Symptom prevalence differences of depression as measured by BDI and PHQ scales in the Look AHEAD study

OBJECTIVE

To compare depressive symptomatology as assessed by two frequently used measures, the Beck Depression Inventory (BDI-1A) and Patient Health Questionnaire (PHQ-9).

METHODS

Investigators conducted a cross-sectional secondary analysis of data collected as part of the follow-up observational phase of the Look AHEAD study. Rates of agreement between the BDI-1A and PHQ-9 were calculated, and multivariable logistic regression was used to examine the relationship between differing depression category classifications and demographic factors (ie, age, sex, race/ethnicity) or comorbidities (ie, diabetes control, cardiovascular disease).

RESULTS

A high level of agreement (κ = 0.47, 95% CI (0.43 to 0.50)) was found in the level of depressive symptomatology between the BDI-1A and PHQ-9. Differing classifications (minimal, mild, moderate, and severe) occurred in 16.8% of the sample. Higher scores on the somatic subscale of the BDI-1A were significantly associated with disagreement as were having a history of cardiovascular disease, lower health-related quality of life, and minority racial/ethnic classification.

CONCLUSIONS

Either the BDI-1A or PHQ-9 can be used to assess depressive symptomatology in adults with overweight/obesity and type 2 diabetes. However, further assessment should be considered in those with related somatic symptoms, decreased quality of life, and in racial/ethnic minority populations.

History of Cardiovascular Disease, Intensive Lifestyle Intervention, and Cardiovascular Outcomes in the Look AHEAD Trial

OBJECTIVE

To examine the effects of an intensive lifestyle intervention (ILI) on cardiovascular disease (CVD), the Action for Health in Diabetes (Look AHEAD) trial randomized 5,145 participants with type 2 diabetes and overweight/obesity to a ILI or diabetes support and education. Although the primary outcome did not differ between the groups, there was suggestive evidence of heterogeneity for prespecified baseline CVD history subgroups (interaction P = 0.063). Event rates were higher in the ILI group among those with a CVD history (hazard ratio 1.13 [95% CI: 0.90-1.41]) and lower among those without CVD (hazard ratio 0.86 [95% CI: 0.72-1.02]).

METHODS

This study conducted post hoc analyses of the rates of the primary composite outcome and components, adjudicated cardiovascular death, nonfatal myocardial infarction (MI), stroke, and hospitalization for angina, as well as three secondary composite cardiovascular outcomes.

RESULTS

Interaction P values for the primary and two secondary composites were similar (0.060-0.064). Of components, the interaction was significant for nonfatal MI (P = 0.035). This interaction was not due to confounding by baseline variables, different intervention responses for weight loss and physical fitness, or hypoglycemic events. In those with a CVD history, statin use was high and similar by group. In those without a CVD history, low-density lipoprotein cholesterol levels were higher (P = 0.003) and statin use was lower (P ≤ 0.001) in the ILI group.

CONCLUSIONS

Intervention response heterogeneity was significant for nonfatal MI. Response heterogeneity may need consideration in a CVD-outcome trial design.

Weight-based teasing is associated with gain in BMI and fat mass among children and adolescents at-risk for obesity: A longitudinal study

BACKGROUND

Youths with overweight and obesity report frequent instances of weight-based teasing. However, little is known about the prospective associations between weight-based teasing and changes in body composition among youth.

OBJECTIVE

To assess associations between weight-based teasing and changes in body mass index (BMI) and fat mass in a longitudinal study of youths with, or at-risk for, overweight and obesity.

METHODS

One hundred ten youths with, or at-risk for, overweight participated in a longitudinal observational study. The Perception of Teasing Scale was administered at baseline. Height, weight, and body composition were obtained at baseline and at follow-ups (range: 1-15 years).

RESULTS

Mean age at baseline was 11.8 years; 53% had overweight/obesity; 36% were non-Hispanic Black; 55% were female; mean follow-up from baseline: 8.5 years. Adjusting for covariates and repeated measures of BMI or fat mass, linear mixed models revealed that weight-based teasing was associated with greater gain of BMI and fat mass across the follow-up period (ps ≤ .007). Adjusting for covariates, youths reporting high weight-based teasing (two standard deviations above the mean) experienced a 33% greater gain in BMI (an additional 0.20 kg/m² ) and a 91% greater gain in fat mass (an additional 0.65 kg) per year compared with peers who reported no weight-based teasing.

CONCLUSIONS

Among youths with, and at-risk for, overweight and obesity, weight-based teasing was associated with greater weight and fat gain.

Seven-Year Weight Trajectories and Health Outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) Study

Importance

More information is needed about the durability of weight loss and health improvements after bariatric surgical procedures.

Objective

To examine long-term weight change and health status following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB).

Design, Setting, and Participants

The Longitudinal Assessment of Bariatric Surgery (LABS) study is a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Adults undergoing bariatric surgical procedures as part of clinical care between 2006 and 2009 were recruited and followed up until January 31, 2015. Participants completed presurgery, 6-month, and annual research assessments for up to 7 years.

Main Outcome and Measures

Percentage of weight change from baseline, diabetes, dyslipidemia, and hypertension, determined by physical measures, laboratory testing, and medication use.

Results

Of 2348 participants, 1738 underwent RYGB (74%) and 610 underwent LAGB (26%). For RYBG, the median age was 45 years (range, 19-75 years), the median body mass index (calculated as weight in kilograms divided by height in meters squared) was 47 (range, 34-81), 1389 participants (80%) were women, and 257 participants (15%) were nonwhite. For LAGB, the median age was 48 years (range, 18-78), the body mass index was 44 (range, 33-87), 465 participants (76%) were women, and 63 participants (10%) were nonwhite. Follow-up weights were obtained in 1300 of 1569 (83%) eligible for a year-7 visit. Seven years following RYGB, mean weight loss was 38.2 kg (95% CI, 36.9-39.5), or 28.4% (95% CI, 27.6-29.2) of baseline weight; between years 3 and 7 mean weight regain was 3.9% (95% CI, 3.4-4.4) of baseline weight. Seven years after LAGB, mean weight loss was 18.8 kg (95% CI, 16.3-21.3) or 14.9% (95% CI, 13.1-16.7), with 1.4% (95% CI, 0.4-2.4) regain. Six distinct weight change trajectory patterns for RYGB and 7 for LAGB were identified. Most participants followed trajectories in which weight regain from 3 to 7 years was small relative to year-3 weight loss, but patterns were variable. Compared with baseline, dyslipidemia prevalence was lower 7 years following both procedures; diabetes and hypertension prevalence were lower following RYGB only. Among those with diabetes at baseline (488 of 1723 with RYGB [28%]; 175 of 604 with LAGB [29%]), the proportion in remission at 1, 3, 5, and 7 years were 71.2% (95% CI, 67.0-75.4), 69.4% (95% CI, 65.0-73.8), 64.6% (95% CI, 60.0-69.2), and 60.2% (95% CI, 54.7-65.6), respectively, for RYGB and 30.7% (95% CI, 22.8-38.7), 29.3% (95% CI, 21.6-37.1), 29.2% (95% CI, 21.0-37.4), and 20.3% (95% CI, 9.7-30.9) for LAGB. The incidence of diabetes at all follow-up assessments was less than 1.5% for RYGB. Bariatric reoperations occurred in 14 RYGB and 160 LAGB participants.

Conclusions and Relevance

Following bariatric surgery, different weight loss patterns were observed, but most participants maintained much of their weight loss with variable fluctuations over the long term. There was some decline in diabetes remission over time, but the incidence of new cases is low following RYGB.

Trial Registration

clinicaltrials.gov Identifier: NCT00465829.

Relationships of Trait Anxiety and Loss of Control Eating with Serum Leptin Concentrations among Youth

Loss of control (LOC) eating in youth is associated with elevated fasting serum leptin, even after accounting for adiposity. Anxiety is closely linked to, and may exacerbate, LOC eating. Yet, it remains unclear how anxiety relates to leptin, or if the relationship is moderated by the presence of LOC eating. We examined whether self-reported trait anxiety interacted with LOC eating in relation to leptin in a convenience sample of youths (n = 592; 13.1 ± 2.7 years; body mass index z-score (BMIz) = 0.9 ± 1.1; 61.8% girls; 53.5% non-Hispanic White; 36.6% with LOC eating). LOC eating was assessed by interview. Leptin was measured after an overnight fast. Exploratory analyses were conducted to examine anxiety and LOC eating in relation to laboratory intake patterns in three sub-samples. In a generalized linear model adjusting for relevant covariates, anxiety significantly interacted with LOC eating in relation to leptin (p = 0.02), such that greater trait anxiety related to higher concentrations of leptin only among youth with LOC eating. Trait anxiety was not significantly related to fasting serum leptin independently in a generalized linear model adjusting for age, race, height, sex, study type, and fat mass (kg). Exploratory mechanistic analyses of food intake patterns did not identify consistent results for participants with both anxiety and LOC eating. Among youth with LOC eating, anxiety may be associated with higher serum leptin. Prospective data are required to elucidate the directionality and mechanisms of these relationships.

Mortality after bariatric surgery: findings from a 7-year multicenter cohort study

BACKGROUND

Patients having bariatric surgery have lower mortality compared with those with similar body mass index who do not undergo surgery. It is unclear whether mortality post-bariatric surgery is similar to the general population. The benefit of bariatric surgery would be highlighted should people previously at high risk for premature death have comparable, or better, mortality as the general population.

OBJECTIVE

To compare mortality after bariatric surgery to the general U.S. population of the same age, sex, and race.

SETTING

The Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) prospective cohort of 2458 adults who underwent bariatric surgery at 10 U.S. hospitals between 2006 and 2009.

METHODS

Deaths were identified via LABS-2 follow-up and the National Death Index. Standardized mortality ratios (SMR) of post-bariatric surgery mortality observed in LABS-2 versus age-, sex-, race-, and year-adjusted expected mortality in the general U.S. population were calculated and compared with 1, which results when the number of observed and expected deaths are equal.

RESULTS

LABS-2 median follow-up was 6.6 (interquartile range: 5.9-7.0) years postsurgery. Seventy-six deaths were observed over 15,616 person-years (PY) of observation (4.9 deaths/1000 PY). The rate expected in the general U.S. population with the same age, sex, race, and year distribution was 4.8 deaths per 1000 PY (SMR = 1.02, 95% confidence interval [CI]: .80-1.27). There were no significant differences between observed and expected mortality by surgical procedure. Compared with expected mortality in the general U.S. population, people 35-44 years old at time of surgery had significantly more deaths (SMR = 2.06, 95% CI: 1.22-3.25), while people at least 55 years of age had significantly fewer (SMR = .63, 95% CI: .42-.92). Significantly more deaths than expected occurred in the perioperative period and 5-7 years after surgery.

CONCLUSIONS

Mortality within 7 years of bariatric surgery is comparable to the general U.S. population, which is likely to have better survival than people with severe obesity. However, more deaths than expected were identified 5-7 years after surgery.

The association between alexithymia and eating behavior in children and adolescents

OBJECTIVE

Alexithymia, or the difficulty identifying or describing one's own emotions, may be a risk factor for dysregulated eating and excess weight gain. However, the relationships between alexithymia and eating behaviors in community samples of non-clinical youth have not been well-characterized. We hypothesized that alexithymia would be positively associated with disordered and disinhibited eating in a community-based sample of boys and girls without an eating disorder.

METHOD

Two hundred children (8-17 years old) across the weight spectrum completed an interview to assess loss of control (LOC) eating and eating-related psychopathology, a laboratory test meal designed to induce disinhibited eating, and questionnaires to assess alexithymia, eating in the absence of hunger, and emotional eating. Linear and logistic regressions were conducted to examine the relationship between alexithymia and eating variables, with age, sex, race, and fat mass as covariates. Test meal analyses also adjusted for lean mass. Given the overlap between alexithymia and depression, all models were repeated with depressive symptoms as an additional covariate.

RESULTS

Alexithymia was associated with an increased likelihood of reporting LOC eating (p < .05). Moreover, alexithymia was positively associated with disordered eating attitudes, emotional eating, and eating in the absence of hunger (ps < .05). Greater alexithymia was associated with more carbohydrate and less fat intake at the test meal (ps < .05). After adjusting for depressive symptoms, alexithymia remained associated with eating in the absence of hunger and carbohydrate and fat intake (ps < .05).

DISCUSSION

In healthy children, alexithymia is associated with some facets of eating behavior and food intake. If supported prospectively, these preliminary findings suggest alexithymia may be a modifiable risk factor to reduce disordered eating and excess weight gain in youth.

Associations of Weekday and Weekend Sleep with Children's Reported Eating in the Absence of Hunger

Insufficient average sleep duration has been inconsistently associated with poor diet and obesity risks in youth. Inconsistencies in findings across studies may be due to a general failure to examine associations in weekday versus weekend sleep. We hypothesized that greater variations in weekday and weekend sleep duration would be associated with more disinhibited eating behaviors, which, in turn, might be involved in the relationship between sleep and weight. We, therefore, examined, among healthy, non-treatment seeking youth, the associations of average weekly, weekend, and weekday sleep duration with eating in the absence of hunger (EAH), a disinhibited eating behavior associated with disordered eating and obesity. Sleep was assessed via actigraphy for 14 days. Participants completed a self-report measure of EAH. Adiposity was measured by dual-energy X-ray absorptiometry. Linear regressions were used to test the associations of sleep duration with EAH and the associations of sleep duration and EAH, with fat mass. Among 123 participants (8-17 years, 52.0% female, and 30.9% with overweight), there was no significant association between average weekly sleep and EAH. Further, there was no significant association among average weekly sleep duration or EAH and fat mass. However, average weekday sleep was negatively associated, and average weekend sleep was positively associated, with EAH (ps < 0.02). Weekend "catch-up" sleep (the difference between weekend and weekday sleep) was positively associated with EAH (p < 0.01). Findings indicate that shorter weekday sleep and greater weekend "catch-up" sleep are associated with EAH, which may place youth at risk for the development of excess weight gain over time.

Long-term Association of Depression Symptoms and Antidepressant Medication Use With Incident Cardiovascular Events in the Look AHEAD (Action for Health in Diabetes) Clinical Trial of Weight Loss in Type 2 Diabetes

OBJECTIVE

To examine whether depression symptoms or antidepressant medication (ADM) use predicts the probability of cardiovascular events in overweight/obese individuals with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Preplanned analyses of depression and incident cardiovascular disease (CVD) were performed in the Look AHEAD (Action for Health in Diabetes) weight loss trial after a median follow-up of 9.6 years. Depression symptoms, assessed with the Beck Depression Inventory (BDI), were analyzed both as a continuous and dichotomized variable (BDI score <10 or ≥10). ADM use was coded from participants' prescription medications. Four composite CVD outcomes were defined in the study protocol. Sex-stratified Cox proportional hazards models were adjusted for a range of baseline covariates.

RESULTS

Depression symptoms were only significantly associated with a composite secondary outcome comprising CVD death, nonfatal myocardial infarction, nonfatal stroke, hospitalized angina, congestive heart failure, peripheral vascular disease, coronary artery bypass graft, and carotid endarterectomy. Significant sex interactions were observed for BDI score and BDI score ≥10. BDI score was significantly associated with higher probability of this composite outcome in men but was not associated with the outcome in women. BDI score ≥10 was positively associated with this composite outcome in men but was negatively associated in women. Exploratory analysis identified a significant BDI ≥10 × ADM use interaction for this composite outcome that differed in men versus women. Men with both BDI score ≥10 and ADM use compared with those with neither had 60% higher probability of the outcome, whereas women with both compared with those with neither had 50% lower probability.

CONCLUSIONS

Sex differences in the association of depression symptoms and ADM use with incident CVD warrant further investigation.

End-of-Trial Health Outcomes in Look AHEAD Participants who Elected to have Bariatric Surgery

OBJECTIVE

This study examined end-of-trial health outcomes in participants in the Action for Health in Diabetes (Look AHEAD) trial who had bariatric surgery during the approximately 10-year randomized intervention.

METHODS

Data were obtained from the Look AHEAD public access database of 4,901 individuals with type 2 diabetes and overweight/obesity who were assigned to intensive lifestyle intervention (ILI) or a diabetes support and education (DSE) control group. Changes in outcomes in participants who had bariatric surgery were compared with those in participants with BMI ≥ 30 kg/m2 who remained in the ILI and DSE groups.

RESULTS

A total of 99 DSE and 97 ILI participants had bariatric surgery. At randomization, these 196 participants were significantly younger and more likely to be female and to have higher BMI than the remaining ILI (N = 1,972) and DSE (N = 2,009) participants. At trial's end, surgically treated participants lost 19.3% of baseline weight, compared with 5.8% and 3.3% for the ILI and DSE groups, respectively, and were more likely to achieve partial or full remission of their diabetes.

CONCLUSIONS

The large, sustained improvements in weight and diabetes observed in this self-selected sample of surgically treated participants are consistent with results of multiple randomized trials.

Mental disorders and weight change in a prospective study of bariatric surgery patients: 7 years of follow-up

BACKGROUND

Long-term, longitudinal data are limited on mental disorders after bariatric surgery.

OBJECTIVE

To report mental disorders through 7 years postsurgery and examine their relationship with changes in weight and health-related quality of life.

SETTING

Three U.S. academic medical centers.

METHOD

As a substudy of the Longitudinal Assessment of Bariatric Surgery Consortium, 199 adults completed the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition prior to Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric band. Participants who completed ≥1 follow-up through 7 years postsurgery are included (n = 173; 86.9%). Mixed models were used to examine mental disorders over time, and among the RYGB subgroup (n = 104), their relationship with long-term (≥4 yr) pre- to postsurgery changes in weight and health-related quality of life, measured with the Short Form-36 Health Survey, and with weight regain from nadir.

RESULTS

Compared with presurgery (34.7%), the prevalence of having any mental disorder was significantly lower 4 years (21.3%; P < .01) and 5 years (19.2%; P = .01), but not 7 years (29.1%; P = .27) after RYGB. The most common disorders were not related to long-term weight loss postRYGB. However, independent of weight change, mood and anxiety disorders, both pre- and postRYGB, were significantly related to less improvement in mental (but not physical) health-related quality of life. Having a concurrent mood disorder appeared to be associated with greater weight regain (6.4% of maximum weight lost, 95% confidence interval, -.3 to 13.1), but this was not statistically significant (P = .06).

CONCLUSIONS

Bariatric surgery does not result in consistent long-term reductions in mental disorders. Mood disorders may impact long-term outcomes of bariatric surgery.

Psychological status and weight variability over eight years: Results from Look AHEAD

OBJECTIVE

Cross-sectional studies suggest an association between weight cycling and psychological status. Although this is often interpreted as suggesting that weight cycles "cause" psychological distress, the relationship could be bidirectional. This study provides a prospective analysis of the bidirectional association between weight variability and psychological status over an 8-year period in overweight/obese adults with Type 2 diabetes.

METHOD

Data were from the first 8 years of Look AHEAD, a randomized controlled trial comparing health outcomes in individuals with Type 2 diabetes assigned to an intensive lifestyle intervention designed to produce weight loss or a diabetes education and support control group. Psychological status (mental health, depressive symptoms, binge eating) was assessed via surveys and were examined in relation to weight variability at both baseline and year 8. Weight variability was derived from 8 possible annual measurements from participants who had a minimum of 3 consecutive body weight measurements (N = 4,774) and operationalized as the number of year-to-year cycles and the coefficient of variation across all available weight measurements.

RESULTS

Controlling for study group, higher baseline scores on mental health (Short Form-36 Mental Component Summary) and lower levels of depressive symptomatology (Beck Depression Inventory) and binge eating (Questionnaire on Eating and Weight Patterns) were associated with significantly less subsequent weight variability. The prospective association between weight variability and psychological status at year 8 was less robust.

CONCLUSIONS

These results suggest that the cross-sectional relationship between weight variability and psychological status is due primarily to poorer psychological function preceding greater weight instability. (PsycINFO Database Record

A longitudinal examination of suicide-related thoughts and behaviors among bariatric surgery patients

BACKGROUND

Past research suggests self-harm/suicidality are more common among adults who have undergone bariatric surgery than the general population.

OBJECTIVES

To compare prevalence of self-harm/suicidal ideation over time and identify presurgery risk factors for postsurgery self-harm/suicidal ideation.

SETTING

The Longitudinal Assessment of Bariatric Surgery-2 is a cohort study with presurgery and annual postsurgery assessments conducted at 10 U.S. hospitals.

METHODS

Adults with severe obesity undergoing bariatric surgery between March 2006 and April 2009 (n = 2458). Five-year follow-up is reported. Self-reported history of suicidality assessed retrospectively via the Suicide Behavior Questionnaire-Revised (SBQ-R) and self-reported self-harm/suicidal ideation assessed prospectively via the Beck Depression Inventory-Version 1 (BDI-1).

RESULTS

The SBQ-R was completed by 1540 participants; 2217 completed the BDI-1 pre- and postsurgery. Over 75% of participants were female, with a median age of 46 years and body mass index of 45.9 kg/m². Approximately one fourth of participants (395/1534) reported a presurgery history of suicidal thoughts or behavior (SBQ-R). The prevalence of self-harm/suicidal ideation (BDI-1) was 5.3% (95% confidence interval [CI], 3.7-6.8) presurgery and 3.8% (95% CI, 2.5-5.1) at year 1 postsurgery (P = .06). Prevalence increased over time postsurgery to 6.6% (95% CI, 4.6-8.6) at year 5 (P = .001) but was not significantly different than presurgery (P = .12).

CONCLUSIONS

A large cohort of adults with severe obesity who underwent bariatric surgery had a prevalence of self-harm/suicidal ideation that may have decreased in the first postoperative year but increased over time to presurgery levels, suggesting screening for self-harm/suicidality is warranted throughout long-term postoperative care. Several risk factors were identified that may help with enhanced monitoring.

Eating pathology and associations with long-term changes in weight and quality of life in the longitudinal assessment of bariatric surgery study

OBJECTIVE

This study examines the course of eating pathology and its associations with change in weight and health-related quality of life following bariatric surgery.

METHOD

Participants (N = 184) completed the eating disorder examination-bariatric surgery version (EDE-BSV) and the medical outcomes study 36-Item short form health survey (SF-36) prior to and annually following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) for up to 7 years.

RESULTS

The prevalence of ≥ weekly loss of control (LOC) eating, picking/nibbling, and cravings declined post-RYGB and remained lower through 7 years (LOC: 5.4% at Year-7 vs. 16.2% pre-RYGB, p = .03; picking/nibbling: 7.0% vs. 32.4%, p < .001; and cravings: 19.4% vs. 33.6%, p = .02). The prevalence of picking/nibbling was significantly lower 7 years following LAGB vs. pre-LAGB (29.4% vs 45.8%, p = .049), while cravings (p = .13) and LOC eating (p = .95) were not. EDE-BSV global score and ratings of hunger and enjoyment of eating were lower 7 years following both RYGB and LAGB versus pre-surgery (p's for all <.05). LOC eating following RYGB was associated with less long-term weight loss from surgery (p < .01) and greater weight regain from weight nadir (p < .001). Higher post-surgery EDE-BSV global score was associated with less weight loss/greater regain (both p < .001) and worsening/less improvement from surgery in the SF-36 mental component summary scores (p < .01).

DISCUSSION

Initial improvements in eating pathology following RYGB and LAGB were sustained across 7 years of follow-up. Individuals with eating pathology post-RYGB, reflected by LOC eating and/or higher EDE-BSV global score, may be at risk for suboptimal long-term outcomes.

Working toward precision medicine approaches to treat severe obesity in adolescents: report of an NIH workshop

Adolescent severe obesity is a prevalent, chronic, and serious disease with few effective and safe treatment options. To address this issue, a National Institutes of Health-sponsored workshop entitled "Developing Precision Medicine Approaches to the Treatment of Severe Obesity in Adolescents," was convened, bringing together a multidisciplinary group of experts to review the current state of the science and identify (1) what is known regarding the epidemiology and biopsychosocial determinants of severe obesity in adolescents, (2) what is known regarding effectiveness of treatments for severe obesity in adolescents and predictors of response, and (3) gaps and opportunities for future research to develop more effective and targeted treatments for adolescents with severe obesity. Major topical areas discussed at the workshop included: appropriate BMI metrics, valid measures of phenotypes and predictors, mechanisms associated with the development of severe obesity, novel treatments informed by biologically and psychosocially plausible mechanisms, biopsychosocial phenotypes predicting treatment response, standardization of outcome measures and results reporting in research, and improving clinical care. Substantial gaps in knowledge were identified regarding the basic behavioral, psychosocial, and biological mechanisms driving the development of severe obesity and the influence of these factors on treatment response. Additional exploratory and observational studies are needed to better understand the heterogeneous etiology of severe obesity and explain the high degree of variability observed with interventions. Tailored treatment strategies that may be developed by achieving a better understanding of individual differences in genetic endowment, clinical, metabolic, psychological, and behavioral phenotypes, and response to environmental exposures need to be tested. It is anticipated that these recommendations for future research, including strategies to enhance methodological rigor, will advance precision medicine approaches to treat severe obesity in adolescents more effectively.

Physical Function Following a Long-Term Lifestyle Intervention Among Middle Aged and Older Adults With Type 2 Diabetes: The Look AHEAD Study

Background

Lifestyle interventions have been shown to improve physical function over the short term; however, whether these benefits are sustainable is unknown. The long-term effects of an intensive lifestyle intervention (ILI) on physical function were assessed using a randomized post-test design in the Look AHEAD trial.

Methods

Overweight and obese (body mass index ≥ 25 kg/m2) middle-aged and older adults (aged 45-76 years at enrollment) with type 2 diabetes enrolled in Look AHEAD, a trial evaluating an ILI designed to achieve weight loss through caloric restriction and increased physical activity compared to diabetes support and education (DSE), underwent standardized assessments of performance-based physical function including a 4- and 400-m walk, lower extremity physical performance (expanded Short Physical Performance Battery, SPPBexp), and grip strength approximately 11 years postrandomization and 1.5 years after the intervention was stopped (n = 3,783).

Results

Individuals randomized to ILI had lower odds of slow gait speed (<0.8 m/s) compared to those randomized to DSE (adjusted OR [95% CI]: 0.84 [0.71 to 0.99]). Individuals randomized to ILI also had faster gait speed over 4- and 400-m (adjusted mean difference [95% CI]: 0.019 [0.007 to 0.031] m/s, p = .002, and 0.023 [0.012 to 0.034] m/sec, p < .0001, respectively) and higher SPPBexp scores (0.037 [0.011 to 0.063], p = .005) compared to those randomized to DSE. The intervention effect was slightly larger for SPPBexp scores among older versus younger participants (0.081 [0.038 to 0.124] vs 0.013 [-0.021 to 0.047], p = .01).

Conclusions

An intensive lifestyle intervention has modest but significant long-term benefits on physical function in overweight and obese middle-aged and older adults with type 2 diabetes.

ClinicalTrials.gov Identifier

NCT00017953.

Lifestyle Interventions Limit Gestational Weight Gain in Women with Overweight or Obesity: LIFE-Moms Prospective Meta-Analysis

OBJECTIVE

This study aimed to evaluate the effects of varied lifestyle intervention programs designed to ameliorate excess gestational weight gain (GWG) in pregnant women with overweight or obesity compared with standard care, including effects on pregnancy outcomes.

METHODS

Seven clinical centers conducted separate randomized clinical trials to test different lifestyle intervention strategies to modify GWG in diverse populations. Eligibility criteria, specific outcome measures, and assessment procedures were standardized across trials. The results of the separate trials were combined using an individual-participant data meta-analysis.

RESULTS

For the 1,150 women randomized, the percent with excess GWG per week was significantly lower in the intervention group compared with the standard care group (61.8% vs. 75.0%; odds ratio [95% CI]: 0.52 [0.40 to 0.67]). Total GWG from enrollment to 36 weeks' gestation was also lower in the intervention group (8.1 ± 5.2 vs. 9.7 ± 5.4 kg; mean difference: -1.59 kg [95% CI:-2.18 to -0.99 kg]). The results from the individual trials were similar. The intervention and standard care groups did not differ in preeclampsia, gestational diabetes, cesarean delivery, or birth weight.

CONCLUSIONS

Behavioral lifestyle interventions focusing primarily on diet and physical activity among women with overweight and obesity resulted in a significantly lower proportion of women with excess GWG. This modest beneficial effect was consistent across diverse intervention modalities in a large, racially and socioeconomically diverse US population of pregnant women.

An examination of the associations between pediatric loss of control eating, anxiety, and body composition in children and adolescents

BACKGROUND

Data on the link between anxiety and body composition in youth are mixed. Yet, anxiety and disordered eating are highly correlated. One pathway between anxiety and excess body weight and fat mass may be through loss of control (LOC) eating. We examined whether LOC eating mediated the relationship between anxiety and body composition in youth with and without overweight.

METHOD

Non-treatment-seeking youth (8-17 years) participated in studies examining weight and eating behaviors. Anxiety (child- and parent-report of child) and LOC eating were assessed by self-report questionnaires and interviews, respectively. Fat mass was assessed by dual-energy x-ray absorptiometry or air displacement plethysmography. Cross-sectional mediation models with bias-corrected bootstrap confidence intervals (CI) were conducted.

RESULTS

257 youth (12.91 ± 2.76 years; 52.5% female; BMI-z 0.93 ± 1.07) were studied. There was a significant indirect path between child-reported anxiety and both BMI-z (ab = .005, SE = 0.003, 95% CI = 0.001-0.01) and body fat mass (ab = 0.001, SE = 0.001, 95% CI ≤0.001-0.003) through the number of LOC episodes in the past month. No significant indirect paths through the number of LOC episodes was observed for parent-report of child anxiety on BMI-z (ab = 0.004, SE = 0.01, 95% CI = -0.01-0.03) or body fat mass (ab = 0.001, SE = 0.002, 95% CI = -0.002-0.01). No direct paths were observed between anxiety and body composition regardless of the informant.

DISCUSSION

LOC eating appears to mediate the relationship of child-reported anxiety with body composition in non-treatment seeking boys and girls. Prospective data are needed to determine if anxiety promotes LOC eating that results in increased risk for excess body weight and fat gain.

Evaluating the contribution of differences in lean mass compartments for resting energy expenditure in African American and Caucasian American children

BACKGROUND

Resting energy expenditure (REE), adjusted for total lean mass (LM), is lower in African American (AA) than Caucasian American (CA) children. Some adult studies suggest that AA-CA differences in lean mass compartments explain this REE difference. Similar data are limited in children.

OBJECTIVE

To evaluate differences in compartment-specific lean mass between AA and CA children and examine the individual contributions of high-metabolic rate-at-rest trunk lean mass (TrLM) and low-metabolic-rate-at-rest appendicular lean mass (AppLM) for AA-CA differences in REE.

METHODS

We studied a convenience sample of 594 AA (n = 281) and CA (n = 313) children. REE was measured by using indirect calorimetry; dual-energy X-ray absorptiometry was used to assess body composition. ANCOVAs were performed to examine AA-CA differences in TrLM, AppLM and REE. After accounting for age, sex, height, pubertal development, bone mass and adiposity, REE was evaluated adjusting for total LM (model A) and separately adjusting for TrLM and AppLM (model B).

RESULTS

African American children had greater adjusted AppLM (17.8 ± 0.2 [SE] vs. 16.0 ± 0.2 kg, p < 0.001) and lower TrLM (17.2 ± 0.2 vs. 17.7 ± 0.2 kg, p = 0.022) than CA children. REE adjusted for total LM was 77 ± 16 kcal/d lower in AA than CA (p < 0.001). However, after accounting separately for AppLM and TrLM, the discrepancy in REE between the groups declined to 28 ± 19 kcal/d (p = 0.14). In the adjusted model, both TrLM (p < 0.001) and AppLM (p < 0.027) were independently associated with REE.

CONCLUSION

In children, AA-CA differences in REE appear mostly attributable to differences in body composition. Lower REE in AA children is likely due to lower TrLM and greater AppLM.

Relationship of pressure to be thin with gains in body weight and fat mass in adolescents

BACKGROUND

Sociocultural pressure to be thin is commonly reported by adolescents; yet, to what extent such pressure is associated with weight gain has not been evaluated longitudinally.

OBJECTIVE

Examine whether pressure to be thin was positively associated with weight and fat gain in adolescents.

METHODS

Participants were 196 healthy adolescent (age 15 ± 1 years old) girls (65%) and boys of varying weights (BMI 25 ± 7 kg/m² ) studied at baseline and 1-year follow-up. At baseline, adolescents and their mothers reported pressure to be thin by questionnaire. At baseline and follow-up, BMI was calculated, and fat mass was assessed with air displacement plethysmography. Multiple regression was used to examine associations between baseline pressure to be thin and 1-year changes in BMI and fat mass.

RESULTS

Accounting for multiple covariates, including baseline BMI or fat, adolescent-reported pressure from parents and peers and mother-reported pressure toward their teen were associated with greater gains in either adolescent BMI or fat (ps < .05). Adolescent weight status was a moderator of multiple effects (ps < .05).

CONCLUSIONS

Parental and peer pressure to be thin were associated with increases in BMI and fat mass during adolescence, particularly in heavier adolescents. Further research is necessary to clarify how this association operates reciprocally and to identify underlying explanatory mechanisms.

Binge Eating and Weight Loss Outcomes in Individuals with Type 2 Diabetes: 4-Year Results from the Look AHEAD Study

OBJECTIVE

This study aims to assess whether an intensive lifestyle intervention (ILI) for weight reduction precipitates binge eating (BE) and whether BE attenuates 4-year weight loss among participants with type 2 diabetes and overweight or obesity.

METHODS

Participants (N = 4,901) were from Look AHEAD, a randomized controlled trial that compared ILI to diabetes support and education (DSE). Annual assessments of measured weight and self-reported BE were used. By using the yearly time points when a person endorsed BE, participants were classified as no BE, remitted BE, incident BE, inconsistent BE (2-3 years, including baseline), and consistent BE (≥ 4 years, including baseline). Cox regression and mixed-effects models were used for analyses.

RESULTS

ILI participants were marginally more likely to report incident BE at year 4 than those in DSE (P = 0.06). At year 4, ILI participants with remitted BE lost more weight (4.7 ± 0.8%) than those with consistent BE (1.9 ± 1.0%; P = 0.03). ILI participants with no BE lost more weight (4.6 ± 0.2%) than those with incident BE (3.1 ± 0.6%; P = 0.02) and consistent BE (P = 0.01). DSE participants with remitted BE lost more weight than those with incident and consistent BE.

CONCLUSIONS

Preexisting BE did not seem to be a contraindication for ILI, although persistent BE attenuated weight loss. Patients who report new or ongoing BE may need additional treatment.

Contraception and Conception After Bariatric Surgery

OBJECTIVE

To examine contraceptive practices and conception rates after bariatric surgery.

METHODS

The Longitudinal Assessment of Bariatric Surgery-2 is a multicenter, prospective cohort study of adults undergoing first-time bariatric surgery as part of routine clinical care at 10 U.S. hospitals. Recruitment occurred between 2005 and 2009. Participants completed preoperative and annual postsurgical assessments for up to 7 years until January 2015. This report was restricted to women 18-44 years old with no history of menopause, hysterectomy, or estrogen and progesterone therapy. Primary outcomes were self-reported contraceptive practices, overall conception rate, and early (less than 18 months) postsurgical conception. Contraceptive practice (no intercourse, protected intercourse, unprotected intercourse, or tried to conceive) was classified based on the preceding year. Conception rates were determined from self-reported pregnancies.

RESULTS

Of 740 eligible women, 710 (95.9%) completed follow-up assessment(s). Median (interquartile range) preoperative age was 34 (30-39) years. In the first postsurgical year, 12.7% (95% CI 9.4-16.0) of women had no intercourse, 40.5% (95% CI 35.6-45.4) had protected intercourse only, 41.5% (95% CI 36.4-46.6) had unprotected intercourse while not trying to conceive, and 4.3% (95% CI 2.4-6.3) tried to conceive. The prevalence of the first three groups did not significantly differ across the 7 years of follow-up (P for all >.05); however, more women tried to conceive in the second year (13.1%, 95% CI 9.3-17.0; P<.001). The conception rate was 53.8 (95% CI 40.0-71.1) per 1,000 woman-years across follow-up (median [interquartile range] 6.5 [5.9-7.0] years); 42.3 (95% CI 30.2-57.6) per 1,000 woman-years in the 18 months after surgery. Age (adjusted relative risk 0.41 [95% CI 0.19-0.89] per 10 years, P=.03), being married or living as married (adjusted relative risk 4.76 [95% CI 2.02-11.21], P<.001), and rating future pregnancy as important preoperatively (adjusted relative risk 8.50 [95% CI 2.92-24.75], P<.001) were associated with early conception.

CONCLUSIONS

Postsurgical contraceptive use and conception rates do not reflect recommendations for an 18-month delay in conception after bariatric surgery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT00465829.

Behavioral and Psychological Phenotyping of Physical Activity and Sedentary Behavior: Implications for Weight Management

OBJECTIVE

Risk for obesity is determined by a complex mix of genetics and lifetime exposures at multiple levels, from the metabolic milieu to psychosocial and environmental influences. These phenotypic differences underlie the variability in risk for obesity and response to weight management interventions, including differences in physical activity and sedentary behavior.

METHODS

As part of a broader effort focused on behavioral and psychological phenotyping in obesity research, the National Institutes of Health convened a multidisciplinary workshop to explore the state of the science in behavioral and psychological phenotyping in humans to explain individual differences in physical activity, both as a risk factor for obesity development and in response to activity-enhancing interventions.

RESULTS

Understanding the behavioral and psychological phenotypes that contribute to differences in physical activity and sedentary behavior could allow for improved treatment matching and inform new targets for tailored, innovative, and effective weight management interventions.

CONCLUSIONS

This summary provides the rationale for identifying psychological and behavioral phenotypes relevant to physical activity and identifies opportunities for future research to better understand, define, measure, and validate putative phenotypic factors and characterize emerging phenotypes that are empirically associated with initiation of physical activity, response to intervention, and sustained changes in physical activity.