Successful weight loss maintenance: A systematic review of weight control registries

Self-regulatory and self-efficacy mechanisms of weight loss in women within a community-based behavioral obesity treatment

Given the traditional methods of treating obesity through education on controlling eating and increasing exercise have largely failed beyond the very short term, a more intensive focus on psychosocial correlates of those weight-loss behaviors has been suggested. Multiple behavioral theories incorporate self-regulation, self-efficacy, and mood; however, their interrelations and effects over both the short and long term within cognitive-behavioral obesity treatments remain unclear. Within a novel community-based program with women with obesity who had either low (n = 29) or high (n = 71) mood disturbance scores, there were significant improvements in exercise- and eating-related self-regulation and eating-related self-efficacy-primary targets of that intervention-with no significant difference in those changes by mood disturbance grouping. Changes in the summed exercise- and eating-related self-regulation scores significantly mediated relationships between changes in eating-related self-efficacy and weight (over both 6 and 12 months). There were similar results with mediation assessed via the extent exercise-related self-regulation carried over to eating-related self-regulation. In both of those models a reciprocal relationship between self-regulation and self-efficacy changes was indicated. In serial multiple mediation equations, paths of changes in exercise-related self-regulation → eating-related self-regulation → eating-related self-efficacy → weight were significant. However, paths were not significant when change in self-efficacy was entered as the predictor (initial) variable. Findings suggest viability in first focusing on exercise-related self-regulation, then eating-related self-regulation, in the course of increasing self-efficacy and probabilities for inducing enough sustained weight loss to improve obesity-associated health risks. Benefits of field-based research findings generalizing to weight-management applications were suggested.

Cognitive and behavioral weight management strategies during the menopausal transition: Insights from the Menopause and Weight Loss (ME-WEL) project

OBJECTIVE

Most women experience weight gain during the menopausal transition, often attributed to behavioral factors. Nevertheless, some women successfully maintain a healthy weight during this phase. This study aims to identify the successful cognitive and behavioral weight management strategies employed by postmenopausal women who effectively maintained a healthy weight during the menopausal transition (from premenopause to postmenopause).

METHOD

Semi-structured interviews were conducted with 31 Portuguese postmenopausal women, aged 45-65 years (mean and standard deviation 54.06 ± 5.51) who successfully maintained a healthy weight (body mass index: 18.5 kg/m2-24.9 kg/m2) during the menopausal transition. The interviews were conducted via telephone (n = 29) and Zoom (n = 2), based on the participant's preference, and ranged from 11 to 52 min (22.06 ± 9.95). Using MAXQDA software, deductive-dominant content analysis of the interviews was performed. The Interface of R for the Multidimensional Analyses of Texts and Questionnaire software was used for lexical analysis.

RESULTS

The qualitative analysis of cognitive and behavioral strategies for successful weight management yielded 17 categories and 37 sub-categories. Effective cognitive and behavioral strategies (e.g., planning content, stimulus control, support: help from others) were identified, mostly aligning with the Oxford Food and Activity Behaviors Taxonomy. Five new categories emerged: dietary choices, intuitive eating, food literacy, psychological self-care, and effortful inhibition.

CONCLUSION

Knowing effective cognitive and behavioral weight management strategies for menopausal women is relevant, especially considering their status as a high-risk group. This knowledge provides a valuable guide for designing weight management interventions, emphasizing the essential role of behavioral change.

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.

A novel nomogram for predicting optimal weight loss response following diet and exercise intervention in patients with obesity

This study aimed to identify factors associated with optimal weight loss response by analyzing pre-weight loss data from a cohort of 2577 patients with obesity who visited weight management clinics between 2013 and 2022. Out of these, 1276 patients had follow-up data available. Following dietary and exercise interventions, 580 participants achieved optimal weight loss outcomes. Participants were subsequently divided into two groups based on their weight loss outcomes: those who achieved optimal weight loss response and those who did not. Statistical analysis, conducted using RStudio, identified thirteen predictor variables through LASSO and logistic regression, with age emerging as the most influential predictor. A nomogram was developed to predict optimal weight loss response, showing good predictive performance (AUC = 0.807) and clinical applicability, validated by internal validation methods. Decision curve analysis (DCA) further illustrated the nomogram's clinical utility. The developed nomogram prediction model for optimal weight loss response is user-friendly, highly accurate, and demonstrates excellent discriminative and calibration capabilities.

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.

Personal Experiences and Preferences for Weight-Management Services from Adults Living with Overweight and Obesity in the United Kingdom

Evidence-based approaches for weight management in the United Kingdom are lacking. This study examined preferences for behavioural weight-management programmes amongst adults aged eighteen and over in Northern Ireland who had experience living with overweight (i.e., body mass index (BMI) ≥ 25 kg/m2). It involved the design and implementation of an online survey assessing previous experience with weight management and preferences for future weight-management programmes. A total of 94.7% of participants had previously engaged with weight-management services but many struggled to maintain weight loss. Older adults were more likely to be motivated to reduce their weight whilst younger adults were more likely be motivated to change their appearance. A focus on both wellbeing and weight-related outcomes was evident. Participants preferred programmes to be low-cost, delivered by a range of professionals by blended delivery, consisting of short (≤1 h) weekly sessions. These preferences highlighted important considerations for the components of future services to improve engagement and effectiveness.

Implementation of a virtual, shared medical appointment program that focuses on food as medicine principles in a population with obesity: the SLIM program

Background

Multimodal lifestyle interventions, employing food as medicine, stand as the recommended first-line treatment for obesity. The Shared Medical Appointment (SMA) model, where a physician conducts educational sessions with a group of patients sharing a common diagnosis, offers an avenue for delivery of comprehensive obesity care within clinical settings. SMAs, however, are not without implementation challenges. We aim to detail our experience with three implementation models in launching a virtual integrative health SMA for weight management.

Methods

Eligible patients included individuals 18 years of age or older, having a body mass index (BMI) of 30 kg/m2 or 27 kg/m2 or greater with at least one weight related comorbidity. The Practical, Robust Implementation and Sustainability Model (PRISM), Plan, Do, Study, Act (PDSA), and the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) models were applied to guide the implementation of the Supervised Lifestyle Integrative Medicine (SLIM) program, a virtually delivered, lifestyle medicine focused SMA program, in a weight management clinic within a major health system. We describe how these models, along with attendance for the initial cohorts, were used for decision-making in the process of optimizing the program.

Results

172 patients completed the SLIM program over two years. Attendance was lowest for sessions held at 8:00 AM and 4:00 PM compared to sessions at 10:00 AM, 1:00 PM, and 3:00 PM, leading to only offering midday sessions (p = 0.032). Attendance data along with feedback from patients, facilitators, and administrative partners led to changes in the curriculum, session number and frequency, session reminder format, and intake visit number.

Conclusion

The use of implementation and quality improvement models provided crucial insight for deployment and optimization of a virtual, lifestyle medicine focused SMA program for weight management within a large healthcare system.

Exploring the association between theobromine intake and hepatic steatosis in young people

The incidence of non-alcoholic fatty liver disease (NAFLD) tends to be younger. And the role of theobromine in fatty liver disease remains unclear. The purpose of this study was to investigate the relationship between dietary theobromine intake and degree of hepatic steatosis in individuals aged 45 and below, using data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES) and liver ultrasonography transient elastography. A total of 1796 participants aged below 45 years were included from NHANES 2017-2020 data after applying exclusion criteria. Multivariate regression and subgroup analyses were conducted to examine the associations between theobromine intake and controlled attenuation parameter (CAP), adjusting for potential confounders. Generalized additive models and two-piecewise linear regression were used to analyze nonlinear relationships. In the unadjusted Model 1 and preliminarily adjusted Model 2, there was no significant correlation between theobromine intake and CAP values. However, in Models 3 and 4, which accounted for confounding factors, a higher intake of theobromine was significantly associated with lower CAP values. Subgroup analyses in the fully adjusted Model 4 revealed a significant negative correlation among individuals aged 18-45, women, and white populations. Nonlinear analysis revealed a U-shaped relationship in black Americans, with the lowest CAP values at 44.5 mg/day theobromine. This study provides evidence that higher theobromine intake is correlated with lower degree of hepatic steatosis in young people, especially those aged 18-45 years, women, and whites. For black Americans, maintaining theobromine intake around 44.5 mg/day may help minimize liver steatosis. These findings may help personalize clinical nutritional guidance, prevent the degree of hepatic steatosis, and provide pharmacological approaches to reverse fatty liver disease in young people.

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.

Mediterranean-Type Diet Adherence and Body Mass Index through 20 Years of Follow-Up: Results from the ATTICA Cohort Study (2002-2022)

Evidence of the association between dietary habits and long-term body weight status is scarce. This study aimed to evaluate changes in Mediterranean-type diet (MTD) adherence in relation to body weight during 20 years of follow-up. Data from n = 1582 participants from the ATTICA cohort study (2002-2022) were used. MTD adherence was assessed via MedDietScore, and body weight status via body mass index (BMI) by 3 different measurements. We found that MTD adherence and changes in this adherence were inversely related to BMI at 20 years and the mean BMI during the 20-year follow-up. In multi-adjusted linear regression models, a 1/55 increase in baseline, 10-year, and 20-year MedDietScore was associated with a decrease of 0.05-0.13 kg/m2 in BMI at 20 years and of 0.08-0.09 kg/m2 in the mean BMI. Being consistently close to the MTD for 20 years was associated with a >90% decreased risk of maintaining overweight/obesity during the 20-year period. Strong, protective, long-lasting effects of the MTD were observed, even in those who deviated from the MTD in the follow-up (41% of the sample). Our results highlight the need to focus on the overall diet quality to minimize the risk of maintaining an excessive body weight during the life-course.

Weight Management Interventions for Adults With Idiopathic Intracranial Hypertension: A Systematic Review and Practice Recommendations

BACKGROUND AND OBJECTIVES

Idiopathic intracranial hypertension (IIH) is associated with obesity; however, there is a lack of clinical consensus on how to manage weight in IIH. The aim of this systematic review was to evaluate weight loss interventions in people with IIH to determine which intervention is superior in terms of weight loss, reduction in intracranial pressure (ICP), benefit to visual and headache outcomes, quality of life, and mental health.

METHODS

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered with PROSPERO (CRD42023339569). MEDLINE and CINAHL were searched for relevant literature published from inception until December 15, 2022. Screening and quality appraisal was conducted by 2 independent reviewers. Recommendations were graded using Scottish Intercollegiate Guidelines Network methodology.

RESULTS

A total of 17 studies were included. Bariatric surgery resulted in 27.2-27.8 kg weight loss at 24 months (Level 1- to 1++). Lifestyle weight management interventions resulted in between 1.4 and 15.7 kg weight loss (Level 2+ to 1++). Bariatric surgery resulted in the greatest mean reduction in ICP (-11.9 cm H2O) at 24 months (Level 1++), followed by multicomponent lifestyle intervention + acetazolamide (-11.2 cm H2O) at 6 months (Level 1+) and then a very low-energy diet intervention (-8.0 cm H2O) at 3 months (Level 2++). The least ICP reduction was shown at 24 months after completing a 12-month multicomponent lifestyle intervention (-3.5 cm H2O) (Level 1++). Reduction in body weight was shown to be highly correlated with reduction in ICP (Level 2++ to 1++).

DISCUSSION

Bariatric surgery should be considered for women with IIH and a body mass index (BMI) ≥35 kg/m2 since this had the most robust evidence for sustained weight management (grade A). A multicomponent lifestyle intervention (diet + physical activity + behavior) had the most robust evidence for modest weight loss with a BMI <35 kg/m2 (grade B). Longer-term outcomes for weight management interventions in people with IIH are required to determine whether there is a superior weight loss intervention for IIH.

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.

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.

Nutritional Strategies to Prevent Weight Gain and Obesity

It has now been 25 years since the World Health Organisation (Geneva, Switzerland) drew attention to the obesity epidemic (later becoming a pandemic) [...].

Clinical considerations and pathophysiological associations among obesity, weight loss, heart failure, and hypertension

PURPOSE OF REVIEW

To describe the relationship between three pandemics: hypertension, obesity, and heart failure. From pathophysiology to treatment, understanding how these disease entities are linked can lead to breakthroughs in their prevention and treatment. The relevance of this review lies in its discussion of novel pharmacological and surgical treatment strategies for obesity and hypertension, and their role in the prevention and treatment of heart failure.

RECENT FINDINGS

Novel medications such as GLP-1 agonists have demonstrated sustained weight loss in patients with obesity, and concurrent improvements in their cardiometabolic profile, and possibly also reductions in hypertension-related comorbidities including heart failure. Surgical therapies including laparoscopic bariatric surgery represent an important treatment strategy in obese patients, and recent studies describe their use even in patients with advanced heart failure, including those with ventricular assist devices.

SUMMARY

These developments have deep implications on our efforts to understand, mitigate, and ultimately prevent the three pandemics, and offer promising improvements to quality of life, survival, and the cost burden of these diseases.

Exercise and Experiments of Nature

In this article, we highlight the contributions of passive experiments that address important exercise-related questions in integrative physiology and medicine. Passive experiments differ from active experiments in that passive experiments involve limited or no active intervention to generate observations and test hypotheses. Experiments of nature and natural experiments are two types of passive experiments. Experiments of nature include research participants with rare genetic or acquired conditions that facilitate exploration of specific physiological mechanisms. In this way, experiments of nature are parallel to classical "knockout" animal models among human research participants. Natural experiments are gleaned from data sets that allow population-based questions to be addressed. An advantage of both types of passive experiments is that more extreme and/or prolonged exposures to physiological and behavioral stimuli are possible in humans. In this article, we discuss a number of key passive experiments that have generated foundational medical knowledge or mechanistic physiological insights related to exercise. Both natural experiments and experiments of nature will be essential to generate and test hypotheses about the limits of human adaptability to stressors like exercise. © 2023 American Physiological Society. Compr Physiol 13:4879-4907, 2023.

Exercise for counteracting weight recurrence after bariatric surgery: a systematic review and meta-analysis of randomized controlled trials

Exercise is recommended to prevent post-surgical weight recurrence. Yet, whether exercise interventions are efficacious in this regard has not been systematically evaluated. Moreover, clinicians lack evidence-based information to advise patients on appropriate exercise frequency, intensity, time, and type (FITT) for preventing weight recurrence. Thus, we conducted a meta-analysis of randomized controlled trials (RCTs) involving exercise interventions specifying FITT and weight measurement ≥12 months post-surgery. We reviewed scientific databases up through February 2022 for RCTs comparing exercise interventions reporting FITT and a nonexercise control group on weight ≥12 months post-surgery. Procedures following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were registered at the international prospective register of systematic reviews (PROSPERO: CRD42022342337). Of 1368 studies reviewed, 5 met inclusion criteria (n = 189; 47.8 ± 4.2 yr, 36.1 6 ± 3.8 kg·m2, 83.2 ± 9.5% female; 61.7% underwent Roux-en-Y gastric bypass). Exercise interventions were largely supervised, lasted 12-26 weeks, and prescribed 80-210 minutes/week of moderate-to-vigorous intensity combined aerobic and resistance exercise over ≤5 days. Within-group effects showed non-statistically significant weight loss for exercise (d = - .15, 95% confidence interval [CI]: -1.96, 1.65; -1.4 kg; P = .87) and weight gain for control (d = .11, 95% CI: -1.70,1.92; +1.0 kg; P = .90), with no difference between these groups (d = -2.26, 95% CI: -2.07, 1.55; -2.4 kg; P = .78). Exercise elicited an additional 2.4 kg weight loss versus control, although this effect was small and statistically non-significant. Ability to draw definitive conclusions regarding efficacy of exercise interventions for counteracting post-surgical weight recurrence was limited by the small number of trials and methodological issues. Findings highlight the need for more rigorous RCTs of exercise interventions specifically designed to reduce post-surgical weight recurrence.

Effectiveness of including weight management in smoking cessation treatments: A meta-analysis of behavioral interventions

INTRODUCTION

The potential of weight gain after smoking cessation reduces the incentive to quit. This meta-analysis examines the efficacy of behavioral interventions for smoking cessation that also address post-cessation weight gain.

METHODS

Medline, Web of Science, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials on behavioral treatments targeting both health outcomes. Six separate meta-analyses were undertaken to assess treatment efficacy on smoking abstinence and weight outcomes at end of treatment (EOT), short-term, and long-term follow-up. Individual and treatment moderators were examined as well as methodological quality and publication bias of studies.

RESULTS

A total of 28 studies were included in the meta-analysis. There was a statistically significant positive impact of treatments addressing both targets on smoking outcomes at EOT (RR = 1.279, 95% CI: 1.096, 1.492, p = .002), but not at follow-ups. Age impacted on EOT abstinence rates Q (1) = 4.960, p = .026) while increasing the number of sessions significantly improved EOT abstinence rates (p = .020). There was no statistically significant impact of these treatments on weight at EOT (Hedges' g = -0.015, 95% CI: -.164, 0.135, p = .849) or follow-ups (short term: Hedges' g = 0.055, 95% CI: -0.060, 0.170, p = .347; long term: Hedges' g = -0.320, 95% CI: -.965, 0.325, p = .331). There were minimal impacts of publication bias, mostly related to sample size, meaning studies including small sample sizes revealed larger effect sizes on abstinence at EOT.

DISCUSSION

Addressing post-cessation weight management in treatments for smoking cessation significantly enhances tobacco abstinence at EOT though it was not found to have a lasting impact after treatment.

Differences in Adherence to American Heart Association's Life's Essential 8, Diet Quality, and Weight Loss Strategies Between Those With and Without Recent Clinically Significant Weight Loss in a Nationally Representative Sample of US Adults

Background The American Heart Association defines ideal cardiovascular health based on 8 risk factors (Life's Essential 8 [LE8]); a high LE8 score (range 0-100) reflects greater adherence to their recommendations. Weight status influences cardiovascular health, yet individuals may use detrimental diet and weight loss strategies to improve weight status. We assessed differences in LE8 adherence, diet quality, and weight loss strategies between those with and without a recent history of clinically significant weight loss (CSWL). Methods and Results Data from 2007 to 2016 National Health and Nutrition Examination Survey questionnaires, clinical measures, and 24-hour dietary recalls were assessed to determine LE8 adherence, diet quality (Healthy Eating Index), and weight loss strategies between adults with: (1) intentional CSWL ≥5%; and (2) non-CSWL <5%, weight maintenance, or weight gain over the past 12 months using ANCOVA and chi-square tests. Those with CSWL demonstrated higher scores for diet quality (P=0.014), physical activity (P<0.001), and blood lipids (P<0.001). Those without CSWL reported lower BMI (P<0.001). There were no differences in total LE8 cardiovascular health scores between those with and without CSWL. More individuals with CSWL reported weight loss strategies of exercising (P=0.016); those without CSWL reported skipping meals (P=0.002) and using prescription diet pills (P<0.001). Conclusions Greater adherence to the LE8 recommendations was observed among individuals with CSWL, although overall LE8 scores were low. Future research should address the implementation of evidence-based strategies that improve diet quality while promoting optimal cardiovascular health among those with intent to lose weight.

Medical Nutrition Therapy Interventions Provided by Dietitians for Adult Overweight and Obesity Management: An Academy of Nutrition and Dietetics Evidence-Based Practice Guideline

Overweight and obesity affect most adults living in the United States and are causally linked to several adverse health outcomes. Registered dietitian nutritionists or international equivalents (dietitians) collaborate with each client and other health care professionals to meet client-centered goals, informed by the best available evidence, and translated through a lens of clinical expertise and client circumstances and preferences. Since the last iteration of the Academy of Nutrition and Dietetics guideline on adult weight management in 2014, considerable research has been conducted and circumstances confronting dietitians have evolved. Thus, updated guidance is needed. The objective of this evidence-based practice guideline is to provide recommendations for dietitians who deliver medical nutrition therapy behavioral interventions for adults (18 years and older) with overweight and obesity to improve cardiometabolic outcomes, quality of life, and weight outcomes, when appropriate for and desired by the client. Recommendations in this guideline highlight the importance of considering complex contributors to overweight and obesity and individualizing interventions to client-centered goals based on specific needs and preferences and shared decision making. The described recommendations have the potential to increase access to care and decrease costs through utilization of telehealth and group counseling as effective delivery methods, and to address other barriers to overweight and obesity management interventions. It is essential for dietitians to collaborate with clients and interprofessional health care teams to provide high-quality medical nutrition therapy interventions using the nutrition care process to promote attainment of client-centered outcomes for adults with overweight or obesity.

Telehealth acceptance and commitment therapy for weight loss: Protocol of the WeLNES full scale randomized controlled trial

Behavioral interventions delivered via one-on-one telephone coaching (hereafter referred to as telehealth) for weight loss have had great population-level reach but to date limited efficacy. Acceptance and Commitment Therapy (ACT) has promise to improve behavioral weight loss treatment efficacy by addressing the fundamental challenges of weight loss and maintenance: overeating in response to internal (e.g., stress) and external (e.g., high calorie foods) cues. Here we describe the Weight Loss, Nutrition, and Exercise Study (WeLNES) randomized controlled trial that is testing the efficacy of an ACT-based telehealth coaching intervention for weight loss in comparison to a Standard Behavioral Therapy (SBT)-based telehealth coaching intervention. A total of 398 adults with overweight or obesity are being recruited and randomized to either ACT or SBT telehealth coaching. Participants in both arms are offered twenty-five telehealth coaching sessions in year one and nine booster sessions in year two. All participants receive a Bluetooth-enabled scale to self-monitor weight and a Fitbit Inspire + Fitbit app for tracking diet and physical activity. The primary aim is to determine whether a greater proportion of ACT participants will achieve a clinically significant weight loss of ≥10% compared with SBT participants at 12-months. Secondary outcomes include change in weight from baseline to 6, 12, and 24-months. Whether the effect of ACT on weight loss is mediated by ACT processes and is moderated by baseline factors will also be examined. If ACT proves efficacious, ACT telehealth coaching will offer an effective, broadly scalable weight loss treatment-thereby making a high public health impact.

Does Healthcare Provider Counseling for Weight Management Behaviors among Hispanic Adults Who Are Overweight/Obese Vary by Acculturation Level?

This cross-sectional study explored differences in the receipt of health care provider (HCP) counseling to control/lose weight and adopt weight-related lifestyle behavior changes among Hispanic respondents according to acculturation level. Differences in reported action regarding HCP counseling were also examined. Data from four National Health and Nutrition Examination Survey (NHANES) cycles (2011-2018) were analyzed, with the analytic sample limited to Hispanic respondents who were overweight/obese. Respondents' acculturation levels were derived from their reported country of origin and the primary language spoken at home. Respondents who reported speaking only Spanish or more Spanish than English at home were classified as primarily speaking Spanish at home. In contrast, those who reported speaking Spanish and English equally, more English than Spanish, or only English were categorized as primarily speaking English at home. Weighted multivariate logistic regression models were utilized to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to determine if differences in acculturation levels existed regarding the likelihood of receiving HCP counseling to (1) control/lose weight, (2) increase exercise/PA, and (3) reduce fat/calorie intake. Similar analyses examined differences in reported action regarding HCP counseling according to acculturation level. The analysis found no significant differences in receiving HCP counseling according to acculturation level. However, non-US-born respondents who primarily spoke Spanish at home were less likely than US-born respondents to report acting to control/lose weight (p = 0.009) or increase exercise/PA (p = 0.048), but were more likely to report having taken action to reduce fat/calorie intake (p = 0.016). This study revealed differences between acting on recommendations of health care professionals according to acculturation level, indicating a need for interventions tailored to acculturation levels.

Substituting sedentary time with sleep or physical activity and subsequent weight-loss maintenance

OBJECTIVE

In this study, the associations between the substitution of sedentary time with sleep or physical activity at different intensities and subsequent weight-loss maintenance were examined.

METHODS

This prospective study included 1152 adults from the NoHoW trial who had achieved a successful weight loss of ≥5% during the 12 months prior to baseline and had BMI ≥25 kg/m² before losing weight. Physical activity and sleep were objectively measured during a 14-day period at baseline. Change in body weight was included as the primary outcome. Secondary outcomes were changes in body fat percentage and waist circumference. Cardiometabolic variables were included as exploratory outcomes.

RESULTS

Using isotemporal substitution models, no associations were found between activity substitutions and changes in body weight or waist circumference. However, the substitution of sedentary behavior with moderate-to-vigorous physical activity was associated with a decrease in body fat percentage during the first 6 months of the trial (-0.33% per 30 minutes higher moderate-to-vigorous physical activity [95% CI: -0.60% to -0.07%], p = 0.013).

CONCLUSIONS

Sedentary behavior had little or no influence on subsequent weight-loss maintenance, but during the early stages of a weight-loss maintenance program, substituting sedentary behavior with moderate-to-vigorous physical activity may prevent a gain in body fat percentage.

The effect of folic acid supplementation on body weight and body mass index: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Several trials have evaluated the effects of folate supplementation on obesity indices. However, their results were inconsistent. Therefore, the current meta-analysis was conducted to summarize data from available randomized clinical trials (RCTs) about the impact of folate supplementation on weight and body mass index (BMI).

METHOD

Medline/PubMed, Scopus, Embase, and ISI web of science were searched to identify relevant articles up to December 2020. The effect sizes were expressed as weighted mean difference (WMD) and 95% confidence intervals (CI) using the random-effects model.

RESULTS

Pooled data from nine studies showed that folic acid supplementation did not change body weight (WMD: -0.16 kg, 95%CI: -0.47 to 0.16, P = 0.32) and BMI (WMD: -0.23 kg/m², 95%CI: -0.49 to 0.03, P = 0.31), but there was significant heterogeneity between the included studies for BMI (I² = 90.1%, P < 0.001). Moreover, subgroup analyses in level of homocysteine and health status indicated significant effect of folic acid supplementation on BMI in those with homocysteine level ≥15 μmol/L (WMD: -0.17 kg/cm2, -0.33 to -0.01, p = 0.03) and in women with polycystic ovary syndrome (PCOS) (WMD: - 0.30kg/cm2, -0.54 to -0.06, p = 0.01).

CONCLUSION

Our outcomes demonstrated that folic acid improves BMI in those with homocysteine levels ≥15 μmol/L and women with PCOS.

Weight management strategies in Middle-Aged Women (MAW): Development and validation of a questionnaire based on the Oxford Food and Activity Behaviors Taxonomy (OxFAB-MAW) in a Portuguese sample

Background

The Oxford Food and Activity Behaviors (OxFAB) taxonomy systematize the cognitive-behavioral strategies adopted by individuals who are attempting to manage their weight. The present study aimed to (1) develop a questionnaire based on the OxFAB taxonomy, specifically adapted for middle-aged women-the OxFAB-MAW-stage of life and sex, which present a high incidence of obesity, (2) assess the psychometric properties of this tool, and (3) evaluate the discriminative power of the OxFAB-MAW (normal weight vs. obesity).

Methods

Overall, 1,367 Portuguese middle-aged women between 45 and 65 years (M = 52.3, SD = 5.15) filled in a sociodemographic, health, and menopause-related questionnaire, as well as the OxFAB-MAW.

Results

Confirmatory factor analysis demonstrated an acceptable model fit (comparative fit index = 0.928, Tucker-Lewis index = 0.913, root mean square error of approximation = 0.072, and standardized root mean square residual = 0.054). Five domains with one item were grouped into other domains, and the Weight Management Aids domain was also removed. The OxFAB-MAW showed factorial, convergent, discriminant, and external validity, as well as composite reliability.

Conclusion

The OxFAB-MAW questionnaire is a valid, reliable, and theory-driven tool for assessing weight management strategies in middle-aged women, being able to discriminate between clinical and non-clinical groups (normal weight vs. obesity) in several domains. This instrument can be used to gather valid and reliable data, useful in both research and clinical settings (especially focused on structuring interventions and preventive obesity programs within this specific life cycle stage).

Contrasts of Initial and Gain Scores in Obesity Treatment-Targeted Psychosocial Variables by Women Participants' Weight Change Patterns Over 2 Years

The typical pattern of weight change associated with behavioral obesity treatments has been some loss in weight through approximately 6 months, followed by near complete regain. However, patterns vary widely across individuals. The objectives are to determine whether recent prediction model-based indications of relations among changes in psychosocial correlates of the weight loss behaviors of physical activity and controlled eating vary by patterns of weight change. Women with obesity enrolled in a community-based behavioral obesity treatment who failed to lose at least 5% of their baseline weight (Minimal Effect group, n = 44), lost 5% or greater and then regained most during months 6 to 24 (Loss/Regain group, n = 42), or lost 5% or greater and then maintained/continued loss (Loss/Loss group n = 42) were evaluated. Improvements in physical activity- and eating-related self-regulation and self-efficacy, mood, and emotional eating over 6 months were significant overall and generally most favorable in the Loss/Loss group and least favorable in the Minimal Effect group. Expected model-based relationships between 6-month changes in the aforementioned psychosocial variables were significant and generally not significantly affected by weight change group. However, group substantially affected the prediction of self-regulation of eating at month 24-a key correlate of long-term weight loss. Findings suggested community-based obesity treatment targets and emphases.

Adherence to the Mediterranean lifestyle pattern is associated with favorable weight loss outcomes: the MedWeight study

Individual lifestyle targets have been associated with weight loss outcomes, yet few studies have examined associations of one's total lifestyle with weight loss maintenance. We aimed to examine the relationship between lifestyle patterns and weight loss outcomes in weight loss maintainers and regainers. We hypothesized that higher adherence to a broader healthy lifestyle favors maintenance (over regain). This is a cross-sectional analysis of 470 adults (62% women) with a history of overweight/obesity and significant weight loss 12 months before study entry. Participants were classified as maintainers (current weight ≤90% maximum weight) or regainers. They were asked to fill in a series of questionnaires on demographics and lifestyle habits (dietary intake and eating behaviors through two 24-hour recalls, physical activity, and sleep). A total Mediterranean Lifestyle Index (total-MLI, range 0-13) was generated by summing up ratings in the lifestyle domain quartiles (diet quality, physical activity, and sleep habits) and dietary behaviors (seasonal food and vegetable intake, intake of traditional foods, responsibility for food preparation, conviviality). Maintainers scored higher in the total-MLI than regainers (6.93 ± 2.31 vs 5.78 ± 2.49, P < .001). Adherence to the total-MLI was associated with 28% higher odds for weight loss maintenance (per unit increment) in linear analyses. Being in the highest total-MLI quartile was associated with 5.27 (95% CI, 2.77-10.02) odds for maintenance. Higher adherence to a comprehensive Mediterranean lifestyle pattern was associated with higher odds for weight loss maintenance. Our findings suggest that even modest shifts toward a healthier living may contribute to favorable weight loss outcomes.

Modifiable risk factors and long term risk of type 2 diabetes among individuals with a history of gestational diabetes mellitus: prospective cohort study

OBJECTIVES

To evaluate the individual and combined associations of five modifiable risk factors with risk of type 2 diabetes among women with a history of gestational diabetes mellitus and examine whether these associations differ by obesity and genetic predisposition to type 2 diabetes.

DESIGN

Prospective cohort study.

SETTING

Nurses' Health Study II, US.

PARTICIPANTS

4275 women with a history of gestational diabetes mellitus, with repeated measurements of weight and lifestyle factors and followed up between 1991 and 2009.

MAIN OUTCOME MEASURE

Self-reported, clinically diagnosed type 2 diabetes. Five modifiable risk factors were assessed, including not being overweight or obese (body mass index <25.0), high quality diet (top two fifthsof the modified Alternate Healthy Eating Index), regular exercise (≥150 min/week of moderate intensity or ≥75 min/week of vigorous intensity), moderate alcohol consumption (5.0-14.9 g/day), and no current smoking. Genetic susceptibility for type 2 diabetes was characterised by a genetic risk score based on 59 single nucleotide polymorphisms associated with type 2 diabetes in a subset of participants (n=1372).

RESULTS

Over a median 27.9 years of follow-up, 924 women developed type 2 diabetes. Compared with participants who did not have optimal levels of any of the risk factors for the development of type 2 diabetes, those who had optimal levels of all five factors had >90% lower risk of the disorder. Hazard ratios of type 2 diabetes for those with one, two, three, four, and five optimal levels of modifiable factors compared with none was 0.94 (95% confidence interval 0.59 to 1.49), 0.61 (0.38 to 0.96), 0.32 (0.20 to 0.51), 0.15 (0.09 to 0.26), and 0.08 (0.03 to 0.23), respectively (P_trend<0.001). The inverse association of the number of optimal modifiable factors with risk of type 2 diabetes was seen even in participants who were overweight/obese or with higher genetic susceptibility (P_trend<0.001). Among women with body mass index ≥25 (n=2227), the hazard ratio for achieving optimal levels of all the other four risk factors was 0.40 (95% confidence interval 0.18 to 0.91). Among women with higher genetic susceptibility, the hazard ratio of developing type 2 diabetes for having four optimal factors was 0.11 (0.04 to 0.29); in the group with optimal levels of all five factors, no type 2 diabetes events were observed.

CONCLUSIONS

Among women with a history of gestational diabetes mellitus, each additional optimal modifiable factor was associated with an incrementally lower risk of type 2 diabetes. These associations were seen even among individuals who were overweight/obese or were at greater genetic susceptibility.

Oxford Food and Activity Behaviors 20-item questionnaire to assess personal weight management strategies: Development and testing

OBJECTIVE

The aim of this study was to develop a shortened Oxford Food and Activity Behaviors (OxFAB) questionnaire to identify the cognitive and behavioral strategies used by individuals during weight-management attempts.

METHODS

This study reduced an existing 117-item questionnaire (the original OxFAB questionnaire) through identifying clusters of techniques from the responses of 278 people living with obesity and, within those clusters, identifying the most representative question or questions. Questions were rephrased to cover multiple strategies at the domain level, with several alternative phrasings developed for new questions. Face validity was tested through think-aloud interviews with 12 people living with obesity. Questions were rephrased accordingly and tested using test-retest (n = 172). Prevalence- and bias-adjusted κ (PABAK) were calculated, and questions with PABAK < 0.41 were rewritten and evaluated in a new test-retest sample (n = 130).

RESULTS

OxFAB20 consists of 20 questions covering diet, physical activity, and cognitive strategies for weight management. Test-retest resulted in a mean PABAK score of 0.56 (SD = 0.14). Questions were revised where appropriate. The questionnaire is available for use via a CC-BY license.

CONCLUSIONS

The OxFAB20 questionnaire provides a practical tool for researchers to identify the cognitive and behavioral strategies used by individuals during attempts at weight control.

Identifying weight management clusters and examining differences in eating behaviour and psychological traits: An exploratory study

Previous research has suggested differences in psychological traits and eating behaviours between groups of individuals with varying weight management profiles, for example, differences between individuals who have maintained weight loss compared to those who have not. However, no study has looked at differences in traits across a sample with a broad range of characteristics including variations in bodyweight and its management. Across two studies, we identified and validated weight management profiles using a clustering approach and examined trait differences across groups. Data were collected using online questionnaires (Study 1: secondary data analysis; Study 2: primary data analysis allowing for cluster validation). Cluster analysis was implemented with BMI, diet history, weight suppression (difference between highest and current weight) as primary grouping variables, and age and gender as covariates. Differences in psychological and eating behaviour traits (e.g., restraint) were explored across clusters. In study 1, 423 participants (27.21 ± 9.90 years) were grouped into 5 clusters: 'lean men', 'lean young women', 'lean middle-aged women', 'successful' and 'unsuccessful dieters'. The cluster structure was broadly replicated with two additional groups identified ('lean women without dieting' and 'very successful dieters') in study 2 with 368 participants (34.41 ± 13.63 years). In both studies, unsuccessful dieters had higher restrained and emotional eating scores than lean individuals, and in study 1, they also had higher food addiction scores than successful dieters. Individuals could be grouped in terms of their weight management profiles and differences in psychological and eating behaviour traits were evident across these groups. Considering the differences in traits between the clusters may further improve the effectiveness and adherence of weight management advice.

Childhood trauma, posttraumatic stress disorder symptoms, early maladaptive schemas, and schema modes: a comparison of individuals with obesity and normal weight controls

BACKGROUND

Previous research on the psychological mechanisms of obesity has primarily focused on acute psychopathology. However, there is limited literature on the role of more complex and entrenched psychological processes in weight management. The current study aimed to expand previous research by examining more enduring psychological constructs, including early maladaptive schemas (EMS), schemas modes, and trauma.

METHODS

Participants (N = 125) comprised adults with normal weight (n = 40) and obesity (n = 85) from community and clinical settings in Australia. Eligible participants completed a series of self-report questionnaires via Research Electronic Data Capture (REDCap). Two, separate, one-way multivariate analysis of variance (MANOVA) were conducted to examine group differences on the outcome variables.

RESULTS

Findings indicated a significant effect of group on EMS and schema modes, V = .51, F(32, 92) = 2.97, p < .001, partial η² = .51. Follow-up univariate tests revealed that individuals with obesity endorsed significantly more maladaptive schemas and schema modes and significantly less healthy schema modes than individuals with normal weight. In addition, results demonstrated a significant effect of group on childhood trauma and posttraumatic stress disorder (PTSD) symptoms, V = .19, F(6, 118) = 4.70, p < .001, partial η² = .19. Subsequent univariate tests and chi-square analyses indicated that individuals with obesity reported significantly more childhood trauma as well as significantly more PTSD symptoms within the last month than normal weight individuals.

CONCLUSION

This was the first study to compare EMS and schema modes in treatment-seeking individuals with obesity and normal weight controls using the short form version 3 of the Young Schema Questionnaire and revised, 118-item, Schema Mode Inventory. Overall, findings revealed that individuals with obesity experience more complex and enduring psychological difficulties than normal weight individuals. Increased assessment and targeted treatment of these underlying mental health concerns may contribute to a more holistic conceptualisation of obesity and could improve the long-term success of weight management.

Pilot randomized trial of cognitive-behavioral treatment plus contingency management for quitting smoking and weight gain prevention among smokers with overweight or obesity

BACKGROUND

Post-cessation weight gain is a risk factor for relapse among quitters. The primary study aim was to evaluate, among smokers with overweight or obesity, the feasibility and acceptability of a cognitive-behavioral treatment (CBT) plus contingency management (CM) for quitting smoking and weight control. The secondary aim was to examine preliminary tobacco abstinence and weight change outcomes.

METHODS

In an 8-week pilot randomized clinical trial, 41 participants (M_age = 52.73, SD = 10.91, 56.1% females) with overweight or obesity (M_BMI = 31.86, SD = 4.7) received a CBT for both quitting smoking and weight gain prevention (n = 24) or the same treatment plus CM (n = 17), consisting of providing incentives contingent upon smoking abstinence biochemically verified.

RESULTS

Recruitment success rate was 80.39% (41/51), completion rate was 90.24% (37/41), and mean number of sessions attended (out of 15 possible) was 13.20 (SD = 3.1). Mean satisfaction rating for the treatment (1-10 likert-type scale with 10 being most satisfactory) was 9.73 (SD =.61). Preliminary efficacy data indicated that the CM group achieved higher abstinence rates compared with the CBT condition (100% vs. 58.33%, p = .007). Abstinent participants increased 1.25 kg (SD = 1.79) their baseline body weight at the end of treatment (p = .001).

CONCLUSIONS

Providing weight gain prevention strategies and CM within a smoking cessation treatment seems feasible and acceptable. Preliminary data indicated that including CM facilitates tobacco abstinence rates, nevertheless no advantage for CM was found for weight control.

Korean medicine registry of herbal medicine for weight loss

INTRODUCTION

In South Korea, the prevalence of obesity has continuously increased over the last decade, and the burden of social and economic costs has also increased immensely. The purpose of this study is to investigate the clinical characteristics and current status of patients receiving herbal medicine (HM) treatment for weight loss in Korean medicine (KM) by constructing a multi-institutional prospective registry.

METHODS AND ANALYSIS

This is a prospective, observational, multi-center registry, including patients visiting the KM clinics in South Korea for weight loss. This study will collaborate with 15 KM clinics and recruit patients into the registry between October 2021 and October 2022. The study population will include patients visiting the KM clinics for weight loss. A total of 1000 eligible patients visiting the KM clinics for weight loss who decide to undergo HM treatment will be enrolled in the registry. After enrollment, we will collect the individual characteristics of each patient, such as body mass index, body composition test, liver and kidney function tests, and information on prescribed HM. We will also record the adverse events at each visit.

DISCUSSION

This study is the first prospective, multicenter registry of HM for weight loss in KM clinics. The results of this registry may show the current status of patients who receive HM treatments for weight loss and provide evidence for reasonable decision-making on KM healthcare policy for obese patients in the future.

The Role of Physical Activity in Long-term Weight Loss: 36-month Results From a Randomized Controlled Trial

BACKGROUND

Physical activity (PA) may promote long-term weight loss, but facilitating high levels of PA in behavioral weight loss programs is challenging.

PURPOSE

This study reports the 36-month follow-up of a behavioral weight loss trial that tested the efficacy of increasing the emphasis on PA during treatment and using traditional or acceptance-based therapy (ABT) for this purpose. We also examined the extent to which long-term weight loss differed by PA pattern and tested if individual differences in eating behavior moderated this relationship.

METHODS

Participants (N = 320) were randomized to (1) standard behavioral weight loss treatment (BT), (2) BT with a focus on PA, or (3) ABT with a focus on PA. Weight loss and PA were measured at 24- and 36-month follow-up.

RESULTS

There were no differences between conditions in weight loss or PA at 24 or 36 months. Participants consistently engaging in high PA experienced the greatest weight losses. The positive impact of PA on weight loss was more pronounced among those with low emotional eating and those who believed that exercise did not affect their appetite.

CONCLUSIONS

Findings emphasize the difficulty of improving long-term PA among adults with overweight/obesity beyond what standard behavioral weight loss treatment achieves. This study highlights the need to develop new PA treatment strategies, and suggests that ABT for weight loss may be more effective when applied to eating behavior versus PA. Results also demonstrate the importance of addressing problematic eating behavior and cognitions to fully realize the benefits of PA for weight loss.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov identifier: NCT02363010.

Combining Persuasive System Design Principles and Behavior Change Techniques in Digital Interventions Supporting Long-term Weight Loss Maintenance: Design and Development of eCHANGE

BACKGROUND

Long-term weight maintenance after weight loss is challenging, and innovative solutions are required. Digital technologies can support behavior change and, therefore, have the potential to be an effective tool for weight loss maintenance. However, to create meaningful and effective digital behavior change interventions that support end user values and needs, a combination of persuasive system design (PSD) principles and behavior change techniques (BCTs) might be needed.

OBJECTIVE

This study aimed to investigate how an evidence-informed digital behavior change intervention can be designed and developed by combining PSD principles and BCTs into design features to support end user values and needs for long-term weight loss maintenance.

METHODS

This study presents a concept for how PSD principles and BCTs can be translated into design features by combining design thinking and Agile methods to develop and deliver an evidence-informed digital behavior change intervention aimed at supporting weight maintenance. Overall, 45 stakeholders participated in the systematic and iterative development process comprising co-design workshops, prototyping, Agile development, and usability testing. This included prospective end users (n=17, 38%; ie, people with obesity who had lost ≥8% of their weight), health care providers (n=9, 20%), healthy volunteers (n=4, 9%), a service designer (n=1, 2%), and stakeholders from the multidisciplinary research and development team (n=14, 31%; ie, software developers; digital designers; and eHealth, behavior change, and obesity experts). Stakeholder input on how to operationalize the design features and optimize the technology was examined through formative evaluation and qualitative analyses using rapid and in-depth analysis approaches.

RESULTS

A total of 17 design features combining PSD principles and BCTs were identified as important to support end user values and needs based on stakeholder input during the design and development of eCHANGE, a digital intervention to support long-term weight loss maintenance. The design features were combined into 4 main intervention components: Week Plan, My Overview, Knowledge and Skills, and Virtual Coach and Smart Feedback System. To support a healthy lifestyle and continued behavior change to maintain weight, PSD principles such as tailoring, personalization, self-monitoring, reminders, rewards, rehearsal, praise, and suggestions were combined and implemented into the design features together with BCTs from the clusters of goals and planning, feedback and monitoring, social support, repetition and substitution, shaping knowledge, natural consequences, associations, antecedents, identity, and self-belief.

CONCLUSIONS

Combining and implementing PSD principles and BCTs in digital interventions aimed at supporting sustainable behavior change may contribute to the design of engaging and motivating interventions in line with end user values and needs. As such, the design and development of the eCHANGE intervention can provide valuable input for future design and tailoring of evidence-informed digital interventions, even beyond digital interventions in support of health behavior change and long-term weight loss maintenance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04537988; https://clinicaltrials.gov/ct2/show/NCT04537988.

Food as Medicine for Obesity Treatment and Management

PURPOSE

Nutrition is an important lifestyle modification used in the treatment of obesity. The purpose of this review is to highlight different dietary interventions used to promote weight loss in both adults and children.

METHODS

A search using PubMed was performed for articles on topics related to nutrition and management and/or treatment of obesity in adults adolescents and children. The literature was reviewed and pertinent sources were used for this narrative review.

DISCUSSION

There are many effective nutrition interventions used to treat obesity, including altering macronutrient composition, implementing different dietary patterns, and changing meal timing. Although these interventions can induce weight loss in adults, management of obesity in children is more difficult given their varied nutrition needs in growth and development. The use of food as medicine in obesity treatment is individualized based on patient's age, food preference, and concurrent medical conditions.

IMPLICATIONS

Given the multifactorial etiology of obesity, treatment requires multidisciplinary care beyond nutrition intervention.

Weight Maintenance after Dietary Weight Loss: Systematic Review and Meta-Analysis on the Effectiveness of Behavioural Intensive Intervention

After a low-calorie diet, only 25% of patients succeed in maintaining the result of weight loss for a long time. This systematic review and meta-analysis aims to explore whether patients undergoing intensive intervention during the maintenance phase have a greater preservation of the weight achieved during the previous slimming phase than controls. A bibliographic search was conducted using PubMed, Scopus, and Cochrane databases for clinical trials and randomised, controlled trials investigating the role of choice in weight-loss-maintenance strategies. Only studies with a follow-up of at least 12 months were considered. A total of eight studies, for a total of 1454 patients, was identified, each comparing a group that followed a more intensive protocol to a control group. Our metanalysis highlighted that an intensive approach even in the maintenance phase could be important to ensure greater success in the phase following the weight-loss period. However, it should be pointed out that the improvement was not so different from the trend of the respective controls, with a non-statistically significant mean difference of the effect size (0.087; 95% CI −0.016 to 0.190 p = 0.098). This finding, along with the observation of a weight regain in half of the selected studies, suggests this is a long work that has to be started within the weight-loss phase and reinforced during the maintenance phase. The problem of weight control in patients with obesity should be understood as a process of education to a healthy lifestyle and a balanced diet to be integrated in the context of a multidisciplinary approach.

Increases in physical activity are associated with a faster rate of weight loss during dietary energy restriction in women with overweight and obesity

This secondary analysis examined the influence of changes in physical activity (PA), sedentary time and energy expenditure (EE) during dietary energy restriction on the rate of weight loss (WL) and 1-year follow-up weight change in women with overweight/obesity.Measurements of body weight and composition (air-displacement plethysmography), resting metabolic rate (indirect calorimetry), total daily (TDEE) and activity EE (AEE), minutes of PA and sedentary time (PA monitor) were taken at baseline, after 2 weeks, after ≥5% WL or 12 weeks of continuous (25% daily energy deficit) or intermittent (75% daily energy deficit alternated with ad libitum day) energy restriction, and at 1-year post-WL. The rate of WL was calculated as total %WL/number of dieting weeks. Data from both groups were combined for analyses.Thirty-seven participants (age=35±10y; BMI=29.1±2.3kg/m2) completed the intervention (WL=-5.9±1.6%) and 18 returned at 1-year post-WL (weight change=+4.5±5.2%). Changes in sedentary time at 2 weeks were associated with the rate of WL during energy restriction (r=-0.38; p=0.03). Changes in total (r=0.54; p<0.01), light (r=0.43; p=0.01) and moderate-to-vigorous PA (r=0.55; p<0.01), sedentary time (r=-0.52; p<0.01), steps per day (r=0.39; p=0.02), TDEE (r=0.46; p<0.01) and AEE (r=0.51; p<0.01) during energy restriction were associated with the rate of WL. Changes in total (r=-0.50; p=0.04) and moderate-to-vigorous PA (r=-0.61; p=0.01) between post-WL and follow-up were associated with 1-year weight change (r=-0.51; p=0.04).These findings highlight that PA and sedentary time could act as modifiable behavioural targets to promote better weight outcomes during dietary energy restriction and/or weight maintenance.

Exploring perceptions about Mindfulness and Mindful Eating Programs for low-income women with overweight in primary health care

Background: Obesity and overweight are public health problems of multifactorial etiology, aggravated by the challenge that is maintaining weight loss. Used in the context of general health, mindfulness-based interventions (MBIs) have also showed positive effects when targeting changes to overweight-related eating behaviors. Methods: This study consists of a pragmatic randomized controlled trial conducted with 284 women from primary health care units. Data were collected from the last session with 16 focus groups, considering each intervention group (mindfulness or mindful eating) Aim: This article aims to present the perceptions of low-income overweight women who participated in Mindfulness and Mindful Eating intervention groups in primary health care according to each type of intervention. Results: Seven themes were identified: course challenges; valorization of the teacher's attitudes; mindfulness understanding; self-awareness development; change of expectations; development of a different food-weight relationship; and discover of a wide range of benefits. Conclusion: Mindfulness and Mindful eating interventions affect not only an individual's relationship with body and food, but also life and human relations. The results indicate the feasibility of the intervention, which addresses a large number of patients who lack treatment options for overweight or emotional and psychological issues associated with this condition. MBIs such as mindful eating are applicable in primary health care facilities, targeting overweight women and supporting treatment by addressing a repressed demand in the system. Similar to mind-body therapies, these interventions allow for comprehensive care.ClinicalTrials.gov, (NCT02893150) on 30 March 2017.

Relationships Between Dietary Intake and Weight-Related Experiential Avoidance Following Behavioral Weight-Loss Treatment

BACKGROUND

Interventions targeting weight-related experiential avoidance (EA) and disinhibited eating (DE) may also improve diet quality. Participants with overweight/obesity and DE who recently completed a behavioral weight-loss program were randomized to receive acceptance and commitment therapy or continued behavioral weight-loss treatment. In this secondary analysis, we explored (1) change in diet quality from baseline to 6-month follow-up (FU) and (2) whether weight-related EA at baseline and (3) change in weight-related EA during treatment were related to change in diet quality from baseline to FU.

METHOD

Veterans (N = 68) completed food frequency questionnaires at baseline and FU, which were used to generate diet quality scores on the healthy eating index-15 (HEI-15). Weight-related EA was assessed using the Acceptance and Action Questionnaire for Weight-Related Difficulties-Revised (AAQW-R) at baseline, post-treatment, and FU. Aims were examined with mixed ANOVA analyses.

RESULTS

Across both treatment groups, HEI-15 scores declined from baseline to FU. Women's HEI-15 decreased by about 5 times that of men. Baseline AAWQ-R was negatively associated with change in HEI-15. Neither AAWQ-R at post-treatment nor change in AAQW-R from baseline to post-treatment was significantly associated with change in HEI-15 at FU.

CONCLUSIONS

Greater weight-related EA at baseline was associated with lower diet quality at FU, but change in weight-related EA during treatment did not predict change in diet quality at FU. Interventions targeting DE and weight-loss may require specific components to improve and sustain healthy dietary intake in Veterans with obesity and DE.

Investigating the effect of an online self-compassion for weight management (SC4WM) intervention on self-compassion, eating behaviour, physical activity and body weight in adults seeking to manage weight: protocol for a randomised controlled trial

INTRODUCTION

Individual weight management, defined as engaging in behaviours to maintain or lose weight, can improve health and well-being. However, numerous factors influence weight management outcomes, such as genetics, biology, stress, the social and physical environment. Consequently, weight management can be hard. Self-compassion, described as treating oneself kindly in times of failure or distress, has shown promise in improving weight management outcomes. The objectives of this study are twofold: (1) to examine the efficacy of an online self-compassion for weight management (SC4WM) intervention coupled with an online commercial weight management programme (WW Weight Watchers reimagined) with increasing self-compassion and improving weight management outcomes (eating behaviour, physical activity and body weight) in comparison with the WW programme only and (2) to explore whether improvements in weight management outcomes are moderated by eating restraint, weight self-stigma, perceived stress and psychological coping.

METHODS AND ANALYSIS

To achieve these objectives, 240 participants seeking to manage their weight were randomised to either an online behavioural commercial weight management programme (WW) or the online WW +SC4 WM intervention. Validated measures of self-compassion, stress, weight self-stigma, eating restraint, psychological coping and weight management outcomes were administered online at baseline, 4 weeks and at a 12-week follow-up.

ETHICS AND DISSEMINATION

Ethics has been granted by the University of Auckland Health Research Ethics committee. Results will be communicated in peer-review journals, conferences and a doctoral thesis. If effective in increasing self-compassion and improving weight management outcomes, the intervention could be made more widely available to supplement behavioural weight management programmes.

TRIAL REGISTRATION NUMBER

ACTRN12621000580875; Pre-results.

The Associations Between the Anorexic Readiness Syndrome, Familism, and Body Image Among Physically Active Girls

Introduction: Anorexic Readiness Syndrome (ARS) is a construct of prophylactic importance, useful in the selection of people showing a tendency to use restrictive diets and increased concentration on the body. The aim of the research was to verify the significance of the type of physical activity, body perception and familism for the development of ARS. Material and Method: The research was carried out in the first half of 2021on a sample of 163 girls. It consisted of: (1) physically inactive girls (n = 48), (2) physically active girls in disciplines other than aesthetic (n = 69), (3) girls engaged in aesthetic physical activity (n = 46). The study used: Anorexic Readiness Syndrome Questionnaire (ARS-12), Familism Scale (FS) and Body Image Avoidance Questionnaire (BIAQ). Results: The highest average ARS score was recorded in the group of girls engaged in aesthetic activity. A significant difference in the severity of ARS occurs between people who do not engage in activity and those who practice aesthetic activity. The severity of ARS rises as the difference between real and ideal body weight increases. People active in aesthetic disciplines who obtained a high score on the Respect scale (FS subscale) have a lower ARS score than those physically active in other disciplines who obtained low scores on the Respect scale. The higher the score on the Material success and achievement scale (FS), the greater the ARS intensity in all subgroups. What is much more important in shaping ARS is the perception of your body. The focus on eating and body weight and Clothing and appearance (BIAQ subscales) are relevant to the ARS and moderate the relationship between Material success (FS subscale) and anorexic readiness. Conclusions: People engaging in aesthetic physical activity are more likely to suffer from ARS. The family can certainly prevent a child from developing anorexic readiness by shaping a sense of community and family identity, a clear division of roles, limiting the importance of materialism and competition in raising children. The prevention of ARS and eating disorders should also focus on strengthening the realistic assessment of body parameters and their acceptance, as well as promoting strategies for healthy weight control.

Technical report: an online international weight control registry to inform precision approaches to healthy weight management

BACKGROUND

Personalizing approaches to prevention and treatment of obesity will be a crucial aspect of precision health initiatives. However, in considering individual susceptibility to obesity, much remains to be learned about how to support healthy weight management in different population subgroups, environments and geographical locations.

SUBJECTS/METHODS

The International Weight Control Registry (IWCR) has been launched to facilitate a deeper and broader understanding of the spectrum of factors contributing to success and challenges in weight loss and weight loss maintenance in individuals and across population groups. The IWCR registry aims to recruit, enroll and follow a diverse cohort of adults with varying rates of success in weight management. Data collection methods include questionnaires of demographic variables, weight history, and behavioral, cultural, economic, psychological, and environmental domains. A subset of participants will provide objective measures of physical activity, weight, and body composition along with detailed reports of dietary intake. Lastly, participants will be able to provide qualitative information in an unstructured format on additional topics they feel are relevant, and environmental data will be obtained from public sources based on participant zip code.

CONCLUSIONS

The IWCR will be a resource for researchers to inform improvements in interventions for weight loss and weight loss maintenance in different countries, and to examine environmental and policy-level factors that affect weight management in different population groups. This large scale, multi-level approach aims to inform efforts to reduce the prevalence of obesity worldwide and its associated comorbidities and economic impacts.

TRIAL REGISTRATION

NCT04907396 (clinicaltrials.gov) sponsor SB Roberts; Tufts University IRB #13075.

OUP accepted manuscript

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:

A: Appropriate Antithrombotic therapy.

B: Better functional and psychological status.

C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).

What goes on in digital behaviour change interventions for weight loss maintenance targeting physical activity: A scoping review

OBJECTIVE

To identify the core components of digital behaviour change interventions for weight loss maintenance targeting physical activity, in terms of: (i) behaviour change techniques, (ii) mechanisms of action, (iii) modes of delivery, (iv) dose and (v) tailoring/personalization. In addition, the links between these components were investigated.

METHODS

A literature search was performed in five electronic databases: PubMed, Embase, CINHAL, PsycINFO and Web of Science. Two reviewers independently screened the identified articles and extracted data related with the study characteristics and behaviour change techniques, mechanism of action, mode of delivery, dose, and tailoring, using standardized classifications whenever available (e.g. behaviour change techniques taxonomy).

RESULTS

Seventeen articles reporting 11 original studies were selected. Two studies were protocols, 9 studies presented results for weight change and all but one showed no significant differences between the intervention and control groups. Eight studies (73%) provided adequate information on behaviour change techniques. Five studies (45%) provided partial information about how the behaviour change techniques were linked to mechanisms of action, and only one study (0.9%) described these links for all the techniques. Around half of the studies reported the modes through which behaviour change techniques were delivered. Descriptions of dose were present in most studies, but with minimal information. The use of tailoring or personalization approaches was mentioned in eight studies (73%), but descriptions of what was tailored and how were minimal.

CONCLUSIONS

The compilation of information regarding intervention components was difficult due to the lack of information and systematization in reporting across papers. This is particularly true for the reporting of the links between behaviour change techniques and the other core intervention components. This information is crucial to help us understand in the context of behaviour change interventions what works or does not work, how it works and why.

A Theory- and Evidence-Based Digital Intervention Tool for Weight Loss Maintenance (NoHoW Toolkit): Systematic Development and Refinement Study

Background

Many weight loss programs show short-term effectiveness, but subsequent weight loss maintenance is difficult to achieve. Digital technologies offer a promising means of delivering behavior change approaches at low costs and on a wide scale. The Navigating to a Healthy Weight (NoHoW) project, which was funded by the European Union’s Horizon 2020 research and innovation program, aimed to develop, test, and evaluate a digital toolkit designed to promote successful long-term weight management. The toolkit was tested in an 18-month, large-scale, international, 2×2 factorial (motivation and self-regulation vs emotion regulation) randomized controlled trial that was conducted on adults with overweight or obesity who lost ≥5% of their body weight in the preceding 12 months before enrollment into the intervention.

Objective

This paper aims to describe the development of the NoHoW Toolkit, focusing on the logic models, content, and specifications, as well as the results from user testing.

Methods

The toolkit was developed by using a systematic approach, which included the development of the theory-based logic models, the selection of behavior change techniques, the translation of these techniques into a web-based app (NoHoW Toolkit components), technical development, and the user evaluation and refinement of the toolkit.

Results

The toolkit included a set of web-based tools and inputs from digital tracking devices (smart scales and activity trackers) and modules that targeted weight, physical activity, and dietary behaviors. The final toolkit comprised 34 sessions that were distributed through 15 modules and provided active content over a 4-month period. The motivation and self-regulation arm consisted of 8 modules (17 sessions), the emotion regulation arm was presented with 7 modules (17 sessions), and the combined arm received the full toolkit (15 modules; 34 sessions). The sessions included a range of implementations, such as videos, testimonies, and questionnaires. Furthermore, the toolkit contained 5 specific data tiles for monitoring weight, steps, healthy eating, mood, and sleep.

Conclusions

A systematic approach to the development of digital solutions based on theory, evidence, and user testing may significantly contribute to the advancement of the science of behavior change and improve current solutions for sustained weight management. Testing the toolkit by using a 2×2 design provided a unique opportunity to examine the effect of motivation and self-regulation and emotion regulation separately, as well as the effect of their interaction in weight loss maintenance.

A staged approach to address youth unresponsive to initial obesity intervention: a randomized clinical trial

BACKGROUND/OBJECTIVE

Maintenance interventions inherently require BMI improvement to maintain. This overlooks individuals initially unresponsive to obesity interventions. Staged pediatric clinical treatment guidelines were adapted to the school setting to develop an escalated treatment option for individuals initially unresponsive. This staged randomized controlled trial examined differences between escalated treatment (Take CHARGE!) and a maintenance program (PE Planners). Take CHARGE was hypothesized to have greater improvements in BMI as a percentage of the 95th BMI Percentile (%BMIp95) than PE Planners.

SUBJECTS/METHODS

From 2018 to 2020, 171 middle and high schoolers (BMI Percentile ≥ 85) were recruited from a Houston school district to participate in a staged obesity intervention in their physical education (PE) class. After receiving a semester-long intensive lifestyle intervention (ILI) with established efficacy, all participants were randomized to Take CHARGE (n = 85) or PE Planners (n = 86). Take CHARGE escalated the behavioral treatment of obesity received in ILI with more frequent individual sessions, additional opportunities for parental and school staff involvement, and increased mentorship from trained college students. PE Planners allowed participants to decide how they wanted to be active in PE class. Mixed linear modeling examined %BMIp95 overtime between groups. This trial was registered at ClinicalTrials.gov (#NCT04362280).

RESULTS

Participants were 13.63 ± 1.32 years old; 59% were female, and 85% were Hispanic. Among those initially unresponsive to ILI, Take CHARGE had significantly greater decreases in %BMIp95 than PE Planners (β = -0.01, p < 0.01). Conversely, among those initially responsive, Take CHARGE had significantly smaller decreases in %BMIp95 than PE Planners (β = 0.02, p < 0.05). Intention-to-treat analysis had similar results.

CONCLUSIONS

Participant outcomes in semester two differed based on initial response. Individuals responsive to initial intervention were most likely to benefit from a maintenance intervention and those initially unresponsive benefited more from escalated treatment. This indicates the need for staged intervention protocols to better address obesity in the school setting.

The association between binge eating disorder and weight management in overweight and obese adults: A systematic literature review

Aim: Weight loss is shown to improve obesity-related health problems as long as it is maintained for a long term. The purpose of this systematic review was to investigate the association between binge eating disorder and weight management in overweight and obese adults. Methods: A systematic search following the preferred reporting items for systematic reviews and meta-analyses guidelines was conducted across PubMed, Ebsco and Cochrane Library from inception through December 2020 to identify studies that assessed the association between binge eating disorder and weight management (e.g., weight loss, weight gain and weight loss maintenance) in overweight and obese adults. We included studies that examined adults (≥18 years old) being overweight and obese with and without binge eating behaviour. Two authors independently screened and evaluated studies for methodological quality. Results: Nine articles were selected, including 3685 participants. Three of the included studies were randomised control trials and the remaining were observational studies. The majority of the studies included support that people who have binge eating disorder may have an additional barrier maintaining their weight loss compared to people who do not suffer from binge eating disorder. Conclusion: Our systematic review revealed that binge eating disorder may have a negative association with weight loss maintenance. Further well-conducted prospective cohort studies and randomised clinical trials are required to investigate the possible mechanisms and whether any such mechanisms are modifiable. These will lead us to more efficient strategies targeting weight management.

"You Are Always at War With Yourself" The Perceptions and Beliefs of People With Obesity Regarding Obesity as a Disease

Obesity as a disease remains poorly understood by key stakeholders. Here, in people living with severe obesity, perceptions and beliefs relating to obesity as a disease and obesity causality were examined. Semi-structured interviews were conducted in a tertiary care obesity clinic. 23 people with obesity (10 males, 13 females) volunteered. An overall agreement that obesity is a disease was present. Perceptions related to why obesity is and is not a disease were diverse: Lack of control and addiction, biological determinism, and personal responsibility. For weight loss maintenance, the perceptions and beliefs were heterogeneous with biological factors not considered a determinant of success. Instead, exercise, support, and willpower were described as associated with success. Barriers related to remaining in a weight-reduced state included the following: Emotional eating, sustainability of diet, occupational impact, and defeatism due to misaligned expectation and outcome. In conclusion, people living with obesity tend to agree obesity is a disease yet an incomplete understanding of the disease is present.