Instrumentalization of Eating Improves Weight Loss Maintenance in Obesity

Protocol for a randomised, double-blinded, controlled trial of youth with childhood-onset obesity treated with semaglutide 2.4 mg/week: the RESETTLE trial

INTRODUCTION

Childhood-onset obesity poses significant health risks, including early-onset type 2 diabetes, cardiovascular disease, and reduced quality of life. Hospital-based non-pharmacological obesity care can reduce childhood obesity, but 25% of children do not respond. Therefore, this study investigates the effect of the glucagon-like peptide-1 receptor agonist, semaglutide, as an add-on to hospital-based obesity care in youth who still have obesity following hospital-based obesity care as children. Furthermore, biomedical and psychosocial factors linked to treatment response will be investigated, alongside an exercise-based strategy to prevent weight regain and maintain a healthy body composition after semaglutide treatment.

METHODS AND ANALYSIS

This is an investigator-initiated, randomised, placebo-controlled, double-blind trial. We will enrol expectedly 180-270 young adults aged 18-28 years based on their previous response to a paediatric obesity management programme and their current body mass index (BMI). Participants are categorised into four groups: low treatment response (BMI SD score (SDS) reduction <0.10; BMI ≥30 kg/m2); medium treatment response (BMI SDS reduction >0.25; BMI ≥30 kg/m2); high treatment response (BMI SDS reduction >0.50; BMI <30 kg/m2) and a population-based reference group with normal weight development in childhood. Participants with BMI ≥30 kg/m2 are randomised 2:1 to subcutaneous injections of semaglutide 2.4 mg/week or placebo as an add-on to hospital-based obesity care for 68 weeks. The primary outcome is the change in BMI from randomisation to the end of treatment with semaglutide compared with placebo. Secondary endpoints are changes in weight and body composition.

ETHICS AND DISSEMINATION

The trial has been approved by the Danish Medicines Agency and the Ethical Committee of the Capital Region of Denmark (H-20039422). The trial will be conducted in accordance with the Declaration of Helsinki and follow the guidelines for Good Clinical Practice. Results will be presented at international scientific conferences and published in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

EudraCT 2019-002274-31.

Intergenerational differences in healthy eating beliefs among British Pakistanis with type 2 diabetes

INTRODUCTION

There are growing concerns on how to prevent, slow down and induce remission of type 2 diabetes mellitus (T2DM). Recent evidence has found diet and lifestyle interventions can cause remission of T2DM, however, there are challenges for diverse groups such as British Pakistanis who are four times more at risk of T2DM. There is a need to understand the food behaviours of different generational groups to develop culturally appropriate strategies to support diabetes prevention programmes.

AIMS

This study explores beliefs about healthy eating and food practices related to T2DM among British Pakistanis to understand the challenges they face in implementing healthy diets.

METHOD

We carried out 26 semi-structured qualitative interviews via telephone and face-to-face. The sample included T2DM British Pakistanis living in Bradford (UK), aged between 18 and 71 with a mean age of 50 (SD = 17.04). Among the participants, 14 were women (54%) and 12 were men (46%), with interviews conducted in both English (76%) and Urdu (24%). Participants were grouped under three generation groups based on age (first generation 65+; second generation 40-64; younger generation 18-39 years). There was no biological link between the generational groups, and they were not part of the same family. Data were analysed using qualitative reflexive thematic analysis.

RESULTS

Findings were categorised into three themes: knowledge and awareness of diabetes symptoms; social and family context of food practices and making sense of healthy eating. The family was the fundamental unit of understanding food-related health behaviours. Eating traditional food was perceived as healthy and deemed practical for first generations who were the initial members of their family to settle in the UK as well as the second generations who had parents born in Pakistan. Younger British Pakistanis were born in the UK and reported that they struggled to eat alternative foods within the home and manage their T2DM.

CONCLUSION

These findings improve our understanding of how three generations of British Pakistanis with T2DM negotiate healthy diets. There is a need for culturally tailored diet modifications and interventions, where different generational needs can be specifically targeted to adopt healthier diets which should be shared and encouraged.

Evaluation of Social Platform-Based Continuity of Care in Improving Cognitive and Prognostic Effects of Young Patients with Diabetic Retinopathy

Objective

This study was performed to evaluate the effectiveness of social platform-based continuity of care in improving cognitive and prognostic effects of young age diabetic patients without diabetic retinopathy (DR).

Methods

A total of 88 young age diabetic patients admitted to the outpatient clinic of First Affiliated Hospital of Soochow University (Endocrine and Ophthalmology Outpatient) from January 2021 to May 2022 were recruited and assigned via random number table method to receive either routine follow-up care (routine group) or social platform-based continuity of care (WeChat group), with 44 patients in each group. Treatment compliance, cognitive-behavioral ability, self-care ability (self-care responsibility, self-care skills, self-status, knowledge of diabetic retinopathy), quality of life (physical function, psychosocial, symptom and visual function, social activity), and prognosis of the patients were analyzed to investigate the effectiveness of WeChat social platform-based continuity of care. All patients were followed up for one year.

Results

Patients receiving WeChat social platform-based continuity of care exhibited obviously higher treatment compliance and better cognitive-behavioral ability, self-care responsibility, self-care skills, self-state, and diabetic retinopathy knowledge follow-up than those with routine care (P<0.05). Patients in the WeChat group had significantly better physical function, mental psychology, symptoms and visual function, and social activity levels than those in the routine group (P<0.05). WeChat-based continuity of care resulted in a significantly lower incidence of visual acuity loss and diabetic retinopathy during follow-up than routine care (P<0.05).

Conclusion

WeChat social platform-based continuity of care effectively improves treatment compliance and diabetic retinopathy awareness, and enhances self-care ability of young patients with diabetes mellitus. The life quality of these patients is improved and the risk of poor prognosis has been reduced.

Thrifty energy phenotype predicts weight regain in postmenopausal women with overweight or obesity and is related to FGFR1 signaling

BACKGROUND&AIMS

Long term improvement of body weight and metabolism is highly requested in obesity. The specific impact of weight loss associated temporary negative energy balance or modified body composition on metabolism and weight regain is unclear.

METHODS

We randomly assigned 80 post-menopausal women (BMI 33.9 (32.2-36.8)kg/m²) to an intervention (IG) or control group (CG). IG underwent a dietary three month-weight loss intervention followed by a four week-weight maintenance period without negative energy balance. The CG was instructed to keep their weight stable. Phenotyping was performed at baseline (M0), after weight loss (M3), the maintenance period (M4) and 24-month follow-up (M24). Co-primary outcomes were changes of insulin sensitivity (ISI_Clamp) and lean body mass (LBM). Energy metabolism and adipose gene expression were secondary endpoints.

RESULTS

Between March 2012 and July 2015, 479 subjects were screened for eligibility. 80 subjects were randomly assigned to IG (n = 40) or CG (n = 40). The total number of dropouts was 18 (IG: n = 13, CG: n = 5). LBM and ISI_Clamp were stable in the CG between M0 and M3, but were changed in the IG at M3 (LBM: -1.4 (95%CI -2.2-(-0.6)) kg and ISI_Clamp: +0.020 (95%CI 0.012-0.028) mg·kg^-1·min^-1/(mU·l^-1)) (p < 0.01 and p < 0.05 for IG vs. CG, respectively). Effects on LBM, ISI_Clamp, FM and BMI were preserved until M4. Lower resting energy expenditure per LBM (REE_LBM) at M3 and stronger difference of REE_LBM between M3 and M4 (ΔREE_LBM-M3M4), which indicates a thrifty phenotype, were positively associated with FM regain at M24 (p = 0.022 and p = 0.044, respectively). Gene set enrichment analysis revealed a relationship of this phenotype to weight loss-induced adaption of adipose FGFR1 signaling.

CONCLUSION

Negative energy balance had no additional effect on insulin sensitivity. FGFR1 signaling might be involved in the adaption of energy expenditure to temporary negative energy balance, which indicates a thrifty phenotype susceptible to weight regain.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT01105143, https://clinicaltrials.gov/ct2/show/NCT01105143, date of registration: April 16th, 2010.

Proteomics reveals unique plasma signatures in constitutional thinness

PURPOSE

Studying the plasma proteome of control versus constitutionally thin (CT) individuals, exposed to overfeeding, may give insights into weight-gain management, providing relevant information to the clinical entity of weight-gain resistant CT, and discovering new markers for the condition.

EXPERIMENTAL DESIGN

Untargeted protein relative quantification of 63 CT and normal-weight individuals was obtained in blood plasma at baseline, during and after an overfeeding challenge using mass spectrometry-based proteomics.

RESULTS

The plasma proteome of CT subjects presented limited specificity with respect to controls at baseline. Yet, CT showed lower levels of inflammatory C-reactive protein and larger levels of protective insulin-like growth factor-binding protein 2. Differences were more marked during and after overfeeding. CT plasma proteome showed larger magnitude and significance in response, suggesting enhanced "resilience" and more rapid adaptation to changes. Four proteins behaved similarly between CT and controls, while five were regulated in opposite fashion. Ten proteins were differential during overfeeding in CT only (including increased fatty acid-binding protein and glyceraldehyde-3-phosphate dehydrogenase, and decreased apolipoprotein C-II and transferrin receptor protein 1).

CONCLUSIONS AND CLINICAL RELEVANCE

This first proteomic profiling of a CT cohort reveals different plasma proteomes between CT subjects and controls in a longitudinal clinical trial. Our molecular observations further support that the resistance to weight gain in CT subjects appears predominantly biological.

CLINICALTRIALS

gov Identifier: NCT02004821.

Exploratory analysis of eating- and physical activity-related outcomes from a randomized controlled trial for weight loss maintenance with exercise and liraglutide single or combination treatment

Weight regain after weight loss remains a major challenge in obesity treatment and may involve alteration of eating and sedentary behavior after weight loss. In this randomized, controlled, double-blind trial, adults with obesity were randomized, in a 1:1:1:1 ratio stratified by sex and age group (<40 years and ≥40 years), to one-year weight loss maintenance with exercise, the GLP-1 receptor agonist liraglutide, or the combination, as compared with placebo, after low-calorie diet-induced weight loss. Primary outcome was change in body weight, which has been published. Here, we investigated the effects of weight loss maintenance with exercise, liraglutide, or the combination on weight loss-induced changes in the pre-specified explorative outcomes, eating and sedentary behavior in 130 participants who completed the trial according to the study protocol (exercise (n = 26), liraglutide (n = 36), combination (n = 29), and placebo (n = 39)). One year after weight loss, the placebo group had decreased postprandial appetite suppression score by 14%, and increased sedentary time by 31 min/day and regained weight. Liraglutide prevented the decrease in postprandial appetite suppression score compared with placebo (0% vs. -14%; P = 0.023) and maintained weight loss. Exercise after weight loss did not increase appetite or sedentary behavior compared with placebo, despite increased exercise energy expenditure and maintained weight loss. The combination of exercise and liraglutide increased cognitive restraint score (13% vs. -9%; P = 0.042), reflecting a conscious restriction of food intake, and decreased sedentary time by 41 min/day (-10 vs. 31 min/day; 95%CI, -82.3 to -0.2; P = 0.049) compared with placebo, which may have facilitated the additional weight loss. Targeting both eating and sedentary behavior could be the most effective for preventing weight regain.Trial registration: EudraCT number, 2015-005585-32; clinicaltrials.gov number, NCT04122716.

Effect of semaglutide and liraglutide in individuals with obesity or overweight without diabetes: a systematic review

Background & Objective:

Although data on the effects of liraglutide and semaglutide in patients with diabetes have been reviewed, their therapeutic outcomes in obese/overweight individuals without diabetes have not been summarized. We conducted a systematic review to evaluate their effects on the latter population.

Methods:

We searched the PubMed, EMBASE, Cochrane, CNKI, and Wanfang databases. Studies regarding obese/overweight adults without diabetes treated with liraglutide/semaglutide compared with other active agents or placebos were accessed. The primary outcomes were the proportions of adults with at least 5% and 10% weight reduction. The secondary outcomes included metabolic indicators and adverse events.

Results:

Eighteen studies with 10,938 obese/overweight adults without diabetes were included. When stratified by the categories of at least 5% and 10% weight loss, the pooled data showed medians 27.7% and 10.3% of control groups versus 65.3% and 30.7% of liraglutide 3 mg once daily, respectively; whereas medians 47.6% and 20.4% of control groups vs 86.6% and 75.3% of semaglutide 2.4 mg once weekly were found in the two categories, respectively. Both agents either improved or had no impact on lipid or glycemia. Liraglutide or semaglutide therapy had discontinuation rates of 2.4%–11.4% which overlapped with 0.7%–8.6% in control groups. The frequency of adverse events was comparable between the treatment groups and the control groups (66.5%–95.8% vs 46.9%–96.1%), which were mild to moderate graded by studies.

Conclusion:

Liraglutide and semaglutide therapy led to a clinically relevant (⩾5%) weight loss of 48.2%–88.7% among obese/overweight adults without diabetes. Both liraglutide and semaglutide are associated with weight loss and are well-tolerated.

What happens after a weight loss intervention? A qualitative study of drivers and challenges of maintaining time-restricted eating among people with overweight at high risk of type 2 diabetes

Time-restricted eating (TRE)¹ has been conceptualised as a strategy for achieving weight loss and improving metabolic health, but limited knowledge exists about how people can maintain TRE in daily life. This study examined how TRE was maintainable in daily life after a three-month intervention (the RESET study) in which participants were encouraged to consume all food and beverages except water within a 10-hour daily window. Specifically, we examined TRE maintenance patterns across participants, including drivers and challenges for maintenance success. A qualitative longitudinal study was conducted, and twenty participants with overweight at high risk of type 2 diabetes were interviewed using a semi-structured interview guide at the end of the intervention and after a three-month follow-up period. Data were analysed longitudinally in two steps inspired by a pattern-oriented longitudinal analysis approach. Seven participants maintained a strict 10-hour window, ten maintained an adjusted TRE regimen (e.g., taking days off), and three did not attempt maintenance. Maintenance drivers included consistent daily rhythms and regular meal patterns, subjective experiences (e.g., feeling healthier), making flexible adjustments to the TRE regimen, family support and avoiding feelings of guilt. Maintenance challenges included social evening events, inconsistent daily rhythms and eating patterns, preoccupation with losing weight, lack of family support and self-blame. TRE was manageable for most participants; however, personalised support for adjusting TRE to daily life is needed to ensure long-term maintenance. Future studies should explore the effectiveness of a personalised TRE concept to determine the usefulness of TRE in real-life settings.

Weight Loss Challenges in Achieving Transplant Eligibility in Patients With Kidney Failure: A Qualitative Study

Rationale & Objective

Patients with kidney failure need kidney replacement therapy to maximize survival. Kidney transplant is a superior mode of kidney replacement therapy for most individuals with kidney failure. Patients with obesity often are not approved for kidney transplant until they lose sufficient weight, as obesity may complicate the surgical procedure, and the risk of graft loss increases with a higher body mass index. To help potential kidney transplant recipient candidates lose weight, further knowledge of their thoughts, feelings, and attitudes is needed.

Study Design

Qualitative study with semistructured interviews and an exploratory research design, guided by qualitative content analysis.

Setting & Participants

Patients at a hospital in Denmark required to lose weight to achieve kidney transplant eligibility.

Analytical Approach

From patients’ responses, we identified descriptive themes using a phenomenological approach. The factors affecting outcomes were derived reflexively from these themes.

Results

Ten interviews were analyzed. Experiences of obesity and weight-loss attempts were described across 4 themes; (1) restrictions and exhaustion, (2) hope and hopelessness, (3) support and self-discipline, and (4) motivation based on severity. A major motivating factor to achieving weight loss in the studied group of patients was their declining kidney function and the fact that kidney transplant cannot be considered until sufficient weight loss is achieved.

Limitations

Thematic saturation was reached after an unexpectedly low number of participants. The patients were only interviewed once and over the phone.

Conclusions

Patients with obesity who are seeking kidney transplant need additional help with the dietary restrictions brought on by kidney disease. They need assistance bridging between a kidney-friendly diet and a sustainable diet that will ensure weight loss. These patients also express not wanting to feel alone in their weight-loss battle. They are looking for help and support to achieve weight loss.

Factors associated with engagement and adherence to a low-energy diet to promote 10% weight loss in patients with clinically significant non-alcoholic fatty liver disease

Objective

Clinical guidelines recommend weight loss to manage non-alcoholic fatty liver disease (NAFLD). However, the majority of patients find weight loss a significant challenge. We identified factors associated with engagement and adherence to a low-energy diet (LED) as a treatment option for NAFLD.

Design

23 patients with NAFLD enrolled in a LED (~800 kcal/day) were individually interviewed. Transcripts were thematically analysed.

Results

14/23 patients achieved ≥10% weight loss, 18/23 achieved ≥7% weight loss and 19/23 achieved ≥5% weight loss. Six themes were generated from the data. A desire to achieve rapid weight loss to improve liver health and prevent disease progression was the most salient facilitator to engagement. Early and significant weight loss, accountability to clinicians and regular appointments with personalised feedback were facilitators to engagement and adherence. The desire to receive positive reinforcement from a consultant was a frequently reported facilitator to adherence. Practical and emotional support from friends and family members was critically important outside of the clinical setting. Irregular working patterns preventing attendance at appointments was a barrier to adherence and completion of the intervention.

Conclusions

Engagement and adherence to a LED in patients with NAFLD were encouraged by early and rapid weight loss, personalised feedback and positive reinforcement in the clinical setting combined with ongoing support from friends and family members. Findings support those identified in patients who completed a LED to achieve type 2 diabetes remission and highlight the importance of behaviour change support during the early stages of a LED to promote adherence.

Dietary adherence and program attrition during a severely energy-restricted diet among people with complex class III obesity: A qualitative exploration

Meal replacement Severely Energy-Restricted Diets (SERDs) produce ≥ 10% loss of body mass when followed for 6 weeks or longer in people with class III obesity (BMI ≥ 40 kg/m2). The efficacy of SERDs continues to be questioned by healthcare professionals, with concerns about poor dietary adherence. This study explored facilitators and barriers to dietary adherence and program attrition among people with class III obesity who had attempted or completed a SERD in a specialised weight loss clinic. Participants who commenced a SERD between January 2016 to May 2018 were invited to participate. Semi-structured in-depth interviews were conducted from September to October 2018 with 20 participants (12 women and 8 men). Weight change and recounted events were validated using the participants' medical records. Data were analysed by thematic analysis using line-by-line inductive coding. The mean age ± SD of participants was 51.2 ± 11.3 years, with mean ± SD BMI at baseline 63.7 ± 12.6 kg/m2. Five themes emerged from participants' recounts that were perceived to facilitate dietary adherence: (1.1) SERD program group counselling and psychoeducation sessions, (1.2) emotionally supportive clinical staff and social networks that accommodated and championed change in dietary behaviours, (1.3) awareness of eating behaviours and the relationship between these and progression of disease, (1.4) a resilient mindset, and (1.5) dietary simplicity, planning and self-monitoring. There were five themes on factors perceived to be barriers to adherence, namely: (2.1) product unpalatability, (2.2) unrealistic weight loss expectations, (2.3) poor program accessibility, (2.4) unforeseeable circumstances and (2.5) externalised weight-related stigma. This study highlights opportunities where SERD programs can be optimised to facilitate dietary adherence and reduce barriers, thus potentially improving weight loss outcomes with such programs. Prior to the commencement of a SERD program, healthcare professionals facilitating such programs could benefit from reviewing participants to identify common barriers. This includes identifying the presence of product palatability issues, unrealistic weight loss expectations, socio-economic disadvantage, and behaviour impacting experiences of externalised weight-related stigma.

Factors Associated with Favorable Changes in Food Preferences After Bariatric Surgery

PURPOSE

Bariatric surgery may shift food preferences towards less energy-dense foods. Eating behavior is multifactorial, and the mechanisms driving changes in food preferences could be a combination of a physiological response to surgery and social and psychological factors. This exploratory study aimed to identify potential factors explaining the variation in changes in food preferences after bariatric surgery.

MATERIALS AND METHODS

Physiological, social, and psychological data were collected before, 6 weeks or 6 months after surgery. All variables were analyzed in combination using LASSO regression to explain the variation in changes in energy density at an ad libitum buffet meal 6 months after bariatric surgery (n=39).

RESULTS

The following factors explained 69% of the variation in changes in food preferences after surgery and were associated with more favorable changes in food preferences (i.e., a larger decrease in energy density): female gender, increased secretion of glicentin, a larger decrease in the hedonic rating of sweet and fat and a fatty cocoa drink, a lower number of recent life crises, a low degree of social eating pressure, fulfilling the diagnostic criteria for binge eating disorder, less effort needed to obtain preoperative weight loss, a smaller household composition, a lower degree of self-efficacy and a higher degree of depression, nutritional regime competence, and psychosocial risk level.

CONCLUSION

Factors explaining the variation in altered food preferences after bariatric surgery not only include a physiological response to surgery but also social and psychological factors.

Motives for weight loss and weight loss maintenance: results from the MedWeight study

BACKGROUND

The relationship of weight loss motives with long-term outcomes is equivocal. We aimed to examine differences in weight loss motives of maintainers and regainers, as well as explore associations between motives and successful maintenance.

METHODS

The study sample includes 607 adults, with a history of overweight/obesity and self-reported ≥10% voluntary weight loss, 12 months before study entry. Participants were classified as maintainers (weighing ≤90% maximum weight) or regainers. Volunteers identified possible motives for weight loss and maintenance (maintainers only), from a specific list.

RESULTS

Both maintainers and regainers were predominantly motivated by physical appearance (38.6% versus 39.9%, P > 0.05) and self-esteem (26.8% versus 32.0%, P > 0.05) for weight loss. Compared to regainers, more maintainers reported weight reduction driven by social purposes (16.6% versus 9.4%, P = 0.022) and less were prompted by friends/family to lose weight (21.1% versus 31.7%, P = 0.005). In maintainers, shifts in motives from weight loss to maintenance phase were found, including an increased prevalence of health motives (6.4% versus 9.6%, P < 0.001) and decreased physical appearance motives (38.6% versus 30.3%, P < 0.001). Reporting physical appearance as main maintenance motive was inversely associated with maintained weight loss, after adjusting for age, sex and years of education (B = -3.49 [1.07], P = 0.001); maintainers reporting physical appearance as the main motive maintained 3.5% less weight loss compared to those who did not (P = 0.001).

CONCLUSIONS

The present study has highlighted motivational influences associated with weight loss outcomes. Future studies should explore the ability of people with overweight/obesity to act upon motives for long-term weight management, as well as the impact of shifting through motives on the magnitude of maintenance.

'I have been all in, I have been all out and I have been everything in-between': A 2-year longitudinal qualitative study of weight loss maintenance

BACKGROUND

Qualitative studies investigating weight management experiences are usually cross-sectional or of short duration, which limits understanding of the long-term challenges.

METHODS

Eleven women [mean (SD) age 44.9 (9.8) years; body mass index 40.3 (4.0) kg m^-2 ] participated in this longitudinal qualitative study, which included up to 20 weeks of total diet replacement (825-853 kcal day^-1 ) and ongoing support for weight loss maintenance (WLM), to 2 years. Semi-structured interviews were conducted at baseline and programme end, as well as at key intervals during the intervention. Questions examined five theoretical themes: motivation, self-regulation, habits, psychological resources and social/environmental influences. Data were coded and analysed in nvivo (https://qsrinternational.com/nvivo) using the framework method.

RESULTS

In total, 64 interviews were completed (median, n = 6 per participant). Mean (SD) weight loss was 15.7 (9.6) kg (14.6% body weight) at 6 months and 9.6 (9.9) kg (8.8% body weight) at 2 years. The prespecified theoretical model offered a useful framework to capture the variability of experiences. Negative aspects of obesity were strong motivations for weight loss and maintenance. Perceiving new routines as sustainable and developing a 'maintenance mindset' was characteristic of 'Maintainers', whereas meeting emotional needs at the expense of WLM goals during periods of stress and negative mood states was reported more often by 'Regainers'. Optimistic beliefs about maintaining weight losses appeared to interfere with barrier identification and coping planning for most participants.

CONCLUSIONS

People tended to be very optimistic about WLM without acknowledging barriers and this may undermine longer-term outcomes. The potential for regain remained over time, mainly as a result of emotion-triggered eating to alleviate stress and negative feelings. More active self-regulation during these circumstances may improve WLM, and these situations represent important targets for intervention.

Predictors of weight loss after bariatric surgery-a cross-disciplinary approach combining physiological, social, and psychological measures

BACKGROUND

Bariatric surgery leads to a substantial weight loss (WL), however, a subset of patients undergoing surgery fails to achieve adequate WL. The reason for the individual variation in WL remains unexplained. Using an exploratory cross-disciplinary approach, we aimed to identify preoperative and early postoperative factors explaining the variation in WL after bariatric surgery.

METHODS

Sixty-one subjects were recruited. Eighteen subjects did not receive surgery and three subjects dropped out, leaving a total sample of 40 subjects. Physiological, social, and psychological data were collected before and 6 months after surgery. All variables were analyzed in combination using a least absolute shrinkage and selection operator (LASSO) regression to explain the variation in WL 18 months after Roux-en-Y gastric bypass (n = 30) and sleeve gastrectomy (n = 10).

RESULTS

Mean WL was 31% (range: 10-52%). The following preoperative factors predicted 59% of the variation in WL: type of surgery (14%), diabetes status (12%), economic resources (9%), sex (7%), binge eating disorder (7%), degree of depression (5%), household type (3%), and physical activity (1%). Including information on early responses after surgery increased the ability to predict WL to 78% and was explained by early WL (47%), changes in energy density of food consumed from a buffet meal (9%), changes in glicentin (5%), degree of depression (5%), sex (5%), type of surgery (2%), economic resources (2%), and changes in drive for thinness (1%).

CONCLUSIONS

Using a cross-disciplinary approach, a substantial part of the individual variation in WL was explained by a combination of basic patient characteristics, psychological profile, and social conditions as well as physiological, psychological and behavioral responses to surgery. These results suggest that patient characteristics collected in a cross-disciplinary approach may help determine predictors for less successful WL after bariatric surgery. If verified in larger cohorts this may form the basis for individualized postoperative support to optimize WL outcome.

Protocol for a randomised controlled trial of the combined effects of the GLP-1 receptor agonist liraglutide and exercise on maintenance of weight loss and health after a very low-calorie diet

INTRODUCTION

The success rate of weight loss maintenance is limited. Therefore, the purpose of this study is to investigate the maintenance of weight loss and immunometabolic health outcomes after diet-induced weight loss followed by 1-year treatment with a glucagon-like peptide-1 receptor agonist (liraglutide), physical exercise or the combination of both treatments as compared with placebo in individuals with obesity.

METHODS AND ANALYSIS

This is an investigator-initiated, randomised, placebo-controlled, parallel group trial. We will enrol expectedly 200 women and men (age 18-65 years) with obesity (body mass index 32-43 kg/m2) to adhere to a very low-calorie diet (800 kcal/day) for 8 weeks in order to lose at least 5% of body weight. Subsequently, participants will be randomised in a 1:1:1:1 ratio to one of four study groups for 52 weeks: (1) placebo, (2) exercise 150 min/week+placebo, (3) liraglutide 3.0 mg/day and (4) exercise 150 min/week+liraglutide 3.0 mg/day. The primary endpoint is change in body weight from randomisation to end-of-treatment.

ETHICS AND DISSEMINATION

The trial has been approved by the ethical committee of the Capital Region of Denmark and the Danish Medicines Agency. The trial will be conducted in agreement with the Declaration of Helsinki and monitored to follow the guidelines for good clinical practice. Results will be submitted for publication in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

2015-005585-32.

Can type 2 diabetes be reversed and how can this best be achieved? James Lind Alliance research priority number one

The James Lind Alliance, in association with Diabetes UK, conducted a survey of people with Type 2 diabetes to establish their priorities for research. The number one research priority was found to be 'Can Type 2 diabetes be cured or reversed, what is the best way to achieve this, and is there a point beyond which the condition cannot be reversed?'. The present review summarizes the current understanding of weight loss-induced reversal of Type 2 diabetes. It considers the diagnostic criteria for remission and describes the clinical features of post-diabetes. It is of great importance to recognize these, as post-diabetes differs considerably from the high cardiovascular risk state of prediabetes. Current data demonstrate long-term stable β-cell function, providing weight regain is prevented. If an individual, having previously demonstrated susceptibility to Type 2 diabetes, returns to their previous weight then recurrence of the condition is certain. Appropriate use of the terms 'reversal' and 'remission' is discussed, with emphasis that the word 'cure' is inappropriate. Evidence-based means of achieving and maintaining remission of Type 2 diabetes are described, together with a summary of the information on the steadily diminishing chance of achieving reversal with increasing duration of Type 2 diabetes.

An Integrated Understanding of the Molecular Mechanisms of How Adipose Tissue Metabolism Affects Long-term Body Weight Maintenance

Lifestyle-based weight loss interventions frequently demonstrate long-term inefficiency and weight regain. Identification of underlying mechanisms and predictors to identify subjects who will benefit from lifestyle-based weight loss strategies is urgently required. We analyzed 143 adults of the randomized Maintain trial (Maintain-Adults) after intended weight loss to identify mechanisms contributing to the regulation of body weight maintenance. Unbiased RNA sequencing of adipose and skeletal muscle biopsies revealed fatty acid metabolism as a key pathway modified by weight loss. Variability of key enzymes of this pathway, estimates of substrate oxidation, and specific serum acylcarnitine (AC) species, representing a systemic snapshot of in vivo substrate flux, predicted body weight maintenance (defined as continuous or dichotomized [< or ≥3% weight regain] variable) 18 months after intended weight loss in the entire cohort. Key results were confirmed in a similar randomized controlled trial in 137 children and adolescents (Maintain-Children), which investigated the same paradigm in a pediatric cohort. These data suggest that adaption of lipid utilization in response to negative energy balance contributes to subsequent weight maintenance. Particularly a functional role for circulating ACs, which have been suggested to reflect intracellular substrate utilization, as mediators between peripheral energy stores and control of long-term energy homeostasis was indicated.

Effects of a combined dietary, exercise and behavioral intervention and sympathetic system on body weight maintenance after intended weight loss: Results of a randomized controlled trial

BACKGROUND

Lifestyle based weight loss interventions are hampered by long-term inefficacy. Prediction of individuals successfully reducing body weight would be highly desirable. Although sympathetic activity is known to contribute to energy homeostasis, its predictive role in body weight maintenance has not yet been addressed.

OBJECTIVES

We investigated, whether weight regain could be modified by a weight maintenance intervention and analyzed the predictive role of weight loss-induced changes of the sympathetic system on long-term weight regain.

DESIGN

156 subjects (age > 18; BMI ≥ 27 kg/m²) participated in a 12-week weight reduction program. After weight loss (T0), 143 subjects (weight loss > 8%) were randomized to a 12-month lifestyle intervention or a control group. After 12 months (T12) no further intervention was performed until month 18 (T18). Weight regain at T18 (regain_BMI) was the primary outcome. Evaluation of systemic and tissue specific estimates of sympathetic system was a pre-defined secondary outcome.

RESULTS

BMI was reduced by 4.67 ± 1.47 kg/m² during the initial weight loss period. BMI maintained low in subjects of the intervention group until T12 (+0.07 ± 2.98 kg/m²; p = 0.58 compared to T0), while control subjects regained +0.98 ± 1.93 kg/m² (p < 0.001 compared to T0). The intervention group regained more weight than controls after ceasing the intervention (1.17 ± 1.34 vs. 0.57 ± 0.93 kg/m²) until T18. Consequently, BMI was not different at T18 (33.49 (32.64; 34.33) vs. 34.18 (33.61; 34.75) kg/m²; p=0.17). Weight loss-induced modification of urinary metanephrine excretion independently predicted regain_BMI (R² = 0.138; p < 0.05). The lifestyle intervention did not modify the course of urinary metanephrines after initial weight loss.

CONCLUSIONS

Our lifestyle intervention successfully maintained body weight during the intervention period. However, no long-term effect could be observed beyond the intervention period. Predictive sympathetic activity was not persistently modified by the intervention, which may partially explain the lack of long-term success of such interventions.

Habit-based interventions for weight loss maintenance in adults with overweight and obesity: a randomized controlled trial

OBJECTIVES

The objective of this study was to determine whether habit-based interventions are clinically beneficial in achieving long-term (12-month) weight loss maintenance and explore whether making new habits or breaking old habits is more effective.

METHODS

Volunteer community members aged 18-75 years who had overweight or obesity (BMI ≥ 25 kg/m²) were randomized in a single-blind, three-arm, randomized controlled trial. Ten Top Tips (TTT), Do Something Different (DSD), and the attention-only waitlist (WL) control groups were conducted for 12 weeks from July to October 2015. Participants were followed up post-intervention (all groups) and at 6 and 12-month post-intervention (Ten Top Tips and Do Something Different only). The primary outcome was weight-loss maintenance at 12-month follow-up. Secondary outcomes included weight loss at all time points, fruit and vegetable consumption, exercise, wellbeing, depression, anxiety, habit strength, and openness to change.

RESULTS

Of the 130 participants assessed for eligibility, 75 adults (mean BMI 34.5 kg/m² [SD 6.2]), with a mean age of 51 years were recruited. Assessments were completed post-intervention by 66/75 (88%) of participants and by 43/50 (86%) at 12 months. At post-intervention, participants in the Ten Top Tips (-3.3 kg; 95% CI -5.2, -1.4) and Do Something Different (-2.9 kg; 95% CI -4.3, -1.4) interventions lost significantly more weight (P = < .001) than those on the waitlist control (-0.4 kg; 95% CI -1.2, 0.3). Both intervention groups continued to lose further weight to the 12-month follow-up; TTT lost an additional -2.4 kg (95% CI -5.1, 0.4) and DSD lost -1.7 kg (95% CI -3.4, -0.1). At 12-month post-intervention, 28/43 (65%) of participants in both intervention groups had reduced their total body weight by ≥5%, a clinically important change.

CONCLUSIONS

Habit-based weight-loss interventions-forming new habits (TTT) and breaking old habits (DSD), resulted in clinically important weight-loss maintenance at 12-month follow-up.

Patient profiling for success after weight loss surgery (GO Bypass study): An interdisciplinary study protocol

Despite substantial research efforts, the mechanisms proposed to explain weight loss after gastric bypass (RYGB) and sleeve gastrectomy (SL) do not explain the large individual variation seen after these treatments. A complex set of factors are involved in the onset and development of obesity and these may also be relevant for the understanding of why success with treatments vary considerably between individuals. This calls for explanatory models that take into account not only biological determinants but also behavioral, affective and contextual factors. In this prospective study, we recruited 47 women and 8 men, aged 25–56 years old, with a BMI of 45.8 ± 7.1 kg/m² from the waiting list for RYGB and SL at Køge hospital, Denmark. Pre-surgery and 1.5, 6 and 18 months after surgery we assessed various endpoints spanning multiple domains. Endpoints were selected on basis of previous studies and include: physiological measures: anthropometrics, vital signs, biochemical measures and appetite hormones, genetics, gut microbiota, appetite sensation, food and taste preferences, neural sensitivity, sensory perception and movement behaviors; psychological measures: general psychiatric symptom-load, depression, eating disorders, ADHD, personality disorder, impulsivity, emotion regulation, attachment pattern, general self-efficacy, alexithymia, internalization of weight bias, addiction, quality of life and trauma; and sociological and anthropological measures: sociodemographic measures, eating behavior, weight control practices and psycho-social factors.

Joining these many endpoints and methodologies from different scientific disciplines and creating a multi-dimensional predictive model has not previously been attempted. Data on the primary endpoint are expected to be published in 2018.

Trial registration

Clinicaltrials. gov ID NCT02070081.