Randomized clinical trials of weight loss maintenance: a review

Total Lifestyle Coaching: A Pilot Study Evaluating the Effectiveness of a Mind-Body and Nutrition Telephone Coaching Program for Obese Adults at a Community Health Center

BACKGROUND

Stress and obesity are interrelated and common among low-income adults. Mind-body interventions have been shown to reduce psychological distress and have been incorporated into many weight loss interventions. However, few of these programs have incorporated a telephone coaching component.

OBJECTIVE

We designed and piloted a novel weight loss telephone coaching intervention for this population and examined its effectiveness on weight loss and improvements in health behaviors in obese community health center patients.

METHODS

This was a 6-month, single-arm, prospective, pre-post pilot study. The study took place at a community health center near Boston, Massachusetts. Participants were 27 overweight and obese community health center patients. The intervention consisted of one in-person intake with the registered dietitian, trained in mind-body approaches, and approximately 1 phone coaching session every 2 weeks for 6 consecutive months. Anthropometric data consisted of weight, body mass index (BMI), and blood pressure. Questionnaires consisted of the Perceived Stress Scale-10 item, the CIGNA Healthy Eating Survey, Section H: Behavioral Eating, a physical activity questionnaire, and a nutritional habits questionnaire. We used paired samples t tests to assess pre-post changes in weight, BMI, blood pressure, perceived stress, behavioral eating, and physical activity. We also conducted semistructured exit interviews to learn about participants' experiences in this program.

RESULTS

There was a trend toward weight reduction (P < .1, Cohen's d = 0.33) and significant improvements in systolic blood pressure (P = .001, Cohen's d = 0.72), perceived stress (P = .001, Cohen's d = 0.75), and behavioral eating (P = .009, Cohen's d = 0.54). Improvements in weight were sustained 6 months after completion of the intervention.

CONCLUSION

Results suggest that a telephone nutrition health coaching intervention is feasible and may facilitate weight loss in obese community health center patients. Future randomized-controlled studies are warranted to better understand these improvements.

CLINICALTRIALSGOV REGISTRATION

NCT03025217.

Long-term weight loss following a randomised controlled trial of a weight management programme for men delivered through professional football clubs: the Football Fans in Training follow-up study

Background

Rising levels of obesity require interventions that support people in long-term weight loss. The Football Fans in Training (FFIT) programme uses loyalty to football teams to engage men in weight loss. In 2011/12, a randomised controlled trial (RCT) found that the FFIT programme was effective in helping men lose weight up to 12 months.

Objectives

To investigate the long-term weight, and other physical, behavioural and psychological outcomes up to 3.5 years after the start of the RCT; the predictors, mediators and men’s qualitative experiences of long-term weight loss; cost-effectiveness; and the potential for long-term follow-up via men’s medical records.

Design

A mixed-methods, longitudinal cohort study.

Setting

Thirteen professional Scottish football clubs from the RCT and 16 additional Scottish football clubs that delivered the FFIT programme in 2015/16.

Participants

A total of 665 men who were aged 35–65 years at the RCT baseline measures and who consented to follow-up after the RCT (intervention group, n = 316; comparison group, n = 349), and 511 men who took part in the 2015/16 deliveries of the FFIT programme.

Interventions

None as part of this study.

Main outcome measures

Objectively measured weight change from the RCT baseline to 3.5 years.

Results

In total, 488 out of 665 men (73.4%) attended 3.5-year measurements. Participants in the FFIT follow-up intervention group sustained a mean weight loss from baseline of 2.90 kg [95% confidence interval (CI) 1.78 to 4.02 kg; p < 0.001], and 32.2% (75/233) weighed ≥ 5% less than at baseline. Participants in the FFIT follow-up comparison group (who participated in routine deliveries of the FFIT programme after the RCT) lost a mean of 2.71 kg (95% CI 1.65 to 3.77 kg; p < 0.001), and 31.8% (81/255) achieved ≥ 5% weight loss. Both groups showed long-term improvements in body mass index, waist circumference, percentage body fat, blood pressure, self-reported physical activity (PA) (including walking), the consumption of fatty and sugary foods, fruit and vegetables and alcohol, portion sizes, self-esteem, positive and negative affect, and physical and mental health-related quality of life (HRQoL). Mediators included self-reported PA (including walking) and sitting time, the consumption of fatty and sugary foods and fruit and vegetables, portion sizes, self-esteem, positive affect, physical HRQoL, self-monitoring of weight, autonomous regulation, internal locus of control, perceived competence, and relatedness to other FFIT programme participants and family members. In qualitative interviews, men described continuing to self-monitor weight and PA. Many felt that PA was important for weight control, and walking remained popular; most were still aware of portion sizes and tried to eat fewer snacks. The FFIT programme was associated with an incremental cost-effectiveness of £10,700–15,300 per quality-adjusted life-year (QALY) gained at 3.5 years, and around £2000 per QALY gained in the lifetime analysis. Medical record linkage provided rich information about the clinical health outcomes of the FFIT RCT participants, and 90% of men (459/511) who took part in the 2015/16 FFIT programme gave permission for future linkage.

Conclusions

Participation in the FFIT programme under both research (during the FFIT RCT) and routine (after the FFIT RCT) delivery conditions led to significant long-term weight loss. Further research should investigate (1) how to design programmes to improve long-term weight loss maintenance, (2) longer-term follow-up of FFIT RCT participants and (3) very long-term follow-up via medical record linkage.

Trial registration

Current Controlled Trials ISRCTN32677491.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 6, No. 9. See the NIHR Journals Library website for further project information. The Scottish Executive Health Department Chief Scientist Office (CSO) funded the feasibility pilot that preceded the FFIT RCT (CZG/2/504). The Medical Research Council (MRC) funded Kate Hunt and additional developmental research through the MRC/CSO Social and Public Health Sciences Unit Gender and Health programme (5TK50/25605200-68094).

Successful and unsuccessful weight-loss maintainers: strategies to counteract metabolic compensation following weight loss

Adaptive thermogenesis and reduced fat oxidative capacity may accompany weight loss, continuing in weight maintenance. The present study aimed (1) to determine whether weight-reduced and weight-loss relapsed women are at greater metabolic risk for weight gain compared with BMI-matched controls with no weight-loss history, and (2) to identify protective strategies that might attenuate weight loss-associated adaptive thermogenesis and support successful weight-loss maintenance. Four groups of women were recruited: reduced-overweight/obese (RED, n 15), controls (low-weight stable weight; LSW, n 19) BMI <27 kg/m²; relapsed-overweight/obese (REL, n 11), controls (overweight/obese stable weight; OSW, n 11) BMI >27 kg/m². Body composition (bioelectrical impedance), 75 g oral glucose tolerance test, fasting and postprandial metabolic rate (MR) and substrate utilisation (RER) and physical activity (accelerometer (7 d)) were measured. Sociobehavioural questionnaires and 3 × 24 h diet recalls were completed. Fasting and postprandial MR, RER and total daily energy intake (TDEI) were not different between RED and REL v. controls (P > 0·05). RED consumed less carbohydrate (44·8 (sd 10·3) v. 53·4 (sd 10·0) % TDEI, P = 0·020), more protein (19·2 (sd 6·0) v. 15·6 (sd 4·2) % TDEI, P = 0·049) and increased physical activity, but behaviourally reported greater dietary restraint (P = 0·002) compared with controls. TDEI, macronutrient intake and physical activity were similar between OSW and REL. REL reported higher subjective fasting and lower postprandial ratings of prospective food consumption compared with OSW. Weight-reduced women had similar RMR (adjusted for fat-free mass) compared with controls with no weight-loss history. Increased physical activity, higher protein intake and greater lean muscle mass may have counteracted weight loss-associated metabolic compensation and highlights their importance in weight-maintenance programmes.

Long-term weight loss trajectories following participation in a randomised controlled trial of a weight management programme for men delivered through professional football clubs: a longitudinal cohort study and economic evaluation

BACKGROUND

Obesity is a major public health concern requiring innovative interventions that support people to lose weight and keep it off long term. However, weight loss maintenance remains a challenge and is under-researched, particularly in men. The Football Fans in Training (FFIT) programme engages men in weight management through their interest in football, and encourages them to incorporate small, incremental physical activity and dietary changes into daily life to support long-term weight loss maintenance. In 2011/12, a randomised controlled trial (RCT) of FFIT demonstrated effectiveness and cost-effectiveness at 12 months. The current study aimed to investigate long-term maintenance of weight loss, behavioural outcomes and lifetime cost-effectiveness following FFIT.

METHODS

A longitudinal cohort study comprised 3.5-year follow-up of the 747 FFIT RCT participants. Men aged 35-65 years, BMI ≥ 28 kg/m2 at RCT baseline who consented to long-term follow-up (n = 665) were invited to participate: those in the FFIT Follow Up Intervention group (FFIT-FU-I) undertook FFIT in 2011 during the RCT; the FFIT Follow Up Comparison group (FFIT-FU-C) undertook FFIT in 2012 under routine (non-research) conditions. The primary outcome was objectively-measured weight loss (from baseline) at 3.5 years. Secondary outcomes included changes in self-reported physical activity and diet at 3.5 years. Cost-effectiveness was estimated at 3.5 years and over participants' lifetime.

RESULTS

Of 665 men invited, 488 (73%; 65% of the 747 RCT participants) attended 3.5-year measurements. The FFIT-FU-I group sustained a mean weight loss of 2.90 kg (95% CI 1.78, 4.02; p < 0.001) 3.5 years after starting FFIT; 32.2% (75/233) weighed ≥5% less than baseline. The FFIT-FU-C group had lost 2.71 kg (1.65, 3.77; p < 0.001) at the 3.5-year measurements (2.5 years after starting FFIT); 31.8% (81/255) weighed ≥5% less than baseline. There were significant sustained improvements in self-reported physical activity and diet in both groups. The estimated incremental cost-effectiveness of FFIT was £10,700-£15,300 per QALY gained at 3.5 years, and £1790-£2200 over participants' lifetime.

CONCLUSIONS

Participation in FFIT under research and routine conditions leads to long-term weight loss and improvements in physical activity and diet. Investment in FFIT is likely to be cost-effective as part of obesity management strategies in countries where football is popular.

TRIAL REGISTRATION

ISRCTN32677491 , 20 October 2011.

Using the Habit App for Weight Loss Problem Solving: Development and Feasibility Study

Background

Reviews of weight loss mobile apps have revealed they include very few evidence-based features, relying mostly on self-monitoring. Unfortunately, adherence to self-monitoring is often low, especially among patients with motivational challenges. One behavioral strategy that is leveraged in virtually every visit of behavioral weight loss interventions and is specifically used to deal with adherence and motivational issues is problem solving. Problem solving has been successfully implemented in depression mobile apps, but not yet in weight loss apps.

Objective

This study describes the development and feasibility testing of the Habit app, which was designed to automate problem-solving therapy for weight loss.

Methods

Two iterative single-arm pilot studies were conducted to evaluate the feasibility and acceptability of the Habit app. In each pilot study, adults who were overweight or obese were enrolled in an 8-week intervention that included the Habit app plus support via a private Facebook group. Feasibility outcomes included retention, app usage, usability, and acceptability. Changes in problem-solving skills and weight over 8 weeks are described, as well as app usage and weight change at 16 weeks.

Results

Results from both pilots show acceptable use of the Habit app over 8 weeks with on average two to three uses per week, the recommended rate of use. Acceptability ratings were mixed such that 54% (13/24) and 73% (11/15) of participants found the diet solutions helpful and 71% (17/24) and 80% (12/15) found setting reminders for habits helpful in pilots 1 and 2, respectively. In both pilots, participants lost significant weight (P=.005 and P=.03, respectively). In neither pilot was an effect on problem-solving skills observed (P=.62 and P=.27, respectively).

Conclusions

Problem-solving therapy for weight loss is feasible to implement in a mobile app environment; however, automated delivery may not impact problem-solving skills as has been observed previously via human delivery.

Trial Registration

ClinicalTrials.gov NCT02192905; https://clinicaltrials.gov/ct2/show/NCT02192905 (Archived by WebCite at http://www.webcitation.org/6zPQmvOF2)

Mediators of two selective prevention interventions targeting both obesity and eating disorders

The present study tested hypothesized mechanisms underlying the effects of two selective prevention interventions targeting both obesity and eating disorders (Healthy Weight and the newly developed Project Health), relative to video control. Tests examined mediation for the significant weight gain prevention and eating disorder symptom prevention effects previously reported. College students (N = 364; 72% women) with weight concerns were randomized to condition and assessed for 2-years post-intervention. Project Health participants had significant improvements in 2 of the 7 proposed mediators relative to comparisons (i.e., cognitive dissonance, the unhealthy Western dietary pattern) but change in these variables did not mediate its effect on long-term BMI change. Two variables emerged as full mediators of the eating disorder prevention effects for both experimental interventions: body dissatisfaction and negative affect. Analyses failed to support the exploratory hypothesis that change in eating disorder symptoms mediated the effects of condition on BMI gain. This report is the among the first to examine mediation for programs aimed at preventing both weight gain and eating disorders, particularly in mixed-gender groups. Mediational analyses are essential in identifying the mechanism of intervention action, which can inform improvements to prevention programs.

Neurofeedback of visual food cue reactivity: a potential avenue to alter incentive sensitization and craving

FMRI-based neurofeedback transforms functional brain activation in real-time into sensory stimuli that participants can use to self-regulate brain responses, which can aid the modification of mental states and behavior. Emerging evidence supports the clinical utility of neurofeedback-guided up-regulation of hypoactive networks. In contrast, down-regulation of hyperactive neural circuits appears more difficult to achieve. There are conditions though, in which down-regulation would be clinically useful, including dysfunctional motivational states elicited by salient reward cues, such as food or drug craving. In this proof-of-concept study, 10 healthy females (mean age = 21.40 years, mean BMI = 23.53) who had fasted for 4 h underwent a novel 'motivational neurofeedback' training in which they learned to down-regulate brain activation during exposure to appetitive food pictures. FMRI feedback was given from individually determined target areas and through decreases/increases in food picture size, thus providing salient motivational consequences in terms of cue approach/avoidance. Our preliminary findings suggest that motivational neurofeedback is associated with functionally specific activation decreases in diverse cortical/subcortical regions, including key motivational areas. There was also preliminary evidence for a reduction of hunger after neurofeedback and an association between down-regulation success and the degree of hunger reduction. Decreasing neural cue responses by motivational neurofeedback may provide a useful extension of existing behavioral methods that aim to modulate cue reactivity. Our pilot findings indicate that reduction of neural cue reactivity is not achieved by top-down regulation but arises in a bottom-up manner, possibly through implicit operant shaping of target area activity.

Weight outcome after 2 years of a diet that excludes six processed foods: exploratory study of the "1,2,3 diet" in a moderately obese population

BACKGROUND

The Paleolithic diet, a diet devoid of food-processing procedure, seems to produce a greater decrease in weight compared to healthy reference diets but its limited food choices make it difficult to implement in our modern times where refined food is dominant.

OBJECTIVE

To evaluate the effects of a 2-year diet that excludes only six refined foodstuffs implicated in obesity. Professional contact was kept minimal to approximate the approach used by most dieters.

DESIGN

Single-arm, open-label, exploratory study.

SETTING

One academic medical center, outpatient setting.

PATIENTS

One hundred and five subjects with a mean age of 50 (SD, 14 years) and mean body mass index of 30.5 kg/m² (SD, 4 kg/m²). Thirty-nine percent had type 2 diabetes.

INTERVENTION

An ad libitum diet that excludes six refined foodstuffs (margarine, vegetable oils, butter, cream, processed meat, and sugary drinks) called the "1,2,3 diet".

OUTCOMES

Weight at 2 years was the primary outcome. Secondary outcomes included number of patients who lost more than 5% of initial body weight, glycated hemoglobin (HbA_1c) level, and changes in dietary behavior.

RESULTS

Average weight loss was 4.8 kg (p<0.001), representing 5.6% of their initial body weight. Among completers (51%), the average weight loss was 5.5 kg (p<0.001), and 56% had a reduction of at least 5% of their initial body weight. Among diabetics, weight loss was similar to nondiabetics, and mean HbA_1c level decreased by 1% (p=0.001) without modification in glucose-lowering medications. A higher intake of bread, dairy products, chocolate, and fresh fruits was the typical trend in dietary changes reported by completers.

CONCLUSION

In this exploratory study, there was a significant long-term weight loss with the "1,2,3 diet" despite minimal professional contact. Given the lack of a control group and high attrition rate, further evaluation of this diet is warranted.

Dietary Intake after Weight Loss and the Risk of Weight Regain: Macronutrient Composition and Inflammatory Properties of the Diet

Weight regain after successful weight loss is a big problem in obesity management. This study aimed to investigate whether weight regain after a weight loss period is correlated with the macronutrient composition and/or the inflammatory index of the diet during that period. Sixty one overweight and obese adults participated in this experimental study. Subjects lost approximately 10% of their initial weight by means of very low-calorie diet for five weeks, or a low calorie diet for 12 weeks. After that, subjects in both groups followed a strict weight maintenance diet based on individual needs for four weeks, which was followed by a nine-month weight maintenance period without dietary counseling. Anthropometrics and dietary intake data were recorded before weight loss (baseline) and during the weight maintenance period. On average, participants regained approximately half of their lost weight. We found no evidence that macronutrient composition during the weight maintenance period was associated with weight regain. The dietary inflammatory index (r = 0.304, p = 0.032) was positively correlated with weight regain and remained significant after correction for physical activity (r = 0.287, p = 0.045). Our data suggest that the inflammatory properties of diet play a role in weight regain after weight loss in overweight and obese adults.

Developing dimensions for a multicomponent multidisciplinary approach to obesity management: a qualitative study

BACKGROUND

There have been consistent recommendations for multicomponent and multidisciplinary approaches for obesity management. However, there is no clear agreement on the components, disciplines or processes to be considered within such an approach. In this study, we explored multicomponent and multidisciplinary approaches through an examination of knowledge, skills, beliefs, and recommendations of stakeholders involved in obesity management. These stakeholders included researchers, practitioners, educators, and patients.

METHODS

We used qualitative action research methods, including convergent interviewing and observation, to assist the process of inquiry.

RESULTS

The consensus was that a multicomponent and multidisciplinary approach should be based on four central meta-components (patient, practitioner, process, and environmental factors), and specific components of these factors were identified. Psychologists, dieticians, exercise physiologists and general practitioners were nominated as key practitioners to be included.

CONCLUSIONS

A complex condition like obesity requires that multiple components be addressed, and that both patients and multiple disciplines are involved in developing solutions. Implementing cycles of continuous improvement to deal with complexity, instead of trying to control for it, offers an effective way to deal with complex, changing multisystem problems like obesity.

Evidence Base for Optimal Preoperative Preparation for Bariatric Surgery: Does Mandatory Weight Loss Make a Difference?

PURPOSE OF REVIEW

Preoperative weight loss regimens prior to bariatric surgery have been a routine and common practice for many centers, in the US and around the world. The mandated participation in such programs has largely been influenced by loco-regional payer requirements. The relationship between adherence to a mandatory weight loss regimen and achieved preoperative weight loss as well as the clinical impact of preoperative weight loss on bariatric outcomes remains uncertain.

RECENT FINDINGS

This review examines the available current literature, in the context of previous findings, regarding the impact of mandated preoperative weight loss regimens and mandatory weight loss on bariatric outcomes. The reviewed studies do not provide sufficient evidence that mandatory participation in a preoperative weight loss regimen prior to bariatric surgery is associated with achieved weight loss or durable bariatric outcome benefit. Preoperative weight loss, when achieved, may confer a positive benefit on postoperative complications; however, this is not a consistent finding in the literature and requires further validation. The practice of mandating participation in a preoperative weight loss regimen or requiring mandatory weight loss prior to bariatric surgery is not supported by current literature and may serve as an obstacle to medically necessary and potentially life-saving treatment.

Identifying the mechanisms through which behavioral weight-loss treatment improves food decision-making in obesity

OBJECTIVES

Behavioral weight loss (BWL) programs are the recommended treatment for obesity, yet it is unknown whether these programs change one's ability to use self-control in food choices and what specific mechanisms support such change. Using experimental economics methods, we investigated whether changes in dietary behavior in individuals with obesity following BWL are driven by one or more of the following potential mechanisms: changes in the perception of the 1) health or 2) taste of food items, and/or 3) shifting decision weights for health versus taste attributes. Therefore, we compared these mechanisms between obese participants and lifetime normal weight controls (NW) both before and after BWL.

METHODS

Females with obesity (N = 37, mean BMI = 33.2) completed a food choice task involving health ratings, taste ratings, and decision-making pre- and post-standard BWL intervention. NW controls (N = 30, BMI = 22.4) completed the same task.

RESULTS

Individuals with obesity exhibited increased self-control (selecting healthier, less tasty food choices) post-treatment. However, their rates of self-control remained significantly lower than NW. We found no differences in initial health perceptions across groups, and no changes with treatment. In contrast, taste ratings and the relative value of taste versus health decreased following treatment. Although, post-treatment participants continued to perceive unhealthy foods as tastier and used less self-control than NW controls, they showed significant improvements in these domains following a BWL intervention.

CONCLUSIONS

To help individuals improve dietary decisions, additional research is needed to determine how to make greater changes in taste preferences and/or the assignment of value to taste versus health attributes in food choices.

Secondary psychological outcomes in a controlled trial of Emotional Freedom Techniques and cognitive behaviour therapy in the treatment of food cravings

OBJECTIVE

Examining the effectiveness of psychological interventions in treating secondary psychological outcomes of obesity has become prioritized in recent times. The objective of the present study was to compare an eight-week Cognitive-Behavioural Therapy (CBT) and Emotional Freedom Techniques (EFT) intervention program, in the treatment of food cravings and secondary psychological outcomes among overweight or obese adults (N = 83).

METHOD

A controlled non-inferiority trial was performed comparing group-delivered CBT to group-delivered EFT. Participants completed the Patient Health Questionnaire at pre- and post-intervention, and at six and 12-months follow-up.

RESULTS

The CBT group did not report any significant changes in anxiety scores over time, but the decrease in depression symptoms pre-to post-intervention was significant and this was maintained at 6-and 12-months. Anxiety and depression scores significantly decreased from pre-to post-intervention for the EFT group, and was maintained at 6- and 12-month follow-up. Somatoform scores significantly decreased from pre-intervention to all follow-up points for the CBT group, while the EFT group did not report any significant changes in somatoform symptoms. Results also revealed that EFT is capable of producing reductions in anxiety and depression symptoms, and may be comparable to gold standard approaches such as CBT.

CONCLUSION

The current study supports the hypothesis that psychological intervention is beneficial for treating psychological comorbidities of obesity and points to the role mental health issues may play in this area.

Weight Fluctuation and Cancer Risk in Postmenopausal Women: The Women's Health Initiative

Background: Weight cycling, defined by an intentional weight loss and subsequent regain, commonly occurs in overweight and obese women and is associated with some negative health outcomes. We examined the role of various weight-change patterns during early to mid-adulthood and associated risk of highly prevalent, obesity-related cancers (breast, endometrial, and colorectal) in postmenopausal women.Methods: A total of 80,943 postmenopausal women (age, 63.4 ± 7.4 years) in the Women's Health Initiative Observational Study were categorized by self-reported weight change (weight stable; weight gain; lost weight; weight cycled [1-3, 4-6, 7-10, >10 times]) during early to mid-adulthood (18-50 years). Three site-specific associations were investigated using Cox proportional hazard models [age, race/ethnicity, income, education, smoking, alcohol, physical activity, hormone therapy, diet, and body mass index (BMI)].Results: A total of 7,464 (breast = 5,564; endometrial = 788; and colorectal = 1,290) incident cancer cases were identified between September 1994 and August 2014. Compared with weight stability, weight gain was significantly associated with risk of breast cancer [hazard ratio (HR), 1.11; 1.03-1.20] after adjustment for BMI. Similarly, weight cycling was significantly associated with risk of endometrial cancer (HR = 1.23; 1.01-1.49). Weight cycling "4 to 6 times" was most consistently associated with cancer risk, showing a 38% increased risk for endometrial cancer [95% confidence interval (CI), 1.08-1.76] compared with weight stable women.Conclusions: Weight gain and weight cycling were positively associated with risk of breast and endometrial cancer, respectively.Impact: These data suggest weight cycling and weight gain increase risk of prevalent cancers in postmenopausal women. Adopting ideal body-weight maintenance practices before and after weight loss should be encouraged to reduce risk of incident breast and endometrial cancers. Cancer Epidemiol Biomarkers Prev; 26(5); 779-86. ©2017 AACR.

Peer Group and Text Message-Based Weight-Loss and Management Intervention for African American Women

About 80% of African American (AA) women are overweight or obese. Accessible and effective weight management programs targeting weight loss, weight maintenance and the prevention of weight regain are needed to improve health of AA women. A feasibility study was conducted to examine the feasibility, acceptability, and potential efficacy of a 16-week intervention protocol for weight loss and management that combined daily text messages and biweekly peer group sessions. Modest but statistically significant reductions were detected in weight and body mass index from baseline to 16 weeks. At baseline, 36% of participants were in action and maintenance stages in measures of the stages of change for weight loss and management; this percent increased to 82% at 16 weeks. Findings of this feasibility study provide preliminary evidence of an educational intervention that could motivate women and lead to successful behavior change, and successful weight loss and management for AA women.

Ecological Momentary Assessment in Behavioral Research: Addressing Technological and Human Participant Challenges

Background

Ecological momentary assessment (EMA) assesses individuals’ current experiences, behaviors, and moods as they occur in real time and in their natural environment. EMA studies, particularly those of longer duration, are complex and require an infrastructure to support the data flow and monitoring of EMA completion.

Objective

Our objective is to provide a practical guide to developing and implementing an EMA study, with a focus on the methods and logistics of conducting such a study.

Methods

The EMPOWER study was a 12-month study that used EMA to examine the triggers of lapses and relapse following intentional weight loss. We report on several studies that informed the implementation of the EMPOWER study: (1) a series of pilot studies, (2) the EMPOWER study’s infrastructure, (3) training of study participants in use of smartphones and the EMA protocol and, (4) strategies used to enhance adherence to completing EMA surveys.

Results

The study enrolled 151 adults and had 87.4% (132/151) retention rate at 12 months. Our learning experiences in the development of the infrastructure to support EMA assessments for the 12-month study spanned several topic areas. Included were the optimal frequency of EMA prompts to maximize data collection without overburdening participants; the timing and scheduling of EMA prompts; technological lessons to support a longitudinal study, such as proper communication between the Android smartphone, the Web server, and the database server; and use of a phone that provided access to the system’s functionality for EMA data collection to avoid loss of data and minimize the impact of loss of network connectivity. These were especially important in a 1-year study with participants who might travel. It also protected the data collection from any server-side failure. Regular monitoring of participants’ response to EMA prompts was critical, so we built in incentives to enhance completion of EMA surveys. During the first 6 months of the 12-month study interval, adherence to completing EMA surveys was high, with 88.3% (66,978/75,888) completion of random assessments and around 90% (23,411/25,929 and 23,343/26,010) completion of time-contingent assessments, despite the duration of EMA data collection and challenges with implementation.

Conclusions

This work informed us of the necessary preliminary steps to plan and prepare a longitudinal study using smartphone technology and the critical elements to ensure participant engagement in the potentially burdensome protocol, which spanned 12 months. While this was a technology-supported and -programmed study, it required close oversight to ensure all elements were functioning correctly, particularly once human participants became involved.

Repeated lifestyle interventions lead to progressive weight loss: A retrospective review chart study

Aims: This study aimed to investigate whether repeated lifestyle interventions lead to progressive weight loss or to weight cycling. Methods: A retrospective review chart study with follow-up on 2120 participants (mean±SD age 36±15 years; body weight 116±28 kg; fat 43±6%). All had participated in one to four 11–12 week lifestyle interventions (residential weight loss programme, mixed activities). Weight loss was promoted through a hypocaloric diet (−500 to −700 kcal/day) and daily physical activity (1–3 hours/day). Primary outcomes were weight loss and change in body composition (bioimpedance measurements) after the intervention periods and at follow-up. Results: A total of 2120, 526, 139 and 47 people participated in one to four interventions with mean±SEM times from start to follow-up of 1.3±0.1, 2.9±0.2, 4.2±0.3 and 5.2±0.4 years respectively. Overall 50, 41, 18 and 11% of the participants were lost to follow-up after one to four interventions, respectively. The cumulated weight loss at follow-up increased with the number of interventions from one to four: 12.2±0.1, 15.9±0.7, 16.1±1.2 and 18.5±2.0 kg ( p<0.001). The ratios between cumulated loss of fat and fat free mass after one to four interventions decreased with the number of interventions (2.4, 2.2, 2.1 and 1.4). Rates of weight loss during the interventions ranged from 0.70±0.06 to 1.06±0.01 kg/week and the maximum weight regain during the follow-up periods was 0.039±0.007 kg/week. Conclusions: Repeated relatively short lifestyle interventions in a selected and motivated group can be an efficient method for weight loss maintenance with only limited body weight cycling in the interim periods. However, the relationship between loss of fat and fat free mass might change in an unfavourable direction.

A minireview of effects of green tea on energy expenditure

In recent years, individuals have begun to tend more frequently to some natural and herbal products to be used alone or as a combination with diet and exercise for ensuring the weight loss. Green tea is the leading one of these products. In some studies, it is reported that the green tea causes an increase in thermogenesis and substrate with fat oxidation by affecting on the sympathetic nervous system. It is reported that green tea has two main components that are associated with energy expenditure. One of them is caffeine and the other is catechin content. Each of these two components has an impact on energy mechanism separately. In this minireview article, mechanisms of action and effects of caffeine and catechin, which are found in green tea composition, on energy expenditure are assessed.

Psychosocial changes as correlates of weight regain vs. continued loss within 2-year trials of a self-regulation-focused community-based intervention

Although health-enhancing weight reductions are associated with behavioural treatments initially, a trajectory towards full regain typically begins within 6-9 months. Women with obesity (body mass index = 30-40 kg m^-2 ) who lost at least 3% of their baseline weight within two trials of a new cognitive-behavioural treatment incorporating physical activity prior to changes in eating behaviours, and either regained ≥50% of that weight over 2 years (Regain group, n=32) or continued to lose weight (ContinuedLoss group, n = 34), were assessed from months 6 to 24 on changes in weight-loss behaviours and psychosocial predictors of those behaviours derived from established behavioural theories. For the Regain group, significant decreases in physical activity and fruit/vegetable intake during months 12-24, from both months 6 to 24 and 12 to 24 in eating- and physical activity-related self-regulation and from months 6 to 24 in eating-related self-efficacy (i.e. feelings of ability), were found. No significant behavioural or psychosocial changes were found over those times in the ContinuedLoss group. Changes in self-regulation and self-efficacy completely mediated the relationship between changes in fruit/vegetable intake and group (Regain vs. ContinuedLoss) (McFadden's R ²  = 0.19 and 0.20, respectively), with self-regulation independently contributing to the explained variance. Changes over both months 6-24 and 12-24 in self-regulation significantly mediated the relationship between changes in physical activity and group membership (McFadden's R ²  = 0.24 and 0.27, respectively). Findings suggested that approximately 6 months after treatment initiation would be a suitable time to intervene with some bolstering methods, while approximately 12 months post-initiation would be most applicable for others.

Initial body fat gain is related to brain volume changes in adolescents: A repeated-measures voxel-based morphometry study

OBJECTIVE

Individuals with obesity versus those within a healthy weight range show brain volume differences, but it is unclear whether these differences reflect initial vulnerability factors or are secondary to weight gain.

METHODS

One hundred sixty-two adolescents (M age = 15.3 ± 1.1; 81 females) with healthy weight were scanned at baseline. Sixty subjects (M baseline age: 15.2 ± 1.1; M follow-up age: 17.7 ± 1.2; 34 females) completed a second scan at 2- or 3-year follow-up. Voxel-based morphometry assessed global and regional gray matter (GM) and white matter (WM) volumes. Body fat percentage was assessed yearly over follow-up.

RESULTS

Baseline global/regional GM/WM volume did not predict body fat gain over follow-up. Adolescents who gained body fat showed greater decreases in GM volume in the putamen compared with those who showed loss of body fat. Adolescents who gained body fat showed greater increases in WM volume in the anterior cingulate cortex compared with those who showed stability of or loss of body fat.

CONCLUSIONS

Body fat gain versus stability and loss produce GM and WM volume changes, rather than baseline volumetric differences predicting body fat gain.

African Americans in Standard Behavioral Treatment for Obesity, 2001-2015: What Have We Learned?

African Americans (AAs) bear a disproportionate burden of the obesity epidemic, yet have historically been underrepresented in weight loss research. We conducted a narrative review of large ( N > 75) randomized prospective clinical trials of standard behavioral treatment for weight loss that reported results in the past 15 years (2001-2015) to (a) determine the rates of inclusion and reported results for AAs and (b) further identify strategies that may result in improved outcomes. Of the 23 trials reviewed, 69.6% of the studies met or exceeded population estimates for AAs in the United States. However, only 10 reported outcomes and/or considered race in the analytic approach. At 6 months, AA participants consistently lost less weight than White participants. The use of culturally tailored intervention materials and monthly personal telephone calls were reported as factors that may have enhanced treatment response. Future behavioral weight loss trials should also increase reporting of outcomes by race.

Non-pharmacological interventions in non-alcoholic fatty liver disease patients

Patients with non-alcoholic fatty liver disease have unhealthy diets, sedentary behaviour and not enough physical activity. This lifestyle triggers liver disease and probably favours its progression. It also has significant deleterious effects on health and longevity and should therefore be corrected by first-line therapy at all stages of the disease. However, important questions remain: is weight loss alone beneficial or do particular diets have beneficial effects beyond weight loss? Which specific micro- or macronutrients are clearly harmful? Does exercise without weight loss improve hepatic histology and what type of exercise is optimal? Does moderate or only vigorous exercise have metabolic and hepatic benefits? What is the efficacy of lifestyle measures outside of clinical trials? And most importantly, what is the turning point in the natural history of liver disease when non-pharmacological measures should be combined with drug therapy?

Supporting the transition from weight loss to maintenance: development and optimisation of a face-to-face behavioural intervention component

After weight loss, most individuals regain lost weight. Interventions to support the transition from successful loss to weight loss maintenance (WLM), regardless of the method of prior weight loss, are needed. The aims of this study were to (1) develop a face-to-face behavioural intervention session to support overweight and obese individuals who have recently lost a clinically significant amount of weight in the transition to WLM; (2) to assess the single-session intervention for acceptability and feasibility prior to its use in a larger, 12-month, multi-component trial; and (3) to optimise the intervention session for future use based on participant feedback. Participants with a Body Mass Index of ≥25 kg/m2 prior to a ≥5% weight loss in the previous 12 months were recruited via the local government authority and community-based advertisements. Each attended the one-hour session with a trained facilitator, which focused on setting maintenance-relevant weight, eating, and physical activity goals. Semi-structured interviews were carried out immediately post-session to obtain feedback on the acceptability of this intervention component. Data were used to generate recommendations for changes to the session, which were discussed by the team, and used to optimise the session. Seventeen participants (13 female; median WL = 13%) were recruited. All participants evaluated the intervention session positively; 11 participants suggested improvements including reducing information provision in favour of greater focus on identifying and coping with barriers, and the inclusion of practical examples. The systematic refinement and optimisation process resulted in an acceptable and feasible face-to-face behavioural intervention session (described here), which will be tested as part of a multi-component intervention. We anticipate the session could be used to supplement existing support including online services, and has the potential to benefit people who have lost a clinically significant amount of weight to achieve WLM over the long term.

The role of endoscopic therapy in obesity management: intragastric balloons and aspiration therapy

Weight management is increasingly incorporating endoscopic bariatric therapy (EBT). As the global burden of obesity and its comorbidities has increased, it is evident that novel therapeutic approaches will be necessary to address the obesity epidemic. EBTs offer greater efficacy than diet and lifestyle modification and lower invasiveness than bariatric surgery. The US Food and Drug Administration has approved two intragastric balloons and aspiration therapy for the treatment of obesity: Apollo Orbera is indicated for the treatment of Class I and Class II obesity, Re Shape Integrated Dual Balloon system is indicated for the same range with a comorbidity, and Aspire Bariatrics AspireAssist is approved for patients with a body mass index of 35-55 kg/m². These devices have proven safe and effective in clinical trials and are gaining commercial acceptance in the USA; the Orbera has been used extensively outside the USA for over 20 years. These devices will need to be delivered in the context of a multidisciplinary weight loss program, integrating comprehensive care of obesity. Patient selection is important, and ensuring appropriate patient expectations and understanding of alternatives such as pharmacologic therapy and surgery is essential. With several EBTs on the horizon, patients with obesity will have an even broader array of safe and effective options for weight management in the future.

Sustainable Lifestyle Change-Participatory Design of Support Together with Persons with Obesity in the Third Age

Sustainable lifestyle changes due to obesity are difficult to achieve regardless methods used. We need to know more about the lived experience of obesity and older persons' needs for support to make a sustainable change. This paper focuses on the need-finding process in designing support for a sustainable lifestyle change. Multistage focus group interviews were conducted with persons aged 61-72 living in Northern Sweden. A participatory and appreciative reflection and action (PAAR) approach was used in the group-sessions. Probes were used to increase reflections and achieve a deeper knowledge about the participants' needs of support. Data were analysed using qualitative thematic content analysis. Our findings revealed that to be able to succeed with a lifestyle change a focus has to be on a converted way of thinking, managing vulnerability, and achieving an emotional balance. To achieve a sustainable lifestyle change due to obesity in the third age the focus has to be on a health identity instead of a weight identity. Personalised support with enjoyable physical activities should be designed and developed. Strategies for emotional balance based on autonomy and self-empowerment must be included. This knowledge is important when designing support for sustainable change.

FTO genotype and weight loss: systematic review and meta-analysis of 9563 individual participant data from eight randomised controlled trials

OBJECTIVE

 To assess the effect of the FTO genotype on weight loss after dietary, physical activity, or drug based interventions in randomised controlled trials.

DESIGN

 Systematic review and random effects meta-analysis of individual participant data from randomised controlled trials.

DATA SOURCES

 Ovid Medline, Scopus, Embase, and Cochrane from inception to November 2015.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

 Randomised controlled trials in overweight or obese adults reporting reduction in body mass index, body weight, or waist circumference by FTO genotype (rs9939609 or a proxy) after dietary, physical activity, or drug based interventions. Gene by treatment interaction models were fitted to individual participant data from all studies included in this review, using allele dose coding for genetic effects and a common set of covariates. Study level interactions were combined using random effect models. Metaregression and subgroup analysis were used to assess sources of study heterogeneity.

RESULTS

 We identified eight eligible randomised controlled trials for the systematic review and meta-analysis (n=9563). Overall, differential changes in body mass index, body weight, and waist circumference in response to weight loss intervention were not significantly different between FTO genotypes. Sensitivity analyses indicated that differential changes in body mass index, body weight, and waist circumference by FTO genotype did not differ by intervention type, intervention length, ethnicity, sample size, sex, and baseline body mass index and age category.

CONCLUSIONS

 We have observed that carriage of the FTO minor allele was not associated with differential change in adiposity after weight loss interventions. These findings show that individuals carrying the minor allele respond equally well to dietary, physical activity, or drug based weight loss interventions and thus genetic predisposition to obesity associated with the FTO minor allele can be at least partly counteracted through such interventions.

SYSTEMATIC REVIEW REGISTRATION

 PROSPERO CRD42015015969.

Social facilitation maintenance treatment for adults with obesity: study protocol for a randomised-controlled feasibility study (SFM study)

INTRODUCTION

The long-term success of non-surgical weight loss treatment in adults with obesity is limited by substantial relapse, and only a few evidence-based weight loss maintenance treatments exist. This clinical trial investigates the feasibility and efficacy of a social facilitation maintenance programme for weight loss maintenance, tailored to meet the needs of obese adults who have undergone a lifestyle weight loss intervention.

METHODS AND ANALYSIS

In a single-centre, open feasibility trial, 72 adults currently or previously obese or overweight who have undergone a lifestyle weight loss intervention are centrally randomised to 4 months of social facilitation maintenance treatment or treatment as a usual control condition. In 16 outpatient group sessions, the social facilitation maintenance treatment, based on a socioecological model and on evidence supporting social facilitation as a key process in maintaining weight loss, focuses on promoting interpersonal relationships to build up a healthy lifestyle for long-term weight loss maintenance. Primary outcome is the amount of weight regain at 6-month follow-up, compared with pre-treatment weight, derived from measured body weight. Secondary outcomes address feasibility, including recruitment, attrition, assessment non-completion, compliance and patients' programme evaluation; and in comparison with pre-weight loss maintenance, social and interpersonal functioning, eating behaviour and physical activity, psychological and physical symptoms, body composition and risk of comorbidity, and quality of life at post-treatment and follow-up assessments.

ETHICS AND DISSEMINATION

The study was approved by the Ethical Committee at the University of Leipzig (165-13-15072013). The study results will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

DRKS00005182.

Self-directed interventions to promote weight loss: a systematic review and meta-analysis

Many self-directed weight-loss interventions have been developed using a variety of delivery formats (e.g., internet and smartphone) and change techniques. Yet, little research has examined whether self-directed interventions can exclusively promote weight loss. MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Library were systematically reviewed for randomised controlled trials evaluating self-directed interventions in relation to weight-loss outcomes in adults. Standardised mean differences (SMD) and 95% confidence intervals (CI) were calculated using a random effects model. Twenty-seven trials incorporating 36 comparisons met our inclusion criteria. Participants using self-directed interventions lost significantly more weight (MD = -1.56 kg, CI -2.25, -0.86 ranging from 0.6 to 5.3 kg) compared to those in the minimal intervention or no-treatment groups (3.1-month follow-up median). The majority of interventions were internet based (18 evaluations) and these were effective at 3 months (MD = -1.74 kg, CI -2.65, -0.82 ranging from 0.6 to 4.8 kg) (SMD = -0.48, 95% CI -0.72, -0.24, I(2) = 82%; p < .0001; 16 evaluations) and 6 months follow-up (MD = -2.71 kg, CI -4.03, -1.39 ranging from 2.2 to 5.3 kg) (SMD = -0.59, 95% CI -0.99, -0.19, I(2) = 76%; p = .004; 4 evaluations). Self-directed weight-loss interventions can generate modest weight loss for up to 6 months but may need to be supplemented by other interventions to achieve sustained and clinically meaningful weight loss.

Evaluating the Maintenance of Lifestyle Changes in a Randomized Controlled Trial of the 'Get Healthy, Stay Healthy' Program

Background

Extending contact with participants after initial, intensive intervention may support maintenance of weight loss and related behaviors.

Objective

This community-wide trial evaluated a text message (short message service, SMS)-delivered, extended contact intervention (‘Get Healthy, Stay Healthy’ (GHSH)), which followed on from a population-level, behavioral telephone coaching program.

Methods

This study employed a parallel, randomized controlled trial: GHSH compared with no continued contact (standard practice). Participants (n=228) were recruited after completing a 6-month lifestyle telephone coaching program: mean age = 53.4 (standard deviation (SD)=12.3) years; 66.7% (152/228) female; mean body mass index (BMI) upon entering GHSH=29.5 kg/m2 (SD = 6.0). Participants received tailored text messages over a 6-month period. The message frequency, timing, and content of the messages was based on participant preference, ascertained during two tailoring telephone calls. Primary outcomes of body weight, waist circumference, physical activity (walking, moderate, and vigorous sessions/week), and dietary behaviors (fruit and vegetable serves/day, cups of sweetened drinks per day, takeaway meals per week; fat, fiber and total indices from the Fat and Fiber Behavior Questionnaire) were assessed via self-report before (baseline) and after (6-months) extended contact (with moderate-vigorous physical activity (MVPA) also assessed via accelerometry).

Results

Significant intervention effects, all favoring the intervention group, were observed at 6-months for change in weight (-1.35 kg, 95% confidence interval (CI): -2.24, -0.46, P=.003), weekly moderate physical activity sessions (0.56 sessions/week, 95% CI: 0.15, 0.96, P=.008) and accelerometer-assessed MVPA (24.16 minutes/week, 95% CI: 5.07, 43.25, P=.007). Waist circumference, other physical activity outcomes and dietary outcomes, did not differ significantly between groups.

Conclusions

The GHSH extended care intervention led to significantly better anthropometric and physical activity outcomes than standard practice (no contact). This evidence is useful for scaling up the delivery of GHSH as standard practice following the population-level telephone coaching program.

The impact of continued intervention on weight: Five-year results from the weight loss maintenance trial

OBJECTIVE

In the Weight Loss Maintenance (WLM) Trial, a personal contact (PC) intervention sustained greater weight loss relative to a self-directed (SD) group over 30 months. This study investigated the effects of continued intervention over an additional 30 months and overall weight change across the entire WLM Trial.

METHODS

WLM had 3 phases. Phase 1 was a 6-month weight loss program. In Phase 2, those who lost ≥4 kg were randomized to a 30-month maintenance trial. In Phase 3, PC participants (n = 196, three sites) were re-randomized to no further intervention (PC-Control) or continued intervention (PC-Active) for 30 more months; 218 SD participants were also followed.

RESULTS

During Phase 3, weight increased 1.0 kg in PC-Active and 0.5 kg in PC-Control (mean difference 0.6 kg; 95% CI:-1.4 to 2.7; P = 0.54). Mean weight change over the entire study was -3.2 kg in those originally assigned to PC (PC-Combined) and -1.6 kg in SD (mean difference -1.6 kg; 95% CI:-3.0 to -0.1; P = 0.04).

CONCLUSIONS

After 30 months of the PC maintenance intervention, continuation for another 30 months provided no additional benefit. However, across the entire study, weight loss was slightly greater in those originally assigned to PC.

Neural vulnerability factors that increase risk for future weight gain

Theorists have proposed several neural vulnerability factors that may increase overeating and consequent weight gain. Early cross-sectional imaging studies could not determine whether aberrant neural responsivity was a precursor or consequence of overeating. However, recent prospective imaging studies examining predictors of future weight gain and response to obesity treatment, and repeated-measures imaging studies before and after weight gain and loss have advanced knowledge of etiologic processes and neural plasticity resulting from weight change. The present article reviews evidence from prospective studies using imaging and behavioral measures reflecting neural function, as well as randomized experiments with humans and animals that are consistent or inconsistent with 5 neural vulnerability theories for excessive weight gain. Extant data provide strong support for the incentive sensitization theory of obesity and moderate support for the reward surfeit theory, inhibitory control deficit theory, and dynamic vulnerability model of obesity, which attempted to synthesize the former theories into a single etiologic model. However, existing data provide only minimal support for the reward deficit theory. Findings are synthesized into a new working etiologic model that is based on current scientific knowledge. Important directions for future studies, which have the potential to support or refute this working etiologic model, are delineated. (PsycINFO Database Record

A feasibility randomised controlled trial of a motivational interviewing-based intervention for weight loss maintenance in adults

BACKGROUND

Obesity has significant health and NHS cost implications. Relatively small reductions in weight have clinically important benefits, but long-term weight loss maintenance (WLM) is challenging. Behaviour change interventions have been identified as key for WLM. Motivation is crucial to supporting behaviour change, and motivational interviewing (MI) has been identified as a successful approach to changing health behaviours. The study was designed as an adequately powered, pragmatic randomised controlled trial (RCT); however, owing to recruitment issues, the study became a feasibility trial.

OBJECTIVES

To assess recruitment, retention, feasibility, acceptability, compliance and delivery of a 12-month intervention to support WLM. Secondary objectives were to assess the impact of the intervention on body mass index (BMI) and other secondary outcomes.

DESIGN

Three-arm individually randomised controlled trial comprising an intensive arm, a less intensive arm and a control arm.

SETTING

Community setting in South Wales and the East Midlands.

PARTICIPANTS

Individuals aged 18-70 years with a current or previous BMI of ≥ 30 kg/m(2) who could provide evidence of at least 5% weight loss during the previous 12 months.

INTERVENTION

Participants received individually tailored MI, which included planning and self-monitoring. The intensive arm received six face-to-face sessions followed by nine telephone sessions. The less intensive arm received two face-to-face sessions followed by two telephone sessions. The control arm received a leaflet advising them on healthy lifestyle.

MAIN OUTCOME MEASURES

Feasibility outcomes included numbers recruited, retention and adherence. The primary effectiveness outcome was BMI at 12 months post randomisation. Secondary outcomes included waist circumference, waist-to-hip ratio, physical activity, proportion maintaining weight loss, diet, quality of life, health service resource usage, binge eating and well-being. A process evaluation assessed intervention delivery, adherence, and participants' and practitioners' views. Economic analysis aimed to assess cost-effectiveness in terms of quality-adjusted life-years (QALYs).

RESULTS

A total of 170 participants were randomised. Retention was good (84%) and adherence was excellent (intensive, 83%; less intensive, 91%). The between-group difference in mean BMI indicated the intensive arm had BMIs 1.0 kg/m(2) lower than the controls [95% confidence interval (CI) -2.2 kg/m(2) to 0.2 kg/m(2)]. Similarly, a potential difference was found in weight (average difference of 2.8 kg, 95% CI -6.1 kg to 0.5 kg). The intensive arm had odds of maintaining on average 43% [odds ratio(OR) 1.4, 95% CI 0.6 to 3.5] higher than controls. None of these findings were statistically significant. Further analyses controlling for level of adherence indicated that average BMI was 1.2 kg/m(2) lower in the intensive arm than the control arm (95% CI -2.5 kg/m(2) to 0.0 kg/m(2)). The intensive intervention led to a statistically significant difference in weight (mean -3.7 kg, 95% CI -7.1 kg to -0.3 kg). The other secondary outcomes showed limited evidence of differences between groups. The intervention was delivered as planned, and both practitioners and participants were positive about the intervention and its impact. Although not powered to assess cost-effectiveness, results of this feasibility study suggest that neither intervention as currently delivered is likely to be cost-effective in routine practice.

CONCLUSION

This is the first trial of an intervention for WLM in the UK, the intervention is feasible and acceptable, and retention and adherence were high. The main effectiveness outcome showed a promising mean difference in the intensive arm. Owing to the small sample size, we are limited in the conclusions we can draw. However, findings suggest that the intensive intervention may facilitate long-term weight maintenance and, therefore, further testing in an effectiveness trial may be indicated. Research examining WLM is in its infancy, further research is needed to develop our understanding of WLM and to expand theory to inform the development of interventions to be tested in rigorously designed RCTs with cost-effectiveness assessed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN35774128.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 50. See the NIHR Journals Library website for further project information.

Psychosocial predictors of weight loss by race and sex

This paper examined the psychosocial predictors of weight loss among race and sex subgroups. Analyses included overweight and obese participants from the PREMIER study, a previously published randomized trial that examined the effects of two multi-component lifestyle interventions on blood pressure among pre-hypertensive and stage 1 hypertensive adults. Both intervention conditions received behavioural recommendations for weight loss and group sessions. Weight and psychosocial measures of self-efficacy and social support for diet and exercise were assessed at baseline and at 6 months. There were 157 African-American (AA) women, 46 AA men, 203 non-AA women and 182 non-AA men with an average age of 50 years and average body mass index of 34 at baseline. Multiple predictor regression models were performed individually by race and sex subgroup. Among AA women, increases in diet self-efficacy were associated with weight loss. Among AA men, increases in diet-related social support and self-efficacy, along with increases in family support to exercise, were associated with weight loss (all Ps <0.05). Among non-AA women, increases in friends' support to exercise and exercise-related self-efficacy were associated with weight loss, and among non-AA men only increases in diet self-efficacy were associated with weight loss (all Ps <0.05). These results emphasize the need for targeted interventions based on race and sex to optimize the impact of lifestyle-based weight loss programmes.

Efficacy of a Text Message-Delivered Extended Contact Intervention on Maintenance of Weight Loss, Physical Activity, and Dietary Behavior Change

Background

Extending contact with participants after the end of an initial intervention is associated with successful maintenance of weight loss and behavior change. However, cost-effective methods of extending intervention contact are needed.

Objective

This study investigated whether extended contact via text message was efficacious in supporting long-term weight loss and physical activity and dietary behavior change in breast cancer survivors.

Methods

Following the end of an initial 6-month randomized controlled trial of a telephone-delivered weight loss intervention versus usual care, eligible and consenting intervention participants received a 6-month extended contact intervention via tailored text messages targeting a range of factors proposed to influence the maintenance of behavior change. In this single-group, pre-post designed study, within group changes in weight, moderate-to-vigorous physical activity (Actigraph GT3X+ accelerometers), and total energy intake (2x24 hour dietary recalls) were evaluated from baseline to end of initial intervention (6 months), end of extended contact intervention (12 months), and after a no-contact follow-up (18 months) via linear mixed models. Feasibility of implementation was assessed through systematic tracking of text message delivery process outcomes, and participant satisfaction was assessed through semistructured interviews.

Results

Participants at baseline (n=29) had a mean age of 54.9 years (SD 8.8), body mass index of 30.0 kg/m² (SD 4.2), and were recruited a mean 16.6 months (SD 3.2) post diagnosis. From baseline to 18 months, participants showed statistically significantly lower mean weight (-4.2 kg [95% CI -6.0 to -2.4]; P<.001) and higher physical activity (mean 10.4 mins/day [95% CI 3.6-17.2]; P=.003), but no significant differences in energy intake (P=.200). Participants received a mean of 8 text messages every 2 weeks (range 2-11) and reported a high rate of satisfaction.

Conclusions

In comparison to interventions without extended contact, results suggest text message–delivered extended contact may support the attenuation of weight regain and promote the maintenance of physical activity.

Combinations of obesity prevention strategies in US elementary schools: a critical review

The prevalence of obesity among children has roughly tripled in the past 30 years. Given the numerous health risks associated with obesity, elementary schools have implemented a variety of prevention programs targeting this problem. This review examines recent studies of combinations of obesity prevention programs in US elementary schools and offers recommendations about effective strategies. We found 12 studies that met selection criteria and reviewed their findings related to obesity-related outcomes. Among the single intervention strategies, neither physical activity nor education alone demonstrated efficacy in reducing objective measures of obesity. Most studies of programs with two or three components (i.e., physical activity plus nutrition, physical activity plus both education and nutrition) reported statistically significant improvements in objective obesity-related outcomes. Studies evaluating programs with community and parental involvement suggest that these components may increase effectiveness. However, studies assessing outcomes following the cessation of the program showed a reversal of positive effects, suggesting that long-term implementation of programs is important for sustained gains. Results suggest that combinations of obesity prevention programs sustained over time are most likely to be effective.

Reward Region Responsivity Predicts Future Weight Gain and Moderating Effects of the TaqIA Allele

Because no large prospective study has investigated neural vulnerability factors that predict future weight gain, we tested whether neural response to receipt and anticipated receipt of palatable food and monetary reward predicted body fat gain over a 3-year follow-up in healthy-weight adolescent humans and whether the TaqIA polymorphism moderates these relations. A total of 153 adolescents completed fMRI paradigms assessing response to these events; body fat was assessed annually over follow-up. Elevated orbitofrontal cortex response to cues signaling impending milkshake receipt predicted future body fat gain (r = 0.32), which is a novel finding that provides support for the incentive sensitization theory of obesity. Neural response to receipt and anticipated receipt of monetary reward did not predict body fat gain, which has not been tested previously. Replicating an earlier finding (Stice et al., 2008a), elevated caudate response to milkshake receipt predicted body fat gain for adolescents with a genetic propensity for greater dopamine signaling by virtue of possessing the TaqIA A2/A2 allele, but lower caudate response predicted body fat gain for adolescents with a genetic propensity for less dopamine signaling by virtue of possessing a TaqIA A1 allele, though this interaction was only marginal [p-value <0.05 corrected using voxel-level familywise error rate (pFWE) = 0.06]. Parental obesity, which correlated with TaqIA allele status (odds ratio = 2.7), similarly moderated the relation of caudate response to milkshake receipt to future body fat gain, which is another novel finding. The former interaction implies that too much or too little dopamine signaling and reward region responsivity increases risk for overeating, suggesting qualitatively distinct reward surfeit and reward deficit pathways to obesity.

SIGNIFICANCE STATEMENT

Because no large prospective study has investigated neural vulnerability factors that predict future weight gain we tested whether neural response to receipt and anticipated receipt of palatable food and monetary reward predicted body fat gain over 3-year follow-up in healthy-weight adolescent humans and whether the TaqIA polymorphism moderates these relations. Elevated reward activation in response to food cues predicted future body fat gain. Elevated reward response to food receipt predicted body fat gain for adolescents with a TaqIA A2/A2 allele and lower reward response predicted body fat gain for those with a TaqIA A1 allele. Results imply that too much or too little dopamine signaling and reward region responsivity increases risk for overeating.

Cost-Effectiveness Analysis of Qsymia for Weight Loss

BACKGROUND

Phase 3 clinical trial results reveal that Qsymia is a clinically effective long-term treatment for obesity, but whether this treatment is cost-effective compared to a diet and lifestyle intervention has yet to be explored.

OBJECTIVE

To quantify the incremental cost-effectiveness of Qsymia (phentermine and topiramate extended-release) for health-related quality of life improvements.

STUDY DESIGN AND METHODS

Estimates are based on cost and quality of life outcomes from a 56-week, multicenter, placebo-controlled, phase 3 clinical trial undertaken in 93 health centers in the US. Participants were overweight and obese adults (aged 18-70 years) with a body-mass index of 27-45 kg/m(2) and two or more comorbidities (hypertension, dyslipidemia, diabetes or pre-diabetes or abdominal obesity). The intervention was diet and lifestyle advice plus the recommended dose of Qsymia (phentermine 7.5 mg plus topiramate 46.0 mg) vs. control, which included diet and lifestyle advice plus placebo. The study was from the payer perspective. Costs included the prescription cost, medication cost offsets and physician appointment costs. Effectiveness was measured in terms of quality-adjusted life years gained (QALYs). The main outcome measure was incremental cost per QALY gained of the intervention relative to control.

RESULTS

Our base-case model, in which participants take Qsymia for 1 year with benefits linearly decaying over the subsequent 2 years, generates an incremental cost-effectiveness ratio (ICER) of $48,340 per QALY gained. Using the base-case assumptions, probabilistic sensitivity analyses reveal that the ICER is below $50,000 per QALY in 54 % of simulations. However, results are highly dependent on the extent to which benefits are maintained post medication cessation. If benefits persist for only 1 year post cessation, the ICER increases to $74,480.

CONCLUSION

Although base-case results suggest that Qsymia is cost-effective, this result hinges on the time on Qsymia and the extent to which benefits are maintained post medication cessation. This should be an area of future research.

The Impact of Gender and Protein Intake on the Success of Weight Maintenance and Associated Cardiovascular Risk Benefits, Independent of the Mode of Food Provision: The DiOGenes Randomized Trial

OBJECTIVE

Maintenance of weight loss and associated cardiovascular benefits after following energy-restricted diets is still a challenging field, and thorough investigation is needed. The present research aimed to determine the role of protein and gender in relation to two different intervention models related to food supply, in a weight maintenance trial.

SUBJECTS AND METHODS

The DiOGenes trial was a long-term, multicenter, randomized, dietary intervention study, conducted in eight European countries (Clinical Trials.gov, NCT00390637), focusing on assessing the effectiveness of weight maintenance over 6 months. This secondary analysis intended to evaluate the different benefits for weight maintenance and cardiometabolic markers of two dietary advice delivery models: "shop + instruction intervention" vs "instruction-alone intervention," which were further categorized for gender and macronutrient intake.

RESULTS

The weight maintenance intervention based on different macronutrient intake showed, independently of the advice delivery model, in both sexes that higher protein consumption was more effective for weight stability, showing better results in obese women (low protein: 1.65 kg in males and 0.73 Kg in females vs high protein: 1.45 kg in males and -0.93 Kg in females) . Measurements concerning cardiovascular risk markers from subjects on both structured models produced similar trends in the subsequent follow-up period, with a lower rebound in women for most of the markers analyzed.

CONCLUSION

The reported dietary benefits for weight sustainability should be ascribed to the macronutrient distribution (higher protein diets) rather than to the structured mode of delivery. Higher weight regain in males was noted, as well as a metabolic divergence attributable to the sex, with a better biochemical outcome in women.

How applicable are results of systematic reviews and meta-analyses of health behaviour maintenance? A critical evaluation

OBJECTIVE

To evaluate the practical applicability of systematic reviews and meta-analyses to the maintenance of physical activity or weight loss by assessing methodological and reporting aspects.

METHODS

To identify relevant studies a literature search was conducted in MEDLINE, EMBASE, Cochrane Library, PsycINFO, PSYNDEX, Google scholar, and reference lists. Each article was evaluated for methodological quality, operationalization of maintenance, and practicability following the RE-AIM framework and the PRISMA statement.

RESULTS

Twenty-four systematic reviews and meta-analyses were included of which 14 were published in the last four years. There were multiple definitions of maintenance. In addition the instances of redundancy, and neglect of thematic fields are identified. Eighty-seven percent of the reviews showed methodological flaws. The potential practical use of the outcomes was limited.

CONCLUSION

The applicability of systematic reviews and meta-analyses regarding health behaviour maintenance is limited with regard to reporting, methodology and thematic coverage. For practitioners, synthesis of quantitative and qualitative evidence with theoretical models is lacking.

A review of technology-based interventions to maintain weight loss

BACKGROUND

For many decades, healthcare providers and researchers have developed weight-loss interventions to help people achieve weight loss. Unfortunately, it is typical for people to lose weight quickly during the intervention period but then slowly regain weight until they return to their approximate baseline. Technology-based maintenance interventions are among the newest approaches to long-term weight loss. Several advantages make technology helpful for maintaining weight loss. The purpose of this article was to review and critique the randomized controlled trials of technology-based weight-loss maintenance interventions (WLMIs) for adults.

MATERIALS AND METHODS

A systematic search through electronic databases and a manual citation search were conducted. Limited numbers of controlled trials published since 2000 that included randomization, and technology-based WLMIs were identified.

RESULTS

The characteristics of the eight studies were diverse. The average score of study design quality was moderate. The results of the effectiveness of technology-based WLMIs were mixed. Technology-based WLMIs are more likely to be effective than usual care but not more effective than personal contact.

CONCLUSIONS

Based on the review, guidelines were established for the selection and potential success of technology-based WLMIs. The effectiveness of technology-based maintenance interventions for weight loss varied, and potential strategies and approaches are discussed to improve their effectiveness. Further studies are needed to better evaluate and refine the efficacy of technology-based WLMIs.

Healthy behaviours and 10-year incidence of diabetes: a population cohort study

OBJECTIVE

To examine the association between meeting behavioural goals and diabetes incidence over 10 years in a large, representative Swedish population.

METHODS

Population-based prospective cohort study of 32,120 individuals aged 35 to 55 years participating in a health promotion intervention in Västerbotten County, Sweden (1990 to 2013). Participants underwent an oral glucose tolerance test, clinical measures, and completed diet and activity questionnaires. Poisson regression quantified the association between achieving six behavioural goals at baseline - body mass index (BMI) <25 kg/m(2), moderate physical activity, non-smoker, fat intake <30% of energy, fibre intake ≥15 g/4184 kJ and alcohol intake ≤20 g/day - and diabetes incidence over 10 years.

RESULTS

Median interquartile range (IQR) follow-up time was 9.9 (0.3) years; 2211 individuals (7%) developed diabetes. Only 4.4% of participants met all 6 goals (n=1245) and compared to these individuals, participants meeting 0/1 goals had a 3.74 times higher diabetes incidence (95% confidence interval (CI)=2.50 to 5.59), adjusting for sex, age, calendar period, education, family history of diabetes, history of myocardial infarction and long-term illness. If everyone achieved at least four behavioural goals, 14.1% (95% CI: 11.7 to 16.5%) of incident diabetes cases might be avoided.

CONCLUSION

Interventions promoting the achievement of behavioural goals in the general population could significantly reduce diabetes incidence.

Retaining critical therapeutic elements of behavioral interventions translated for delivery via the Internet: recommendations and an example using pain coping skills training

Evidence supporting the efficacy of behavioral interventions based on principles of cognitive behavioral therapies has spurred interest in translating these interventions for delivery via the Internet. However, the benefits of this dissemination method cannot be realized unless the translated interventions are as effective as possible. We describe a challenge that must be overcome to ensure this occurs—Internet interventions must retain therapeutic components and processes underlying the success of face-to-face interventions on which they are based. These components and processes vary in the ease with which they can be translated to the online environment. Moreover, some are subtle and may be overlooked, despite being recognized as essential to the success of face-to-face interventions. We provide preliminary guidance for retaining critical therapeutic components and processes in the translation process, using Pain Coping Skills Training for osteoarthritis pain to illustrate methods. Directions for future research are also discussed.

Relation of the multilocus genetic composite reflecting high dopamine signaling capacity to future increases in BMI

Because food intake exerts its rewarding effect by increasing dopamine (DA) signaling in reward circuitry, it theoretically follows that individuals with a greater number of genotypes putatively associated with high DA signaling capacity are at increased risk for overeating and subsequent weight gain. We tested the association between the multilocus genetic composite risk score, defined by the total number of genotypes putatively associated with greater DA signaling capacity (i.e. TaqIA A2 allele, DRD2-141C Ins/Del and Del/Del genotypes, DRD4-S allele, DAT1-S allele, and COMT Val/Val genotype), and future increases in Body Mass Index (BMI) in three prospective studies. Participants in Study 1 (N = 30; M age = 15.2; M baseline BMI = 26.9), Study 2 (N = 34; M age = 20.9; M baseline BMI = 28.2), and Study 3 (N = 162; M age = 15.3, M baseline BMI = 20.8) provided saliva samples from which epithelial cells were collected, permitting DNA extraction. The multilocus genetic composite risk score was associated with future increases in BMI in all three studies (Study 1, r = 0.37; Study 2, r = 0.22; Study 3, r = 0.14) and the overall sample (r = 0.19). DRD4-S was associated with increases in BMI in Study 1 (r = 0.42), Study 2 (r = 0.27), and in the overall sample (r = 0.17). DAT1-S was associated with increases in BMI in Study 3 (r = 0.17) and in the overall sample (r = 0.12). There were no associations between the other genotypes (TaqIA, COMT, and DRD2-141C) and change in BMI over 2-year follow-up. Data suggest that individuals with a genetic propensity for greater DA signaling capacity are at risk for future weight gain and that combining alleles that theoretically have a similar function may provide a more reliable method of modeling genetic risk associated with future weight gain than individual genotypes.

Personalized weight loss strategies-the role of macronutrient distribution

A large number of different dietary approaches have been studied in an attempt to achieve healthy, sustainable weight loss among individuals with overweight and obesity. Restriction of energy intake is the primary method of producing a negative energy balance leading to weight loss. However, owing to the different metabolic roles of proteins, carbohydrates and lipids in energy homeostasis, diets of similar overall energy content but with different macronutrient distribution can differentially affect metabolism, appetite and thermogenesis. Evidence increasingly suggests that the fuel values of calories provided by distinct macronutrients should be considered separately, as metabolism of specific molecular components generates differences in energy yield. The causes of variation in individual responses to various diets are currently under debate, and some evidence suggests that differences are associated with specific genotypes. This Review discusses all available systematic reviews and meta-analyses, and summarizes the results of relevant randomized controlled intervention trials assessing the influence of macronutrient composition on weight management. The initial findings of research into personalized nutrition, based on the interactions of macronutrient intake and genetic background and its potential influence on dietary intervention strategies, are also discussed.