Predictors of racial differences in weight loss: the PROPEL trial

OBJECTIVE

Studies have consistently shown that African American individuals lose less weight in response to behavioral interventions, but the mechanisms leading to this result have been understudied.

METHODS

Data were derived from the PROmoting Successful Weight Loss in Primary CarE in Louisiana (PROPEL) study, which was a cluster-randomized, two-arm trial conducted in primary care clinics. In the PROPEL trial, African American individuals lost less weight compared with patients who belonged to other racial groups after 24 months. In the current study, counterfactual mediation analyses among 445 patients in the intervention arm of PROPEL were used to determine which variables mediated the relationship between race and weight loss. The mediators included treatment engagement, psychosocial, and lifestyle factors.

RESULTS

At 6 months, daily weighing mediated 33% (p = 0.008) of the racial differences in weight loss. At 24 months, session attendance and daily weighing mediated 35% (p = 0.027) and 66% (p = 0.005) of the racial differences in weight loss, respectively. None of the psychosocial or lifestyle variables mediated the race-weight loss association.

CONCLUSIONS

Strategies specifically targeting engagement, such as improving session attendance and self-weighing behaviors, among African American individuals are needed to support more equitable weight losses over extended time periods.

Exercise-induced Changes in Central Adiposity During an RCT: Effect of Exercise Dose and Associations With Compensation

CONTEXT

Exercise can decrease central adiposity, but the effect of exercise dose and the relationship between central adiposity and exercise-induced compensation is unclear.

OBJECTIVE

Test the effect of exercise dose on central adiposity change and the association between central adiposity and exercise-induced weight compensation.

METHODS

In this ancillary analysis of a 6-month randomized controlled trial, 170 participants with overweight or obesity (mean ± SD body mass index: 31.5 ± 4.7 kg/m2) were randomized to a control group or exercise groups that reflected exercise recommendations for health (8 kcal/kg/week [KKW]) or weight loss and weight maintenance (20 KKW). Waist circumference was measured, and dual-energy X-ray absorptiometry assessed central adiposity. Predicted weight change was estimated and weight compensation (weight change - predicted weight change) was calculated.

RESULTS

Between-group change in waist circumference (control: .0 cm [95% CI, -1.0 to 1.0], 8 KKW: -.7 cm [95% CI, -1.7 to .4], 20 KKW: -1.3 cm [95% CI, -2.4 to -.2]) and visceral adipose tissue (VAT; control: -.02 kg [95% CI, -.07 to .04], 8 KKW: -.01 kg [95% CI, -.07 to .04], 20 KKW: -.04 kg [95% CI, -.10 to .02]) was similar (P ≥ .23). Most exercisers (82.6%) compensated (weight loss less than expected). Exercisers who compensated exhibited a 2.5-cm (95% CI, .8 to 4.2) and .23-kg (95% CI, .14 to .31) increase in waist circumference and VAT, respectively, vs those who did not (P < .01). Desire to eat predicted VAT change during exercise (β = .21; P = .03).

CONCLUSION

In the presence of significant weight compensation, exercise at doses recommended for health and weight loss and weight maintenance leads to negligible changes in central adiposity.

Selecting foods from FNDDS when calculating food intake: Does the reference matter?

To estimate food intake, the nutrient content of food must be known or inferred by matching it to a nutrient database. This study evaluated how different procedures for matching foods to the Food and Nutrient Database for Dietary Studies (FNDDS) affect food intake estimates. Adult participants estimated a meal with the PortionSize app, which contains a subset of FNDDS codes (PortionSize FNDDS). Meals were covertly weighed (weigh back), and intake was estimated by referencing the FNDDS dataset. Combination foods were evaluated by 1) a composite generated by summing the nutrient values (from FNDDS) from single food items and 2) using the single composite food code from FNDDS. Raters analyzed food images from the PortionSize app to estimate intake with the digital photography of foods (DPF) method. Raters estimated intake from: 1) PortionSize FNDDS and 2) full FNDDS. Using PortionSize's FNDDS database, participants' energy intake estimates were equivalent to rater estimated energy intake. Raters estimated almost identical energy intake when they used PortionSize vs. full FNDDS. Using the full FNDDS, the DPF's energy estimates were similar to weigh back. Estimation of energy intake with a single FNDDS code was not equivalent to estimations from summing the nutrient values for combination foods.

Effects of Episodic Food Insecurity on Psychological and Physiological Responses in African American Women With Obesity (RESPONSES): Protocol for a Longitudinal Observational Cohort Study

BACKGROUND

Food insecurity is a risk factor for multiple chronic diseases, including obesity. Importantly, both food insecurity and obesity are more prevalent in African American women than in other groups. Furthermore, food insecurity is considered a cyclic phenomenon, with episodes of food adequacy (ie, enough food to eat) and food shortage (ie, not enough food to eat). More research is needed to better understand why food insecurity is linked to obesity, including acknowledging the episodic nature of food insecurity as a stressor and identifying underlying mechanisms.

OBJECTIVE

The objective of this study is to investigate the episodic nature of food insecurity as a stressor via responses in body weight and psychological and physiological parameters longitudinally and do so in a health-disparate population-African American women.

METHODS

We enrolled 60 African American women (food-insecure cohort: n=30, 50%; food-secure cohort: n=30, 50%) aged 18-65 years with obesity (BMI 30-50 kg/m2) to measure (1) daily body weight remotely over 22 weeks and (2) psychological and physiological parameters via clinic assessments at the beginning and end of the 22-week study. Furthermore, we are assessing episodes of food insecurity, stress, hedonic eating, and appetite on a weekly basis. We hypothesize that food-insecure African American women with obesity will demonstrate increased body weight and changes in psychological and physiological end points, whereas food-secure African American women with obesity will not. We are also examining associations between changes in psychological and physiological parameters and changes in body weight and performing a mediation analysis on the psychological parameters assessed at the study midpoint. Psychological questionnaires are used to assess stress; executive function, decision-making, and motivation; and affect and nonhomeostatic eating. Physiological measurements are used to evaluate the levels of cortisol, dehydroepiandrosterone-sulfate (DHEA-S), C-reactive protein, thyroid hormones, blood glucose, glycated hemoglobin, and insulin, as well as allostatic load.

RESULTS

This study has completed participant recruitment (n=60). At the time of study enrollment, the mean age of the participants was almost 47 (SD 10.8) years, and they had a mean BMI of 39.6 (SD 5.31) kg/m2. All data are anticipated to be collected by the end of 2023.

CONCLUSIONS

We believe that this is the first study to examine changes in body weight and psychological and physiological factors in food-insecure African American women with obesity. This study has significant public health implications because it addresses the cyclic nature of food insecurity to identify underlying mechanisms that can be targeted to mitigate the adverse relationship between food insecurity and obesity and reduce health disparities in minority populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05076487; https://clinicaltrials.gov/study/NCT05076487.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52193.

Validity of an Artificial Intelligence-Based Application to Identify Foods and Estimate Energy Intake Among Adults: A Pilot Study

Background

The commercial application Openfit allows for automatic identification and quantification of food intake through short video capture without a physical reference marker. There are no known peer-reviewed publications on the validity of this Nutrition Artificial Intelligence (AI).

Objectives

To test the validity of Openfit to identify food automatically and semiautomatically (with user correction), test the validity of Openfit at quantifying energy intake (kcal) automatically and semiautomatically, and assess satisfaction and usability of Openfit.

Methods

During a laboratory-based visit, adults (7 male and 17 female), used Openfit to automatically and semiautomatically record provided meals, which were covertly weighed. Foods logged were identified as an "exact match," "far match," or an "intrusion" using Food and Nutrient Database for Dietary Studies (FNDDS) codes. Descriptive data were stratified by meal, food item, and FNDDS group, and presented with or without beverages. Bland-Altman analyses assessed errors over levels of energy intake. Participants completed a User Satisfaction Survey (USS) and the Computer Systems Usability Questionnaire (CSUQ). Open-ended questions were assessed with qualitative methods.

Results

Exact matches, far matches, and intrusions were 46%, 41%, and 13% for automated identification, and 87%, 23%, and 0% for semiautomated identification, respectively. Error for automated and semiautomated energy estimates were 43% and 33% with beverages, and 16% and 42% without beverages. Bland-Altman analyses indicated larger error for higher energy meals. Overall mean scores were 2.4 for the CSUQ and subscale means scores ranged from 4.1 to 5.5. for the USS. Participants recommended improvements to Openfit's Nutrition AI, manual estimation, and overall app.

Conclusion

Openfit worked relatively well for automatically and semiautomatically identifying foods. Error in automated energy estimates was relatively high; however, after excluding beverages, error was relatively low (16%). For semiautomated energy estimates, error was comparable to previous studies. Improvements to the Nutrition AI, manual estimation and overall application may increase Openfit's usability and validity.This trial was registered at clinicaltrials.gov as NCT05343585.

The Personalized Nutrition Study (POINTS): evaluation of a genetically informed weight loss approach, a Randomized Clinical Trial

Weight loss (WL) differences between isocaloric high-carbohydrate and high-fat diets are generally small; however, individual WL varies within diet groups. Genotype patterns may modify diet effects, with carbohydrate-responsive genotypes losing more weight on high-carbohydrate diets (and vice versa for fat-responsive genotypes). We investigated whether 12-week WL (kg, primary outcome) differs between genotype-concordant and genotype-discordant diets. In this 12-week single-center WL trial, 145 participants with overweight/obesity were identified a priori as fat-responders or carbohydrate-responders based on their combined genotypes at ten genetic variants and randomized to a high-fat (n = 73) or high-carbohydrate diet (n = 72), yielding 4 groups: (1) fat-responders receiving high-fat diet, (2) fat-responders receiving high-carbohydrate diet, (3) carbohydrate-responders receiving high-fat diet, (4) carbohydrate-responders receiving high-carbohydrate diet. Dietitians delivered the WL intervention via 12 weekly diet-specific small group sessions. Outcome assessors were blind to diet assignment and genotype patterns. We included 122 participants (54.4 [SD:13.2] years, BMI 34.9 [SD:5.1] kg/m2, 84% women) in the analyses. Twelve-week WL did not differ between the genotype-concordant (-5.3 kg [SD:1.0]) and genotype-discordant diets (-4.8 kg [SD:1.1]; adjusted difference: -0.6 kg [95% CI: -2.1,0.9], p = 0.50). With the current ability to genotype participants as fat- or carbohydrate-responders, evidence does not support greater WL on genotype-concordant diets. ClinicalTrials identifier: NCT04145466.

Initial weight loss and early intervention adherence predict long-term weight loss during the Promoting Successful Weight Loss in Primary Care in Louisiana lifestyle intervention

OBJECTIVE

This study tested whether initial weight change (WC), self-weighing, and adherence to the expected WC trajectory predict longer-term WC in an underserved primary-care population with obesity.

METHODS

Data from the intervention group (n = 452; 88% women; 74% Black; BMI 37.3 kg/m2 [SD: 4.6]) of the Promoting Successful Weight Loss in Primary Care in Louisiana trial were analyzed. Initial (2-, 4-, and 8-week) percentage WC was calculated from baseline clinic weights and daily at-home weights. Weights were considered adherent if they were on the expected WC trajectory (10% at 6 months with lower [7.5%] and upper [12.5%] bounds). Linear mixed-effects models tested whether initial WC and the number of daily and adherent weights predicted WC at 6, 12, and 24 months.

RESULTS

Percentage WC during the initial 2, 4, and 8 weeks predicted percentage WC at 6 (R2  = 0.15, R2  = 0.28, and R2  = 0.50), 12 (R2  = 0.11, R2  = 0.19, and R2  = 0.32), and 24 (R2  = 0.09, R2  = 0.11, and R2  = 0.16) months (all p < 0.01). Initial daily and adherent weights were significantly associated with WC as individual predictors, but they only marginally improved predictions beyond initial weight loss alone in multivariable models.

CONCLUSIONS

These results highlight the importance of initial WC for predicting long-term WC and show that self-weighing and adherence to the expected WC trajectory can improve WC prediction.

Dietary intake during a pragmatic cluster-randomized weight loss trial in an underserved population in primary care

BACKGROUND

Currently there are limited data as to whether dietary intake can be improved during pragmatic weight loss interventions in primary care in underserved individuals.

METHODS

Patients with obesity were recruited into the PROPEL trial, which randomized 18 clinics to either an intensive lifestyle intervention (ILI) or usual care (UC). At baseline and months 6, 12, and 24, fruit and vegetable (F/V) intake and fat intake was determined. Outcomes were analyzed by repeated-measures linear mixed-effects multilevel models and regression models, which included random cluster (clinic) effects. Secondary analyses examined the effects of race, sex, age, and food security status.

RESULTS

A total of 803 patients were recruited. 84.4% were female, 67.2% African American, 26.1% received Medicaid, and 65.5% made less than $40,000. No differences in F/V intake were seen between the ILI and UC groups at months 6, 12, or 24. The ILI group reduced percent fat at months 6, 12, and 24 compared to UC. Change in F/V intake was negatively correlated with weight change at month 6 whereas change in fat intake was positively associated with weight change at months 6, 12, and 24 for the ILI group.

CONCLUSIONS

The pragmatic weight loss intervention in primary care did not increase F/V intake but did reduce fat intake in an underserved population with obesity. F/V intake was negatively associated with weight loss at month 6 whereas percent fat was positively correlated with weight loss throughout the intervention. Future efforts better targeting both increasing F/V intake and reducing fat intake may promote greater weight loss in similar populations.

TRIAL REGISTRATION

NCT Registration: NCT02561221.

Learning about Our Vices from Devices: A Model of Individual Learning with an Application to Consumer Food Waste

The proliferation of personal, household and workplace sensors and devices has created individual environments rich with purposeful and incidental feedback capable of altering behavior. We formulate an empirical learning model suitable for understanding individual behavioral responses in such environments. We estimate this model using data collected about the joint personal decisions of food selection, intake, and waste during a study in which users photographed their meal selections and plate waste over the course of a week with a cell phone. Despite neutral recruitment language and no expectation that participants would alter food intake in response to the assessment procedures, we found a substantial learning-by-doing effect in plate waste reduction as those who document greater plate waste in their captured photographs waste less on subsequent days. Further we identified that participants reduced plate waste by learning to eat more rather than by learning to reduce the amount of food selected.

A scalable, virtual weight management program tailored for adults with type 2 diabetes: effects on glycemic control

BACKGROUND

The objective was to test the efficacy of a scalable, virtually delivered, diabetes-tailored weight management program on glycemic control in adults with type 2 diabetes (T2D).

METHODS

This was a single arm, three-site clinical trial. Participants had baseline HbA1c between 7-11% and BMI between 27-50 kg/m². Primary outcome was change in HbA1c at 24 weeks. Secondary outcomes were changes in body weight, waist circumference, the Diabetes Distress Scale (DDS), quality of life (IWQOL-L), and hunger (VAS). Generalized linear effects models were used for statistical analysis.

RESULTS

Participants (n = 136) were 56.8 ± 0.8 y (Mean ± SEM), 36.9 ± 0.5 kg/m², 80.2% female, 62.2% non-Hispanic white. Baseline HbA1c, weight, and total DDS score were 8.0 ± 0.09%, 101.10 ± 1.47 kg, and 2.35 ± 0.08, respectively. At week 24, HbA1c, body weight, and total DDS decreased by 0.75 ± 0.11%, 5.74 ± 0.50%, 0.33 ± 0.10 units, respectively (all p < 0.001). Also, at week 24, quality of life increased by 9.0 ± 1.2 units and hunger decreased by 14.3 ± 2.4 units, (both p < 0.0001).

CONCLUSIONS

The scalable, virtually delivered T2D-tailored weight management program had favorable and clinically meaningful effects on glycemic control, body weight, and psychosocial outcomes.

Physical activity and weight loss in a pragmatic weight loss trial

The purpose of this study was to determine the association between changes in physical activity and changes in body weight in a cluster-randomized weight loss trial conducted in an underserved population in Louisiana. This study reports analyses conducted in the intervention group only, which was a 24-month multi-component weight loss program delivered by health coaches embedded in primary care clinics. Physical activity was assessed at baseline and at 6, 12, and 24 months of follow-up and changes in body weight were expressed as percent weight change from baseline. Among the sample of 402 patients, percent changes in body weight (mean ± SE) across increasing tertiles of changes in walking between baseline and 24 months were -3.2 ± 1.0%, -5.5 ± 0.9%, and -7.3 ± 0.9%, respectively (p = 0.001). Changes in body weight across increasing tertiles of changes in moderate-to-vigorous-intensity activity between baseline and 24 months were -4.3 ± 1.0%, -5.0 ± 0.9%, and -7.0 ± 0.9%, respectively (p = 0.04). In conclusion, this multi-component intervention resulted in clinically significant weight loss, and greater increases in physical activity over the intervention period were associated with greater percent reductions in body weight. These results are consistent with those from other studies conducted primarily in non-underserved populations.

Mediators of weight change in underserved patients with obesity: exploratory analyses from the Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL) cluster-randomized trial

BACKGROUND

Intensive lifestyle interventions (ILIs) stimulate weight loss in underserved patients with obesity, but the mediators of weight change are unknown.

OBJECTIVES

We aimed to identify the mediators of weight change during an ILI compared with usual care (UC) in underserved patients with obesity.

METHODS

The PROPEL (Promoting Successful Weight Loss in Primary Care in Louisiana) trial randomly assigned 18 clinics (n = 803) to either an ILI or UC for 24 mo. The ILI group received an intensive lifestyle program; the UC group had routine care. Body weight was measured; further, eating behaviors (restraint, disinhibition), dietary intake (percentage fat intake, fruit and vegetable intake), physical activity, and weight- and health-related quality of life constructs were measured through questionnaires. Mediation analyses assessed whether questionnaire variables explained between-group variations in weight change during 2 periods: baseline to month 12 (n = 779) and month 12 to month 24 (n = 767).

RESULTS

The ILI induced greater weight loss at month 12 compared with UC (between-group difference: -7.19 kg; 95% CI: -8.43, -6.07 kg). Improvements in disinhibition (-0.33 kg; 95% CI: -0.55, -0.10 kg), percentage fat intake (-0.25 kg; 95% CI: -0.50, -0.01 kg), physical activity (-0.26 kg; 95% CI: -0.41, -0.09 kg), and subjective fatigue (-0.28 kg; 95% CI: -0.46, -0.10 kg) at month 6 during the ILI partially explained this between-group difference. Greater weight loss occurred in the ILI at month 24, yet the ILI group gained 2.24 kg (95% CI: 1.32, 3.26 kg) compared with UC from month 12 to month 24. Change in fruit and vegetable intake (0.13 kg; 95% CI: 0.05, 0.21 kg) partially explained this response, and no variables attenuated the weight regain of the ILI group.

CONCLUSIONS

In an underserved sample, weight change induced by an ILI compared with UC was mediated by several psychological and behavioral variables. These findings could help refine weight management regimens in underserved patients with obesity.This trial was registered at clinicaltrials.gov as NCT02561221.

Intraclass correlation coefficients for weight loss cluster randomized trials in primary care: The PROPEL trial

The aim of this study was to compute intra-class correlations (ICCs) for weight-related and patient-reported outcomes in a cluster randomized clinical trial (cRCT) for weight loss. Baseline and follow-up data from the Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL) cRCT were used in this analysis. ICCs were computed for baseline and follow-up measures, and changes in body weight, cardiometabolic risk factors and health-related and weight-related quality of life at 6, 12, 18 and 24 months. Baseline ICCs ranged from 0 for PROMIS measures of anxiety and fatigue to 0.055 for total cholesterol (median = 0.019). The ICCs were higher for changes and decreased over time during follow-up. The ICCs for changes were highest in the pooled sample (intervention and usual care combined) followed by the intervention and usual care groups, respectively. The results demonstrated significant ICCs for several outcomes in a weight loss cRCT. The ICCs differed in magnitude depending on whether baseline versus longitudinal data were used, whether data were combined across treatment arms or were considered separately, and varied across the follow-up period. All these factors must be considered when choosing an ICC to inform sample size estimates for future weight loss cRCTs conducted in primary care settings.

A Randomized Controlled Trial to Address Consumer Food Waste with a Technology-aided Tailored Sustainability Intervention

There is growing concern whether pro-environmental behavioral interventions can generate sufficient reductions in carbon emissions to address climate change. While many have suggested enhanced tailoring of interventions to increase effect sizes, and while individual tailoring is common among health interventions, little is known about how individual tailoring may impact effect sizes for pro-environmental behavioral interventions. Using a novel technology-aided delivery and measurement approach, we conduct a randomized controlled trial featuring an individually tailored intervention focused on reducing the amount of food wasted by participants over approximately one week in their normal living conditions. We find large significant effects for the focal area of food wasted during dining (a 79% reduction), a null effect on food wasted over all household stages (preparation, dining and clean outs), and desirable or null effects for critical antecedent (e.g., waste during preparation, continued purchases of fresh produce), concurrent (e.g., food selection and consumption), and attendant behaviors (e.g., waste from storage clean outs, avoiding waste deposits in landfills).

Assessing initial validity of the PortionSize app to estimate dietary intake among adults: A pilot and feasibility study (Preprint)

Background

Accurately assessing dietary intake can promote improved nutrition. The PortionSize app (Pennington Biomedical Research Center) was designed to quantify and provide real-time feedback on the intake of energy, food groups, saturated fat, and added sugar.

Objective

This study aimed to assess the preliminary feasibility and validity of estimating food intake via the PortionSize app among adults.

Methods

A total of 15 adults (aged 18-65 years) were recruited and trained to quantify the food intake from a simulated meal by using PortionSize. Trained personnel prepared 15 simulated meals and covertly weighed (weigh back) the amount of food provided to participants as well as food waste. Equivalence tests (±25% bounds) were performed to compare PortionSize to the weigh back method.

Results

Participants were aged a mean of 28 (SD 12) years, and 11 were female. The mean energy intake estimated with PortionSize was 742.9 (SD 328.2) kcal, and that estimated via weigh back was 659.3 (SD 190.7) kcal (energy intake difference: mean 83.5, SD 287.5 kcal). The methods were not equivalent in estimating energy intake (P=.18), and PortionSize overestimated energy intake by 83.5 kcal (12.7%) at the meal level. Estimates of portion sizes (gram weight; P=.01), total sugar (P=.049), fruit servings (P=.01), and dairy servings (P=.047) from PortionSize were equivalent to those estimated via weigh back. PortionSize was not equivalent to weigh back with regard to estimates for carbohydrate (P=.10), fat (P=.32), vegetable (P=.37), grain (P=.31), and protein servings (P=.87).

Conclusions

Due to power limitations, the equivalence tests had large equivalence bounds. Though preliminary, the results of this small pilot study warrant the further adaptation, development, and validation of PortionSize as a means to estimate energy intake and provide users with real-time and actionable dietary feedback.

Weight loss in primary care: A pooled analysis of two pragmatic cluster-randomized trials

OBJECTIVE

The aim of this study was to report the results of five weight-loss interventions in primary care settings in underserved patients and to compare the level of pragmatism across the interventions using the Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) tool.

METHODS

Data from 54 primary care clinics (2,210 patients) were pooled from the Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL) and Rural Engagement in Primary Care for Optimizing Weight Reduction (REPOWER) cluster-randomized trials. Clinics were randomized to one of five comparators: PROPEL usual care, PROPEL combination of in-clinic and telephone visits, REPOWER in-clinic individual visits, REPOWER in-clinic group visits, or REPOWER telephone group visits.

RESULTS

At 24 months, weight loss (kilograms) was -0.50 (95% CI: -1.77 to 0.76), -3.05 (-4.10 to -2.01), -4.30 (-5.35 to -3.26), -4.79 (-5.83 to -3.75), and -4.80 (-5.96 to -3.64) in the PROPEL usual care, REPOWER in-clinic individual visits, REPOWER telephone group visits, REPOWER in-clinic group visits, and PROPEL in-clinic and telephone visits arms, respectively. At 24 months, percentage of weight loss was -0.360 (-1.60 to 0.88), -3.00 (-4.02 to -1.98), -4.23 (-5.25 to -3.20), -4.67 (-5.69 to -3.65), and -4.69 (-5.82 to -3.56), respectively, in the five arms. The REPOWER in-clinic individual visits intervention was the most pragmatic and reflects the current Centers for Medicare and Medicaid Services funding model, although this intervention produced the least weight loss.

CONCLUSIONS

Clinically significant weight loss over 6 months in primary care settings is achievable using a variety of lifestyle-based treatment approaches. Longer-term weight-loss maintenance is more difficult to achieve.

Initial Weight Change and Long-Term Changes in Weight and Compensation during Supervised Exercise Training

INTRODUCTION

Our primary aim was to investigate the association between initial weight change and longer-term changes in weight and compensation (predicted weight loss-observed weight loss) during exercise. As secondary aims, we investigated if initial weight change was related to change in cardiometabolic risk markers and energy balance modulators.

METHODS

Two 6-month randomized controlled exercise trials conducted in individuals with overweight or obesity were analyzed (study 1, n = 312; study 2, n = 102). In both studies, participants in an exercise condition (4 kcal·kg-1·wk-1 [KKW], 8 KKW, 12 KKW, or 20 KKW) were split into tertiles based on percent weight change from baseline to week 4. Tertiles 1 and 3 exhibited the least and most initial weight loss, respectively. Changes in end points were compared between tertiles.

RESULTS

At month 6, weight loss was lower in tertile 1 than tertile 3 (study 1: -3.6%, 95% confidence interval [CI] = -4.6 to -2.6; study 2: -1.8%, 95% CI = -3.1 to -0.4; P ≤ 0.034). Tertile 1 also showed greater compensation than tertile 3 in study 1 (3.0 kg, 95% CI = 2.2 to 3.9) and study 2 (1.5 kg, 95% CI = 0.3 to 2.6; P ≤ 0.048). Changes in triglycerides and, in study 1, HDL cholesterol were less favorable in tertile 1 versus tertile 3 (P ≤ 0.043); however, changes in other cardiometabolic markers were similar (P ≥ 0.209). In study 2, tertile 1 increased energy intake and exhibited maladaptive changes in eating behaviors relative to tertile 3 (P < 0.050). No between-tertile differences in cumulative exercise energy expenditure and physical activity were evident (P ≥ 0.321).

CONCLUSIONS

Less initial weight loss was associated with longer-term attenuated weight loss and greater compensation during aerobic exercise training. Individuals who display less initial weight loss during exercise may require early interventions to decrease compensation and facilitate weight loss.

Meal composition during an ad libitum buffet meal and longitudinal predictions of weight and percent body fat change: The role of hyper-palatable, energy dense, and ultra-processed foods

BACKGROUND

Foods that increase obesity risk are ubiquitous in the US food environment. Such foods may be the target of hedonic eating, which may facilitate weight gain and lead to obesity. The study tested whether meal composition during an ad libitum buffet meal was associated with 1-year weight and percent body fat changes among healthy younger adults without obesity. Hyper-palatable foods (HPF) were the study focus; comparisons were conducted with high energy dense (HED) and ultra-processed foods (UPF).

DESIGN

Younger adults without obesity (N = 82; 43% male; mean age 26.8) completed an ad libitum buffet meal and provided body composition measurements at baseline and 1-year follow up. Multiple regression models tested associations between the proportion of the target food consumed (HPF, HED, or UPF) during the ad libitum meal and 1) weight change and 2) percent body fat change. The proportion of HPF was characterized by HPF group, specifically carbohydrate and sodium (CSOD) foods or fat and sodium (FSOD) foods.

RESULTS

Participants who consumed a greater proportion of CSOD HPF in their ad libitum buffet meals had significantly greater weight change (b = 0.354, p = .003) and percent body fat change (b = 0.247, p = .036) at 1-year follow up. In contrast, no significant associations were found between the proportion of FSOD HPF, HED, or UPF consumed and anthropometric outcomes (p values = .099-.938).

CONCLUSIONS

Eating a greater proportion of hyper-palatable CSOD foods ad libitum appears to be a pattern of hedonic eating, which may increase an individual's risk for weight and body fat gain in early adulthood.

A Systematic Review of Dietary Supplements and Alternative Therapies for Weight Loss

OBJECTIVE

Dietary supplements and alternative therapies are commercialized as a panacea for obesity/weight gain as a result of the minimal regulatory requirements in demonstrating efficacy. These products may indirectly undermine the value of guideline-driven obesity treatments. Included in this study is a systematic review of the literature of purported dietary supplements and alternative therapies for weight loss.

METHODS

A systematic review was conducted to evaluate the efficacy of dietary supplements and alternative therapies for weight loss in participants aged ≥18 years. Searches of Medline (PubMed), Cochrane Library, Web of Science, CINAHL, and Embase (Ovid) were conducted. Risk of bias and results were summarized qualitatively.

RESULTS

Of the 20,504 citations retrieved in the database search, 1,743 full-text articles were reviewed, 315 of which were randomized controlled trials evaluating the efficacy of 14 purported dietary supplements, therapies, or a combination thereof. Risk of bias and sufficiency of data varied widely. Few studies (n = 52 [16.5%]) were classified as low risk and sufficient to support efficacy. Of these, only 16 (31%) noted significant pre/post intergroup differences in weight (range: 0.3-4.93 kg).

CONCLUSIONS

Dietary supplements and alternative therapies for weight loss have a limited high-quality evidence base of efficacy. Practitioners and patients should be aware of the scientific evidence of claims before recommending use.

The effects of the form of sugar (solid vs. beverage) on body weight and fMRI activation: A randomized controlled pilot study

Objective

To test if sugar sweetened beverages (SSBs) and sugar sweetened solids (SSSs) have differential effects on body weight and reward processing in the brain.

Methods

In a single blind randomized controlled pilot trial (RCT), twenty participants with BMI between 20 and 40 kg/m² were randomized to consume a 20 fluid ounce soda (SSB, 248 kcal) or the equivalent in solid form (SSS; similar to thick gelatin or gummy candy) daily. At baseline and day 28, fasting body weight and fed-state BOLD fMRI of the brain were assessed. Differences in fMRI signals between views of low-fat (LF (<30%)) high sugar (HS (>30%)) food, and non-food images were calculated in brain regions implicated in energy homeostasis, taste, and reward.

Results

All participants in the SSB (6F 4M; 8 Caucasian; 36±14 y, 28.2±5.5 kg/m²; Mean±SD) and SSS (3F 7M; 6 Caucasian; 39±12; 26.3±4.4) groups completed the study. Weight change was 0.27±0.78 kg between SSB and SSS participants. Changes in the fMRI response to LF/HS foods in reward, homeostatic and taste regions tended to not be different between the groups over the four weeks. However, activation of the right substantia nigra increased following the SSB but decreased activation following the SSS in response to LF/HS foods over 28 days (-0.32±0.12). Ratings of wanting for LF/HS foods were correlated with activation in several brain regions, including the OFC.

Conclusions

Change in weight was modest between the groups in this study. Daily consumption of a SSB over 28 days led to mixed responses to LF/HS foods in areas of the brain associated with reward. Ratings of wanting are correlated with fMRI activation inside an MRI scanner.

Effects of a 2-Year Primary Care Lifestyle Intervention on Cardiometabolic Risk Factors: A Cluster-Randomized Trial

BACKGROUND

Intensive lifestyle interventions (ILIs) are the first-line approach to effectively treat obesity and manage associated cardiometabolic risk factors. Because few people have access to ILIs in academic health centers, primary care must implement similar approaches for a meaningful effect on obesity and cardiometabolic disease prevalence. To date, however, effective lifestyle-based obesity treatment in primary care is limited. We examined the effectiveness of a pragmatic ILI for weight loss delivered in primary care among a racially diverse, low-income population with obesity for improving cardiometabolic risk factors over 24 months.

METHODS

The PROPEL trial (Promoting Successful Weight Loss in Primary Care in Louisiana) randomly allocated 18 clinics equally to usual care or an ILI and subsequently enrolled 803 (351 usual care, 452 ILI) adults (67% Black, 84% female) with obesity from participating clinics. The usual care group continued to receive their normal primary care. The ILI group received a 24-month high-intensity lifestyle-based obesity treatment program, embedded in the clinic setting and delivered by health coaches in weekly sessions initially and monthly sessions in months 7 through 24.

RESULTS

As recently demonstrated, participants receiving the PROPEL ILI lost significantly more weight over 24 months than those receiving usual care (mean difference, -4.51% [95% CI, -5.93 to -3.10]; P<0.01). Fasting glucose decreased more in the ILI group compared with the usual care group at 12 months (mean difference, -7.1 mg/dL [95% CI, -12.0 to -2.1]; P<0.01) but not 24 months (mean difference, -0.8 mg/dL [95% CI, -6.2 to 4.6]; P=0.76). Increases in high-density lipoprotein cholesterol were greater in the ILI than in the usual care group at both time points (mean difference at 24 months, 4.6 mg/dL [95% CI, 2.9-6.3]; P<0.01). Total:high-density lipoprotein cholesterol ratio and metabolic syndrome severity (z score) decreased more in the ILI group than in the usual care group at both time points, with significant mean differences of the change of -0.31 (95% CI, -0.47 to -0.14; P<0.01) and -0.21 (95% CI, -0.36 to -0.06; P=0.01) at 24 months, respectively. Changes in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and blood pressure did not differ significantly between groups at any time point.

CONCLUSIONS

A pragmatic ILI consistent with national guidelines and delivered by trained health coaches in primary care produced clinically relevant improvements in cardiometabolic health in an underserved population over 24 months. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02561221.

Digital Tools to Support Family-Based Weight Management for Children: Mixed Methods Pilot and Feasibility Study

BACKGROUND

Family-based behavioral therapy is an efficacious approach to deliver weight management counseling to children and their parents. However, most families do not have access to in-person, evidence-based treatment. We previously developed and tested DRIVE (Developing Relationships that Include Values of Eating and Exercise), a home-based parent training program to maintain body weight among children at risk for obesity, with the intent to eventually disseminate it nationally alongside SafeCare, a parent support program that focuses on parent-child interactions. Currently the DRIVE program has only been tested independently of SafeCare. This study created the "mHealth DRIVE" program by further adapting DRIVE to incorporate digital and mobile health tools, including remotely delivered sessions, a wireless scale that enabled a child-tailored weight graph, and a pedometer. Telehealth delivery via mHealth platforms and other digital tools can improve program cost-effectiveness, deliver long-term care, and directly support both families and care providers.

OBJECTIVE

The objective of this study was to examine preliminary acceptability and effectiveness of the mHealth DRIVE program among children and parents who received it and among SafeCare providers who potentially could deliver it.

METHODS

Study 1 was a 13-week pilot study of a remotely delivered mHealth family-based weight management program. Satisfaction surveys were administered, and height and weight were measured pre- and post-study. Study 2 was a feasibility/acceptability survey administered to SafeCare providers.

RESULTS

Parental and child satisfaction (mean of 4.9/6.0 and 3.8/5.0, respectively) were high, and children's (N=10) BMI z-scores significantly decreased (mean -0.14, SD 0.17; P=.025). Over 90% of SafeCare providers (N=74) indicated that SafeCare families would benefit from learning how to eat healthily and be more active, and 80% of providers reported that they and the families would benefit from digital tools to support child weight management.

CONCLUSIONS

Pediatric mHealth weight management interventions show promise for effectiveness and acceptability by families and providers.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03297541, https://clinicaltrials.gov/ct2/show/NCT03297541.

Diet quality, weight loss, and diabetes incidence in the Diabetes Prevention Program (DPP)

BACKGROUND

We evaluated whether diet quality is a predictor of weight loss and reduced diabetes risk, independent of caloric intake in the Diabetes Prevention Program (DPP) cohort, a randomized clinical trial of adults at risk for diabetes.

METHODS

This secondary analysis included 2914 participants with available data (964 intensive lifestyle (ILS), 977 metformin, 973 placebo). Dietary intake was assessed using a 117-item food frequency questionnaire. Diet quality was quantified using the Alternative Healthy Eating Index 2010 (AHEI). AHEI ranges from 0 to 110, with higher scores corresponding to higher quality diets. ILS participants had greater improvement (p < 0.001) in AHEI over 1-year (4.2 ± 9.0) compared to metformin (1.2 ± 8.5) and placebo (1.4 ± 8.4). We examined the association between AHEI change and weight change from baseline to 1-year using linear regression, and that between 1-year AHEI change and incident diabetes, using hazard models over an average 3 years follow-up. Models were evaluated within treatment group and adjusted for relevant characteristics including caloric intake, physical activity, BMI and AHEI. Models testing incident diabetes were further adjusted for baseline fasting and 2 h glucose.

RESULTS

An increase in AHEI score was associated with weight loss in ILS [β per 10-point increase (SE) -1.2 kg (0.3, p < 0.001)], metformin [- 0. 90 kg (0.2, p < 0.001)] and placebo [- 0.55 kg (0.2, p = 0.01)]. However, AHEI change was not associated with incident diabetes in any group before or after adjustment for weight change.

CONCLUSIONS

Controlling for weight, diet quality was not associated with diabetes incidence but helps achieve weight loss, an important factor in diabetes prevention.

The Design of a Randomized Clinical Trial to Evaluate a Pragmatic and Scalable eHealth Intervention for the Management of Gestational Weight Gain in Low-Income Women: Protocol for the SmartMoms in WIC Trial

BACKGROUND

Less than one-third of women gain an appropriate amount of weight during pregnancy, which can influence the long-term health of both the mother and the child. Economically disadvantaged women are the most vulnerable to maternal obesity, excessive weight gain during pregnancy, and poor birth outcomes. Effective and scalable health care strategies to promote healthy weight gain during pregnancy specifically tailored for these women are lacking.

OBJECTIVE

This paper presents the design and protocol of a biphasic, community-based eHealth trial, SmartMoms in WIC, to increase the adherence to healthy gestational weight gain (GWG) recommendations in low-income mothers receiving women, infant, and children (WIC) benefits.

METHODS

Phase 1 of the trial included using feedback from WIC mothers and staff and participants from 2 community peer advisory groups to adapt an existing eHealth gestational weight management intervention to meet the needs of women receiving WIC benefits. The health curriculum, the format of delivery, and incentive strategies were adapted to be culturally relevant and at an appropriate level of health literacy. Phase 2 included a pragmatic randomized controlled trial across the 9 health care regions in Louisiana with the goal of enrolling 432 women. The SmartMoms in WIC intervention is an intensive 24-week behavioral intervention, which includes nutrition education and exercise strategies, and provides the technology to assist with weight management, delivered through a professionally produced website application.

RESULTS

Phase 1 of this trial was completed in July 2019, and recruitment for phase 2 began immediately thereafter. All data are anticipated to be collected by Spring 2023.

CONCLUSIONS

The SmartMoms in WIC curriculum was methodically developed using feedback from community-based peer advisory groups to create a culturally relevant, mobile behavioral intervention for mothers receiving WIC benefits. The randomized clinical trial is underway to test the effectiveness of a sustainable eHealth program on the incidence rates of appropriate GWG. SmartMoms in WIC may be able to offer an innovative, cost-effective, and scalable solution for GWG management in women served by WIC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04028843; https://clinicaltrials.gov/ct2/show/NCT04028843.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18211.

Selection, intake, and plate waste patterns of leftover food items among U.S. consumers: A pilot study

Many campaigns promote the preservation and consumption of leftover food items as a critical household strategy to accomplish national consumer food waste reduction goals. We fill a gap in knowledge about the consumption and creation of leftovers in the United States by analyzing data from a pilot study in which 18 subjects tracked food selection, intake, and plate waste across all eating occasions for about one week. Subjects noted which items selected for consumption were leftovers, i.e., previously prepared but uneaten items that were stored for future consumption, and which unfinished items were saved to become leftovers. We found that 12% of items selected for consumption were leftovers while 24% of selected items that were not fully consumed were kept to become a leftover. Leftovers were most frequently vegetables, cheeses, and meats, and most frequently selected on Mondays and for lunch. Regression analyses isolate significant dining patterns with respect to leftovers, including evidence that leftovers were less likely to be fully consumed than non-leftover items, and that larger meals led to more uneaten food. This suggests that strategies to reduce meal size may be most effective in reducing food waste by limiting the creation of leftovers in the first place. Strategies to make leftovers more attractive and appealing may also reduce food waste.

Weight Loss in Underserved Patients - A Cluster-Randomized Trial

BACKGROUND

Evidence of the effectiveness of treatment for obesity delivered in primary care settings in underserved populations is lacking.

METHODS

We conducted a cluster-randomized trial to test the effectiveness of a high-intensity, lifestyle-based program for obesity treatment delivered in primary care clinics in which a high percentage of the patients were from low-income populations. We randomly assigned 18 clinics to provide patients with either an intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, or usual care. Patients in the intensive-lifestyle group participated in a high-intensity program delivered by health coaches embedded in the clinics. The program consisted of weekly sessions for the first 6 months, followed by monthly sessions for the remaining 18 months. Patients in the usual-care group received standard care from their primary care team. The primary outcome was the percent change from baseline in body weight at 24 months.

RESULTS

All 18 clinics (9 assigned to the intensive program and 9 assigned to usual care) completed 24 months of participation; a median of 40.5 patients were enrolled at each clinic. A total of 803 adults with obesity were enrolled: 452 were assigned to the intensive-lifestyle group, and 351 were assigned to the usual-care group; 67.2% of the patients were Black, and 65.5% had an annual household income of less than $40,000. Of the enrolled patients, 83.4% completed the 24-month trial. The percent weight loss at 24 months was significantly greater in the intensive-lifestyle group (change in body weight, -4.99%; 95% confidence interval [CI], -6.02 to -3.96) than in the usual-care group (-0.48%; 95% CI, -1.57 to 0.61), with a mean between-group difference of -4.51 percentage points (95% CI, -5.93 to -3.10) (P<0.001). There were no significant between-group differences in serious adverse events.

CONCLUSIONS

A high-intensity, lifestyle-based treatment program for obesity delivered in an underserved primary care population resulted in clinically significant weight loss at 24 months. (Funded by the Patient-Centered Outcomes Research Institute and others; PROPEL ClinicalTrials.gov number, NCT02561221.).

The Validity, Time Burden, and User Satisfaction of the FoodImage™ Smartphone App for Food Waste Measurement Versus Diaries: A Randomized Crossover Trial

The FoodImage™ smartphone app transmits to researchers users' photographs of food selection and food waste, and includes user-tagged information about waste reasons and destination. Twenty-four participants were trained to record food waste using FoodImage, food waste diaries requiring visual estimation of waste quantities, and diaries requiring scale weights. Participants used each method during three staged food-waste scenarios (food preparation, eating, and clean-out) in a randomized crossover trial. Two participants had extreme values for the weighed diary method; therefore, accuracy results are reported with and without these two participants' data. Error was calculated as waste estimated with the experimental method minus directly weighed waste. Mean absolute error from FoodImage was significantly smaller than or equal to the error from both diary methods in each scenario. Furthermore, the mean values from FoodImage were equivalent to directly weighed values in two out of the three tasks; while weighed diaries were equivalent in two tasks only when the two participants with extreme values were removed. Visually estimated diaries were equivalent for only one task. All 24 participants preferred FoodImage to diaries and all rated FoodImage as less time consuming. Over one week, FoodImage would require ~24 fewer minutes of users' time to record all data. Unlike food waste diaries, FoodImage also transmits data to researchers in real-time and provides detailed data on food selection and intake. ClinicalTrials.gov Identifier: NCT03309306.

Unpacking the Decline in Food Waste Measured in Chinese Households from 1991 to 2009

Food waste reduction is an explicit goal for many countries, yet a paucity of highquality primary measurements of food waste are available to inform policy. We analyze repeated physical measurements of discarded food from more than 37,000 households enrolled in the China Health and Nutrition Survey (CHNS) from 1991 to 2009 and describe relevant food waste patterns and trends within households over a period of dramatic change. Over a period in which average real household incomes tripled, food discarded per person declined by about 20% on a quantity basis and by about 40% on a Calorie basis during the study, with an estimated annual per capita household waste of 14.9 kg in 2009. Comparing across households within narrower periods of the data, we find changing associations between income and food waste, with a weakly negative association during the 1990s and a significant positive association during the 2000s. Carbohydrates, particularly grains and vegetables and fruits, experienced the greatest reduction in waste. Food waste reduction rates over the study period were greatest among small households and rural households. Certain characteristics were associated with higher per person waste levels throughout the study period, including rural residence, intense physical activity levels, and a lack of home refrigeration.

Effect of 2 years of calorie restriction on liver biomarkers: results from the CALERIE phase 2 randomized controlled trial

PURPOSE

Calorie restriction (CR) is an effective treatment for obesity-related liver and metabolic disease. However, CR studies in individuals without obesity are needed to see if CR could delay disease onset. Liver biomarkers indicate hepatic health and are linked to cardiometabolic disease. Our aim was to examine the effects of a 2-year CR intervention on liver biomarkers in healthy individuals without obesity.

METHODS

The Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy (CALERIE) study was a 2-year randomized controlled trial. Overall, 218 participants (body mass index: 25.1 ± 1.7 kg/m²) were enrolled into a control group (n = 75) that ate ad libitum (AL), or a CR group (n = 143) that aimed to decrease energy intake by 25%. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), and bilirubin were measured during the trial.

RESULTS

At month 24, relative to the AL group, ALP (- 7 ± 1 IU/L; P < 0.01) and GGT (- 0.11 ± 0.04 log IU/L; P = 0.02) decreased and bilirubin increased (0.21 ± 0.06 log mg/dL; P < 0.01) in the CR group; no between-group differences in ALT (- 1 ± 1 IU/L; P > 0.99) or AST (2 ± 2 IU/L; P = 0.68) were revealed. However, sex-by-treatment-by-time interactions (P < 0.01) were observed, with CR (vs. control) inducing reduced ALT and GGT and increased AST in men only (P ≤ 0.02).

CONCLUSIONS

In metabolically healthy individuals without obesity, 2 years of CR improves several liver biomarkers, with potentially greater improvements in men. These data suggest that sustained CR may improve long-term liver and metabolic disease risk in healthy adults.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT00427193). Registered January 2007.

Adaptations to exercise in compensators and noncompensators in the E-MECHANIC Trial

Rating of perceived exertion (RPE) and respiratory exchange ratio (RER) have previously been associated with acute exercise compensation. This study examined adaptations in the RPE and RER with long-term exercise training in individuals who did (noncompensators) and did not (compensators) lose the expected amount of weight. Participants (n = 110, 71.8% women, means ± SD; age 49 ± 12 yr) completed 24 wk of supervised exercise training at 65-85% V̇o_2peak to achieve a prescribed dose of 8 kcal·kg body wt^-1·wk^-1 (8 KKW) or 20 KKW. Participants were categorized as noncompensators (n = 55) or compensators (n = 55) based on the percent of expected weight loss (%EWL) achieved. Changes in RPE and RER during exercise over time (baseline, week 12, week 24) were compared by weight compensation category. Individual %EWL in relation to RPE, RER, and training intensity (%V̇o_2peak) was evaluated over the same time period. RPE and RER for a given workload decreased from baseline to week 12 and stabilized through week 24, regardless of weight compensation (time P < 0.0001). Noncompensators had a higher RPE relative to heart rate, which was partly explained by higher %V̇o_2peak. RPE and %V̇o_2peak both positively predicted %EWL, independent of age, sex, and exercise dose. Training intensity and RPE were positively associated with weight loss on the individual level, warranting further investigation into self-selection in exercise-based programs. Understanding individual heterogeneity in training intensity and behavioral responses may improve future weight management efforts that involve exercise.NEW & NOTEWORTHY In sedentary individuals with overweight and obesity, achievement of expected weight loss from long-term exercise training was associated with individual adaptations in perceived exertion. Contrary to our hypothesis, those with higher relative perceived exertion achieved a larger proportion of their expected weight loss, which was partly explained by a higher self-selected exercise training intensity.

Baseline Habitual Physical Activity Predicts Weight Loss, Weight Compensation, and Energy Intake During Aerobic Exercise

OBJECTIVE

This study aimed to determine whether different measures of habitual physical activity (PA) at baseline predict weight change, weight compensation, and changes in energy intake (EI) during a 24-week supervised aerobic exercise intervention.

METHODS

Data from 108 participants (78 women; 48.7 [SD: 11.6] years; BMI 31.4 [SD: 4.6] kg/m² ), randomly assigned to either the moderate-dose exercise group (8 kcal/kg of body weight per week) or the high-dose exercise group (20 kcal/kg of body weight per week) of the Examination of Mechanisms of Exercise-induced Weight Compensation (E-MECHANIC) trial, were analyzed. Moderate-to-vigorous PA (MVPA), steps per day, and PA energy expenditure (PAEE) were measured with SenseWear armbands (BodyMedia, Pittsburgh, Pennsylvania), and total activity energy expenditure and EI were estimated with doubly labeled water, all over 2 weeks, before and toward the end of the intervention. Multiple linear regression models, adjusted for sex, exercise group, and baseline value of the outcome, were used.

RESULTS

Baseline habitual MVPA levels predicted weight change (β = -0.275; P = 0.020), weight compensation (β = -0.238; P = 0.043), and change in EI (β = -0.318; P = 0.001). Associations between baseline PAEE and outcomes were comparable, whereas steps per day and, importantly, total activity energy expenditure (via doubly labeled water) did not significantly predict change in weight-related outcomes.

CONCLUSIONS

While acknowledging substantial variability in the data, on average, lower baseline habitual MVPA and PAEE levels were associated with less weight loss from exercise, higher compensation, and increased EI.

Change in self-efficacy, eating behaviors and food cravings during two years of calorie restriction in humans without obesity

Calorie restriction (CR) enhances longevity in humans who are normal weight, overweight and obese. While dietary regimens can change self-efficacy, eating behaviors, and food cravings in individuals with obesity, the responses of these measures to prolonged CR in individuals who are exclusively not obese is unknown. The aim of this analysis was to test the effects of a two-year CR intervention on self-efficacy and eating attitudes and behaviors in humans without obesity by analyzing data from the Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy Phase 2 (CALERIE 2) study. Participants (n = 218, BMI range = 21.3-29.0 kg/m2) were randomized to a 25% CR group or an ad libitum (AL) group. Eating attitudes and behaviors and self-efficacy were assessed using validated questionnaires at baseline, month 12, and month 24. Dietary restraint and self-efficacy increased in the CR compared to the AL group (ES ≥ 0.32). Increased self-efficacy was negatively related to weight change (ρ < -0.24). In the CR group, males showed a reduction in cravings for carbohydrates and fats at month 24, whereas females did not. The CR group showed elevations in state hunger, which were transient, and disinhibited eating (ES ≥ 0.37). In individuals without obesity, dietary restraint and self-efficacy could be important in promoting long-term CR for individuals looking to use CR as a tool to improve longevity.

Effect of different doses of supervised exercise on food intake, metabolism, and non-exercise physical activity: The E-MECHANIC randomized controlled trial

BACKGROUND

Exercise is recommended for weight management, yet exercise produces less weight loss than expected, which is called weight compensation. The mechanisms for weight compensation are unclear.

OBJECTIVE

The aim of this study was to identify the mechanisms responsible for compensation.

METHODS

In a randomized controlled trial conducted at an academic research center, adults (n = 198) with overweight or obesity were randomized for 24 wk to a no-exercise control group or 1 of 2 supervised exercise groups: 8 kcal/kg of body weight/wk (KKW) or 20 KKW. Outcome assessment occurred at weeks 0 and 24. Energy intake, activity, and resting metabolic rate (RMR) were measured with doubly labeled water (DLW; with and without adjustments for change in RMR), armband accelerometers, and indirect calorimetry, respectively. Appetite and compensatory health beliefs were measured by self-report.

RESULTS

A per-protocol analysis included 171 participants (72.5% women; mean ± SD baseline body mass index: 31.5 ± 4.7 kg/m2). Significant (P < 0.01) compensation occurred in the 8 KKW (mean: 1.5 kg; 95% CI: 0.9, 2.2 kg) and 20 KKW (mean: 2.7 kg; 95% CI: 2.0, 3.5 kg) groups, and compensation differed significantly between the exercise groups (P = 0.01). Energy intake by adjusted DLW increased significantly (P < 0.05) in the 8 KKW (mean: 90.7 kcal/d; 95% CI: 35.1, 146.4 kcal/d) and 20 KKW (mean: 123.6 kcal/d; 95% CI: 64.5, 182.7 kcal/d) groups compared with control (mean: -2.3 kcal/d; 95% CI: -58.0, 53.5 kcal/d). Results were similar without DLW adjustment. RMR and physical activity (excluding structured exercise) did not differentially change among the 3 groups. Participants with higher compared with lower compensation reported increased appetite ratings and beliefs that healthy behaviors can compensate for unhealthy behaviors. Furthermore, they increased craving for sweet foods, increased sleep disturbance, and had worsening bodily pain.

CONCLUSIONS

Compensation resulted from increased energy intake and concomitant increases in appetite, which can be treated with dietary or pharmacological interventions. Compensation was not due to activity or metabolic changes. This trial was registered at clinicaltrials.gov as NCT01264406.

Racial Variations in Appetite-Related Hormones, Appetite, and Laboratory-Based Energy Intake from the E-MECHANIC Randomized Clinical Trial

African Americans (AAs) have a higher obesity risk than Whites; however, it is unclear if appetite-related hormones and food intake are implicated. We examined differences in appetite-related hormones, appetite, and food intake between AAs (n = 53) and Whites (n = 111) with overweight or obesity. Participants were randomized into a control group or into supervised, controlled exercise groups at 8 kcal/kg of body weight/week (KKW) or 20 KKW. Participants consumed lunch and dinner at baseline and follow-up, with appetite and hormones measured before and after meals (except leptin). At baseline, AAs had lower peptide YY (PYY; p < 0.01) and a blunted elevation in PYY after lunch (p = 0.01), as well as lower ghrelin (p = 0.02) and higher leptin (p < 0.01) compared to Whites. Despite desire to eat being lower and satisfaction being higher in AAs relative to Whites (p ≤ 0.03), no racial differences in food intake were observed. Compared to Whites, leptin increased in the 8 KKW group in AAs (p = 0.01), yet no other race-by-group interactions were evident. Differences in appetite-related hormones between AAs and Whites exist; however, their influence on racial disparities in appetite, food intake, and obesity within this trial was limited.

Cardiovascular Health, Adiposity, and Food Insecurity in an Underserved Population

This study investigated associations between cardiovascular health (CVH), adiposity, and food insecurity by race, sex, and health literacy in a sample of 800 underserved patients with obesity (body mass index [BMI] ≥ 30 kg/m²). CVH was assessed using American Heart Association Life’s Simple 7 (LS7) and adiposity was estimated using BMI and waist circumference (WC). Mixed models including interaction terms between food insecurity and sex, race, and health literacy were analyzed for LS7, BMI, and WC. Stratified models were analyzed as indicated by significant interactions. Mean BMI and WC were 37.3 kg/m² (4.6 SD) and 113.5 cm (12.4 SD), respectively. Among patients, 31% were food insecure and 31% had low health literacy. There were significant positive associations between food insecurity and BMI (p = 0.03) and WC (p = 0.03) in the overall sample. In sex-stratified models, women who were food insecure had higher BMI (p = 0.02) and WC (p = 0.007) than their food secure counterparts. Further, food insecure patients with better health literacy had greater BMI (p = 0.004) and WC (p = 0.007) than their food secure counterparts. Results suggest that adiposity is a greater burden in food insecure patients, which may be an important consideration for obesity treatment in underserved populations.

Efficacy of a Home-Based Parent Training-Focused Weight Management Intervention for Preschool Children: The DRIVE Randomized Controlled Pilot Trial

OBJECTIVES

To pilot-test a home-based parent training intervention aimed at maintaining body weight among children at risk for obesity (> the 75th body mass index percentile).

METHODS

Sixteen parent-child dyads were randomized to a health education or Developing Relationships that Include Values of Eating and Exercise (DRIVE) intervention arm. The DRIVE curriculum was a structured parenting program to promote healthy weight in children by relying on behavioral principles to promote skill acquisition in the family's natural setting. Body weight and waist circumference were measured at baseline and weeks 9 and 19.

RESULTS

Body mass index z-score, body weight, and percent body weight increased in children in the health education arm vs DRIVE at weeks 9 and 19. Body weight, percent body weight, and waist circumference decreased in parents in DRIVE vs the health education arm at week 19, whereas no differences were shown at week 9.

CONCLUSIONS AND IMPLICATIONS

The DRIVE program mitigated weight gain in a small sample of at-risk children and showed promising results in reducing weight in parents. Home-based interventions emphasizing parent-child interactions are indicated as a practical model to deliver weight management in children.

Long-Term Weight Loss With Metformin or Lifestyle Intervention in the Diabetes Prevention Program Outcomes Study

BACKGROUND

Identifying reliable predictors of long-term weight loss (LTWL) could lead to improved weight management.

OBJECTIVE

To identify some predictors of LTWL.

DESIGN

The DPP (Diabetes Prevention Program) was a randomized controlled trial that compared weight loss with metformin, intensive lifestyle intervention (ILS), or placebo. Its Outcomes Study (DPPOS) observed patients after the masked treatment phase ended. (ClinicalTrials.gov: NCT00004992 and NCT00038727).

SETTING

27 DPP and DPPOS clinics.

PARTICIPANTS

Of the 3234 randomly assigned participants, 1066 lost at least 5% of baseline weight in the first year and were followed for 15 years.

MEASUREMENTS

Treatment assignment, personal characteristics, and weight.

RESULTS

After 1 year, 289 (28.5%) participants in the metformin group, 640 (62.6%) in the ILS group, and 137 (13.4%) in the placebo group had lost at least 5% of their weight. After the masked treatment phase ended, the mean weight loss relative to baseline that was maintained between years 6 and 15 was 6.2% (95% CI, 5.2% to 7.2%) in the metformin group, 3.7% (CI, 3.1% to 4.4%) in the ILS group, and 2.8% (CI, 1.3% to 4.4%) in the placebo group. Independent predictors of LTWL included greater weight loss in the first year in all groups, older age and continued metformin use in the metformin group, older age and absence of either diabetes or a family history of diabetes in the ILS group, and higher fasting plasma glucose levels at baseline in the placebo group.

LIMITATION

Post hoc analysis; examination of nonrandomized subsets of randomized groups after year 1.

CONCLUSION

Among persons with weight loss of at least 5% after 1 year, those originally randomly assigned to metformin had the greatest loss during years 6 to 15. Older age and the amount of weight initially lost were the most consistent predictors of LTWL maintenance.

PRIMARY FUNDING SOURCE

National Institutes of Health.

A free-choice high-fat, high-sucrose diet induces hyperphagia, obesity, and cardiovascular dysfunction in female cycling and pregnant rats

The main objective of these studies was to characterize metabolic, body composition, and cardiovascular responses to a free-choice high-fat, high-sucrose diet in female cycling and pregnant rats. In the nonpregnant state, female Sprague-Dawley rats offered a 3-wk free-choice high-fat, high-sucrose diet had greater energy intake, adiposity, serum leptin, and triglyceride concentrations compared with rats fed with standard chow and developed glucose intolerance. In addition, choice-diet-fed rats had larger cardiac ventricular weights, smaller kidney and pancreas weights, and higher blood pressure than chow-fed rats, but they did not exhibit resistance artery endothelial dysfunction. When the free-choice diet continued throughout pregnancy, rats remained hyperphagic, hyperleptinemic, and obese. Choice pregnant rats exhibited uterine artery endothelial dysfunction and had smaller fetuses compared with chow pregnant rats. Pregnancy normalized mean arterial blood pressure and pancreas weights in choice rats. These studies are the first to provide a comprehensive evaluation of free-choice high-fat, high-sucrose diet on metabolic and cardiovascular functions in female rats, extending the previous studies in males to female cycling and pregnant rodents. Free-choice diet may provide a new model of preconceptual maternal obesity to study the role of increased energy intake, individual food components, and preexisting maternal obesity on maternal and offspring physiological responses during pregnancy and after birth.

Maternal Pre-Pregnancy Cardiovascular Risk Factors and Offspring and Grandoffspring Health: Bogalusa Daughters

Both maternal pre-pregnancy body mass index (BMI) and gestational weight gain have been associated with cardiovascular health in the offspring beyond two generations. A total of 274 daughters (aged 12⁻54) of 208 mothers who participated in the Bogalusa Heart Study were interviewed about their reproductive history. Mothers' data was taken from the original study, and cardiovascular measures at the visit prior to pregnancy were correlated with daughter's measures. Maternal pre-pregnancy BMI, skinfold, and waist circumference were examined as a predictor of daughters' blood pressure, lipids, and glucose, as well as a predictor of birthweight and gestational age of grandchildren. Maternal pre-pregnancy BMI was associated with higher blood pressure and lower low-density lipoprotein (LDL) and cholesterol in the daughters. Most maternal cardiometabolic risk factors were not associated with grandchildren's birth outcomes, even though higher cholesterol and LDL was associated with lower gestational age, and higher BMI and skinfold thickness with an increased risk of preterm birth. In this pilot study, some associations were found between maternal adiposity and cardiovascular risk, daughters' cardiovascular risk, and grandchild birth outcomes. Lack of conclusive associations could be due to a true lack of effect, effects being primarily mediated through daughter's BMI, or the low power of the study.

Efficacy of a school-based obesity prevention intervention at reducing added sugar and sodium in children's school lunches: the LA Health randomized controlled trial

BACKGROUND

Decreasing selection and consumption of sodium and added sugars in the school cafeteria setting is important to provide optimal nutrition to children.

OBJECTIVE

The ofjective of this study is to determine whether Louisiana (LA) Health, a school-based obesity prevention intervention, could successfully reduce children's selection and consumption of sodium and added sugars during school lunches vs. the control group.

DESIGN

Food selection, consumption, and plate waste from student lunches (3 consecutive days) in 33 public schools in rural Louisiana were collected and analyzed using the digital photography of foods method at baseline and after a 28-month obesity prevention intervention (LA Health) beginning in 4th-6th grade (87% of children received free or reduced cost lunch). Selection and consumption of energy, added sugar, and sodium was objectively measured using digital photography of foods. Mixed models, including Race and BMI, were used to determine whether change in selection and consumption differed by group.

RESULTS

Sodium decreased for selection (- 233.1 ± 89.4 mg/lunch, p = 0.04) and consumption (- 206.3 ± 65.9, mg/lunch) in the intervention (vs. control) by month 18, and in consumption by month 28 (- 153.5 ± 66.9 mg/lunch, p = 0.03). Change in added sugar consumption decreased in the intervention (vs. control) at month 18 (- 3.7 ± 1.6, p = 0.05) and at month 28 (- 3.5 ± 1.6 tsp/lunch, p = 0.05).

CONCLUSIONS

LA Health decreased the amount of added sugar and sodium selected and consumed, but not plate waste, by month 28. Results highlight the importance of long-term interventions and policies targeting provision and selection to improve dietary patterns in children, with less focus on plate waste.

Food cravings and body weight: a conditioning response

PURPOSE OF REVIEW

To provide current information on interventions that alter food cravings. Specifically, dietary, physical activity, pharmacologic, and bariatric surgery interventions are examined. Lastly, the effects of social determinants and current controversies on food cravings are outlined.

RECENT FINDINGS

Dietary, pharmacologic, and bariatric surgery weight loss interventions decrease food cravings. Physical activity interventions also decrease cravings. There is potential to see differential responses in food cravings in different demographic and socioeconomic groups, but more research is needed.

SUMMARY

Food cravings influence body weight. Food craving reductions are because of reductions in the frequency of consuming craved foods, independent of energy content, but further research is warranted. Most findings continue to support the conditioning model of food cravings.

Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL): Rationale, design and baseline characteristics

Underserved and minority populations suffer from a disproportionately high prevalence of obesity and related comorbidities. Effective obesity treatment programs delivered in primary care that produce significant weight loss are currently lacking. The purpose of this trial is to test the effectiveness of a pragmatic, high intensity lifestyle-based obesity treatment program delivered within primary care among an underserved population. We hypothesize that, relative to patients who receive usual care, patients who receive a high-intensity, health literacy- and culturally-appropriate lifestyle intervention will have greater percent reductions in body weight over 24 months. Eighteen clinics (N = 803 patients) serving low income populations with a high proportion of African Americans in Louisiana were randomized to the intervention or usual car. Patients in the intervention participate in a high-intensity lifestyle program delivered by health coaches employed by an academic health center and embedded in the primary care clinics. The program consists of weekly (16 in-person/6 telephone) sessions in the first six months, followed by sessions held at least monthly for the remaining 18 months. Primary care practitioners in usual care receive information on weight management and the current Centers for Medicare and Medicaid Services reimbursement for obesity treatment. The primary outcome is percent weight loss at 24 months. Secondary outcomes include absolute 24-month changes in body weight, waist circumference, blood pressure, fasting glucose and lipids, health-related quality of life, and weight-related quality of life. The results will provide evidence on the effectiveness of implementing high-intensity lifestyle and obesity counseling in primary care settings among underserved populations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02561221.

Plate waste of adults in the United States measured in free-living conditions

We analyze food-item level data collected from 50 adults from the United States using the Remote Food Photography Method® to provide the first estimates of plate waste gathered from adults across multiple consecutive meals and days in free-living conditions, and during laboratory-based meals with fixed food items and quantities. We find average plate waste in free-living conditions is 5.6 grams (7.7 kcals) per item and that 3.3% of all food selected is returned as plate waste, where the percent waste figure is substantially lower than previously published plate waste estimates gathered primarily from dine-out settings in the United States such as buffets and institutional settings with limited-choice meals (e.g., school cafeterias). Plate waste from the same participants during the laboratory-based meals is significantly higher with an average of 203.2 grams of solid plate waste per meal (531.3 kcals) or 39.1% of the food provided, which is similar to the plate waste percentages found reported in some school cafeteria settings. The amount of plate waste generated in free-living conditions is significantly positively associated with portion size selected for an item. In a multivariate analysis that controls for macronutrient profile, items selected from the vegetables, fats/oils/dressings, and grains categories are associated with significantly greater amounts of plate waste per item. We find no significant associations between free-living plate waste and gender, age, race or body mass index but find that women leave more plate waste in the lab meal where portion sizes are pre-determined by the researcher and similar for all respondents. We discuss possible implications of these findings for programs focused on reducing plate waste and food waste among consumers.

Effects of Increasing Exercise Intensity and Dose on Multiple Measures of HDL (High-Density Lipoprotein) Function

OBJECTIVE

Measures of HDL (high-density lipoprotein) function are associated with cardiovascular disease. However, the effects of regular exercise on these measures is largely unknown. Thus, we examined the effects of different doses of exercise on 3 measures of HDL function in 2 randomized clinical exercise trials.

APPROACH AND RESULTS

Radiolabeled and boron dipyrromethene difluoride-labeled cholesterol efflux capacity and HDL-apoA-I (apolipoprotein A-I) exchange were assessed before and after 6 months of exercise training in 2 cohorts: STRRIDE-PD (Studies of Targeted Risk Reduction Interventions through Defined Exercise, in individuals with Pre-Diabetes; n=106) and E-MECHANIC (Examination of Mechanisms of exercise-induced weight compensation; n=90). STRRIDE-PD participants completed 1 of 4 exercise interventions differing in amount and intensity. E-MECHANIC participants were randomized into 1 of 2 exercise groups (8 or 20 kcal/kg per week) or a control group. HDL-C significantly increased in the high-amount/vigorous-intensity group (3±5 mg/dL; P=0.02) of STRRIDE-PD, whereas no changes in HDL-C were observed in E-MECHANIC. In STRRIDE-PD, global radiolabeled efflux capacity significantly increased 6.2% (SEM, 0.06) in the high-amount/vigorous-intensity group compared with all other STRRIDE-PD groups (range, -2.4 to -8.4%; SEM, 0.06). In E-MECHANIC, non-ABCA1 (ATP-binding cassette transporter A1) radiolabeled efflux significantly increased 5.7% (95% CI, 1.2-10.2%) in the 20 kcal/kg per week group compared with the control group, with no change in the 8 kcal/kg per week group (2.6%; 95% CI, -1.4 to 6.7%). This association was attenuated when adjusting for change in HDL-C. Exercise training did not affect BODIPY-labeled cholesterol efflux capacity or HDL-apoA-I exchange in either study.

CONCLUSIONS

Regular prolonged vigorous exercise improves some but not all measures of HDL function. Future studies are warranted to investigate whether the effects of exercise on cardiovascular disease are mediated in part by improving HDL function.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00962962 and NCT01264406.

Validity of a Digital Diet Estimation Method for Use with Preschool Children

BACKGROUND

The validity of using the Remote Food Photography Method (RFPM) for measuring food intake of minority preschool children's intake is not well documented.

OBJECTIVE

Our aim was to determine the validity of intake estimations made by human raters using the RFPM compared with those obtained by weighing all foods and beverages consumed by 3- to 5-year-old children (weighed method).

DESIGN

We conducted a cross-sectional observational study.

PARTICIPANTS/SETTINGS

A convenience sample of 54 3- to 5-year-old Hispanic and African-American children were observed during a 12-hour period at Baylor Metabolic Research Unit between June 2013 and January 2014.

MAIN OUTCOME MEASURES

All foods/beverages consumed by the children were provided by Baylor research coordinators who took and wirelessly transmitted before-and-after pictures of the trays to trained human raters at the Pennington Biomedical Research Center who estimated grams consumed. Energy and macronutrients were calculated using the Food and Nutrient Database for Dietary Studies or food facts data provided by manufacturers.

STATISTICAL ANALYSES

Paired t test, mean differences, and Bland-Altman limits of agreement were performed.

RESULTS

Compared to the weighed method, the rater method significantly overestimated total intake by 34±71 g (P<0.0001), with a mean percent error of 2.9% (root mean square error=7.1%), and total energy intake by 75±102 kcal (P<0.0001), with a mean percent error of 7.5% (root mean square error=12.3%). The standard error for the macronutrient intakes ranged from 11.0% to 20.2%. The Bland-Altman approach demonstrated a positive slope for the rater method relative to the weighed method for total intake in grams (P=0.006), carbohydrate (P=0.01), and protein (P=0.01) (ie, magnitude of the bias increased with increasing intakes).

CONCLUSIONS

The rater method overestimated total intake in grams and energy in kilocalories in minority preschool children in a well-controlled condition and needs to be further tested in a free-living environment.

The role of fMRI in drug development

Functional magnetic resonance imaging (fMRI) has been known for over a decade to have the potential to greatly enhance the process of developing novel therapeutic drugs for prevalent health conditions. However, the use of fMRI in drug development continues to be relatively limited because of a variety of technical, biological, and strategic barriers that continue to limit progress. Here, we briefly review the roles that fMRI can have in the drug development process and the requirements it must meet to be useful in this setting. We then provide an update on our current understanding of the strengths and limitations of fMRI as a tool for drug developers and recommend activities to enhance its utility.

Perceptual Characterization of the Macronutrient Picture System (MaPS) for Food Image fMRI

Food image fMRI paradigms are used widely for investigating the neural basis of ingestive behavior. However, these paradigms have not been validated in terms of ingestive behavior constructs, engagement of food-relevant neural systems, or test-retest reliability, making the generalizability of study findings unclear. Therefore, we validated the Macronutrient Picture System (MaPS) (McClernon et al., 2013), which includes food images from the six categories represented in the Geiselman Food Preference Questionnaire (FPQ) (Geiselman et al., 1998). Twenty-five healthy young adults (n = 21 female, mean age = 20.6 ± 1.1 years, mean BMI = 22.1 ± 1.9 kg/m²) rated the MaPS images in terms of visual interest, appetitive quality, nutrition, emotional valence, liking, and frequency of consumption, and completed the FPQ. In a second study, 12 individuals (n=8 female, mean age = 25.0 ± 6.5 years, mean BMI = 28.2 ± 8.7 kg/m²) viewed MaPS and control images (vegetables and non-food) during two separate 3T BOLD fMRI scans after fasting overnight. Intuitively, high fat/high sugar (HF/HS) and high fat/high complex carbohydrate (HF/HCCHO) images achieved higher liking and appetitive ratings, and lower nutrition ratings, than low fat/low complex carbohydrate/high protein (LF/LCHO/HP) images on average. Within each food category, FPQ scores correlated strongly with MaPS image liking ratings (p < 0.001). Brain activation differences between viewing images of HF/HS and vegetables, and between HF/HCCHO and vegetables, were seen in several reward-related brain regions (e.g., putamen, insula, and medial frontal gyrus). Intra-individual, inter-scan agreement in a summary measure of brain activation differences in seven reward network regions of interest was high (ICC = 0.61), and was even higher when two distinct sets of food images with matching visual ratings were shown in the two scans (ICC = 0.74). These results suggest that the MaPS provides valid representation of food categories and reliably activates food-reward-relevant neural systems.

Pharmacotherapy for Patients with Obesity

BACKGROUND

Although pharmacotherapy is not the cornerstone of obesity treatment, it is a valuable tool that could be considered for patients who have not had adequate benefit from lifestyle interventions or who have difficulty maintaining initial weight loss over longer periods.

CONTENT

This review focuses on the role of antiobesity drugs, the mechanisms by which the drugs work, potential pharmacological targets in the neural control of food intake and regulation of body weight, the history of antiobesity drugs, a summary of efficacy and safety data from clinical trials, and the clinical application of pharmacotherapy. Currently, 5 approved drug therapies are available in the US for long-term weight management, with only 2 of these meeting the stronger Food and Drug Administration (FDA) criteria of 5% weight loss relative to a placebo after 1 year and others receiving approval based on the categorical criterion of the proportions of patients achieving 5% weight loss. Interpretation of the results of clinical trials conducted before regulatory agency approval is limited by high dropout rates; thus, the results might not be replicable in clinical practice settings. Many patients who are suitable candidates for pharmacotherapy are not using the new drugs due to lack of insurance coverage and high out-of-pocket costs.

SUMMARY

With the availability of 4 new drugs since 2012, clinicians in the US now have more tools for long-term weight management. The quality of pharmacotherapy clinical investigations needs considerable improvement. Future research should focus on examining the mediators and moderators of response.