Effects of Dietary Self-Monitoring, Physical Activity, Liraglutide 3.0 mg, and Placebo on Weight Loss in the SCALE IBT Trial

INTRODUCTION

Individuals who enroll in intensive behavioral therapy (IBT) programs are asked to make several lifestyle changes simultaneously. However, few studies have examined the relative effects of adherence to different treatment components on weight loss.

OBJECTIVE

This secondary analysis of the SCALE IBT trial assessed adherence to the medication regimen, dietary self-monitoring, and physical activity recommendations and their relative contributions to weight change in individuals with obesity who were provided with IBT combined with either liraglutide 3.0 mg or placebo.

METHODS

SCALE IBT was a double-blinded, multicenter, randomized controlled trial comparing 56-week weight losses in individuals with obesity who received liraglutide 3.0 mg (n = 142) or placebo (n = 140), as an adjunct to IBT. Adherence to dietary self-monitoring, physical activity, and medication usage (liraglutide or placebo) were measured during the 56-week treatment period. A regression model was used to estimate the relative contribution of adherence to each treatment component to weight loss at week 56.

RESULTS

The proportion of individuals who adhered to each intervention component decreased over time. Compared with non-adherence, complete adherence to dietary self-monitoring and physical activity recommendations were associated with estimated weight changes of -7.2% (95% CI -10.4 to -4.0; p < 0.0001) and -2.0% (95% CI -3.2 to -0.8; p = 0.0009), respectively. Complete adherence to liraglutide predicted an additional weight loss of -6.5% (95% CI -10.2 to -2.9; p = 0.0005) relative to individuals who did not adhere to the medication regimen, while adherence to placebo did not have a statistically significant effect on weight loss (p = 0.33).

CONCLUSIONS

High adherence to dietary self-monitoring and use of liraglutide 3.0 mg was associated with clinically relevant weight loss with IBT and adjunctive pharmacotherapy. The effect of adherence to physical activity was significant but smaller.

Changes in neural responsivity to highly palatable foods following roux-en-Y gastric bypass, sleeve gastrectomy, or weight stability: An fMRI study

OBJECTIVE

This prospective, observational fMRI study examined changes over time in blood oxygen level dependent (BOLD) response to high- and low-calorie foods (HCF and LCF) in bariatric surgery candidates and weight-stable controls.

METHODS

Twenty-two Roux-en-Y gastric bypass (RYGB) participants, 18 vertical sleeve gastrectomy (VSG) participants, and 19 weight-stable controls with severe obesity underwent fMRI before and 6 months after surgery/baseline. BOLD signal change in response to images of HCF vs. LCF was examined in a priori regions of interest.

RESULTS

RYGB and VSG participants lost 23.6% and 21.1% of initial weight, respectively, at 6 months, and controls gained 1.0%. Liking ratings for HCF decreased significantly in the RYGB and VSG groups but remained stable in the control group. BOLD response in the ventral tegmental area (VTA) to HCF (vs. LCF) declined significantly more at 6 months in RYGB compared to control participants but not in VSG participants. Changes in fasting ghrelin correlated positively with changes in VTA BOLD signal in both RYGB and VSG but not in control participants.

CONCLUSIONS

Results implicate the VTA as a critical site for modulating postsurgical changes in liking of highly palatable foods and suggest ghrelin as a potential substrate requiring further investigation.

Readiness redefined: a behavioral task during screening predicted 1-year weight loss in the look AHEAD study

OBJECTIVE

Predicting outcome in weight loss trials from baseline characteristics has proved difficult. Readiness to change is typically measured by self-report.

METHODS

Performance of a behavioral task, completion of food records, from the screening period in the Look AHEAD study (n = 549 at four clinical centers) was assessed. Completeness of records was measured by the number of words and Arabic numerals (numbers) recorded per day, the number of eating episodes per day, and days per week where physical activity was noted. The primary outcome was weight loss at one year.

RESULTS

In univariable analysis, both the number of words recorded and the number of numbers recorded were associated with greater weight loss. In multivariable analysis, individuals who recorded 20-26, 27-33, and ≥34 words per day lost 9.12%, 11.40%, and 12.08% of initial weight, compared to 8.98% for individuals who recorded less than 20 words per day (P values of 0.87, 0.008, and <0.001, respectively, compared to <20 words per day).

CONCLUSIONS

Participants who kept more detailed food records at screening lost more weight after 1 year than individuals who kept sparser records. The use of objective behavioral screening tools may improve the assessment of weight loss readiness.

Four-year change in cardiorespiratory fitness and influence on glycemic control in adults with type 2 diabetes in a randomized trial: the Look AHEAD Trial

OBJECTIVE

To examine an intensive lifestyle intervention (ILI) compared with diabetes support and education (DSE) on 4-year change in fitness and physical activity (PA), and to examine the effect of change in fitness and PA, adjusting for potential confounders, on glycemic control in the Look AHEAD Trial.

RESEARCH DESIGN AND METHODS

Subjects were overweight/obese adults with type 2 diabetes mellitus (T2DM) with available fitness data at 4 years (n = 3,942).This clinical trial randomized subjects to DSE or ILI. DSE subjects received standard care plus information related to diet, PA, and social support three times per year. ILI subjects received weekly intervention contact for 6 months, which was reduced over the 4-year period, and were prescribed diet and PA. Measures included weight, fitness, PA, and HbA1c.

RESULTS

The difference in percent fitness change between ILI and DSE at 4 years was significant after adjustment for baseline fitness and change in weight (3.70 vs. 0.94%; P < 0.01). At 4 years, PA increased by 348 (1,562) kcal/week in ILI vs. 105 (1,309) kcal/week in DSE (P < 0.01). Fitness change at 4 years was inversely related to change in HbA1c after adjustment for clinical site, treatment, baseline HbA1c, prescribed diabetes medication, baseline fitness, and weight change (P < 0.01). Change in PA was not related to change in HbA1c.

CONCLUSIONS

A 4-year ILI increased fitness and PA in overweight/obese individuals with T2DM. Change in fitness was associated with improvements in glycemic control, which provides support for interventions to improve fitness in adults with T2DM.

Axis I psychopathology in bariatric surgery candidates with and without binge eating disorder: results of structured clinical interviews

BACKGROUND

Prior studies have reached contradictory conclusions concerning whether binge eating disorder (BED) is associated with greater psychopathology in extremely obese patients who seek bariatric surgery. This study used the Structured Clinical Interview for DSM-IV Diagnoses (SCID) to compare rates of axis I psychopathology in surgery candidates who were determined to have BED or to be currently free of eating disorders. The relationship of BED to other psychosocial functioning and weight loss goals also was examined.

METHODS

One hundred ninety five bariatric surgery patients completed the Weight and Lifestyle Inventory and the Beck Depression Inventory-II (BDI-II) and were later administered the Eating Disorder Examination. Of these 195, 44 who were diagnosed with BED, and 61 who were currently free of eating pathology, completed a telephone-administered SCID.

RESULTS

Significantly more BED than non-BED participants had a current mood disorder (27.3% vs. 4.9%, p = 0.002) as well as a lifetime history of this condition (52.3% vs. 23.0%, p = 0.003). More BED than non-BED participants also had a current anxiety disorder (27.3% vs. 8.2%, p = 0.014) and lifetime anxiety disorder (36.4% vs. 16.4%, p = 0.019). BED also was associated with greater symptoms of depression, as measured by the BDI-II, as well as with lower self-esteem. BED and non-BED groups, however, did not differ in their desired weight loss goals following surgery.

CONCLUSIONS

The present findings indicate that the presence of BED, in patients who seek bariatric surgery, is associated with an increased prevalence of axis I psychopathology, beyond the already elevated rate observed with severe (i.e., class III) obesity.

One-year changes in symptoms of depression and weight in overweight/obese individuals with type 2 diabetes in the Look AHEAD study

Depressed individuals are frequently excluded from weight loss trials because of fears that weight reduction may precipitate mood disorders, as well as concerns that depressed participants will not lose weight satisfactorily. The present study examined participants in the Look AHEAD study to determine whether moderate weight loss would be associated with incident symptoms of depression and suicidal ideation, and whether symptoms of depression at baseline would limit weight loss at 1 year. Overweight/obese adults with type 2 diabetes (n = 5,145) were randomly assigned to an Intensive Lifestyle Intervention (ILI) or a usual care group, Diabetes Support and Education (DSE). Of these, 5,129 participants completed the Beck Depression Inventory (BDI) and had their weight measured at baseline and 1 year. Potentially significant symptoms of depression were defined by a BDI score ≥10. Participants in ILI lost 8.6 ± 6.9% of initial weight at 1 year, compared to 0.7 ± 4.8% for DSE (P < 0.001, effect size = 1.33), and had a reduction of 1.4 ± 4.7 points on the BDI, compared to 0.4 ± 4.5 for DSE (P < 0.001, effect size = 0.23). At 1 year, the incidence of potentially significant symptoms of depression was significantly lower in the ILI than DSE group (6.3% vs. 9.6%) (relative risk (RR) = 0.66, 95% confidence interval (CI) = 0.5, 0.8; P < 0.001). In the ILI group, participants with and without symptoms of depression lost 7.8 ± 6.7% and 8.7 ± 6.9%, respectively, a difference not considered clinically meaningful. Intentional weight loss was not associated with the precipitation of symptoms of depression, but instead appeared to protect against this occurrence. Mild (or greater) symptoms of depression at baseline did not prevent overweight/obese individuals with type 2 diabetes from achieving significant weight loss.

Continuous glucose monitoring to assess the ecologic validity of dietary glycemic index and glycemic load

BACKGROUND

The circumstances under which the glycemic index (GI) and glycemic load (GL) are derived do not reflect real-world eating behavior. Thus, the ecologic validity of these constructs is incompletely known.

OBJECTIVE

This study examined the relation of dietary intake to glycemic response when foods are consumed under free-living conditions.

DESIGN

Participants were 26 overweight or obese adults with type 2 diabetes who participated in a randomized trial of lifestyle modification. The current study includes baseline data, before initiation of the intervention. Participants wore a continuous glucose monitor and simultaneously kept a food diary for 3 d. The dietary variables included GI, GL, and intakes of energy, fat, protein, carbohydrate, sugars, and fiber. The glycemic response variables included AUC, mean and SD of continuous glucose monitoring (CGM) values, percentage of CGM values in euglycemic and hyperglycemic ranges, and mean amplitude of glycemic excursions. Relations between daily dietary intake and glycemic outcomes were examined.

RESULTS

Data were available from 41 d of monitoring. Partial correlations, controlled for energy intake, indicated that GI or GL was significantly associated with each glycemic response outcome. In multivariate analyses, dietary GI accounted for 10% to 18% of the variance in each glycemic variable, independent of energy and carbohydrate intakes (P < 0.01).

CONCLUSIONS

The data support the ecologic validity of the GI and GL constructs in free-living obese adults with type 2 diabetes. GI was the strongest and most consistent independent predictor of glycemic stability and variability.

Obesity, psychiatric status, and psychiatric medications

This article has shown that obesity is related to several psychiatric disorders, the most thoroughly researched of which is depression. In both community and clinical populations, the observed relationship is more consistent in women than in men, and is stronger in more severely obese individuals. The presence of BED also is associated with elevated risk of additional psychopathology. Longitudinal research provides evidence to support a pathway from obesity to depression, as well as one from depression to obesity. Weight loss, particularly with nonpharmacologic methods, appears to have favorable group-level effects on mood, but may be associated with adverse outcomes for some individuals. Persons who require antipsychotic medications are at risk for weight gain and metabolic abnormalities, and their management should be informed by consensus guidelines.

Intentional weight loss and changes in symptoms of depression: a systematic review and meta-analysis

OBJECTIVE

Obesity is related to increased risk of several health complications, including depression. Many studies have reported improvements in mood with weight loss, but results have been equivocal. The present meta-analysis examined changes in symptoms of depression that were reported in trials of weight loss interventions. Between-groups comparisons of different weight loss methods (for example, lifestyle modification, diet-alone and pharmacotherapy) were examined, as were within-group changes for each treatment type.

METHOD

MEDLINE was searched for articles published between 1950 and January 2009. Several obesity-related terms were intersected with terms related to depression. Results were filtered to return only studies of human subjects, published in English. Of 5971 articles, 394 were randomized controlled trials. Articles were excluded if they did not report mean changes in weight or symptoms of depression, included children or persons with psychiatric disorders (other than depression), or provided insufficient data for analysis. Thirty-one studies (n=7937) were included. Two authors independently extracted a description of each study treatment, sample characteristics, assessment methods and changes in weight and symptoms of depression. Treatments were categorized as lifestyle modification, non-dieting, dietary counseling, diet-alone, exercise-alone, pharmacotherapy, placebo or control interventions.

RESULTS

Random effects models found that lifestyle modification was superior to control and non-dieting interventions for reducing symptoms of depression, and marginally better than dietary counseling and exercise-alone programs. Exercise-alone programs were superior to controls. No differences were found for comparisons of pharmacologic agents and placebos. Within-group analyses found significant reductions in symptoms of depression for nearly all active interventions. A meta-regression found no relationship between changes in weight and changes in symptoms of depression in lifestyle modification interventions.

CONCLUSIONS

On average, obese individuals in weight loss trials experienced reductions in symptoms of depression. Future studies should examine incidence and resolution of clinically significant depressive disorders with weight loss interventions.

Socially desirable responding by bariatric surgery candidates during psychological assessment

BACKGROUND

Most bariatric surgery programs in the United States require preoperative psychological evaluations for candidates for surgery. Among those who perform these evaluations is concern that many patients engage in "impression management" or minimizing the symptoms of distress to receive a recommendation to proceed with surgery from the mental health professional. We sought to assess the prevalence of socially desirable responding and its associations with measures of psychological functioning among bariatric surgery candidates at 2 academic medical centers in the United States.

METHODS

The participants were male (n = 66) and female (n = 293) bariatric surgery candidates who presented for psychological evaluation. The participants completed 2 measures of socially desirable response styles (Marlowe-Crowne Social Desirability Scale and Personality Assessment Inventory Positive Impression Management scale) and standardized measures of anxiety, depression, and alcohol-related problems.

RESULTS

The participants exhibited elevated scores on the social desirability indicators, with 33.3-39.8% scoring above the recommended cut-score on the Personality Assessment Inventory Positive Impression Management scale and 62.3-67% scoring 1 standard deviation above the standardization mean on the Marlowe-Crowne Social Desirability Scale. Scores on the Marlowe-Crowne Social Desirability Scale and Personality Assessment Inventory Positive Impression Management scale correlated inversely with the clinical measures of anxiety and depression, and the high/low scorers on the social desirability indices exhibited significant differences in anxiety and depression. Thus, elevated scores on the social desirability indices were associated with underreporting of certain clinical symptoms.

CONCLUSION

A substantial proportion of bariatric surgery candidates appear to present themselves in an overly favorable light during the psychological evaluation. This response style is associated with less reporting of psychological problems and might interfere with the accurate assessment of patient functioning.

Binge eating disorder and the outcome of bariatric surgery at one year: a prospective, observational study

Previous studies have suggested that binge eating disorder (BED) impairs weight loss following bariatric surgery, leading some investigators to recommend that patients receive behavioral treatment for this condition before surgery. However, many of these investigations had significant methodological limitations. The present observational study used a modified intention-to-treat (ITT) population to compare 1-year changes in weight in 59 surgically treated participants, determined preoperatively to be free of a current eating disorder, with changes in 36 individuals judged to have BED. Changes in weight and binge eating in the latter group were compared with those in 49 obese individuals with BED who sought lifestyle modification for weight loss. BED was assessed using criteria proposed for the Diagnostic and Statistical Manual (DSM) 5. At 1 year, surgically treated participants without BED lost 24.2% of initial weight, compared with 22.1% for those with BED (P > 0.309). Both groups achieved clinically significant improvements in several cardiovascular disease (CVD) risk factors. Participants with BED who received lifestyle modification lost 10.3% at 1 year, significantly (P < 0.001) less than surgically treated BED participants. The mean number of binge eating days (in the prior 28 days) fell sharply in both BED groups at 1 year. These two groups did not differ significantly in BED remission rates or in improvements in CVD risk factors. The present results, obtained in carefully studied participants, indicate that the preoperative presence of BED does not attenuate weight loss or improvements in CVD risk factors at 1 year in surgically treated patients. Longer follow-up of participants is required.

Targeting dietary fat or glycemic load in the treatment of obesity and type 2 diabetes: a randomized controlled trial

AIMS

To compare the effects of lifestyle modification programs that prescribe low-glycemic load (GL) vs. low-fat diets in a randomized trial.

METHODS

Seventy-nine obese adults with type 2 diabetes received low-fat or low-GL dietary instruction, delivered in 40-week lifestyle modification programs with identical goals for calorie intake and physical activity. Changes in weight, HbA(1c), and other metabolic parameters were compared at weeks 20 and 40.

RESULTS

Weight loss did not differ between groups at week 20 (low-fat: -5.7±3.7%; low-GL: -6.7±4.4%, p=.26) or week 40 (low-fat: -4.5±7.5%; low-GL: -6.4±8.2%, p=.28). Adjusting for changes in antidiabetic medications, subjects on the low-GL diet had larger reductions in HbA(1c) than those on the low-fat diet at week 20 (low-fat: -0.3±0.6%; low-GL: -0.7±0.6%, p=.01), and week 40 (low-fat: -0.1±1.2%; low-GL: -0.8±1.3%; p=.01). Groups did not differ significantly on any other metabolic outcomes (p≥.06).

CONCLUSIONS

Results suggest that targeting GL, rather than dietary fat, in a low-calorie diet can significantly enhance the effect of weight loss on HbA(1c) in patients with type 2 diabetes.

Constructing common cohorts from trials with overlapping eligibility criteria: implications for comparing effect sizes between trials

BACKGROUND

Comparing findings from separate trials is necessary to choose among treatment options, however differences among study cohorts may impede these comparisons.

PURPOSE

As a case study, to examine the overlap of study cohorts in two large randomized controlled clinical trials that assess interventions to reduce risk of major cardiovascular disease events in adults with type 2 diabetes in order to explore the feasibility of cross-trial comparisons

METHODS

The Action for Health in Diabetes (Look AHEAD) and The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trials enrolled 5145 and 10,251 adults with type 2 diabetes, respectively. Look AHEAD assesses the efficacy of an intensive lifestyle intervention designed to produce weight loss; ACCORD tests pharmacological therapies for control of glycemia, hyperlipidemia, and hypertension. Incidence of major cardiovascular disease events is the primary outcome for both trials. A sample was constructed to include participants from each trial who appeared to meet eligibility criteria and be appropriate candidates for the other trial's interventions. Demographic characteristics, health status, and outcomes of members and nonmembers of this constructed sample were compared.

RESULTS

Nearly 80% of Look AHEAD participants were projected to be ineligible for ACCORD; ineligibility was primarily due to better glycemic control or no early history of cardiovascular disease. Approximately 30% of ACCORD participants were projected to be ineligible for Look AHEAD, often for reasons linked to poorer health. The characteristics of participants projected to be jointly eligible for both trials continued to reflect differences between trials according to factors likely linked to retention, adherence, and study outcomes.

LIMITATIONS

Accurate ascertainment of cross-trial eligibility was hampered by differences between protocols.

CONCLUSIONS

Despite several similarities, the Look AHEAD and ACCORD cohorts represent distinct populations. Even within the subsets of participants who appear to be eligible and appropriate candidates for trials of both modes of intervention, differences remained. Direct comparisons of results from separate trials of lifestyle and pharmacologic interventions are compromised by marked differences in enrolled cohorts.

Attrition from randomized controlled trials of pharmacological weight loss agents: a systematic review and analysis

Clinical trials of obesity treatments have been limited by substantial dropout. Participant-level variables do not reliably predict attrition, and study-level variables have not yet been examined. We searched MEDLINE and identified 24 large randomized controlled trials of weight loss medications. These trials were comprised of 23 placebo and 32 drug groups. Two authors independently extracted the following for each treatment group: (i) treatment received; (ii) design characteristics (inclusion of a lead-in period, selection of participants with weight-related comorbidities, study location and number of study visits); (iii) sample characteristics (sample size, % female, and mean baseline age and body mass index); and (iv) attrition (total, adverse event [AE]-related and non-AE-related) at 1 year. The primary outcome was total attrition, which was significantly related to treatment (i.e. 34.9%, 28.6%, 28.3% and 35.1% in placebo, orlistat, sibutramine and rimonabant groups, respectively, P < 0.0001). In adjusted multivariable models, total attrition was significantly lower in groups that completed a pre-randomization lead-in period than in those that did not (29.1% vs. 39.9%, P < 0.01). Gender also was significantly related to total attrition; groups with more women had higher dropout (P < 0.01). The pattern was similar for predicting non-AE-related attrition. Findings suggest ways to design studies that maximize retention.

Changes in symptoms of depression with weight loss: results of a randomized trial

Recent studies of rimonabant have re-awakened interest in the possible adverse psychiatric effects of weight loss, as well as of weight loss medications. This study examined changes in symptoms of depression in 194 obese participants (age = 43.7 +/- 10.2 years; BMI = 37.6 +/- 4.1 kg/m(2)) in a 1-year randomized trial of lifestyle modification and medication. Participants were assigned to (i) sibutramine alone; (ii) lifestyle modification alone; (iii) sibutramine plus lifestyle modification (i.e., combined therapy); or (iv) sibutramine plus brief therapy. Participants completed the Beck Depression Inventory-II (BDI-II) at baseline and weeks 6, 10, 18, 26, 40, and 52. At 1 year, participants in combined therapy lost the most weight and those in sibutramine alone the least (12.1 +/- 8.8% vs. 5.5 +/- 6.5%; P < 0.01). Mean BDI-II scores across all participants declined from 8.1 +/- 6.9 to 6.2 +/- 7.7 at 1 year (P < 0.001), with no significant differences among groups. Despite this favorable change, 13.9% of participants (across the four groups) reported potentially discernible increases (>or= 5 points on the BDI-II) in symptoms of depression at week 52. They lost significantly less weight than participants in the rest of the sample (5.4 +/- 7.8% vs. 9.0 +/- 7.8%, respectively; P < 0.03). The baseline prevalence of suicidal ideation was 3.6%. Seven new cases of suicidal ideation were observed during the year, with three in lifestyle modification alone. Further research is needed to identify characteristics of obese patients at risk of negative mood changes (and suicidal ideation) in response to behavioral and pharmacologic therapies.

Obesity among those with mental disorders: a National Institute of Mental Health meeting report

The National Institute of Mental Health convened a meeting in October 2005 to review the literature on obesity, nutrition, and physical activity among those with mental disorders. The findings of this meeting and subsequent update of the literature review are summarized here. Levels of obesity are higher in those with schizophrenia and depression, as is mortality from obesity-related conditions such as coronary heart disease. Medication side effects, particularly the metabolic side effects of antipsychotic medications, contribute to the high levels of obesity in those with schizophrenia, but increased obesity and visceral adiposity have been found in some but not all samples of drug-naïve patients as well. Many of the weight-management strategies used in the general population may be applicable to those with mental disorders, but little is known about the effects of these strategies on this patient population or how these strategies may need to be adapted for the unique needs of those with mental disorders. The minimal research on weight-management programs for those with mental disorders indicates that meaningful changes in dietary intake and physical activity are possible. Physical activity is an important component of any weight-management program, particularly for those with depression, for which a substantial body of research indicates both mental and physical health benefits. Obesity among those with mental disorders has not received adequate research attention, and empirically-based interventions to address the increasing prevalence of obesity and risk of cardiovascular and metabolic diseases in this population are lacking.

Impact of a weight management program on health-related quality of life in overweight adults with type 2 diabetes

BACKGROUND

Inconsistent findings have been reported regarding improved health-related quality of life (HRQOL) after weight loss. We tested the efficacy of a weight management program for improving HRQOL in overweight or obese adults diagnosed as having type 2 diabetes mellitus.

METHODS

We conducted a randomized multisite clinical trial at 16 outpatient research centers with 2 treatment arms and blinded measurements at baseline and the end of year 1. A total of 5145 participants (mean [SD] age, 58.7 [6.9] years; mean [SD] body mass index [calculated as weight in kilograms divided by height in meters squared], 36.0 [5.9]; 59.5% women; 63.1% white) were randomized to an intensive lifestyle intervention (ILI) or to diabetes support and education (DSE). Main outcome measures included the 36-Item Short-Form Health Survey physical component summary (PCS) and mental health component summary (MCS) scores and Beck Depression Inventory II (BDI-II) scores. Baseline mean (SD) scores were 47.9 (7.9) for PCS, 54.0 (8.1) for MCS, and 5.7 (5.0) for BDI-II.

RESULTS

Improved HRQOL was demonstrated by the PCS and BDI-II scores (P < .001) in the ILI arm compared with the DSE arm. The largest effect was observed for the PCS score (difference, -2.91; 99% confidence interval, -3.44 to -2.37). The greatest HRQOL improvement occurred in participants with the lowest baseline HRQOL levels. Mean (SD) changes in weight (ILI, -8.77 [8.2] kg and DSE, -0.86 [5.0] kg), improved fitness, and improved physical symptoms mediated treatment effects associated with the BDI-II and PCS.

CONCLUSIONS

Overweight adults diagnosed as having type 2 diabetes experienced significant improvement in HRQOL by enrolling in a weight management program that yielded significant weight loss, improved physical fitness, and reduced physical symptoms.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00017953.

Impact of a weight management program on health-related quality of life in overweight adults with type 2 diabetes

BACKGROUND

Inconsistent findings have been reported regarding improved health-related quality of life (HRQOL) after weight loss. We tested the efficacy of a weight management program for improving HRQOL in overweight or obese adults diagnosed as having type 2 diabetes mellitus.

METHODS

We conducted a randomized multisite clinical trial at 16 outpatient research centers with 2 treatment arms and blinded measurements at baseline and the end of year 1. A total of 5145 participants (mean [SD] age, 58.7 [6.9] years; mean [SD] body mass index [calculated as weight in kilograms divided by height in meters squared], 36.0 [5.9]; 59.5% women; 63.1% white) were randomized to an intensive lifestyle intervention (ILI) or to diabetes support and education (DSE). Main outcome measures included the 36-Item Short-Form Health Survey physical component summary (PCS) and mental health component summary (MCS) scores and Beck Depression Inventory II (BDI-II) scores. Baseline mean (SD) scores were 47.9 (7.9) for PCS, 54.0 (8.1) for MCS, and 5.7 (5.0) for BDI-II.

RESULTS

Improved HRQOL was demonstrated by the PCS and BDI-II scores (P < .001) in the ILI arm compared with the DSE arm. The largest effect was observed for the PCS score (difference, -2.91; 99% confidence interval, -3.44 to -2.37). The greatest HRQOL improvement occurred in participants with the lowest baseline HRQOL levels. Mean (SD) changes in weight (ILI, -8.77 [8.2] kg and DSE, -0.86 [5.0] kg), improved fitness, and improved physical symptoms mediated treatment effects associated with the BDI-II and PCS.

CONCLUSIONS

Overweight adults diagnosed as having type 2 diabetes experienced significant improvement in HRQOL by enrolling in a weight management program that yielded significant weight loss, improved physical fitness, and reduced physical symptoms.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00017953.

Self-reported stigmatization among candidates for bariatric surgery

The popularity of bariatric surgery has increased the focus on the psychological aspects of extreme obesity. Although a growing literature has documented the psychosocial burden associated with extreme obesity, surprisingly little attention has been paid to the experience of weight-related stigmatization among extremely obese individuals. The present study investigated self-reported experiences of weight-related stigmatization, weight-related quality of life, and depressive symptoms among 117 extremely obese individuals (BMI = 48.2 +/- 7.5 kg/m2) who presented for bariatric surgery at the Hospital of the University of Pennsylvania. In general, these individuals reported infrequent weight-related stigma, which was unrelated to BMI. Some specific forms of stigmatization, however, appear to be related to body size. The occurrence of stigmatization was associated with poorer weight-related quality of life and greater symptoms of depression.

Weight loss expectations and goals in a population sample of overweight and obese US adults

The purpose of this study was to investigate weight loss expectations and goals in a population sample of US adults who planned to make a weight loss attempt, and to examine predictors of those expectations and goals. Participants were 658 overweight and obese adults (55% women, mean age = 47.9 years, BMI = 31.8 kg/m(2)) who responded to a telephone survey about weight loss. Respondents reported weight loss expectations (i.e., reductions they realistically expected) and goals (i.e., reductions they ideally desired) for an upcoming "serious and deliberate" weight loss attempt. They also reported the expectations they had, and the reductions they actually achieved, in a previous attempt. Respondents' weight loss expectations for their upcoming attempt (8.0% reduction in initial weight) were significantly more modest than their goals for that attempt (16.8%), and smaller than the losses that they expected (12.0%), and achieved (8.9%) in their most recent past attempt (Ps <or= 0.003). Women and participants with higher BMIs had greater weight loss expectations and goals. After controlling for BMI, age, and gender, previous weight loss was unrelated to expectations (but was inversely related to goals) for the upcoming weight loss attempt. Results suggest that overweight and obese individuals can select realistic weight loss expectations that are more modest than their ideal goals. BMI and gender appear to be more important than previous weight loss experiences in determining expectations among persons planning a weight loss attempt.

Impression management or real change? Reports of depressive symptoms before and after the preoperative psychological evaluation for bariatric surgery

BACKGROUND

Many bariatric surgery programs require that candidates undergo a preoperative mental health evaluation. Candidates may be motivated to suppress or exaggerate psychiatric symptoms (i.e., engage in impression management), if they believe doing so will enhance their chances of receiving a recommendation to proceed with surgery.

METHOD

237 candidates for bariatric surgery completed the Beck Depression Inventory-II (BDI-ll) as part of their preoperative psychological evaluation (Time 1). They also completed the BDI-II approximately 2-4 weeks later, for research purposes, after they had received the mental health professional's unconditional recommendation to proceed with surgery (Time 2).

RESULTS

There was a small but statistically significant increase in mean BDI-II scores from Time 1 to Time 2 (11.4 vs 12.7, P<.001). Clinically significant changes, defined as a change from one range of symptom severity to another, were observed in 31.2% of participants, with significant increases in symptoms occurring nearly twice as often as reductions (20.7% vs 10.5%, P<.008). Demographic variables were largely unrelated to changes in BDI-II scores from Time 1 to Time 2.

CONCLUSION

Approximately one-third of bariatric surgery candidates reported a clinically significant change in depressive symptoms after receiving psychological "clearance" for surgery. Possible explanations for these findings include measurement error, impression management, and true changes in psychiatric status.

Psychiatric considerations of the massive weight loss patient

As bariatric surgery for extreme obesity continues to grow in popularity, so does interest in postbariatric surgery body-contouring surgery. There is an extensive literature on the psychological characteristics of persons with extreme obesity who undergo bariatric surgery and the psychological changes that typically occur postoperatively. Far less, however, is known about the psychological aspects of body contouring following massive weight loss. This article reviews the psychosocial characteristics of individuals with extreme obesity who undergo bariatric surgery, as well as the changes in these traits that typically occur postoperatively. Because there have been few studies of the psychological aspects of patients who have lost massive amounts of weight, we use related literatures on the relationship between body image dissatisfaction and other plastic surgical procedures to identify the most relevant research and clinical issues for this unique patient population. Appropriate psychiatric screening and management of these patients is believed to play an important role in successful postoperative outcomes.

Psychological evaluation of bariatric surgery applicants: procedures and reasons for delay or denial of surgery

BACKGROUND

Psychologists play an important role as members of the bariatric surgery team. The current investigation examined the frequency with which psychologists recommend delay or denial of surgery for psychological reasons, the procedures they use in making their clinical decisions, and the reasons for such conclusions.

METHOD

A sample of 103 psychologists with experience in conducting pre-surgical psychological evaluations responded to a brief survey.

RESULTS

There was significant variability in the number of evaluations psychologists complete and the instruments they use to make their clinical decisions. For most candidates, the evaluation results in psychological clearance for surgery. However, approximately 15%, on average, are delayed or denied for psychological reasons. The most common reasons for delaying or denying surgery were significant psychopathology (including psychosis or bipolar disorder), untreated or undertreated depression, and lack of understanding about the risks and postoperative requirements of surgery, which were reported by 51, 39, and 30% of respondents, respectively. Several other reasons were reported less frequently and many appeared to be idiosyncratic.

CONCLUSION

Psychologists differ in their preoperative evaluation practices. Further research is needed to determine the reasons for the variability in clinical decision making and the long-term medical and psychosocial outcomes associated with the recommendation to delay or deny surgery for psychosocial reasons. When patients receive such a recommendation, they can be encouraged to seek a second opinion from a mental health professional with bariatric expertise.

Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery

Extreme obesity, characterized by a body mass index (BMI) of 40 kg/m(2) or greater, is associated with significantly increased mortality, principally from cardiovascular disease, type 2 diabetes, and several cancers. It also is associated with an increased risk of psychosocial complications, including depression, eating disorders, and impaired quality of life. This article briefly examines the psychosocial status of extremely obese individuals who seek bariatric surgery and describes changes in functioning that can be expected with surgically induced weight loss. The article combines a review of the literature with clinical impressions gained from the more than 2500 candidates for bariatric surgery whom the authors have evaluated at the Hospital of the University of Pennsylvania.

The role of patients' expectations and goals in the behavioral and pharmacological treatment of obesity

OBJECTIVE

To investigate weight loss expectations and goals among obese treatment seekers and to examine the relationships of these expectations and goals to treatment outcomes.

METHOD

Participants were 180 obese men and women (age 43.8+/-10.1 years; body mass index 37.6+/-4.2 kg/m(2)) who received one of four-year-long treatments that combined behavioral and pharmacological methods. Before treatment, they reported the amount of weight they realistically expected to lose after 4, 12, 26 and 52 weeks of treatment, as well as their ultimate weight loss goals. Expectations and goals were compared across treatment groups and examined in relation to previous weight loss efforts, weight loss and regain in treatment, attrition, satisfaction with treatment and mood.

RESULTS

Participants in all treatment groups expected reductions at week 52 that were significantly greater than the 5-15% of initial weight they were told was realistic and significantly more than they had ever lost before. Weight loss expectations were unrelated to achieved weight loss in all groups but one, in which greater expectations were associated with greater losses. Failure to meet weight loss expectations for the first 26 weeks of treatment was related to lower satisfaction ratings, but was not related to weight regain or attrition over the next 26 weeks. Symptoms of depression were reduced from baseline, regardless of whether participants achieved or failed to achieve their expected weight losses.

CONCLUSION

Across groups, we observed no negative consequences of having (and failing to meet) unrealistic expectations for weight loss.

Behavior Therapy and Cognitive-Behavioral Therapy of Obesity: Is There a Difference?

Current practice guidelines for management of overweight and obesity recommend a program of diet, exercise, and behavior therapy for all persons with a body mass index (calculated as kg/m(2)) of at least 30 (and those with body mass index > or =25 plus two weight-related comorbidities). In this tripartite treatment--often referred to as lifestyle modification--behavior therapy provides a structure that facilitates meeting goals for energy intake and expenditure. Although standard behavior therapy reliably induces mean weight losses of approximately 10% of initial weight, these reductions are difficult to maintain. Some authors argue that a shift in focus from behavior change to cognitive change will improve long-term results of lifestyle modification programs. This review describes, in detail, the standard behavioral treatment of obesity and compares it with an alternative treatment model that is based in a cognitive conceptualization of weight control. A review of the literature suggests that the differences between standard behavior therapy and cognitive-behavioral therapy of obesity lie more in their underlying theories than in their implementation. Empirical comparisons of the long-term effects of these approaches are needed.

How do mental health professionals evaluate candidates for bariatric surgery? Survey results

BACKGROUND

The prevalence of extreme obesity and the popularity of bariatric surgery have increased dramatically in recent years. Many surgery programs require that candidates undergo a preoperative psychological evaluation, but no consensus exists for guiding mental health professionals in the conduct of these evaluations.

METHOD

A survey was sent to bariatric surgeons, who were asked to distribute the surveys to the mental health professionals to whom they refer surgery candidates for preoperative evaluations. 194 respondents provided information on the assessment methods they use, which psychosocial domains are the focus of their evaluations, and what they consider to be contraindications to surgery. Responses to open-ended questions were coded for content.

RESULTS

Most respondents reported using clinical interviews (98.5%), symptom inventories (68.6%), and objective personality/psychopathology tests (63.4%). A minority used tests of cognitive function (38.1%) and projective personality tests (3.6%). Over 90% of respondents listed mental health issues among the most important areas to assess. Similarly, 92.3% listed psychiatric issues as "clear contraindications" to surgery, but no specific disorder was listed by a majority of respondents. Issues related to informed consent and treatment adherence were the non-psychiatric domains most frequently listed as important areas to assess and as contraindications to surgery.

CONCLUSION

The assessment practices of mental health professionals who evaluate bariatric surgery candidates vary widely. No consensus is likely to emerge until large long-term studies identify consistent psychosocial predictors of poor postoperative outcomes.

History of sexual abuse among bariatric surgery candidates

BACKGROUND

A history of sexual abuse is associated with a range of psychosocial difficulties and health risk behaviors in the general population. Sexual abuse also appears to be a risk factor for the development of obesity. Little is known, however, about the prevalence and psychosocial correlates of sexual abuse among persons with extreme obesity who seek bariatric surgery.

METHODS

Questionnaire data were collected from 567 individuals with extreme obesity who presented for bariatric surgery. Those with and without a self-reported history of sexual abuse were compared on several psychosocial variables.

RESULTS

Sixteen percent of the surgery candidates (17.0% of women and 11.5% of men) reported a history of sexual abuse. Those who reported a history of sexual abuse were more likely to report previous emotional difficulties, as well as a personal and family history of substance abuse. They also were significantly more likely to meet the criteria for binge eating disorder, as determined from self-report responses to the Questionnaire on Eating and Weight Patterns, compared with those without a self-reported history of sexual abuse. In addition, those who reported a history of sexual abuse were more likely to report both current and previous psychiatric treatment than were those who denied a history of abuse.

CONCLUSION

A significant minority of bariatric surgery candidates reported a history of sexual abuse. Among these individuals, a history of sexual abuse was associated with both current and past psychiatric problems and treatment. The relationship of these variables to postoperative outcomes, however, is unknown.

A comparison of weight histories in women with class III vs. class I-II obesity

OBJECTIVE

To describe the weight histories of women with extreme or class III obesity (BMI >or= 40 kg/m2) in comparison with a sample of women with class I-II obesity (BMI < 40 kg/m2) and to provide reliability data for a clinical instrument that assesses weight history.

RESEARCH METHODS AND PROCEDURES

Female patients (N = 149) with extreme obesity seeking bariatric surgery and 90 class I-II obese women seeking behavioral treatment completed the Weight and Lifestyle Inventory (WALI), a self-report instrument that assesses age of onset of obesity, maximum weight at different ages, family weight history, and weight changes related to pregnancy. Test-retest reliability data were obtained by administering the WALI to a subsample (n = 58) of class I-II obese participants at their initial visit and at another pretreatment visit 1 to 2 weeks later.

RESULTS

Patients with extreme obesity had a significantly younger age of onset of obesity, were significantly heavier at all age ranges, reported significantly more weight gain with their first pregnancy, and had significantly heavier parents and siblings as compared with less obese patients. There were no significant differences between groups with respect to weight gain during second pregnancies or postpartum weight retention. Robust test-retest correlations were obtained for the weight history items on the WALI.

DISCUSSION

Patients with extreme obesity report more indicators of a genetic predisposition to obesity as compared with less obese patients. The WALI appears to be a reliable instrument for the assessment of weight history in obese patients.

Self-reported eating behaviors of extremely obese persons seeking bariatric surgery: a factor analytic approach

OBJECTIVE

To summarize the self-reported eating behaviors of persons seeking bariatric surgery and to provide reliability data for a clinical instrument that assesses those eating behaviors.

RESEARCH METHODS AND PROCEDURES

Adults (552) with extreme obesity (mean +/- standard deviation BMI = 52.4 +/- 10.1 kg/m2) completed the Weight and Lifestyle Inventory (WALI) before undergoing bariatric surgery. The WALI is a self-report instrument that includes 24 items that assess the eating behaviors to which respondents attribute their excess weight. These items were entered into a principal components analysis with promax rotation. Relationships of factor scores to demographic and psychosocial variables were examined. Test-retest reliability data were obtained from a smaller sample (n = 58) of less obese participants (BMI = 34.4 +/- 4.0 kg/m2) who completed the WALI twice within 2 weeks, before beginning a non-surgical weight loss program.

RESULTS

The principal components analysis yielded five factors with acceptable internal consistency and test-retest reliability. These included: eating in response to negative affect, eating in response to positive affect and social cues, general overeating and impaired appetite regulation, overeating at early meals, and snacking. Each factor was related to symptoms of binge eating disorder, and every factor except the second one was associated with depressive symptoms. Factor scores were unrelated or weakly associated with demographic characteristics.

DISCUSSION

The eating behaviors of persons seeking bariatric surgery can be assessed reliably and parsimoniously with the WALI. The predictive utility of the factors obtained in this study remains to be examined.

Obesity

The prevalence of obesity is growing at an alarming rate. Thus, investigation into the etiology, comorbidities, and treatment of obesity has burgeoned in recent years. While novel therapies--both behavioral and pharmacological--have been developed and tested, the mean weight losses achieved with nonsurgical approaches have remained virtually unchanged over the past 20 years. Fortunately, the modest weight losses achieved with these methods are associated with significant reductions in obesity-related health problems. With the most intensive available treatment (i.e., bariatric surgery), many patients achieve remission of comorbid conditions. This article defines obesity and provides an overview of the disease conditions associated with excess weight. Treatment options and outcomes are reviewed and future steps-including efforts to prevent obesity--are identified. Finally, the literature on the relationship between obesity and depression is examined.

Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features

OBJECTIVE

To assess the prevalence of night eating syndrome (NES) and binge eating disorder (BED) and their related behavioral and psychological correlates in persons who sought bariatric surgery.

RESEARCH METHODS AND PROCEDURES

A consecutive series of 215 persons with extreme obesity (82% women, 70% European American) completed the Weight and Lifestyle Inventory and a semistructured interview as part of a pre-surgery behavioral/psychological assessment. Diagnoses for NES and BED were based on graded diagnostic criteria.

RESULTS

Percentages of participants who met diagnostic criteria for NES by interview were 1.9% for the strictest definition and 8.9% across all definitions of NES. After interview, full DSM-TR criteria for BED were met by 4.2%; an additional 1.4% reported binge eating at least once per week. Self-reported prevalence of NES and BED were higher. Those with NES or BED had significantly more symptoms of depression and a greater history of psychological complications than the remaining sample.

DISCUSSION

The prevalence rates of NES and BED among this population of bariatric surgery candidates were lower than expected based on previous reports. Findings and hypotheses regarding lowered prevalence rates are discussed.

Previous weight loss experiences of bariatric surgery candidates: how much have patients dieted prior to surgery?

OBJECTIVE

To describe the dieting histories of bariatric surgery candidates.

RESEARCH METHODS AND PROCEDURES

One hundred seventy-seven individuals with extreme obesity who sought bariatric surgery completed the Weight and Lifestyle Inventory, a self-report instrument that assesses several variables, including weight and dieting history. Patients' dieting histories were further explored with an aided recall during a preoperative behavioral/psychological evaluation performed by a mental health professional.

RESULTS

Participants who completed the Weight and Lifestyle Inventory reported an average of 4.7 +/- 2.9 successful dieting attempts, defined as those that resulted in a loss of 10 lbs (4.5 kg) or more. These individuals reported a mean total lifetime weight loss of 61.1 +/- 41.3 kg. Despite these efforts, their weight increased from 89.4 +/- 27.4 kg at the time of their first diet (age 21.2 +/- 10.1 years) to 144.5 +/- 30.8 kg at the time they underwent their behavioral/psychological evaluation (age 43.0 +/- 11.0 years). Results of the aided recall revealed that participants had made numerous other efforts to lose weight that were unsuccessful. Self-directed diets and commercial programs were used more frequently.

DISCUSSION

Individuals who sought bariatric surgery reported an extensive history of dieting, beginning in adolescence, that was not successful in halting progressive weight gain. Thus, the recommendation often made by insurance companies that patients delay surgery to attempt more conservative treatment options may be unwarranted, particularly in the presence of significant obesity-related comorbidities. Weight loss histories should be routinely examined during a behavioral evaluation to determine whether additional attempts at non-surgical weight loss are advisable. Future studies also are needed to explore the potential relationship between dieting history and postoperative outcome.

Previous weight loss experiences of bariatric surgery candidates: how much have patients dieted prior to surgery?

OBJECTIVE

To describe the dieting histories of bariatric surgery candidates.

RESEARCH METHODS AND PROCEDURES

One hundred seventy-seven individuals with extreme obesity who sought bariatric surgery completed the Weight and Lifestyle Inventory, a self-report instrument that assesses several variables, including weight and dieting history. Patients' dieting histories were further explored with an aided recall during a preoperative behavioral/psychological evaluation performed by a mental health professional.

RESULTS

Participants who completed the Weight and Lifestyle Inventory reported an average of 4.7 +/- 2.9 successful dieting attempts, defined as those that resulted in a loss of 10 lbs (4.5 kg) or more. These individuals reported a mean total lifetime weight loss of 61.1 +/- 41.3 kg. Despite these efforts, their weight increased from 89.4 +/- 27.4 kg at the time of their first diet (age 21.2 +/- 10.1 years) to 144.5 +/- 30.8 kg at the time they underwent their behavioral/psychological evaluation (age 43.0 +/- 11.0 years). Results of the aided recall revealed that participants had made numerous other efforts to lose weight that were unsuccessful. Self-directed diets and commercial programs were used more frequently.

DISCUSSION

Individuals who sought bariatric surgery reported an extensive history of dieting, beginning in adolescence, that was not successful in halting progressive weight gain. Thus, the recommendation often made by insurance companies that patients delay surgery to attempt more conservative treatment options may be unwarranted, particularly in the presence of significant obesity-related comorbidities. Weight loss histories should be routinely examined during a behavioral evaluation to determine whether additional attempts at non-surgical weight loss are advisable. Future studies also are needed to explore the potential relationship between dieting history and postoperative outcome.

Self-reported eating behaviors of extremely obese persons seeking bariatric surgery: a factor analytic approach

OBJECTIVE

To summarize the self-reported eating behaviors of persons seeking bariatric surgery and to provide reliability data for a clinical instrument that assesses those eating behaviors.

RESEARCH METHODS AND PROCEDURES

Adults (552) with extreme obesity (mean +/- standard deviation BMI = 52.4 +/- 10.1 kg/m(2)) completed the Weight and Lifestyle Inventory (WALI) before undergoing bariatric surgery. The WALI is a self-report instrument that includes 24 items that assess the eating behaviors to which respondents attribute their excess weight. These items were entered into a principal components analysis with promax rotation. Relationships of factor scores to demographic and psychosocial variables were examined. Test-retest reliability data were obtained from a smaller sample (n = 58) of less obese participants (BMI = 34.4 +/- 4.0 kg/m(2)) who completed the WALI twice within 2 weeks, before beginning a non-surgical weight loss program.

RESULTS

The principal components analysis yielded five factors with acceptable internal consistency and test-retest reliability. These included: eating in response to negative affect, eating in response to positive affect and social cues, general overeating and impaired appetite regulation, overeating at early meals, and snacking. Each factor was related to symptoms of binge eating disorder, and every factor except the second one was associated with depressive symptoms. Factor scores were unrelated or weakly associated with demographic characteristics.

DISCUSSION

The eating behaviors of persons seeking bariatric surgery can be assessed reliably and parsimoniously with the WALI. The predictive utility of the factors obtained in this study remains to be examined.

Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features

OBJECTIVE

To assess the prevalence of night eating syndrome (NES) and binge eating disorder (BED) and their related behavioral and psychological correlates in persons who sought bariatric surgery.

RESEARCH METHODS AND PROCEDURES

A consecutive series of 215 persons with extreme obesity (82% women, 70% European American) completed the Weight and Lifestyle Inventory and a semistructured interview as part of a pre-surgery behavioral/psychological assessment. Diagnoses for NES and BED were based on graded diagnostic criteria.

RESULTS

Percentages of participants who met diagnostic criteria for NES by interview were 1.9% for the strictest definition and 8.9% across all definitions of NES. After interview, full DSM-TR criteria for BED were met by 4.2%; an additional 1.4% reported binge eating at least once per week. Self-reported prevalence of NES and BED were higher. Those with NES or BED had significantly more symptoms of depression and a greater history of psychological complications than the remaining sample.

DISCUSSION

The prevalence rates of NES and BED among this population of bariatric surgery candidates were lower than expected based on previous reports. Findings and hypotheses regarding lowered prevalence rates are discussed.

A comparison of weight histories in women with class III vs. class I-II obesity

OBJECTIVE

To describe the weight histories of women with extreme or class III obesity (BMI >or= 40 kg/m(2)) in comparison with a sample of women with class I-II obesity (BMI < 40 kg/m(2)) and to provide reliability data for a clinical instrument that assesses weight history.

RESEARCH METHODS AND PROCEDURES

Female patients (N = 149) with extreme obesity seeking bariatric surgery and 90 class I-II obese women seeking behavioral treatment completed the Weight and Lifestyle Inventory (WALI), a self-report instrument that assesses age of onset of obesity, maximum weight at different ages, family weight history, and weight changes related to pregnancy. Test-retest reliability data were obtained by administering the WALI to a subsample (n = 58) of class I-II obese participants at their initial visit and at another pretreatment visit 1 to 2 weeks later.

RESULTS

Patients with extreme obesity had a significantly younger age of onset of obesity, were significantly heavier at all age ranges, reported significantly more weight gain with their first pregnancy, and had significantly heavier parents and siblings as compared with less obese patients. There were no significant differences between groups with respect to weight gain during second pregnancies or postpartum weight retention. Robust test-retest correlations were obtained for the weight history items on the WALI.

DISCUSSION

Patients with extreme obesity report more indicators of a genetic predisposition to obesity as compared with less obese patients. The WALI appears to be a reliable instrument for the assessment of weight history in obese patients.

Comparison of psychosocial status in treatment-seeking women with class III vs. class I-II obesity

OBJECTIVE

This study compared the psychosocial status and weight loss expectations of women with extreme (class III) obesity who sought bariatric surgery with those of women with class I-II obesity who enrolled in a research study on behavioral weight control.

RESEARCH METHODS AND PROCEDURES

Before treatment, all participants completed the Beck Depression Inventory-II and the Weight and Lifestyle Inventory. This latter questionnaire assesses several domains including symptoms of depression and low self-esteem, history of psychiatric complications, current stressors, and weight loss expectations.

RESULTS

Women with class III obesity, as compared with class I-II, reported significantly more symptoms of depression. Fully 25% of women in the former group appeared to have a significant mood disorder that would benefit from treatment. As compared with women with class I-II obesity, significantly more women with class III obesity also reported a history of psychiatric complications, which included physical and sexual abuse and greater stress related to their physical health and financial/legal matters. Both groups of women had unrealistic weight loss expectations. Those who sought surgery expected to lose 47.6 +/- 9.3% of initial weight, compared with 24.8 +/- 8.7% for those who enrolled in behavioral weight control.

DISCUSSION

These findings suggest that women with extreme obesity who seek bariatric surgery should be screened for psychosocial complications. Those determined to have significant psychiatric distress should be referred for behavioral or pharmacological treatment to alleviate their suffering. Long-term studies are needed to provide definitive guidance concerning the relationship between preoperative psychopathology and the outcome of bariatric surgery.

Comparison of psychosocial status in treatment-seeking women with class III vs. class I–II obesity

OBJECTIVE

This study compared the psychosocial status and weight loss expectations of women with extreme (class III) obesity who sought bariatric surgery with those of women with class I-II obesity who enrolled in a research study on behavioral weight control.

RESEARCH METHODS AND PROCEDURES

Before treatment, all participants completed the Beck Depression Inventory-II and the Weight and Lifestyle Inventory. This latter questionnaire assesses several domains including symptoms of depression and low self-esteem, history of psychiatric complications, current stressors, and weight loss expectations.

RESULTS

Women with class III obesity, as compared with class I-II, reported significantly more symptoms of depression. Fully 25% of women in the former group appeared to have a significant mood disorder that would benefit from treatment. As compared with women with class I-II obesity, significantly more women with class III obesity also reported a history of psychiatric complications, which included physical and sexual abuse and greater stress related to their physical health and financial/legal matters. Both groups of women had unrealistic weight loss expectations. Those who sought surgery expected to lose 47.6 +/- 9.3% of initial weight, compared with 24.8 +/- 8.7% for those who enrolled in behavioral weight control.

DISCUSSION

These findings suggest that women with extreme obesity who seek bariatric surgery should be screened for psychosocial complications. Those determined to have significant psychiatric distress should be referred for behavioral or pharmacological treatment to alleviate their suffering. Long-term studies are needed to provide definitive guidance concerning the relationship between preoperative psychopathology and the outcome of bariatric surgery.

Psychosocial and behavioral aspects of bariatric surgery

Bariatric surgery has become an increasingly popular treatment option for individuals with extreme obesity (defined as a BMI > or = 40 kg/m2) or those with less severe obesity accompanied by significant comorbidities. Sustained postoperative weight loss and improvements in obesity-related health problems make bariatric surgery the most effective treatment for this population. Nevertheless, most experts agree that psychosocial and behavioral factors contribute to successful postoperative outcomes. This paper reviews the literature on the preoperative psychosocial status, eating behaviors, and quality of life of patients who seek bariatric surgery. In addition, the paper examines studies that investigated changes in these factors postoperatively. The review concludes with an agenda for future research in this area.

Health-related quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery

BACKGROUND

Extreme obesity, defined by a body mass index (BMI) > or =40 kg/m2, is associated with increased risk of depression and with impairments in healthrelated quality of life (HRQoL). This study examined the relationships among BMI, HRQoL, and symptoms of depression in persons with extreme obesity.

METHOD

Participants were 306 patients who sought bariatric surgery (mean +/- SD age 43.8+/-9.4 years, BMI 52.8+/-9.3 kg/m2) and who completed questionnaires to assess symptoms of depression and HRQoL prior to surgery. We defined HRQoL impairment as a score > or =1 SD below national means.

RESULTS

Impairments in HRQoL were common: >40% of participants scored in the impaired ranges of physical functioning, physical role limitations, and bodily pain. Results of analyses of variance (ANOVAs) indicated that impairments in HRQoL were significantly related to symptoms of depression. Patients with impaired HRQoL scored above the cut-off point for clinically significant depression, while those without such impairment scored below that cut-off, regardless of BMI. The contribution of BMI to depression was not significant in any ANOVA.

CONCLUSION

HRQoL is more strongly and more directly related to symptoms of depression than is BMI. These findings highlight the need to assess HRQoL in patients with extreme obesity and suggest that interdisciplinary strategies to address HRQoL impairments may be beneficial in this population.