Determinants of weight loss maintenance: a systematic review

Obesity management in primary care: A joint clinical perspective and expert review from the Obesity Medicine Association (OMA) and the American College of Osteopathic Family Physicians (ACOFP) - 2025

Background

This collaboration from the Obesity Medicine Association (OMA) and the American College of Osteopathic Family Physicians (ACOFP) examines obesity management from a primary care perspective.

Methods

This joint perspective is based upon scientific evidence, clinical experience of the authors, and peer review by the OMA and ACOFP leadership. The goal is to identify and answer sentinel questions about obesity management from a primary care perspective, utilizing evidence-based publications, and guided by expert clinical experience.

Results

Obesity is a disease that contributes to both biomechanical complications and the most common cardiometabolic abnormalities encountered in primary care. Barriers that impede optimal care of patients with obesity in primary care include failure to recognize obesity as a disease, lack of accurate diagnosis, insufficient access to obesity treatment resources, inadequate training, insufficient time, lack of adequate reimbursement and the adverse impact of bias, stigma, and discrimination.

Conclusions

Family physicians are often the first line of treatment in the healthcare setting. This affords early intervention opportunities to prevent and/or treat overweight and/or obesity. Patient care is enhanced when primary care clinicians recognize the risks and benefits of anti-obesity medications and bariatric procedures, as well as long-term follow-up. Practical tools regarding the 4 pillars of nutrition therapy, physical activity, behavior modification, and medical interventions (anti-obesity medications and bariatric surgery) may assist primary care clinicians improve the health and lives of patients living with obesity.

Assessing the value for money, from a policy maker perspective, of 24 randomised controlled trial designs for an online weight maintenance guided self-help intervention: an expected value of sample information analysis

OBJECTIVE

To analyse whether conducting a randomised controlled trial (RCT) to evaluate an online weight maintenance guided self-help intervention (Supporting Weight Management (SWiM)) would offer good value for money in the United Kingdom.

METHOD

We examined 24 RCT designs by varying inclusion criteria (participants completing behavioural weight management, specialist-led weight management, diabetes prevention programme, type 2 diabetes remission, digital weight management, all weight management services), trial duration (1-2 years), and sample size (n = 500 or 2000). Trial benefits were estimated by the method of expected value of sample information analysis using a health economic model. The model examines how the proposed intervention affects weight maintenance over time (with uncertainty), and generates estimated lifetime Quality Adjusted Life Years (QALYs) and National Health Service (NHS) costs. Structured expert elicitation with 4 experts was undertaken to quantify pre-trial uncertainty in the effectiveness of SWiM compared with usual care. All trial designs were simulated to estimate trial benefits: the reduction in the costs of an inefficient decision for future populations over 10 years. Trial designs offer value for money if trial benefits exceed trial costs.

RESULTS

For three inclusion criteria options (groups recently completing 'diabetes remission', 'digital weight management' or 'specialist weight management'), the cost of the proposed trials was estimated to exceed the estimated trial benefit (value of the reduction in decision uncertainty) over 10 years. For the other three inclusion criteria options (groups recently completed 'behavioural weight management', 'diabetes prevention programme', or 'all weight loss programmes'), 12 trial designs produced greater benefits than costs. The optimal trial design option would include 'all weight loss programmes', with 2 years follow-up and sample size n = 2000.

CONCLUSION

Investment in a large RCT to evaluate the SWiM intervention for patients completing a range of weight loss interventions offers the greatest value to the NHS.

The Impact of Different Nutritional Approaches on Body Composition in People Living with Obesity

PURPOSE OF REVIEW

This narrative review aimed to provide an overview of the current evidence on the impact of various nutritional strategies on body composition in people living with obesity (PLwO), with particular attention to fat mass (FM), fat-free mass (FFM), and fat distribution.

RECENT FINDINGS

Obesity is increasingly linked to cardiometabolic complications, yet common diagnostic metrics such as body mass index (BMI) do not capture changes in FM or FFM. Recent studies highlight the variable effects of different dietary interventions on body compartments. High-protein and ketogenic diets are associated with greater preservation of FFM and reductions in visceral adipose tissue (VAT), while the Mediterranean diet shows promise for long-term adherence and improvements in metabolic health. Intermittent fasting and time-restricted eating demonstrate efficacy in FM reduction but present mixed results regarding FFM retention and sustainability. Dietary strategies exert diverse effects on body composition in PLwO, underscoring the importance of tailoring interventions to individual metabolic profiles and health goals. Personalized nutrition approaches that prioritize the preservation of lean mass and reduction of VAT, along with sustainable adherence, are critical for optimizing obesity management beyond weight loss alone.

The Interplay Between Psychological and Neurobiological Predictors of Weight Regain: A Narrative Review

Introduction: Obesity is a global health problem requiring effective interventions to achieve weight loss and maintain it in the long term. A major challenge for clinicians is weight regain (WR), defined as progressive weight gain following successful weight loss. WR is affected by multiple factors, including psychological traits linked to specific brain alterations. Understanding these mechanisms is crucial in developing strategies to prevent WR and to ensure effective weight control. Objectives: This narrative review aims to gather current findings on the psychological and neurobiological determinants of WR and to discuss the interplay between these factors. Methods: A literature search was conducted on PubMed, Medline, and Web of Science for English-language studies published between December 1990 and November 2024. Results: WR is driven by interconnected psychological and neurobiological factors that influence eating behavior and the regulation of body weight. Certain personality traits and emotional patterns are associated with specific changes in brain activity, which together affect vulnerability to WR. Although distinct mechanisms can be identified, the complexity of homeostatic and nonhomeostatic appetite control suggests that no single factor predominates. Conclusions: This review highlights the dynamic interplay between psychological and neurobiological predictors of WR. However, due to the narrative nature of this review, the focus on selected determinants, and the limited quality and size of the available studies, further research is needed to comprehensively understand causality and to improve relapse prevention strategies.

Psychosocial factors associated with physical activity, weight management, and sleep in adults with hip and knee osteoarthritis: a systematic review

BACKGROUND

Osteoarthritis (OA) is a chronic disease primarily affecting older adults, mainly impacting the hip and knee joints. The increasing prevalence of OA contributes to rising healthcare demands and costs. Current OA treatment guidelines emphasize the importance of self-management education and guidance, particularly in promoting physical activity and weight management. In addition, improving sleep is crucial for managing OA. Developing effective self-management interventions necessitates a comprehensive understanding of the factors that facilitate these behaviors. Especially for changing health behaviors, it is important to focus on psychosocial factors. Therefore, this systematic review aimed to identify the psychosocial factors associated with physical activity, weight management, and sleep in adults with hip and/or knee OA.

METHODS

Five databases (PubMed, Embase, CINAHL, PyschINFO, Web of Science) were searched for observational studies reporting statistics on the association between psychosocial determinants and physical activity, weight management, or sleep in people with OA. The methodological quality was assessed using the Quality Assessment Tool for Observational Studies of the National Heart, Lung, and Blood Institute. After screening 5,812 articles, 31 studies were included for analysis.

RESULTS

The results showed that intention, self-efficacy, and willpower beliefs were positively associated with physical activity. Kinesiophobia, pain catastrophizing and pain-related fear were negatively associated with physical activity. Depressive symptoms, negative affect, pain catastrophizing, and low willpower beliefs were associated with poor weight management. Anxiety, depression, pain anxiety, and post-traumatic stress disorder were related to poor sleep behavior.

CONCLUSIONS

This review enhances the understanding of the psychosocial factors underlying physical activity, weight management and sleep in OA. These insights are valuable for developing tailored behavior change interventions aimed at improving physical activity, weight management and sleep in patients with hip and/or knee OA. Future research is warranted to gain more in-depth insights, particularly through longitudinal studies and further research into the psychosocial determinants of sleep, as current literature in this area is limited.

The Effectiveness of Nonsurgical Interventions for Weight Loss Maintenance in Adults: An Updated, GRADE-Assessed Systematic Review and Meta-Analysis of Randomized Clinical Trials

CONTEXT

Today, there are many discussions about the best way to maintain weight and prevent weight regain after a period of weight loss.

OBJECTIVES

The aim of this study was to summarize, based on data from randomized clinical trials (RCTs), the impact of nonsurgical interventions for adults' weight loss maintenance.

DATA SOURCES

The Medline (PubMed), Scopus, and Web of Science databases were reviewed during June 2023.

DATA EXTRACTION

Meta-analyses assessing the impacts of nonsurgical interventions for weight loss maintenance were conducted. Effect sizes of nutritional interventions were recalculated by applying a random-effects model. The Grading of Recommendations, Assessment, Development, and Evaluation framework was implemented to determine evidence certainty.

RESULTS

Meta-analysis of data from a total of 56 RCTs (n = 13 270 participants) represented a significant weight reduction after behavior and lifestyle interventions (mean difference [MD], -0.64 kg [95% CI, -1.18 to -0.09]; I2 = 89.5%; P < .001 for heterogeneity). Pharmacological interventions had also a significant effect on weight change during the weight maintenance phase (MD, -2.57 kg [95% CI, -3.12 to -2.02]; I2 = 91.6%; P < .001 for heterogeneity). The weight loss reduction from pharmacological interventions was greater with sibutramine (MD, -2.57; 95% CI: -3.12 to -2.02). Additionally, diet intervention and dietary and physical activity strategies were associated with a negligible trending decrease in weigh regain (respectively: MD, -0.91 kg [95% CI, -2.18 to 0.36], I2 = 55.7%, P = .016 for heterogeneity; and MD, -0.3 kg [95% CI, -4.13 to 3.52], I2 =  94.1%, P < .001).

CONCLUSION

The findings of this review indicate there is a favorable impact of behavior-based interventions and antiobesity medications on weight maintenance.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no CRD42023468056.

Brazil nut consumption within an energy-restricted diet improved cardiometabolic risk markers in women: a quasi-experimental, controlled study (Brazilian Nuts Study)

Consuming functional foods alongside the energy-restricted diet can be a great ally in weight loss and improving cardiometabolic risk factors. Whether Brazil nut (BN) consumption in the context of energy restriction affects them remains to be answered. We aimed to evaluate the effect of BN within an energy-restricted diet on cardiometabolic risk markers among women. This is an eight-week, quasi-experimental, controlled nutritional intervention study. The women were allocated into two energy-restricted (-500 kcal/d) groups: a control free of BN (n=29) and a BN-group (BNG) (n=27) with 2 units/day of BN (~ 347 µg of selenium). Both groups had similar weight loss, but in the BNG, the serum selenium increased by 276.7% and apolipoprotein A1 increased by 27.4%. In addition, BNG had a more pronounced reduction in liver enzymes, and presented the most preserved percentages of lean and fat-free mass in relation to the control group. Consuming 2 units/day of BN in an 8-week weight loss intervention improved cardiometabolic risk markers in women. Our results suggest that regular consumption of BN during energy-restricted diets may be a strategy to minimize adiposity, preserve lean mass, improve serum selenium status, lipid, and liver metabolism markers, and, consequently, help obesity management and its comorbidities.

Adipose cellularity as a measurement of long-term changes in body weight: a Swedish cohort study spanning 1988-2016

Background

Adipocyte size and number (cellularity) determine the adipose mass and may relate to long-term body weight changes.

Methods

We investigated 1014 healthy participants at Karolinska Institutet in Sweden 1988-2016 for body weight and size/number of subcutaneous adipocytes, and 273 for visceral adipocyte size. We measured body weight on 281 subjects about 16 years later. We analysed the association of baseline adipocyte size and number with body weight changes by linear regression including relevant co-factors, and the associations of cellularity (low or high number of either large or small adipocytes) regarding body weight changes by analysis of variance.

Findings

Subcutaneous adipocyte size and number and visceral adipocyte size showed strong relationships with body weight changes irrespective of its mode of expression (adjusted r2 ≥0·15). The relationships were significant (p ≤ 0·027) independent of co-factors (age, sex, initial body weight or height, body fat, obesity, nicotine use, physical activity, and observation time). Interventions (lifestyle change or bariatric surgery) did not influence the associations (p = 0·86). A low or high number of large adipocytes associated with body weight loss, whereas a low or high number of small cells associated with weight stability or weight gain.

Interpretation

Adipose cellularity is associated with long-term changes in body weight, following interventions to decrease body weight. Patients with a high number of large fat cells experienced the most pronounced weight reduction.

Funding

The Stockholm County Council (963296, 994175, 986118), the Center for Innovative Medicine at Karolinska Institutet (986109) and the Swedish Society of Medicine (1001156). None of the funding sources had any involvement in the study.

Reduced food cravings correlated with a 24-month period of weight loss and weight maintenance

Food cravings increase calorie-dense food intake, contributing to weight gain. Although reductions in food cravings are frequently reported during weight loss, it remains unclear whether these changes are sustained during weight maintenance. The study objective was to investigate associations between food cravings and weight changes in a 12-month weight loss trial followed by 12 months of maintenance. Thirty adults participated in a dietary weight loss program that included craving coping strategies, daily weigh-ins and food craving assessments every six months. Twenty-four and twenty participants remained at 12 and 24 months, respectively. Craving frequency and traits decreased during weight loss and stabilized during maintenance. Changes in general food (FCI), sweet, and carbohydrate cravings at 6 months predicted weight change over 24 months. The craving-weight correlations persisted during weight maintenance. Participants achieving >5 % weight loss at 24 months (n = 13) consistently reduced craving traits and FCI, while those with <5 % weight loss (n = 7) showed no significant change. Differences between the groups become significant at 18 and 24 months for craving traits and at 24 months for FCI. Participants who included craved foods into a balanced meal (n = 16) achieved greater weight loss and greater reduction in sweet and high-fat food cravings compared to those who did not (n = 8) at 12 months. This study showed a strong correlation between successful weight loss/maintenance and reduced food cravings, whereas users of the craving control strategy achieved greater weight loss. These results suggest that weight loss reduces cravings, and controlling cravings, in turn, further accelerates weight loss.

Glucagon-Like Peptide-1 Receptor Agonists Decrease Medical and Surgical Complications in Morbidly Obese Patients Undergoing Primary TKA

BACKGROUND

Weight optimization methods in morbidly obese patients with a body mass index (BMI) of ≥40 kg/m 2 undergoing total knee arthroplasty (TKA) have shown mixed results. The purpose of this study was to evaluate the effect of perioperative use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in patients with a BMI of ≥40 kg/m 2 undergoing primary TKA.

METHODS

Using an administrative claims database, patients with morbid obesity undergoing primary TKA were stratified into GLP-1 RA use for 3 months before and after the surgical procedure (treatment group) and GLP-1 RA non-use (control group), and were matched on the basis of patient age, gender, diagnosis of type-2 diabetes mellitus, and Charlson Comorbidity Index (CCI). In addition, these groups were compared with a contemporaneous cohort of patients undergoing TKA with a BMI of 35.0 to 39.9 kg/m 2 . Outcomes including infection, complications, revision, and readmission were compared between the matched cohorts.

RESULTS

There were significant decreases in the rates of 90-day periprosthetic joint infection (PJI) (1.0% compared with 1.8%; p = 0.037), any medical complications (10.6% compared with 12.7%; p = 0.033), pulmonary embolism (<0.4% compared with 0.6%; p = 0.050), and readmissions (5.3% compared with 8.9%; p < 0.001) in patients with a BMI of ≥40 kg/m 2 who were taking GLP-1 RA versus the control group who were not. There were no differences in the 2-year rates of surgical complications (p > 0.05) between these groups. Compared with obese patients (BMI of 35.0 to 39.9 kg/m 2 ), patients who had a BMI of ≥40 kg/m 2 and were taking a GLP-1 RA did not have increased rates of infection or 90-day or 2-year complications (p > 0.05).

CONCLUSIONS

GLP-1 RA administration for at least 90 days prior to and after primary TKA in patients with a BMI of ≥40 kg/m 2 was associated with reductions in the risks of 90-day PJI, any medical complications, and readmission. Additionally, the reduced complication rate that was achieved was similar to that of obese patients with a BMI of 35.0 to 39.9 kg/m 2 undergoing TKA. Randomized clinical trials are needed to define the true effect of these agents on clinical outcomes following TKA.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Assessing the evidence for health benefits of low-level weight loss: a systematic review

Individuals with excess weight are at a higher risk for various physical and mental health conditions. Interventions targeting weight loss can improve health, with modest weight loss of five to ten percent of body weight often considered clinically meaningful for enhancing health outcomes. However, the benefits of achieving low-level weight loss ( < 5% body weight) are poorly understood. We aimed to systematically review relevant literature and synthesise the evidence that assessed the potential health benefits of losing less than five percent body weight. We searched seven academic databases and included studies in any language, from any country, with no time constraints. We included any intervention studies that assessed the impact of less than five percent weight loss on any measured physical or mental health markers or indices. 70 studies from 68 articles were included, with study participants ranging from 14 to 10,742. In total, 137 health markers were assessed, categorised into metabolic markers (n = 42), cardiovascular markers (n = 32), anthropometric measures (n = 19), quality of life indices (n = 10), inflammatory biomarkers (n = 10), renal and hepatic markers (n = 9), psychosocial and behavioural measures (n = 8), pulmonary function (n = 3), total mortality (n = 2), ovulatory function (n = 1), and muscle strength (n = 1). Overall, 60% of studies reported improvements, 37% found no change or mixed results, and 3% observed a worsening of health markers or indices. Based on the available data, 87% of participants (n = 15,839) in the studies reported improvements in health markers or indices as a result of low-level weight loss. Our findings suggest that low-level weight loss can lead to various health benefits and challenges the conventional threshold for effective weight loss.Preregistration The review protocol was pre-registered with PROSPERO (CRD42023406342).

Exploring weight management beliefs during the menopausal transition (ME-WEL project): A qualitative comparative study based on Health Belief Model

OBJECTIVES

While most women experience weight gain during the menopausal transition, a subset successfully maintains a healthy weight. This study explores the determinants influencing different weight experiences during the menopausal transition, using the Health Belief Model (HBM).

DESIGN

Qualitative design.

METHODS

Semi-structured individual interviews with 62 Portuguese post-menopausal women were performed. Among them, 31 women maintained a normal weight from pre-menopause to post-menopause, with a variation not exceeding 5% of pre-menopausal weight, while another 31 women transitioned from normal weight in pre-menopause to overweight or obesity in post-menopause, with an increase above 7% of pre-menopausal weight. Deductive-dominant content analysis and multiple correspondence analysis were performed.

RESULTS

Prominent differences exist between the Unhealthy Weight Gain Group (UWG-G) and the Healthy Weight Maintenance Group (HWM-G). The UWG-G lacks perceived susceptibility in pre-menopause and perceives obesity as stigmatizing. They prioritize immediate changes as benefits, while the HWM-G focuses on self-concept. Both groups face barriers like food cravings and weight loss challenges in middle-aged. For cues to action, the UWG-G emphasizes social support and self-care resources, while the HWM-G emphasizes age progression and healthy behaviour adherence. The HWM-G presents higher self-efficacy.

CONCLUSION

This study confirms the suitability of the HBM in understanding weight management beliefs among post-menopausal women, highlighting differences between women who maintain a healthy weight and those who experience weight gain during this life phase. This facilitates identifying key determinants (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy) crucial for future interventions in weight management.

Psychological well-being factors and the likelihood of transitioning from overweight and obesity to normal weight at population level: Evidence from two cohort studies of UK adults

We examined the prospective associations between psychological well-being related factors (depressive symptoms, life satisfaction, self-efficacy) and transitioning from overweight and obesity to normal body weight (vs persistence of overweight and obesity) and change in body mass index (BMI). We used multiple baselines and follow-ups from the National Child and Development Study (NCDS; 8513 observations) and the British Cohort Study (BCS; 11,113 observations). A proportion (8%-9%) of participants with overweight and obesity (BMI ≥25) at baseline transitioned into normal weight (BMI 18.5-<25) by follow-ups. There was no evidence of better psychological well-being related factors (e.g. lower depressive symptoms) being significantly associated with a transition from overweight and obesity to normal weight or reduced BMI in each cohort and pooled cohort analyses. However, age and gender were associated with transition. At population level, better psychological well-being may not be associated with likelihood of weight loss once obesity is developed in adulthood.

Weight Loss Patterns and Outcomes Over 12 Months on a Commercial Weight Management Program (CSIRO Total Wellbeing Diet Online): Large-Community Cohort Evaluation Study

BACKGROUND

A greater understanding of the effectiveness of digital self-management programs and their ability to support longer-term weight loss is needed.

OBJECTIVE

This study aimed to explore the total weight loss and patterns of weight loss of CSIRO (Commonwealth Scientific and Industrial Research Organisation) Total Wellbeing Diet Online members during their first 12 months of membership and examine the patterns of platform use associated with greater weight loss.

METHODS

Participants were Australian adults who joined the program between October 2014 and June 2022 and were classified as longer-term members, meaning they completed at least 12 weeks of the program, had baseline and 12-week weight data, and had a paid membership of ≥1 year (N=24,035). Weight loss and percentage of starting body weight loss were calculated at 3, 6, 9, and 12 months using 3 statistical approaches: (1) multiple imputations method, (2) all available data, and (3) complete data only. Among members with complete data (6602/24,035, 27.5%), patterns of weight loss and gain were examined, and how this related to total weight loss was explored.

RESULTS

Members were mostly female (19,972/24,035, 83.09%), aged 31 to 50 years (9986/24,035, 41.5%) or 51 to 70 years (12,033/24,035, 50.06%), and most members were classified as overweight or obese (23,050/24,035, 95.9%). Using multiple imputations, the average estimated weight loss was 5.9 (SE 0.0245) kg at 12 weeks, 6.7 (SE 0.0348) kg at 6 months, 6.2 (SE 0.0400) kg at 9 months, and 5.5 (SE 0.0421) kg at 12 months. At 12 months, more than half the members (12,573/24,035, 52.3%) were at least 5% below their starting body weight and 1 in 4 (5865/24,035, 24.4%) were at least 10% below their starting body weight. In the subsample with complete data, the average weight loss at 12 months was 7.8 kg. The most common (961/6602, 14.56% members) weight loss pattern over the first 12 months was 6 months of weight loss, followed by 6 months of weight maintenance. This group had an average weight loss of 10.6 kg at 12 months (11.9% of their starting body weight). In a subgroup of participants who consistently lost weight over the 12-month period (284/6602, 4.3% of the sample), weight loss reached up to 22.3 kg (21.7% of their starting body weight). Weekly platform use was positively associated with total weight loss (r=0.287; P<.001). Members who used the platform >30 times per week (approximately >4 times/d) were more likely to lose weight in the first 6 months of the program.

CONCLUSIONS

This commercial weight loss program was shown to be effective, with 1 in 2 members achieving clinically significant results after 1 year. Greater engagement with the platform was associated with consecutive periods of weight loss and greater weight loss success overall.

Impacts of early psychological changes on correlates of weight-loss maintenance: Seeking increased precision for sustained behavioural obesity treatment effects

ISSUE ADDRESSED

Obesity is an increasing worldwide health issue. In affluent English-speaking countries, obesity ranges from ~28% (Australia) to ~42% (United States) of the adult population. Enabling weight loss beyond an initial 6 months is an unresolved challenge.

METHODS

Women with obesity participated in community-based obesity treatments incorporating either cognitive-behavioural methods emphasizing self-regulatory skills development (n = 106) or typical information/education processes (n = 47). Psychosocial, behavioural, and weight changes were measured.

RESULTS

Significant overall improvements in exercise-related self-regulation and self-efficacy, mood, physical activity/exercise (PA/exercise), diet, and weight were found from baseline-month 6 (weight-loss phase) and baseline-month 12, but not from months 6-12 (weight-loss maintenance phase). Significantly greater improvements were found in the cognitive-behavioural group. Within the weight-loss phase, changes in both PA/exercise and diet significantly contributed to the explained variance in weight loss, whereas within the weight-loss maintenance phase, only change in PA/exercise was a significant predictor. There was no significant relationship of weight loss across phases. Months 6-12 change in PA/exercise significantly mediated relationships of changes in self-regulation→weight, mood→weight, and self-efficacy→weight. Earlier scores and score changes in mood and self-efficacy significantly impacted the subsequent parallel relationships.

CONCLUSIONS

Cognitive-behavioural methods affect psychosocial changes leading to initial changes in diet, PA/exercise, and weight. Those changes then impact subsequent changes in PA/exercise-a primary malleable correlate of maintained weight loss. SO WHAT?: This research extended previous findings to better-inform behavioural obesity-treatment foci to address the pervasive public health problem of attaining and sustaining weight loss. Findings related to PA/exercise will help impact health-promotion outcomes.

Utilization of Glucagon-Like Peptide-1 Receptor Agonist at the Time of Total Hip Arthroplasty for Patients Who Have Morbid Obesity

BACKGROUND

Morbid obesity negatively affects outcomes after total hip arthroplasty (THA). The optimal strategy for weight loss before THA has not been identified. Recently, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have become increasingly popular as an effective pharmacologic weight loss agent. The goal of this study was to evaluate the effect of perioperative GLP-1 RA use in patients who have morbid obesity undergoing primary THA on postoperative outcomes.

METHODS

Using an administrative claims database, patients who had morbid obesity (body mass index [BMI] ≥ 40.0) undergoing primary THA were identified. Patients who had morbid obesity and GLP-1 RA use for three months before and after surgery (treatment) were matched to patients who had morbid obesity without GLP-1 RA use (control) and to a comparison group of patients who had severe obesity (BMI = 35.0 to 39.9) in a 1:4:4 ratio, resulting in 771, 3,084, and 3,084 patients in the treatment, control, and severe obesity comparison group, respectively. Overall group differences in 90-day and 2-year postoperative outcomes were compared using univariable tests, followed by post hoc pairwise testing and P-value adjustment.

RESULTS

Patients who had morbid obesity on GLP-1 RA had a significantly lower rate of 90-day periprosthetic joint infection (1.6 versus 3.2%; P = 0.03), readmission (6.9 versus 9.7%; P = 0.04), any medical complication (10.5 versus 14.1%; P = 0.03), and postoperative hematoma formation (0 versus 1.3%, P < 0.01) than controls. Patients who had morbid obesity on GLP-1 RA demonstrated lower rates of hematoma formation (0 versus 1.0%; P < 0.01) than patients who had severe obesity (BMI = 35.0 to 39.9). There were no differences in 2-year surgical complications.

CONCLUSIONS

Perioperative use of GLP-1 RA in patients who had morbid obesity is associated with reduced risk of acute periprosthetic joint infection and 90-day hospital readmission. The risk is reduced to a level comparable to obese patients who have a BMI < 40.0. Randomized controlled trials are necessary to determine the true effect and mechanism of action.

Long-term effects of a lifestyle modification program for men with obesity delivered in German football clubs

This study examined the long-term effects of a lifestyle modification program delivered at German Bundesliga football clubs. Weekly 90-minute group sessions over 12 weeks combined health education and physical activity and were delivered by coaches affiliated with the football clubs. A total of 371 men (mean age 49.7 years [SD = 7.6]) attended 41 classes at 19 clubs in 2017 and 2018 and participated in the long-term follow-up. Primary outcome was weight-loss at follow-up with a mean observation period of 20.4 months after baseline. Measures were taken partly by research staff and partly by participants themselves. At baseline, the men had a mean weight of 111.3 kg (SD = 16.9). Three months after baseline (posttest), the men had lost a mean of 6.3 kg (95% CI: 5.7-6.9). From posttest to follow-up, growth curve model showed men lost an average of 0.8 kg (95% CI: 0.2-1.4). Weight regain from posttest to follow-up of at least 3% was observed in 75 participants (20.2%) and was associated with less improvement in vegetable consumption in an adjusted logistic regression model. The data suggest that participation in a male-only lifestyle modification program offered by German football clubs may lead to sustained weight loss, but lack of a randomized control group and drop-outs prevent generalization of the results.

Efficacy of in-person versus digital enhanced lifestyle interventions in adults with overweight and obesity

Background

Lifestyle interventions (LIs) are the cornerstone for obesity management. The Mayo Clinic Diet (MCD) offers two approaches for LIs: the In-Person LI (IPLI) and the Digital Enhanced LI (DELI). The IPLI includes a 2-day in-person program with monthly follow-ups, whereas the DELI provides on-demand digital tools. The comparative efficacy of these approaches is currently unknown.

Methods

This retrospective study included two cohorts of adults with a body mass index (BMI) of ≥25 kg/m2 and weight metrics at least 3 months after starting either the IPLI or DELI program. The primary endpoint was the total body weight loss percentage (TBWL%) at 6 months.

Results

The study included 133 participants in the IPLI cohort (mean age 46.3 years, 65.4 % female, BMI 36.4) and 9603 in the DELI cohort (mean age 60.1 years, 85.0 % female, BMI 33.1). The DELI group achieved superior TBWL% at 1, 3, and 6 months compared to the IPLI group (3.4 % vs. 1.5 %, 4.7 % vs. 2.4 %, 5.3 % vs. 2.9 %, respectively; p < 0.001). After adjusting for age, gender, and starting weight, the DELI group maintained a higher TBWL% (difference 2.0 %; 95 % CI [1.0, 3.0], p < 0.001) and a greater proportion of participants achieved >5 % TBWL at 6 months (OR 1.66; 95 % CI [1.08, 2.55], p < 0.023).

Conclusion

The DELI approach resulted in superior weight loss outcomes compared to the IPLI. Further research is needed to explore how digital tools can improve weight loss effectiveness.

Exploring successes, barriers, and enablers in the one-year digital Healthy Weight Coaching

INTRODUCTION

Healthcare professionals' perspectives are often overlooked in the evaluation of digital weight loss interventions. Thus, we examined how healthcare professionals perceive patient success in a one-year web-based weight management program, the Healthy Weight Coaching, aiming to identify key success factors and common challenges within the coaching process.

METHODS

Thematic analysis was conducted on ten semi-structured interviews with healthcare professionals from the Healthy Weight Coaching. Interviewees included individuals of both sexes, with an average age of 41 years, ranging from 10 months to 5 years of coaching experience, and treating 90 to 500 patients.

RESULTS

Three main themes emerged from the analysis: (1) Positive progress during the Healthy Weight Coaching, (2) Factors facilitating success, and (3) Barriers hindering progress. The coaches noted significant positive changes among patients, including increased self-compassion, reduced weight-related stress, and a shift toward holistic well-being. Improvements in eating habits, physical activity, and vegetable consumption were observed, along with reductions in binge eating behaviors. Personal factors such as internal motivation and engagement with the program were crucial for success. Additionally, aspects of the Healthy Weight Coaching program, such as its individualized and supportive environment, flexible coaching approach, and the pivotal role of coaches, were seen as facilitators of success. Patients valued being treated equally and acceptingly and fostering trust and collaboration. However, challenges such as burdensome life situations, limited resources, and inadequate support posed significant barriers to progress. Unrealistic goals and societal pressures were also observed to hinder successful weight management efforts.

CONCLUSION

A comprehensive, individualized approach addressing resource limitations and societal norms can enhance long-term success in weight management programs like the Healthy Weight Coaching, ultimately promoting overall well-being.

Cardiometabolic characteristics of weight cycling: results from a mid-South regional comprehensive health care system

OBJECTIVE

The objective of this study was to determine the unique clinical and cardiometabolic risk characteristics of weight-cyclers and identify differences between weight-cyclers and individuals with other weight-change trajectories.

METHODS

A deidentified database of 1,428,204 Vanderbilt University Medical Center patients from 1997 to 2020 was included based on having ≥5 years of recorded weights. Patients with a history of malignant neoplasm, bariatric surgery, implausible BMI (e.g., <15 or >80 kg/m2), or missing documented height were excluded, yielding 83,261 participants categorized by weight trajectory, i.e., weight-stable, weight-gainer, weight-loser, or weight-cycler, based on criteria of ≥5% weight-change thresholds. Additionally, quartiles of average successive weight variability were evaluated to determine the effect of absolute differences among successive weight values.

RESULTS

Over half (55%) of participants were weight-cyclers, 23% were weight-gainers, 12% were weight-losers, and 10% were weight-stable over 5 years. Although baseline BMI did not differ among groups, weight-cyclers were more likely to have lower high-density lipoprotein cholesterol and higher blood glucose and triglyceride levels and to have been prescribed antihypertensive, dyslipidemia, and/or antidiabetic therapies. They were also younger and more likely to be smokers. Participants with the greatest weight variability (i.e., highest quartile of average successive weight variability) had higher cardiometabolic risk scores.

CONCLUSIONS

Weight cycling was highly prevalent but yielded no meaningful overall change in body weight after 5 years. These findings support a paradigm shift in weight management in individuals with overweight/obesity toward reducing cardiometabolic risk with or without weight loss.

How Would You Manage This Patient With Obesity? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

In 2022, 1 in 8 people in the world were living with obesity, and lifestyle interventions that include diet, exercise, and behavioral modification have been the foundation for management of obesity. Recently, pharmacologic therapies have been developed for management of obesity, the newest of these being glucagon-like peptide 1 receptor agonists. With the development of new pharmacologic options, the American Gastroenterological Association developed a guideline in 2022 to provide evidence-based recommendations for the pharmacologic management of obesity in adults and recommended, for adults with obesity or overweight with weight-related complications who have had an inadequate response to lifestyle interventions, adding pharmacologic agents to lifestyle interventions over continuing lifestyle interventions alone. In this article, 2 experts review the available evidence to answer the following questions: How effective are lifestyle interventions for the treatment of obesity? How effective are pharmacologic interventions for the treatment of obesity? Given these options, how do you engage in a shared decision-making discussion to develop a mutually agreed-on treatment plan?

Impact of low-carbohydrate diet on health status: an umbrella review

Introduction

The prevalence of diet-related non-communicable diseases has increased. A low-carbohydrate diet (LCDs) is one of the most popular interventions. Several systematic reviews and meta-analyses of randomised clinical trials (RCTs) and non-RCTs have linked LCDs to the management of obesity, diabetes, cardiovascular disease, epilepsy, and cancer. However, there has been limited appraisal of the strength and quality of this evidence.

Objective

To systematically appraise existing meta-analyses and systematic reviews of RCTs and non-RCTs on the effects of LCDs on different health conditions. To understand their potential efficacy, we summarised the studies' findings and assessed the strength of the evidence.

Methods

A search was conducted using the PubMed database from inception to October 2021 for systematic reviews and meta-analyses of RCTs and non-RCTs investigating the association between LCDs and multiple health outcomes in humans. The Academy of Nutrition and Dietetics Quality Criteria was used for the quality assessment. In addition, the evolution of heterogeneity, strength of the included studies, and effect sizes were extracted from each systematic review and meta-analysis.

Results

Ten systematic reviews and meta-analyses were included. Of the included reviews, 70% were of positive quality, 30% were neutral, and none were negative. The majority of the studies included strength in each systematic review, and the meta-analyses were of low to medium strength. The existing literature indicates that LCDs may help promote weight reduction in adults who are obese or overweight. This conclusion is supported by the findings of studies included in the analysis, which were of low to moderate strength. Furthermore, compelling data indicates a significant association between low-carbohydrate diets (LCDs) and a reduction in haemoglobin A1c levels among those diagnosed with type 2 diabetes mellitus. In contrast, there was a lack of evidence of this correlation in type 1 diabetes mellitus patients or those with cardiovascular diseases. Additionally, there was limited evidence regarding the effectiveness of LCDs in epilepsy and adult cancer patients.

Conclusion

This review thoroughly examines the current body of information on how LCDs affect various health outcomes. Studies have presented evidence to support the idea that incorporating LCDs can positively influence weight management and HbA1c levels. However, there is a lack of information regarding the association between LCDs and individuals with Type 1 diabetes mellitus and cardiovascular diseases. Additionally, there is limited empirical evidence to substantiate the effectiveness of LCDs in the treatment of epilepsy and adult cancer patients. The long-term effects of LCDs on mortality and other chronic diseases that account for different carbohydrate subtypes is unclear. Further longitudinal cohort studies are required to reach definitive conclusions.

Composite activity type and stride-specific energy expenditure estimation model for thigh-worn accelerometry

BACKGROUND

Accurately measuring energy expenditure during physical activity outside of the laboratory is challenging, especially on a large scale. Thigh-worn accelerometers have gained popularity due to the possibility to accurately detect physical activity types. The use of machine learning techniques for activity classification and energy expenditure prediction may improve accuracy over current methods. Here, we developed a novel composite energy expenditure estimation model by combining an activity classification model with a stride specific energy expenditure model for walking, running, and cycling.

METHODS

We first trained a supervised deep learning activity classification model using pooled data from available adult accelerometer datasets. The composite energy expenditure model was then developed and validated using additional data based on a sample of 69 healthy adult participants (49% female; age = 25.2 ± 5.8 years) who completed a standardised activity protocol with indirect calorimetry as the reference measure.

RESULTS

The activity classification model showed an overall accuracy of 99.7% across all five activity types during validation. The composite model for estimating energy expenditure achieved a mean absolute percentage error of 10.9%. For running, walking, and cycling, the composite model achieved a mean absolute percentage error of 6.6%, 7.9% and 16.1%, respectively.

CONCLUSIONS

The integration of thigh-worn accelerometers with machine learning models provides a highly accurate method for classifying physical activity types and estimating energy expenditure. Our novel composite model approach improves the accuracy of energy expenditure measurements and supports better monitoring and assessment methods in non-laboratory settings.

Curbing the Obesity Epidemic: Should GLP-1 Receptor Agonists Be the Standard of Care for Obesity?

PURPOSE OF REVIEW

This article summarizes the medical management of obesity with an emphasis on incretin-based therapeutics that target the neuro-hormonal basis of obesity.

RECENT FINDINGS

Medications that mimic the effect of incretins, a group of peptide hormones released in response to nutrient intake that regulate appetite, result in potent and durable weight loss. Glucagon-like peptide 1 (GLP-1) agonists and glucose-dependent insulinotropic polypeptide (GIP) agonists such as semaglutide and tirzepatide are approved by the United States Food and Drug Administration (FDA) for the management of obesity. The SELECT trial demonstrated that semaglutide led to a reduction in major adverse cardiovascular events in patients without diabetes who were either overweight and had preexisting cardiovascular disease or obese.

SUMMARY

The treatment of obesity is critical to prevent the progression of cardiovascular-kidney-metabolic syndrome. Incretin-based therapies offer remarkable weight loss and reduce major cardiovascular adverse events.

Impact of physical activity on caloric and macronutrient intake in children and adolescents: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Physical activity is widely promoted to maintain and improve health across all ages. Investigating how physical activity affects subsequent food intake provides insight into the factors that contribute to maintaining energy balance and effective weight management.

OBJECTIVE

This systematic review and meta-analysis summarizes the evidence on the effect of acute physical activity on subsequent food intake in children and adolescents.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) were applied. Randomized controlled trials (RCTs) objectively measuring post-exercise energy intake in children and adolescents aged 5 to 18 years were included. Studies with self-reported food intake were excluded. The databases PubMed, Web of Science and Cochrane Library were searched for RCTs, and the data were summarized at a qualitative and quantitative level. Version 2 of the Cochrane risk-of-bias tool for randomized trials was used to assess risk of bias. Changes in energy intake were examined with random effects meta-analysis. (PROSPERO: CRD42022324259).

RESULTS

Out of 9582 studies, 22 RCTs with cross-over design remained eligible for meta-analysis. The primary outcome was post-intervention energy intake up to the next 24 h. Heterogeneity of studies was moderate, with an I2 of 57%. The median (interquartile range, IQR) energy expended while exercising was 240 (158) kcal. Meta-analysis of 41 study arms (exercise n = 780 and control n = 478) showed no differences in total energy intake between the exercise and control group with a mean difference MD = 23.31 [-27.54, 74.15] kcal. No subgroup differences were found. Macronutrient intake and appetite sensations where not substantially affected.

CONCLUSION

Engaging in exercise is a suitable means of raising activity-induced energy expenditure, without causing any noticeable changes in food intake or hunger within a single day.

Practical strategies to manage obesity in type 2 diabetes

The rising phenomenon of obesity, a major risk factor for the development and progression of type 2 diabetes, is a complex and multifaceted issue that requires a comprehensive and coordinated approach to be prevented and managed. Although novel pharmacological measures to combat obesity have achieved unprecedented efficacy, a healthy lifestyle remains essential for the long-term success of any therapeutic intervention. However, this requires a high level of intrinsic motivation and continued behavioural changes in the face of multiple metabolic, psychological and environmental factors promoting weight gain, particularly in the context of type 2 diabetes. This review is intended to provide practical recommendations in the context of a holistic, person-centred approach to weight management, including evidence-based and expert recommendations addressing supportive communication, shared decision-making, as well as nutritional and pharmacological therapeutic approaches to achieve sustained weight loss.

Physiological and psychological determinants of long-term diet-induced type 2 diabetes (T2DM) remission: A narrative review

Type 2 diabetes mellitus (T2DM) is a highly prevalent metabolic disease, causing a heavy burden on healthcare systems worldwide, with related complications and anti-diabetes drug prescriptions. Recently, it was demonstrated that T2DM can be put into remission via significant weight loss using low-carbohydrate diets (LCDs) and very low-energy diets (VLEDs) in individuals with overweight and obesity. Clinical trials demonstrated remission rates of 25-77%, and metabolic improvements such as improved blood lipid profile and blood pressure were observed. In contrast, clinical trials showed that remission rate declines with time, concurrent with weight gain, or diminished weight loss. This review aims to discuss existing literature regarding underlying determinants of long-term remission of T2DM including metabolic adaptations to weight loss (e.g., role of gastrointestinal hormones), type of dietary intervention (i.e., LCDs or VLEDs), maintaining beta (β)-cell function, early glycemic control, and psychosocial factors. This narrative review is significant because determining the factors that are associated with challenges in maintaining long-term remission may help in designing sustainable interventions for type 2 diabetes remission.

Supporting Sustainable Health Behavior Change: The Whole is Greater Than the Sum of Its Parts

Behavior change is the foundation for effective lifestyle prescriptions, yet such change is individualized, nonlinear and typically requires ongoing support. Health and wellness coaching (HWC) is a behavior change intervention with rapidly accruing evidence of positive impact on health behaviors such as exercise, nutrition and stress management. Furthermore, HWC enhances prevention and mitigates exacerbation of chronic lifestyle diseases, at least in the short-term (up to 6 months post intervention). Although the impact on long-term stability of behavior change remains unclear, it is evident that effective partnering with patients using key communication strategies, autonomy promotion, and flexible permissiveness can empower patients to develop healthy lifestyles. This partnership can be cultivated by clinicians as well as clinical team members including nationally board-certified coaches. Although much research is needed regarding the ongoing maintenance of lifestyle changes beyond 6 months, this article seeks to equip clinicians with current evidence, theoretical insights and practical strategies from a "coach approach" to foster more intrinsic forms of motivation which, in turn, empowers patients to adopt and maintain health-promoting behaviors.

Impact of Covid-19 lockdowns on the anthropometric development in primary school children in the Rhein-Neckar Region, Germany

BACKGROUND

Published data suggests that lockdowns during the COVID-19 pandemic may have negatively affected children's weight development. This study aims to assess the prevalence of overweight and obesity after the COVID-19 lockdowns as well as anthropometric development among primary school children in the Rhein-Neckar Region, Germany.

METHODS

In this cross-sectional study, schools were selected in cooperation with the local health authority to include different socioeconomic backgrounds. Participation was voluntary at school and individual level, requiring written informed consent from legal guardians. Study visits in schools were conducted between October 2021 and July 2022. Anthropometric data from nationally recommended medical examinations at 4 years (U8) and 5 years (U9), data on nutrition, physical activity, and socioeconomic data was collected using questionnaires. zBMI and weight category were calculated based on German reference data.

RESULTS

256 children with a mean age of 8.0 years (7.1-9.3 years) were included in the study. Most participants were from households with an above average income. 5.1% of the children were overweight, 4.7% were obese, 15.6% were underweight, and 74.6% were normal weight with a mean zBMI of -0.25 (SD 1.10), which is significantly lower than the mean zBMI of the German reference population (p < 0.001). No significant changes in zBMI were observed between U8 and U9 (p = 0.16). The mean zBMI decreased by 0.17 (SD 0.72) between U9 and the study visit (p = 0.02). A zBMI decrease of 0.5 was documented for the subgroup of overweight and obese children (p = 0.028) as well as a decrease of 0.23 (SD 0.63) for the normal-weight children subgroup (p < 0.001).

CONCLUSIONS

Contrary to previous reports mean zBMI decreased significantly in the children studied. No significant changes in zBMI were observed between U8 and U9 examinations, which supports the hypothesis that the decrease in zBMI could be attributed to lockdown measures. The study was registered at clinicaltrials.gov on September 21st 2021 under the registration number NCT05077059.

Effectiveness of an Artificial Intelligence-Assisted App for Improving Eating Behaviors: Mixed Methods Evaluation

BACKGROUND

A plethora of weight management apps are available, but many individuals, especially those living with overweight and obesity, still struggle to achieve adequate weight loss. An emerging area in weight management is the support for one's self-regulation over momentary eating impulses.

OBJECTIVE

This study aims to examine the feasibility and effectiveness of a novel artificial intelligence-assisted weight management app in improving eating behaviors in a Southeast Asian cohort.

METHODS

A single-group pretest-posttest study was conducted. Participants completed the 1-week run-in period of a 12-week app-based weight management program called the Eating Trigger-Response Inhibition Program (eTRIP). This self-monitoring system was built upon 3 main components, namely, (1) chatbot-based check-ins on eating lapse triggers, (2) food-based computer vision image recognition (system built based on local food items), and (3) automated time-based nudges and meal stopwatch. At every mealtime, participants were prompted to take a picture of their food items, which were identified by a computer vision image recognition technology, thereby triggering a set of chatbot-initiated questions on eating triggers such as who the users were eating with. Paired 2-sided t tests were used to compare the differences in the psychobehavioral constructs before and after the 7-day program, including overeating habits, snacking habits, consideration of future consequences, self-regulation of eating behaviors, anxiety, depression, and physical activity. Qualitative feedback were analyzed by content analysis according to 4 steps, namely, decontextualization, recontextualization, categorization, and compilation.

RESULTS

The mean age, self-reported BMI, and waist circumference of the participants were 31.25 (SD 9.98) years, 28.86 (SD 7.02) kg/m2, and 92.60 (SD 18.24) cm, respectively. There were significant improvements in all the 7 psychobehavioral constructs, except for anxiety. After adjusting for multiple comparisons, statistically significant improvements were found for overeating habits (mean -0.32, SD 1.16; P<.001), snacking habits (mean -0.22, SD 1.12; P<.002), self-regulation of eating behavior (mean 0.08, SD 0.49; P=.007), depression (mean -0.12, SD 0.74; P=.007), and physical activity (mean 1288.60, SD 3055.20 metabolic equivalent task-min/day; P<.001). Forty-one participants reported skipping at least 1 meal (ie, breakfast, lunch, or dinner), summing to 578 (67.1%) of the 862 meals skipped. Of the 230 participants, 80 (34.8%) provided textual feedback that indicated satisfactory user experience with eTRIP. Four themes emerged, namely, (1) becoming more mindful of self-monitoring, (2) personalized reminders with prompts and chatbot, (3) food logging with image recognition, and (4) engaging with a simple, easy, and appealing user interface. The attrition rate was 8.4% (21/251).

CONCLUSIONS

eTRIP is a feasible and effective weight management program to be tested in a larger population for its effectiveness and sustainability as a personalized weight management program for people with overweight and obesity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04833803; https://classic.clinicaltrials.gov/ct2/show/NCT04833803.

Is Operative Time Associated With Obesity-related Outcomes in TKA?

BACKGROUND

Obesity-based cutoffs in TKA are premised on higher rates of postoperative complications. However, operative time may be associated with postoperative complications, leading to an unnecessary restriction of TKA in patients with obesity. If operative time is associated with these obesity-related outcomes, it should be accounted for in order to ensure all measurable factors associated with negative outcomes are examined for patients with obesity after TKA.

QUESTIONS/PURPOSES

We asked: (1) Is operative time, controlling for BMI class, associated with readmission, reoperation, and postoperative major and minor complications? (2) Is operative time associated with a difference in the direction or strength of obesity-related adverse outcomes?

METHODS

In this comparative study, we extracted all records on elective, unilateral TKA between January 2014 and December 2020 in the American College of Surgeons National Surgical Quality Improvement Program database, resulting in an initial sample of 394,381 TKAs. Patients with emergency procedures (0.1% [270]) and simultaneous bilateral TKAs (2% [8736]), missing or null data (1% [4834]), and those with operative times less than 25 minutes (0.1% [548]) were excluded, leaving 96% (379,993) of our original sample size. The National Surgical Quality Improvement Program database was selected because of its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight (BMI < 18.5 kg/m 2 , < 1% [719]), normal weight (BMI 18.5 to 24.9 kg/m 2 , 9% [34,513]), overweight (BMI 25.0 to 29.9 kg/m 2 , 27% [101,538]), Class I obesity (BMI 30.0 to 34.9 kg/m 2 , 29% [111,712]), Class II obesity (BMI 35.0 to 39.9 kg/m 2 , 20% [76,605]), and Class III obesity (BMI ≥ 40.0 kg/m 2 , 14% [54,906]). The mean operative time was 91 ± 36 minutes, 61% of patients were women (233,062 of 379,993), and the mean age was 67 ± 9 years. Patients with obesity tended to be younger and more likely to have preoperative comorbidities and longer operative times than patients with normal weight. Multivariable logistic regression models examined the main effects of operative time with respect to 30-day readmission, reoperation, and major and minor medical complications, while adjusting for BMI class and other covariates including age, sex, race, smoking status, and number of preoperative comorbidities. We then evaluated the potential interaction effect of BMI class and operative time. This interaction term helps determine whether the association of BMI with postoperative outcomes changes based on the duration of the surgery, and vice versa. If the interaction term is statistically significant, it implies the association of BMI with adverse postoperative outcomes is inconsistent across all patients. Instead, it varies with the operative time. Adjusted odds ratios and 95% confidence intervals were calculated, and interaction effects were plotted.

RESULTS

After controlling for obesity, longer procedure duration was independently associated with higher odds of all outcomes (30-minute estimates; adjusted ORs are per minute), including readmission (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), reoperation (15% per half-hour of surgical duration; adjusted OR 1.005 [95% CI 1.004 to 1.005]; p < 0.001), postoperative major complications (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), and postoperative minor complications (18% per half-hour of surgical duration; adjusted OR 1.006 [95% CI 1.006 to 1.007]; p < 0.001). The interaction effect indicates that patients with obesity had lower odds of reoperation than patients with normal weight when operative times were shorter, but higher odds of reoperation with a longer operative duration.

CONCLUSION

We found that operative time, a proxy for surgical complexity, had a moderate, differential association with obesity over a 30-minute period. Perioperative modification of surgical complexity such as surgical techniques, training, and team dynamics may make safe TKA possible for certain patients who might have otherwise been denied surgery. Decisions to refuse TKA to patients with obesity should be based on a holistic assessment of a patient's operative complexity, rather than strictly assessing a patient's weight or their ability to lose weight. Future studies should assess patient-specific characteristics that are associated with operative time, which can further push the development of techniques and strategies that reduce surgical complexity and improve TKA outcomes.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Weight regain, but not weight loss exacerbates hepatic fibrosis during multiple weight cycling events in male mice

PURPOSE

Weight cycling is a phenomenon characterized by fluctuating body weight that is commonly observed in individuals employing intentional weight loss methods. Despite its prevalence, the impact of weight cycling on health remains equivocal. The current investigation aimed to examine the effects of weight cycling on liver health.

METHODS

The weight cycling model was established by switching the feeding method of mice between ad libitum (AL) and restricted intake (DR or 60% of AL) of the breeding diet to cause weight gain and weight loss, respectively. The weight cycling model comprised two and a half cycles, with one group terminating the experience during the weight-gain period (S-AL) and the other during the weight-loss period (S-DR). Liver tissue was collected to investigate morphology alterations, apoptosis, lipid metabolism, and mitochondrial homeostasis.

RESULTS

The results demonstrated that the termination point of weight cycling affected body weight and hepatic steatosis. All parameters examined in the S-DR mice exhibited a comparable trend to those observed in the DR mice. Notably, S-AL mice showed a significant increase in lipid metabolism-related proteins in the liver compared to AL-fed mice, along with reduced lipid droplets. Moreover, hepatic apoptosis and fibrosis were exacerbated in the S-AL mice compared to AL mice, whereas mitochondrial fusion, biogenesis, and mitophagy were decreased in the S-AL mice.

CONCLUSION

Weight cycling ending in weight gain exacerbated hepatic fibrosis, potentially by inducing apoptosis or disrupting mitochondrial homeostasis. Conversely, weight cycling ending in weight loss demonstrated beneficial effects on hepatic health.

Eating disorders and obesity: bridging clinical, neurobiological, and therapeutic perspectives

Eating disorders (EDs) and obesity are complex health conditions sharing various risk and maintenance factors, intensified in cases of comorbidity. This review explores the similarities and connections between these conditions, examining different facets from a multidisciplinary perspective, among them comorbidities, metabolic and psychological factors, neurobiological aspects, and management and therapy implications. We aim to investigate the common characteristics and complexities of weight and EDs and explore their interrelationships in individuals who experience both. The rising prevalence of EDs in people with obesity necessitates integrated approaches to study this comorbidity and to identify and analyze both common and distinct features of these conditions. This review may offer new opportunities for simultaneous prevention and management approaches, as well as future lines of research.

Returning to sport after injury: the influence of injury appraisals and post-traumatic stress symptoms on adolescent risk-taking intentions post-injury

OBJECTIVE

How youth think about injury risk can affect their decisions about whether to engage in behaviors that can lead to injury. Appraisals also influence the development of post-traumatic stress symptoms (PTSS), which occur in approximately 20% of children after a medically treated injury. The current study examined how the injury appraisals of youth are associated with the development of PTSS post-skateboarding injury, and if PTSS or perceived benefits of the sport are also associated with youths' intentions to return to the sport.

METHOD

One hundred three youth who had a medically treated skateboarding injury within the last year provided survey data on injury appraisals, PTSS, the benefits of skateboarding, and intentions to return to the sport.

RESULTS

A two-stage moderated statistical mediation path model was specified. In the first stage, there was a positive relationship between pain at injury and PTSS, which was attenuated by the moderator, perceived bad luck. PTSS fully mediated the association between perceived pain at the time of injury and intentions to return to skateboarding. In the second stage of the mediation model, the moderator perceived benefits of skateboarding, reversed the negative relationship between PTSS and intentions to return to skateboarding.

CONCLUSIONS

Skateboarders are a group at risk for injury that can lead to PTSS, and they also are likely to return to the sport despite PTSS. This research identifies factors that impact the decision to return to skateboarding after injury. Limitations of the study and implications for mental health support and injury prevention are provided.

Expert Opinion on the Utility of Telemedicine in Obesity Care: Recommendations on a Hybrid Multidisciplinary Integrated Care Follow-Up Algorithm

PURPOSE OF REVIEW

The proposed expert opinion was prepared by a panel of obesity and law specialists from Turkey to review the utility of telemedicine in obesity care and to provide a guidance document with recommendations on a hybrid multidisciplinary integrated care follow-up algorithm and the legislation governing telemedicine practice to assist obesity specialists in practicing the telemedicine.

RECENT FINDINGS

The efficacy and feasibility of telemedicine interventions in supporting obesity management programs even during pandemics confirm that obesity is a particularly well-suited field for telemedicine, emphasizing the strong likelihood of continued utilization of telemedicine in obesity management, beyond the pandemic period. Telemedicine has great potential to address several barriers to ongoing weight-management care, such as challenges of access to specialized care, cost, and time limitations as well as patient adherence to treatment. However, telemedicine practice should complement rather than replace the in-person visits which are unique in building rapport and offering social support. Accordingly, the participating experts recommend the use of a hybrid integrated care model in the management of obesity, with the use of telemedicine, as an adjunct to in-person visits, to enable the provision of suggested intensive obesity management via frequent visits by a multidisciplinary team of obesity specialists. Further research addressing the utility of telemedicine in terms of optimal modality and duration for successful long-term obesity management outcomes is necessary to develop specific guidelines on telemedicine practice. In addition, the legislation governing the norms and protocols on confidentiality, privacy, access, and liability needs to be improved.

Qualitative evaluation of a Salutogenic Healthy Eating Programme for Dutch people with type 2 diabetes

The salutogenic model of health (SMH) is a health-promoting theory that focuses on resources, strengths, and coping capacities in everyday life as a way to improve health and wellbeing. The SMH was applied to develop a programme for enabling healthy eating practices among people with type 2 diabetes mellitus (T2DM): the SALUD programme. This study aims to gain insight in how participants with T2DM experienced the content and meaning of the SALUD programme. Three focus groups with participants (six to eight participants/group) that finished the SALUD programme were conducted. The focus groups were video-recorded, transcribed ad verbatim and thematically analysed. The SALUD programme was perceived by the participants as a positive, meaningful learning experience. Key factors why the participants described the programme as positive were that they felt a sense of social-belonging and (emotionally) safe (theme 1). The SALUD programme's positive encouraging approach presented by the coach invited participants to join an active learning process (theme 2). Performing trial-and-error experiments and weekly reflecting on goals is what characterized active learning. The meaningfulness of the learning process (theme 3) was derived from (i) positive self-confrontation; (ii) exploring mind-body connections and perceiving improved health and (iii) noticing positive changes in their social environment (theme 3). To conclude, the study uncovered that the SALUD programme incited a positive, meaningful learning process for healthy eating and the contextual factors important in this. Potential leads to further improve the SALUD programme are discussed in order to maximize the chance of inciting an inclusive, active learning process.

Longitudinal estimates of resting energy expenditure using predictive equations in individuals with excess weight after weight loss: A systematic review with meta-analysis

BACKGROUND & AIMS

To determine which resting energy expenditure (REE) predictive equation has the lowest bias in the aggregate level in individuals with excess weight during weight loss interventions.

METHODS

Searches were performed in MEDLINE, Web of Science, Scopus, CENTRAL and gray literature databases. Longitudinal studies on weight loss interventions which evaluated REE by predictive equations compared to that measured by indirect calorimetry in adults with excess weight at different follow-up times were included. Meta-analyses were performed with the differences between biases of predictive equations of the REE at the different follow-up times of weight loss.

RESULTS

Of the total of 2178 occurrences found in the databases, only eight studies were included. The Harris-Benedict (1919) equation showed the smallest differences between bias up to the third month (MD = 103.33 kcal; 95%CI = -39.01; 245.67), in the sixth month (MD = 59.16 kcal; 95%CI = 8.74; 109.57) and at the 12th month (MD = -71.41 kcal; 95%CI = -150.38; 7.55) of weight loss follow-up. Weight loss does not seem to have an effect on bias at different follow-up times.

CONCLUSION

Harris-Benedict (1919) equation seems to be the most adequate to assess the REE of individuals with excess weight during weight loss. However, the finding of large estimated predictive intervals may indicate that predictive equations may not be handy tools for individuals losing and regaining weight due to changes other than body weight.

New insights in the mechanisms of weight-loss maintenance: Summary from a Pennington symposium

Obesity is a chronic disease that affects more than 650 million adults worldwide. Obesity not only is a significant health concern on its own, but predisposes to cardiometabolic comorbidities, including coronary heart disease, dyslipidemia, hypertension, type 2 diabetes, and some cancers. Lifestyle interventions effectively promote weight loss of 5% to 10%, and pharmacological and surgical interventions even more, with some novel approved drugs inducing up to an average of 25% weight loss. Yet, maintaining weight loss over the long-term remains extremely challenging, and subsequent weight gain is typical. The mechanisms underlying weight regain remain to be fully elucidated. The purpose of this Pennington Biomedical Scientific Symposium was to review and highlight the complex interplay between the physiological, behavioral, and environmental systems controlling energy intake and expenditure. Each of these contributions were further discussed in the context of weight-loss maintenance, and systems-level viewpoints were highlighted to interpret gaps in current approaches. The invited speakers built upon the science of obesity and weight loss to collectively propose future research directions that will aid in revealing the complicated mechanisms involved in the weight-reduced state.

Perceptions of self-monitoring dietary intake according to a plate-based approach: A qualitative study

Dietary self-monitoring is a behaviour change technique used to help elicit and sustain dietary changes over time. Current dietary self-monitoring tools focus primarily on itemizing foods and counting calories, which can be complex, time-intensive, and dependent on health literacy. Further, there are no dietary self-monitoring tools that conform to the plate-based approach of the 2019 Canada Food Guide (CFG), wherein the recommended proportions of three food groups are visually represented on a plate without specifying daily servings or portion sizes. This paper explored the perceptions of end-users (i.e., general public) and Registered Dietitians of iCANPlateTM-a dietary self-monitoring mobile application resembling the CFG. Qualitative data were collected through virtual focus groups. Focus group questions were based on the Capability, Opportunity, Motivation-Behaviour (COM-B) theoretical framework to explore perceptions of using the CFG and currently available dietary self-monitoring tools. The prototype iCANPlateTM (version 0.1) was presented to gain feedback on perceived barriers and facilitators of its use. Focus group discussions were audio recorded and verbatim transcribed. Trained researchers used thematic analysis to code and analyze the transcripts independently. Seven focus groups were conducted with Registered Dietitians (n = 44) and nine focus groups with members from the general public (n = 52). During the focus groups, participants mainly discussed the capabilities and opportunities required to use the current iteration of iCANPlateTM. Participants liked the simplicity of the application and its capacity to foster self-awareness of dietary behaviours rather than weight control or calorie counting. However, concerns were raised regarding iCANPlateTM's potential to improve adherence to dietary self-monitoring due to specific characteristics (i.e., insufficient classifications, difficulty in conceptualizing proportions, and lack of inclusivity). Overall, participants liked the simplicity of iCANPlateTM and its ability to promote self-awareness of dietary intakes, primarily through visual representation of foods on a plate as opposed to reliance on numerical values or serving sizes, were benefits of using the app. Findings from this study will be used to further develop the app with the goal of increasing adherence to plate-based dietary approaches.

Engineering Virtuous health habits using Emotion and Neurocognition: Flexibility for Lifestyle Optimization and Weight management (EVEN FLOW)

Interventions to preserve functional independence in older adults are critically needed to optimize 'successful aging' among the large and increasing population of older adults in the United States. For most aging adults, the management of chronic diseases is the most common and impactful risk factor for loss of functional independence. Chronic disease management inherently involves the learning and adaptation of new behaviors, such as adopting or modifying physical activity habits and managing weight. Despite the importance of chronic disease management in older adults, vanishingly few individuals optimally manage their health behavior in the service of chronic disease stabilization to preserve functional independence. Contemporary conceptual models of chronic disease management and health habit theory suggest that this lack of optimal management may result from an underappreciated distinction within the health behavior literature: the behavioral domains critical for initiation of new behaviors (Initiation Phase) are largely distinct from those that facilitate their maintenance (Maintenance Phase). Psychological factors, particularly experiential acceptance and trait levels of openness are critical to engagement with new health behaviors, willingness to make difficult lifestyle changes, and the ability to tolerate aversive affective responses in the process. Cognitive factors, particularly executive function, are critical to learning new skills, using them effectively across different areas of life and contextual demands, and updating of skills to facilitate behavioral maintenance. Emerging data therefore suggests that individuals with greater executive function are better able to sustain behavior changes, which in turn protects against cognitive decline. In addition, social and structural supports of behavior change serve a critical buffering role across phases of behavior change. The present review attempts to address these gaps by proposing a novel biobehavioral intervention framework that incorporates both individual-level and social support system-level variables for the purpose of treatment tailoring. Our intervention framework triangulates on the central importance of self-regulatory functioning, proposing that both cognitive and psychological mechanisms ultimately influence an individuals' ability to engage in different aspects of self-management (individual level) in the service of maintaining independence. Importantly, the proposed linkages of cognitive and affective functioning align with emerging individual difference frameworks, suggesting that lower levels of cognitive and/or psychological flexibility represent an intermediate phenotype of risk. Individuals exhibiting self-regulatory lapses either due to the inability to regulate their emotional responses or due to the presence of executive functioning impairments are therefore the most likely to require assistance to preserve functional independence. In addition, these vulnerabilities will be more easily observable for individuals requiring greater complexity of self-management behavioral demands (e.g. complexity of medication regimen) and/or with lesser social support. Our proposed framework also intuits several distinct intervention pathways based on the profile of self-regulatory behaviors: we propose that individuals with intact affect regulation and impaired executive function will preferentially respond to 'top-down' training approaches (e.g., strategy and process work). Individuals with intact executive function and impaired affect regulation will respond to 'bottom-up' approaches (e.g., graded exposure). And individuals with impairments in both may require treatments targeting caregiving or structural supports, particularly in the context of elevated behavioral demands.

Bariatric Surgery and Gut-Brain-Axis Driven Alterations in Cognition and Inflammation

Obesity is associated with systemic inflammation, comorbidities like diabetes, cardiovascular disease and several cancers, cognitive decline and structural and functional brain changes. To treat, or potentially prevent these related comorbidities, individuals with obesity must achieve long-term sustainable weight loss. Often life style interventions, such as dieting and increased physical activity are not successful in achieving long-term weight loss. Meanwhile bariatric surgery has emerged as a safe and effective procedure to treat obesity. Bariatric surgery causes changes in physiological processes, but it is still not fully understood which exact mechanisms are involved. The successful weight loss after bariatric surgery might depend on changes in various energy regulating hormones, such as ghrelin, glucagon-like peptide-1 and peptide YY. Moreover, changes in microbiota composition and white adipose tissue functionality might play a role. Here, we review the effect of obesity on neuroendocrine effects, microbiota composition and adipose tissue and how these may affect inflammation, brain structure and cognition. Finally, we will discuss how these obesity-related changes may improve after bariatric surgery.

The BREAK study protocol: Effects of intermittent energy restriction on adaptive thermogenesis during weight loss and its maintenance

BACKGROUND

Adaptive thermogenesis, defined as the decrease in the energy expenditure components beyond what can be predicted by changes in body mass stores, has been studied as a possible barrier to weight loss and weight maintenance. Intermittent energy restriction (IER), using energy balance refeeds, has been pointed out as a viable strategy to reduce adaptive thermogenesis and improve weight loss efficiency (greater weight loss per unit of energy deficit), as an alternative to a continuous energy restriction (CER). Following a randomized clinical trial design, the BREAK Study aims to compare the effects of IER versus CER on body composition and in adaptive thermogenesis, and understand whether participants will successfully maintain their weight loss after 12 months.

METHODS

Seventy-four women with obesity and inactive (20-45 y) will be randomized to 16 weeks of CER or IER (8x2 weeks of energy restriction interspersed with 7x1 week in energy balance). Both groups will start with 2 weeks in energy balance before energy restriction, followed by 16 weeks in energy restriction, then 8 weeks in energy balance and finally a 12-month weight maintenance phase. Primary outcomes are changes in fat-mass and adaptive thermogenesis after weight loss and weight maintenance. Secondary outcomes include weight loss, fat-free mass preservation, alterations in energy expenditure components, and changes in hormones (thyroid function, insulin, leptin, and cortisol).

DISCUSSION

We anticipate that The BREAK Study will allow us to better understand adaptive thermogenesis during weight loss and weight maintenance, in women with obesity. These findings will enable evidence-based decisions for obesity treatment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05184361.

Behavioral, psychological, and environmental predictors of weight regain in a group of successful weight losers in a widely available weight-management program

OBJECTIVE

The aim of this study was to identify predictors of weight regain and continued weight maintenance among individuals already successful at long-term weight loss in a widely available weight-management program.

METHODS

Participants were 2843 weight-loss maintainers in WeightWatchers who had maintained weight loss ≥9.1 kg for ≥1 year (average 25.5 kg for 3.5 years; BMI = 26.7 kg/m2 ). Validated behavioral, psychosocial, and home environmental questionnaires were administered at study entry and 1 year later. Discriminant analysis identified variables that discriminated gainers (≥2.3-kg gain) from maintainers (±2.3-kg change).

RESULTS

Over the 1 year of follow-up, 43% were gainers (mean [SD], 7.2 [5.4] kg), and 57% were maintainers (0.4 [1.2] kg). Compared with maintainers, gainers were younger and had higher initial weight, more recent weight losses, and larger initial weight losses. Standardized canonical coefficients indicated that the 1-year changes that most discriminated gainers from maintainers were greater decreases in the ability to accept uncomfortable food cravings, urges, and desires to overeat (0.232); self-monitoring (0.166); body image (0.363); and body satisfaction (0.194) and greater increases in disinhibition (0.309) and bodily pain (0.147). The canonical correlation was 0.505 (p < 0.001).

CONCLUSIONS

Future interventions to prevent regain should consider targeting overeating in response to internal and external food cues and declines in self-monitoring and body image.

Interpretative repertoires of long-term weight management: negotiating accountability and explaining success

OBJECTIVE

Public health messages encourage maintaining a stable weight and are influential in shaping normative weight management discourses. We studied how individuals with different weight maintenance histories constructed relations to these discourses in their sense-making on weight management.

DESIGN

Our study used critical discursive psychology (CDP) as a theoretical and methodological framework for examining the accounts of 20 lifelong weight maintainers and 20 weight-loss maintainers (altogether 17 men and 23 women, aged 51-74).

RESULTS

We identified three interpretative repertoires the participants used for making sense of weight management. The lifelong weight maintainers and weight-loss maintainers differed in their ways of using three repertoires. The "everyday challenges" repertoire that emphasized external obstacles was most emphatic in weight-loss maintainers' accounts of unsuccessful weight management, and the "following instructions" repertoire that highlighted control and disciplined behavior in their accounts of success. The "lifestyle and personalized routines" repertoire that stressed customized needs and routinization of practices was most prominent in lifelong weight maintainers' accounts of successful weight management.

CONCLUSION

Our findings stress the importance of alternative ways of talking about and supporting weight management to prevent stigmatization. In conclusion, we suggest employing morally neutral language by focusing on lifestyle and wellbeing instead of weight.

Diet Quality, Cardiometabolic Risk and Diabetes

The alarming rise in obesity worldwide is a dramatic public health concern [...].

Exploratory analysis of reflective, reactive, and homeostatic eating behaviour traits on weight change during the 18-month NoHoW weight maintenance trial

Behaviour change interventions for weight management have found varied effect sizes and frequent weight re-gain after weight loss. There is interest in exploring whether differences in eating behaviour can be used to develop tailored weight management programs. This secondary analysis of an 18-month weight maintenance randomised controlled trial (RCT) aimed to investigate the association between individual variability in weight maintenance success and change in eating behaviour traits (EBT). Data was analysed from the NoHoW trial (Scott et al., 2019), which was designed to measure processes of change after weight loss of ≥5% body weight in the previous year. The sample included 1627 participants (mean age = 44.0 years, SD = 11.9, mean body mass index (BMI) = 29.7 kg/m2, SD = 5.4, gender = 68.7% women/31.3% men). Measurements of weight (kg) and 7 EBTs belonging to domains of reflective, reactive, or homeostatic eating were taken at 4 time points up to 18-months. Increases in measures of 'reactive eating' (binge eating, p < .001), decreases in 'reflective eating' (restraint, p < .001) and changes in 'homeostatic eating' (unlimited permission to eat, p < .001 and reliance on hunger and satiety cues, p < .05) were significantly and independently associated with concomitant weight change. Differences in EBT change were observed between participants who lost, maintained, or re-gained weight for all EBTs (p < .001) except for one subscale of intuitive eating (eating for physical reasons, p = .715). Participants who lost weight (n = 322) exhibited lower levels of reactive eating and higher levels of reflective eating than participants who re-gained weight (n = 668). EBT domains can identify individuals who need greater support to progress in weight management interventions. Increasing reflective eating and reducing reactive eating may enhance weight management success.

Weight loss maintenance after a digital commercial behavior change program (Noom Weight): Observational cross-sectional survey study

Background

Behavioral weight loss programs often lead to significant short-term weight loss, but long-term weight maintenance remains a challenge. Most weight maintenance data come from clinical trials, in-person programs, or general population surveys, but there is a need for better understanding of long-term weight maintenance in real-world digital programs.

Methods

This observational survey study examined weight maintenance reported by individuals who had used Noom Weight, a digital commercial behavior change program, and identified factors associated with greater weight maintenance. The cross-sectional survey was completed by 840 individuals who had lost at least 10% of their body weight using Noom Weight 6-24 months prior.

Results

The study found that 75% of individuals maintained at least 5% weight loss after 1 year, and 49% maintained 10% weight loss. On average, 65% of initial weight loss was maintained after 1 year and 57% after 2 years. Habitual behaviors, such as healthy snacking and exercise, were associated with greater weight maintenance, while demographic factors were not.

Conclusion

This study provides real-world data on the long-term weight maintenance achieved using a fully digital behavioral program. The results suggest that Noom Weight is associated with successful weight maintenance in a substantial proportion of users. Future research will use a randomized controlled trial to track weight maintenance after random assignment and at a 2 year follow-up.

Adolescents' Perspectives on Skateboarding and Injury Risk: The Benefits Outweigh the Risks

OBJECTIVE

Skateboarding is an increasingly popular sport among youth, despite the fact that children and adolescents are the age groups most frequently injured when skateboarding. A greater understanding of the psycho-social factors that motivate participation in skateboarding, including why youth return to the sport after serious injury from skateboarding, is needed to inform injury prevention efforts. This study addressed that gap in knowledge.

METHODS

Twenty-six Canadian adolescent skateboarders 14-17 years of age (20 males and 6 females) who had previously sustained medically attended injuries while skateboarding participated in individual interviews to explore their perspectives on skateboarding and injury risk, including reasons for returning to the sport after injury.

RESULTS

Thematic analyses revealed that participants perceived many unique benefits from skateboarding, including interpersonal benefits, mental and physical health benefits, pleasure, personal growth, and identity development. Participants uniformly identified that a major drawback was the risk of injury, with trickle-down effects of injury including a loss of social contacts (e.g., missing friends), challenges to individual identity from not participating, and injury-specific negative outcomes (e.g., pain, physical limitations). When exploring reasons participants returned to the sport and to the trick or activity that precipitated their injury, the primary theme identified was that the benefits of skateboarding significantly outweighed the costs associated with potential re-injury.

CONCLUSION

Results paint a nuanced picture of psycho-social factors that impact youths' skateboarding and decisions to return to the sport after injury. Implications for injury prevention are discussed.

Mental Health Variables Impact Weight Loss, Especially in Patients with Obesity and Binge Eating: A Mediation Model on the Role of Eating Disorder Pathology

BACKGROUND

Various mental health and eating behavior variables have been independently associated with predicting weight loss in individuals with obesity. This study aims to investigate a mediation model that assesses the distinct contributions of these variables in predicting weight changes in patients with obesity following an outpatient behavioral weight loss intervention (BWLI).

METHODS

General mental health (depression, anxiety, stress, impulsivity), eating behavior (cognitive restraint, disinhibition, hunger), eating disorder pathology, and body mass index (BMI) were assessed in a group of 297 patients with obesity at the admission of a BWLI program. BMI was re-evaluated during the final treatment session. A mediation model was employed to examine whether mental health and eating behavior variables predicted BMI changes, with eating disorder pathology serving as a mediator. The model was tested both overall and within two patient subgroups: those with regular binge eating (≥four episodes/month) and those without.

RESULTS

In the overall sample (n = 238), the relationships between depression, impulsivity, and cognitive restraint with BMI change were mediated by eating disorder pathology. In the subgroup with regular binge eating (n = 99, 41.6%), the associations between stress and disinhibition with BMI change were additionally mediated by eating disorder pathology. In the subgroup without regular binge eating, eating disorder pathology showed no mediating effect.

DISCUSSION

Multiple mental health and eating behavior variables assessed at admission predicted BMI changes, particularly when mediated by eating disorder pathology in patients with regular binge eating. A comprehensive psychopathological assessment prior to starting BWLI may help identify multiple factors affecting prognosis and treatment outcomes. Long-term follow-up studies in this field are required.