first visit, and analyzing the dropout rate at 12 months, it appears that 69.5% of subjects abandon therapy. The main predictor of dropout risk factors at 6 and 12 months is the weight loss during the first 3 months (p < 0.05). As regards the hematological predictors, white blood cell and iron level stated dropout at 12 months. Patients who introduced physical activity had a reduction of - 17% (at 6 months) and -13% (at 12 months) of dropout risk (p < 0.05). As regards the "worker" status, patients classified as"retired" had a decrease risk of dropout vs. other categories of worker (i = 0.58; p < 0.05). Dropout risk at 12 months decrease in patients with a previous history of cancer, Endocrine and psychic and behavioral disorders (p < 0.001).

CONCLUSIONS

The main factor that predisposes patients to continue therapy or to abandon it is the success (or failure) of the diet in the initial period, based on weight lost (or not lost) in the early months of the initiation of therapy. Furthermore, considerable differences were found in different categories of "workers", and with previous "pathologies". The level of physical activity and previous diseases also seem to be predictors of dropout.

Predictors of weight reduction and maintenance in a large cohort of overweight and obese adults in a community setting

AIM

In overweight/obese individuals, modest 5% weight loss and its maintenance promotes health; however, it is challenging and typically unachievable, especially in community settings. Established predictors of weight loss outcome in a community setting are lacking, hindering the development of practical interventions and prevention tools. Our aim was to identify predictors associated with 5% weight reduction (initial 6 months) and maintenance (1 year) in overweight and obese adults undergoing weight reduction treatment, free of charge, in a community setting.

METHODS

Computerised medical files of 11 842 adults aged 50.6 ± 16.3 years, attending 162 primary clinics, were analysed retrospectively. Thirty medical, biochemical and demographic independent variables were tested as potential predictors using multiple logistic regression models.

RESULTS

Significant predictors of high successful weight reduction were: not being treated with insulin (odds ratio (OR) = 0.53), higher baseline body mass index (OR = 1.05) and younger age (OR = 0.98). Weight maintenance predictors were: successful initial weight reduction (OR = 1.26), short time intervals between weighings (OR = 0.88) and frequent weighing (OR = 0.95). Visits to a dietitian were significantly associated with success during both periods: each visit raised the probability of success by 13.4 and 7.6%, respectively. Type 2 diabetes or use of hypoglycaemic drugs were not significant predictors.

CONCLUSIONS

In a community-based setting, number of visits to a dietitian is a strong predictor of successful weight reduction and maintenance. Initial success is a critical predictor of weight loss maintenance. Subgroup of older, diabetic patients treated with insulin has a dramatically lower probability of weight reduction success.

Predictors of early attrition and successful weight loss in patients attending an obesity management program

Background

Our objective was to identify factors that are independently associated with early attrition and successful weight loss (WL) in an obesity-management program.

Methods

Participants were 9,498 patients enrolled in treatment at the Wharton Weight Management Clinic for at least 6 months. Predictors of early attrition (<6 months) and successful WL (≥5 %) were analyzed using relative risk (RR) in men and women separately. Pearson’s correlation was used to determine the relationship between WL and treatment time Weight loss and attrition analysis was restricted to patients who had more than two visits (n = 5415).

Results

Older individuals had lower early attrition (RR Range:0.74–0.92, P < 0.05) and greater WL success (RR Range:1.40–1.65, P < 0.05) than younger individuals. Males with hypertension and females with depression had greater early attrition (RR Range:1.09–1.20, P < 0.05) and lower WL success (RR Range:0.48–0.57, P < 0.05) than those without these health conditions. Males with lower education had greater early attrition (RR = 1.11[1.03–1.19]) than males with higher education, but did not differ in WL. Females who smoked had greater early attrition (RR = 1.06[1.01–1.11]) than females who did not smoke, but did not differ in WL. Ethnicity was not related to early attrition, however, females of Black and Other ethnicities had lower WL success compared to White females (RR Range:0.58–0.74, P < 0.05). After adjusting for treatment time, all above associations were no longer significant and treatment time remained as the only independent predictor of WL success (P < 0.0001).

Conclusion

As WL is positively and independently related with treatment time, individuals at risk for early attrition may need alternative treatment options, in order to improve patient retention and improve WL success.

Laparoscopic Adjustable Gastric Banding (LAGB) Aftercare Attendance and Attrition

BACKGROUND

Regular aftercare attendance following laparoscopic adjustable gastric banding (LAGB) is associated with greater weight loss and fewer post-surgical complications. Despite high reported rates of attrition from LAGB aftercare, the reasons for non-attendance have not been previously explored. The present study aimed to explore patient-reported barriers to LAGB aftercare attendance, and the perceived helpfulness of potential attrition-reducing strategies, in both regular attendees and non-attendees of aftercare.

METHODS

One hundred and seventy-nine participants (107 regular attendees and 72 non-attendees) completed a semi-structured questionnaire, assessing barriers to attrition (101 items) and usefulness of attrition prevention strategies (14 items).

RESULTS

Findings indicate that both regular attendees and non-attendees experience multiple barriers to aftercare attendance. Non-attendees generally reported that barriers had a greater impact on their aftercare attendance. There was evidence for some level of acceptability for attrition-reducing strategies suggesting that LAGB patients may be receptive to such strategies.

CONCLUSIONS

Current findings highlight the importance of assessing barriers to treatment in both attendees and non-attendees. It is proposed that addressing barriers that differentiate non-attendees from attendees may be most effective in reducing attrition from aftercare.

Primary care weight loss maintenance with behavioral nutrition: An observational study

OBJECTIVE

To evaluate the rate of weight loss maintenance, defined as a 10% loss of initial weight maintained beyond 1 year, among patients with BMI > 25 kg/m(2) who had been managed by primary care physicians practicing behavioral nutrition (moderately high-protein diet, carbohydrate restriction, and behavioral therapy).

METHODS

Restrospective analysis of anthropometric characteristics, weight loss, and its determinants was conducted in 14,256 patients.

RESULTS

26.7% of subjects met the success criterion (successful maintenance group; SM), 25.7% did not maintain their weight loss (unsuccessful maintenance group; UM), and 47.6% did not lose 10% of their initial weight (failure group; F). At inclusion, patients in the SM group had a greater BMI and fat mass percentage (40.5% in SM, 38.5% in UM, and 37.0% in F). These patients lost more weight (-14.1% vs. -4.59%) and fat mass (-24.7% vs. -8.21%) than patients in the UM group, and contribution of adiposity to their weight loss was 75.1%. Follow-up of patients in the SM group was characterized by a greater frequency of consultations.

CONCLUSIONS

Management by primary care providers with behavioral nutrition facilitates weight loss maintenance in patients with overweight and obesity. The determinants of success are frequency of consultations, initial BMI, and initial weight loss.

Late successful weight reduction and maintenance among overweight and obese adults--a two-year retrospective study

AIMS

Our purpose was to identify those factors associated with successful late weight reduction and maintenance among overweight and obese adults who failed to achieve initial weight reduction success.

METHODS

Medical computerized files of 5254 participants, who failed to achieve ≥ 5% weight reduction after an initial 6-month period, were retrospectively analyzed to identify predictors associated with late successful weight reduction and maintenance (≥ 5% during the first and second years, respectively). Over 40 independent variables were analyzed. The main outcome was the percentage of weight change.

RESULTS

Significant predictors of late success in weight reduction were as follows: more visits to a dietitian, higher baseline BMI, and any initial weight reduction (0-5%) (OR=3.69, compared with participants who initially gained weight). The use of insulin (OR=0.499) and the presence of hypertension (OR=0.75) were significantly correlated with failure to reduce weight. Predictors of late maintenance were as follows: more visits to a dietitian, higher baseline BMI, any initial weight reduction, a younger age, not being treated with insulin (OR=0.316), and more weighings (OR=1.68).

CONCLUSIONS

A substantial sub-group of obese and overweight patients was able to reduce their weight at a slower rate than the defined successful time of 6 months. Significant specific predictors were identified. Diabetic and hypertensive patients are at a significantly higher risk of failure to reduce and maintain weight. Using regression models, we calculated the probability of successful late weight reduction. This calculation could serve as a clinical tool for a professional team.

Weight loss resistance: a further consideration for the nutritional management of obese Equidae

Evidence-based, weight loss management advice is required to address equine obesity. Changes in body mass (BM), body condition score (BCS), heart (HG) and belly circumference (BG), direct (ultrasonographic) and indirect (D(2)O dilution, bioelectrical impedance analysis [BIA]) measures of body fat as well as indices of insulin resistance (IR) were monitored in 12 overweight (BCS ≥ 7/9) horses and ponies of mixed breed and gender for 16 weeks. Animals were randomly assigned to two groups (Group 1, n=6, BCS 7.6/9 ± 0.6, 489 ± 184.6 kg; Group 2, n=6, BCS 8.1/9 ± 0.6, 479 ± 191.5 kg). Daily dry matter intake (DMI) was restricted to 1.25% BM as one of two, near-isocaloric (DE ∼0.115 MJ/kg BM/day), forage-based diets (Group 1, 0.8% BM chaff-based feed: 0.45% BM hay; Group 2, 1.15% BM hay: 0.1% BM nutrient-balancer). Statistical modelling revealed considerable between-animal heterogeneity in proportional weight losses (0.16-0.55% of Week 1 BM weekly). The magnitude of weight loss resistance (WLR) or sensitivity to dietary restriction was independent of diet or any measured outset variable and was largely (65%) attributed to animal identity. Predicted rates of weight loss decreased over time. BCS and BIA were poor estimates of D(2)O-derived body fat%. Reciprocal changes in depths of retroperitoneal and subcutaneous adipose tissues were evident. Changes in BG were associated with losses in retroperitoneal fat and BM (r(2), 0.67 and 0.79). Indices of IR improved for 9/12 animals by Week 16. For obese animals, weight loss should be initiated by restricting forage DMI to 1.25% BM. Subsequent restriction to 1% BM may be warranted for WLR animals.

Dietary macronutrients and food consumption as determinants of long-term weight change in adult populations: a systematic literature review

This systematic literature review examined the role of dietary macronutrient composition, food consumption and dietary patterns in predicting weight or waist circumference (WC) change, with and without prior weight reduction. The literature search covered year 2000 and onwards. Prospective cohort studies, case–control studies and interventions were included. The studies had adult (18–70 y), mostly Caucasian participants. Out of a total of 1,517 abstracts, 119 full papers were identified as potentially relevant. After a careful scrutiny, 50 papers were quality graded as A (highest), B or C. Forty-three papers with grading A or B were included in evidence grading, which was done separately for all exposure-outcome combinations. The grade of evidence was classified as convincing, probable, suggestive or no conclusion. We found probable evidence for high intake of dietary fibre and nuts predicting less weight gain, and for high intake of meat in predicting more weight gain. Suggestive evidence was found for a protective role against increasing weight from whole grains, cereal fibre, high-fat dairy products and high scores in an index describing a prudent dietary pattern. Likewise, there was suggestive evidence for both fibre and fruit intake in protection against larger increases in WC. Also suggestive evidence was found for high intake of refined grains, and sweets and desserts in predicting more weight gain, and for refined (white) bread and high energy density in predicting larger increases in WC. The results suggested that the proportion of macronutrients in the diet was not important in predicting changes in weight or WC. In contrast, plenty of fibre-rich foods and dairy products, and less refined grains, meat and sugar-rich foods and drinks were associated with less weight gain in prospective cohort studies. The results on the role of dietary macronutrient composition in prevention of weight regain (after prior weight loss) were inconclusive.

Predictors of dropout in weight loss interventions: a systematic review of the literature

Attendance and completion of weight loss intervention is associated with better weight loss outcomes; however, attrition is neither consistently reported nor comprehensively explored in the weight loss literature. A systematic review was undertaken to identify factors associated with attrition in weight loss interventions involving overweight or obese (body mass index ≥ 25) adults (18-65 years). Sixty-one studies published before May 2011 and addressing factors associated with weight loss programme attrition were identified. Conclusions were limited by the large number of variables explored, the small number of studies exploring each variable, the large variety of study settings and methodologies used, the inconsistent reporting of results, and the conflicting findings across studies. A consistent set of predictors has not yet been identified. The majority of studies relied on pre-treatment routinely collected data rather than variables selected because of their theoretical and/or empirical relationship with attrition. However, psychological and behavioural patient factors and processes associated with the treatment were more commonly associated with attrition than patient background characteristics. Future research should consider theoretically grounded social-psychological and behavioural processes as potential predictors of dropout. Identification of patients at risk of dropout will contribute to both the effectiveness and the cost-effectiveness of weight loss interventions.

Center-size as a predictor of weight-loss outcome in multicenter trials including a low-calorie diet

It has not been studied yet whether factors such as the number of subjects recruited by specialized centers for multicenter trials may influence weight loss during a low-calorie diet (LCD). This study aimed at determining whether the number of recruited subjects per center might predict relative weight loss. This is a post hoc analysis of an existing database: 701 obese subjects (77% women, 23% men, mean BMI: 38.9 kg/m(2)) were enrolled at 22 sites (4-85 subjects/site) in five countries to follow a LCD providing 800-1,000 kcal/day during 8 weeks. The main outcome measure was the percentage weight loss after the 8-week LCD. Mean weight loss differed significantly between participating centers (5.8-11.8% of the initial weight; P < 0.001). There was a significant positive correlation between relative weight loss and the number of recruited subjects per center (r = 0.38; P < 0.001). In a multiple stepwise regression analysis, the number of recruited subjects per center appeared to be the main predictive factor of weight loss (R(2) = 0.07; P < 0.001). As the number of participants within each center is clustered, we applied a hierarchical model to model the average weight loss vs. the number of participants included at each center. This model allows to predict that for 10 extra patients in a center, the average weight loss would increase by 0.5%. This is the first study suggesting that the number of recruited subjects per center may impact weight loss, and could therefore be considered as a new predictor for weight loss that is independent from the individual.

Quantitative magnetic resonance (QMR) for longitudinal evaluation of body composition changes with two dietary regimens

We have recently reported a validation study of a prototype low-field strength quantitative magnetic resonance (QMR) instrument for measurement of human body composition (EchoMRI-AH). QMR was very precise, but underreported fat mass (FM) by 2-4 kg when compared to a 4-compartment (4C) model in this cross-sectional study. Here, we report the performance of an updated instrument in two longitudinal studies where FM was decreasing. Healthy obese volunteers were given a modest energy deficit diet for 8 weeks (study A) and obese patients with heart failure and/or at high cardiovascular risk were prescribed a low energy liquid diet for 6 weeks (study B). FM was measured at the start and end of these periods by QMR, dual-energy X-ray absorptiometry (DXA) and 4C. A higher proportion of the weight lost came from fat in study A compared with study B, where loss of total body water (TBW) played a greater part. The intraclass correlation between QMR and 4C estimates of FM loss (DeltaFat) was 0.95, but 20 of 22 estimates of DeltaFat by QMR were lower than the corresponding estimate by the 4C model. Bland-Altman analysis demonstrated that estimates of FM loss by QMR were ~1.0 and 0.7 kg lower than those obtained with 4C (P = 0.0008) and DXA (P = 0.049), respectively. Measurement precision remained high. QMR measurement should prove valuable for quantifying modest changes of FM in small trials.

Adherence and success in long-term weight loss diets: the dietary intervention randomized controlled trial (DIRECT)

BACKGROUND

Data are limited as to whether participants in diet trials truly adhere to their assigned diet and the factors that affect their adherence.

METHODS

We evaluated success and adherence in a two-year dietary intervention randomized controlled trial (DIRECT) in which 322 moderately obese participants (mean age 52 yrs, mean body-mass-index (BMI) 31 kg/m(2), 86% men) were randomized to one of three groups: low-fat, Mediterranean, or low-carbohydrate diets.

RESULTS

Overall compliance at month-24 was 85%, with 90% in low-fat, 85% in Mediterranean, and 78% in low-carbohydrate diet (p = .042 between groups). Attrition was higher in women (29% vs. 14% men, p = .001) and current smokers (25% vs. 14% among maintainers, p = 0.04). In a multivariate model, independent predictors of dropping-out were: higher baseline BMI (OR = 1.11; CI: 1.03-1.21) and less weight loss at month-6 (OR = 1.20; CI: 1.1-1.3). In a multivariate model, greater weight loss achieved at month-6 was the main predictor associated with success in weight loss (> 5%) over 2 years (OR = 1.5; CI: 1.35-1.67). Self-reported complete adherence score to diet was greater on low-carbohydrate diet (p < .05 compared to low-fat) until month-6, but dropped overall from 81% at month-1 to 57% at month-24. Holidays were a trigger to a significant decrease in adherence followed by a partial rebound. Changes in diet composition from month-1 to month-12 were more pronounced in the multi-stage low-carbohydrate diet-group (p < .05). Generally, the most irresistible restricted food items were cookies (45% of dieters) and fruits (30%). Among the physically active (n = 107), 44% reported a tendency to eat less after exercising compared to 10% who tended to eat more.

CONCLUSION

Initial 6-month reduction in weight is the main predictor of both long-term retention and success in weight loss. Special attention is needed for women, current smokers, and during holidays. Physical activity is associated with subsequent reduction in energy intake.

Anthropometric, metabolic, psychosocial and dietary factors associated with dropout in overweight and obese postmenopausal women engaged in a 6-month weight loss programme: a MONET study

The objective of the present study was to examine anthropometric, metabolic, psychosocial and dietary factors associated with dropout in a 6-month weight loss intervention aimed at reducing body weight by 10 %. The study sample included 137 sedentary, overweight and obese postmenopausal women, participating in a weight loss intervention that consisted of either energy restriction (ER) or ER with resistance training (ER+RT). Anthropometric (BMI, percent lean body mass, percent fat mass, visceral adipose tissue and waist circumference), metabolic (total energy expenditure, RMR, insulin sensitivity and fasting plasma levels of leptin and ghrelin), psychosocial (body esteem, self-esteem, stress, dietary restraint, disinhibition, hunger, quality of life, self-efficacy, perceived benefits for controlling weight and perceived risk) and dietary (3-d food record) variables were measured. Thirty subjects out of 137 dropped out of the weight loss programme (22 %), with no significant differences in dropout rates between those in the ER and the ER+RT groups. Overall, amount of weight loss was significantly lower in dropouts than in completers ( − 1·7 (sd 3·5) v. − 5·6 (sd 4·3) kg, P < 0·05); weekly weight loss during the first 4 weeks was also significantly lower. Dropouts consumed fewer fruit servings than completers (1·7 (sd 1·1) v. 2·7 (sd 1·53), P < 0·05) and had higher insulin sensitivity levels (12·6 (sd 3·8) v. 11·1 (sd 2·8) mg glucose/min per kg fat-free mass, P < 0·05). The present results suggest that the rate of weight loss during the first weeks of an intervention plays an important role in the completion of the programme. Thus, participants with low rates of initial weight loss should be monitored intensely to undertake corrective measures to increase the likelihood of completion.

Randomized trial of a behavioral weight loss intervention for low-income women: the Weight Wise Program

Low-income women in the United States have the highest rates of obesity, yet they are seldom included in weight loss trials. To address this research gap, components of two evidence-based weight loss interventions were adapted to create a 16-week intervention for low-income women (Weight Wise Program), which was evaluated in a randomized trial with the primary outcome of weight loss at 5-month follow-up. Participants were low-income women (40-64 years) with a BMI of 25-45. Of 143 participants, 72 were randomized to the Weight Wise Program (WWP) and 71 to the Control Group (CG). Five-month follow-up data were obtained from 64 (89%) WWP and 62 (87%) CG participants. With baseline values carried forward for missing data, WWP participants had a weight change of -3.7 kg compared to 0.7 kg in the CG (4.4 kg difference, 95% confidence interval (CI), 3.2-5.5, P<0.001). For systolic blood pressure (SBP), change in the WWP was -6.5 mm Hg compared to -0.4 mm Hg among controls (6.2 mm Hg difference, 95% CI, 1.7-10.6, P=0.007); for diastolic BP (DBP), changes were -4.1 mm Hg for WWP compared to -1.3 mm Hg for controls (2.8 mm Hg difference, 95% CI, 0.0-5.5, P=0.05). Of the 72 WWP participants, 64, 47, and 19% lost at least 3, 5, and 7% of their initial body weight, respectively. In conclusion, the WWP was associated with statistically significant and clinically important short-term weight loss.

A randomized trial examining differential meal replacement adherence in a weight loss maintenance program after one-year follow-up

The purpose of the present study was to examine the relationship between patterns of meal replacement (MR) adherence and changes in outcomes during a behaviorally-oriented weight loss program. Data from the present study are based on sixty female participants (age: 29-62 years, BMI: 27.99-37.50 kg/m(2)). Participants were randomized into either a control or experimental condition, which tested the use of MRs during weight loss maintenance. Outcome measures included body weight, depression, physical activity, cognitive restraint, disinhibition, hunger, and binge eating collected at four assessment points. Within the experimental condition, we further examined adherence to MRs and its relationship with the outcome measures. We found evidence of differences at baseline on some measures (e.g., weight, physical activity and depression) while on others (cognitive restraint, disinhibition, and hunger), differences that emerged over the course of treatment. Further research is necessary to determine if there are measures associated with successful MR use that can be detected at baseline and if MR adherence itself leads to changes in eating behavior.

Describing patterns of weight changes using principal components analysis: results from the Action for Health in Diabetes (Look AHEAD) research group

PURPOSE

To demonstrate how principal components analysis can be used to describe patterns of weight changes in response to an intensive lifestyle intervention.

METHODS

Principal components analysis was applied to monthly percent weight changes measured on 2,485 individuals enrolled in the lifestyle arm of the Action for Health in Diabetes (Look AHEAD) clinical trial. These individuals were 45 to 75 years of age, with type 2 diabetes and body mass indices greater than 25 kg/m(2). Associations between baseline characteristics and weight loss patterns were described using analyses of variance.

RESULTS

Three components collectively accounted for 97.0% of total intrasubject variance: a gradually decelerating weight loss (88.8%), early versus late weight loss (6.6%), and a mid-year trough (1.6%). In agreement with previous reports, each of the baseline characteristics we examined had statistically significant relationships with weight loss patterns. As examples, males tended to have a steeper trajectory of percent weight loss and to lose weight more quickly than women. Individuals with higher hemoglobin A(1c) (glycosylated hemoglobin; HbA(1c)) tended to have a flatter trajectory of percent weight loss and to have mid-year troughs in weight loss compared to those with lower HbA(1c).

CONCLUSIONS

Principal components analysis provided a coherent description of characteristic patterns of weight changes and is a useful vehicle for identifying their correlates and potentially for predicting weight control outcomes.

Process evaluation of an internet-based resource for weight control: use and views of an obese sample

OBJECTIVE

To investigate use and views of a Web site designed for weight control.

DESIGN

Questionnaire-based evaluation with data collected at baseline, 6 months, and 12 months.

SETTING

Data were collected as part of a community-based, randomized controlled trial.

PARTICIPANTS

Subjects (n = 111) were participants of the intervention arm of a randomized controlled trial evaluating effectiveness of a Web site designed for weight control in an obese sample.

INTERVENTION

Participants were asked to use the intervention Web site for weight control over a 12-month period.

MAIN OUTCOME MEASURE(S)

Participants were asked to report their use and views of the Web site. In addition, use of the Web site was automatically recorded on logging onto the Web site.

ANALYSIS

Descriptive statistics, factor analysis.

RESULTS

Fifty-nine participants (53%) reported using the Web site at 6 months, with 32 participants (29%) still using it at 12 months. The average time spent on the Web site per visit was 21.1 minutes (SD = 16.6) at 6 months and 13.6 minutes (SD = 9.3) at 12 months, with an average number of logons of 15.8 (SD = 15.2) over the trial period. In general, satisfaction scores for the Web site were positive. Scores for ability of the resource to encourage positive behavior change for weight control were marginally negative. Social support sections of the Web site were used least and received the lowest satisfaction ratings.

CONCLUSIONS AND IMPLICATIONS

Despite positive satisfaction scores, use of the resource was limited. It is expected that participants' limited ability to use the Internet may have limited the use of the resource and consequently reduced the social support available to participants. Future investigation of the views and use patterns of current users of Internet-based weight loss resources would help inform future development of such tools.

Randomized trial of weight-loss-diets for young adults varying in fish and fish oil content

OBJECTIVE

To investigate the effect of including seafood and fish oils, as part of an energy-restricted diet, on weight loss in young overweight adults.

DESIGN

Randomized controlled trial of energy-restricted diet varying in fish and fish oil content was followed for 8 weeks. Subjects were randomized to one of four groups: (1) control (sunflower oil capsules, no seafood); (2) lean fish (3 x 150 g portions of cod/week); (3) fatty fish (3 x 150 g portions of salmon/week); (4) fish oil (DHA/EPA capsules, no seafood). The macronutrient composition of the diets was similar between the groups and the capsule groups, were single-blinded.

SUBJECTS

A total of 324 men and women aged 20-40 years, BMI 27.5-32.5 kg/m(2) from Iceland, Spain and Ireland.

MEASUREMENTS

Anthropometric data were collected at baseline, midpoint and endpoint. Confounding factors were accounted for, with linear models, for repeated measures with two-way interactions. The most important interactions for weight loss were (diet x energy intake), (gender x diet) and (gender x initial-weight).

RESULTS

An average man in the study (95 kg at baseline receiving 1600 kcal/day) was estimated to lose 3.55 kg (95% CI, 3.14-3.97) (1); 4.35 kg (95% CI, 3.94-4.75) (2); 4.50 kg (95% CI, 4.13-4.87) (3) and 4.96 kg (95% CI, 4.53-5.40) on diet (4) in 4 weeks, from baseline to midpoint. The weight-loss from midpoint to endpoint was 0.45 (0.41-0.49) times the observed weight loss from baseline to midpoint. The diets did not differ in their effect on weight loss in women. Changes in measures of body composition were in line with changes in body weight.

CONCLUSION

In young, overweight men, the inclusion of either lean or fatty fish, or fish oil as part of an energy-restricted diet resulted in approximately 1 kg more weight loss after 4 weeks, than did a similar diet without seafood or supplement of marine origin. The addition of seafood to a nutritionally balanced energy-restricted diet may boost weight loss.

Diet and exercise intervention in a general population mediators of participation and adherence: the Inter99 study

BACKGROUND

Drop-out rates are high in many lifestyle programmes. To promote adherence, the aim of this study was to identify mediators of participation in a diet and exercise (DE) intervention in a general population.

METHODS

Data were baseline data from a randomized non-pharmacological clinical trial in Copenhagen during 1999-2001. The participation rate was 53.3%. Participants at high risk of ischaemic heart disease (IHD) and who were offered participation in a DE counselling group intervention were included (N = 2022). Clinical characteristics, and demographic, psychosocial and lifestyle factors were measured.

RESULTS

Mediators of acceptance of participation were awareness of an unhealthy lifestyle or a bad health, low self-rated care of own health, perceived susceptibility of cardiovascular disease (CVD; overall and associated with lifestyle), high degree of motivation towards dietary changes and low self-efficacy about increasing physical activity. Overweight and impaired glucose tolerance (IGT)/screen-detected diabetes predicted acceptance whereas an absolute risk score for IHD was inverse associated with acceptance. Mediators of high adherence were low self-efficacy about changing dietary habits and perceived susceptibility of CVD and furthermore screen-detected diabetes and overweight predicted high adherence.

CONCLUSION

Awareness of unhealthy lifestyle, perceived susceptibility of disease and motivation towards lifestyle changes were important mediators of participation. Screen-detected diabetes/IGT predicted participation and adherence whereas overweight individuals were more likely to accept but also to drop out of the course. The use of an absolute risk score in health promotion should be further evaluated.