New interdisciplinary cognitive-behavioural-nutritional approach to obesity treatment: a 5-year follow-up study

Understanding weight regain after a nutritional weight loss intervention: Systematic review and meta-analysis

BACKGROUND & AIMS

The purpose of this systematic review was to analyze the effects of lifestyle interventions on long-term weight maintenance of weight loss. In addition, we seek to address which period is most susceptible to weight regain; and what is the time required for following-up weight maintenance after the intervention.

METHODS

Articles published up to August 2020 were identified using the Medline (PubMed), Embase, Web of Science, CENTRAL and Scopus.

RESULTS

After the selection process, 27 clinical trials involving 7236 individuals were included. The results showed that around 36 weeks after the end of the intervention, weight variation reduces, and a sign of continuous weight gain begin to occur with some patients (n = 208,209) presenting even a completely regain of the lost weight before one year (∼40-48 weeks). However, some strategies used during the weight loss intervention and maintenance period may impact the amount and when the weight regain happens, like intervention type;, intervention duration;, presence of dietitian on the care team;, and maintenance period with counseling by a health professional at least once a month.

CONCLUSION

This systematic review and meta-analysis showed that lifestyle interventions remained effective in maintaining the mean weight (5% lower than baseline weight) after weight loss interventions were over. However, weight regain started 36 weeks after intervention conclusion. And, it turns out, some strategies used during the weight loss intervention and maintenance period may impact the amount and when the weight regain happens. Obesity complexity and chronicity should be considered, therefore constant and lifelong monitoring and support are important.

The challenge of keeping it off, a descriptive systematic review of high-quality, follow-up studies of obesity treatments

The aim of this systematic review is to answer the question: Is substantial, stable, and long-term weight loss a viable goal for adults with obesity? To answer this question, we conducted a broad systematic search of non-surgical and non-pharmacological obesity treatment studies with the following strict criteria: (a) minimum 3-year follow-up, (b) 5% body mass lost, (c) no continued interventions in the follow-up-period, (d) prospective design, and (e) less than 30% attrition from the start of the follow-up period. While the search revealed a very large number of published articles, only eight studies met the inclusion criteria. Several of the nonincluded studies report a majority of participants achieving satisfactory weight loss and little regain, especially among studies with continued interventions during the follow-up period. In contrast, the eight high-quality studies included in this study demonstrate a trend of weight regain towards pretreatment baseline. This review concludes that the majority of high-quality follow-up treatment studies of individuals with obesity are not successful in maintaining weight loss over time. The results suggest that excess weight can be lost but is likely regained over time, for the majority of participants.

Bariatric surgery versus lifestyle interventions for severe obesity: 5-year changes in body weight, risk factors and comorbidities

Changes in body weight (BW), risk factors and comorbidities 5 years after Roux-en-Y gastric bypass (RYGB) or different lifestyle interventions are compared. A total of 209 (75% women) severe obese adults were non-randomly allocated to: (A) RYGB (n = 58), (B) weight loss (WL) camp (n = 30), (C) residential intermittent programme (n = 64) or (D) hospital outpatient programme (n = 57). Body weight, risk factors and comorbidities were assessed at baseline, 1 and 5 years. A total of 89 and 54% completed the 1- and 5-year follow-up. The RYGB group experienced more WL at 5 years (-23.9%, 95% CI [-27.7, -20.0]) compared with lifestyle groups: (B) (-9.2%, 95% CI [-16.9, -1.5]), (C) (-4.1%, 95% CI [-8.0, -0.1]) and (D) (-4.1 kg, 95% CI [-10.0, 1.8]) (all P < 0.001). No differences were observed between lifestyle groups, although groups B and C had significant WL after 5 years (all P < 0.05). Plasma glucose and high-density lipoprotein cholesterol were improved in the RYGB group at 5 years compared with lifestyle groups (all P < 0.05). More patients in the RYGB group experienced remission of hypertension (P < 0.05). RYGB was associated with a lower BW, improved blood parameters and hypertension remission compared with lifestyle interventions at 5 years. However, significant WL was also achieved with lifestyle interventions.

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.

Dance therapy combined with patient education improves quality of life of persons with obesity: A pilot feasibility study for a randomised controlled trial

OBJECTIVE

To assess the effect of dance therapy combined with patient education on quality of life, functional capacity (lower limb power and endurance) and physical activity level in obese individuals.

METHODS

Thirty-three obese patients were randomised to a control group (structured patient education ambulatory program), and 34 to an intervention group (structured patient education ambulatory program combined with weekly sessions of dance therapy). Patients' quality of life, physical function and physical activity level were assessed at baseline and after 16 weeks.

RESULTS

Almost only women were willing to enrol in the study. Participants of the intervention group significantly improved their quality of life (p=0.023), and particularly self-esteem (p=0.014). However, dance therapy added to a patient educational program did not produce statistically significant higher effects than a patient education program alone on functional capacities and patients' physical activity level.

CONCLUSION

A 16 week structured patient educational program combined with dance therapy seems to have a positive effect on the quality of life of obese people, but no effect on functional capacities and physical activity.

PRACTICE IMPLICATION

Dance therapy combined with structured patient education is an interesting approach to improve quality of life of obese people.

Effects of lifestyle interventions that include a physical activity component in class II and III obese individuals: a systematic review and meta-analysis

BACKGROUND

In class II and III obese individuals, lifestyle intervention is the first step to achieve weight loss and treat obesity-related comorbidities before considering bariatric surgery. A systematic review, meta-analysis, and meta-regression were performed to assess the impact of lifestyle interventions incorporating a physical activity (PA) component on health outcomes of class II and III obese individuals.

METHODS

An electronic search was conducted in 4 databases (Medline, Scopus, CINAHL and Sportdiscus). Two independent investigators selected original studies assessing the impact of lifestyle interventions with PA components on anthropometric parameters, cardiometabolic risk factors (fat mass, blood pressure, lipid and glucose metabolism), behaviour modification (PA and nutritional changes), and quality of life in adults with body mass index (BMI) ≥ 35 kg/m2. Estimates were pooled using a random-effect model (DerSimonian and Laird method). Heterogeneity between studies was assessed by the Cochran's chi-square test and quantified through an estimation of the I².

RESULTS

Of the 3,170 identified articles, 56 met our eligibility criteria, with a large majority of uncontrolled studies (80%). The meta-analysis based on uncontrolled studies showed significant heterogeneity among all included studies. The pooled mean difference in weight loss was 8.9 kg (95% CI, 10.2-7.7; p < 0.01) and 2.8 kg/m² in BMI loss (95% CI, 3.4-2.2; p < 0.01). Long-term interventions produced superior weight loss (11.3 kg) compared to short-term (7.2 kg) and intermediate-term (8.0 kg) interventions. A significant global effect of lifestyle intervention on fat mass, waist circumference, blood pressure, total cholesterol, LDL-C, triglycerides and fasting insulin was found (p<0.01), without significant effect on HDL-C and fasting blood glucose.

CONCLUSIONS

Lifestyle interventions incorporating a PA component can improve weight and various cardiometabolic risk factors in class II and III obese individuals. However, further high quality trials are needed to confirm this evidence, especially beyond weight loss.

If it does not significantly change HbA1c levels why should we waste time on it? A plea for the prioritization of psychological well-being in people with diabetes

Despite improvements in pharmacological treatments and methods of care and care delivery, the burden of living with diabetes remains an ongoing challenge, as many people with diabetes are at increased risk of mental health disorders, psychological disturbances and functional problems associated with living with diabetes. Person-centred collaborative care that also meets the psychological needs of the individual is not available to many people with diabetes. The present article examines the role of psychological factors in the onset of diabetes and in relation to living with diabetes. It is argued that the pursuit of psychological well-being is worthy of individual attention in the care of people with diabetes and should not be contingent upon attainment of somatic indices of health. The barriers to attaining this goal are examined, including the costs of treating (or not treating) psychological problems in people with diabetes. Recommendations on how to improve diabetes care are offered, including psychological interventions that are both evidence-based and cost-effective.

Treatment Alternatives for Overweight and Obesity: The Role of Online Interventions

This review examines the application of online interventions to the treatment of obesity. The unprecedented prevalence rates of overweight and obesity worldwide are indicative of the need to develop efficacious treatment alternatives. While research suggests that diet, physical activity and behaviour therapy are core components of effective obesity treatment programs, their ability to penetrate large portions of the population is limited. The empirically verified effectiveness of online interventions for disorders such as depression and social phobia, coupled with unparalleled rates of internet access, suggest that online interventions for overweight and obesity are a feasible and logical treatment modality. A limited number of randomised controlled trials reviewed in this article have evaluated the efficacy of this treatment alternative. Results are promising and encourage further use, development and empirical research in this area.

Using cognitive-behavioural techniques to improve exclusive breastfeeding in a low-literacy disadvantaged population

Despite being an important component of Pakistan's primary health care programme, the rates of exclusive breastfeeding at 6 months remain among the lowest in the world. Low levels of literacy in women and deeply held cultural beliefs and practices have been found to contribute to the ineffectiveness of routine counselling delivered universally by community health workers in Pakistan. We aimed to address this by incorporating techniques of cognitive-behavioural therapy (CBT) into the routine counselling process. We conducted qualitative studies of stakeholders' opinions (mothers, community health workers, their trainers and programme managers) and used this data to develop a psycho-educational approach that combined education with techniques of CBT that could be integrated into the health workers' routine work. The workers were trained to use this approach and feedback was obtained after implementation. The new intervention was successfully integrated into the community health worker programme and found to be culturally acceptable, feasible and useful. Incorporating techniques of CBT into routine counselling may be useful to promote health behaviours in traditional societies with low literacy rates.

Multi-factorial approach associated with a new 'on/off' Orlistat® use in a weight loss maintenance programme: 4 years follow-up

AIM

To assess the efficacy of a specific long-term programme for weight loss maintenance using a new 'on/off' Orlistat approach in obese subjects who previously lost more than 10% of their body weight.

METHODS

50 patients were followed up during 4 years; 34 completed the study. Subjects were followed up by physicians trained in obesity management. Anthropometrical, biological and psychological parameters were measured. Insulin sensitivity was evaluated by euglycaemic insulin clamp. Orlistat was given in case of weight relapse more than 2.5%. Subjects could take Orlistat on a voluntary basis for special occasions.

RESULTS

The BMI of completers remained stable (29.5 ± 0.9 vs. 30.6 ± 1.0 kg/m(2)). 73% of completers maintained 10% or more of their weight loss. Subjects from the no-regain group improved most of their parameters while the regain group did not. Insulin sensitivity was negatively linked to body weight during the follow up (p < 0.01, r(2) = 0.20). A negative relationship has been found between extent of the previous weight loss and the evolution of body weight during the 4 years follow-up (p < 0.01, r(2) = 0.26). Orlistat intake showed a body fat lowering effect (p < 0.05).

CONCLUSION

73% of subjects maintained more than 10% of their weight loss. Subject with a large weight loss amount are at high risk for weight regain. The Orlistat 'on/off' intake regarding his lowering body fat mass effect seems to be efficient.

Do obese patients after weight loss become metabolically normal?

OBJECTIVE

To compare the metabolic cardiovascular risk factors of obese patients after weight loss and 4-year weight loss maintenance afterwards against a matched control group of subjects with a stable body weight and without history of weight loss.

METHOD

50 obese non-diabetic subjects in the study group who previously lost 10% or more of their weight and afterwards entered a 4-year weight loss maintenance programme were matched by age, BMI and sex and compared to 50 weight-stable subjects without history of weight loss. The comparison between both groups was done in term of anthropometrical, metabolic and biological characteristics, early atherosclerosis and insulin sensitivity.

RESULTS

Anthropometrical, metabolic and biological characteristics were similar between the weight loss group and the control matched group. However, insulin sensitivity was still significantly lower in the weight loss than in the matched control group (p = 0.02). Intima media thickness (IMT) also was similar in both groups. We found that lower atherosclerosis measured by IMT at the level of the carotid is associated with better insulin sensitivity (p < 0.05). After the 4-year weight loss maintenance programme, insulin sensitivity improved in the post-weight loss group from 7.9 ± 3.2 to 8.4 ± 3.6 mg/kg/min.

CONCLUSION

All cardiometabolic parameters of obese subjects, except for insulin sensitivity, normalised completely after weight loss. The latter was improved by a weight loss maintenance programme if successfully completed.

New psycho-pedagogic approach to obesity treatment: a 5-year follow-up

OBJECTIVE

The aim of the present study was to evaluate the body weight evolution in obese patients admitted for a 2-week residential program and followed-up on ambulatory basis, as well as to evaluate factors having impact on weight evolution after 5 years.

METHODS

Thirty-nine obese patients participated in a 2-week structured interdisciplinary weight loss program, involving individual and group therapies, and including physical activity, nutritional education and standard cognitive-behavioral techniques. Patients were then followed-up regularly by their general practitioners for 5 years.

RESULTS

After 5 years, 33 subjects completed the study. Seventy percent of the patients lost weight or maintained their weight loss. Total score for dietary structure, eating behavior disorders, dietary surveillance and weight management strategies, as evaluated by a validated questionnaire, was significantly lower in the weight loss group (22.4+/-4.3) as compared to maintenance group (24.4+/-6.1, p<0.05) and regain group (29.7+/-4.0, p<0.01). Patients who lost weight presented a more important follow-up on long-term weight management (p<0.05), a better dietary results (p<0.01) as well as more physical activity (p<0.05) that the regain group.

CONCLUSION

The present study demonstrated that an initial multidimensional and multidisciplinary in-hospital program with a consecutive long-term ambulatory follow-up may lead to a significant weight loss (55%) and/or weight maintenance (15%).

PRACTICE IMPLICATIONS

A multidisciplinary and well-designed initial treatment and long-term follow-up program is mandatory for obesity management.

Efficacy of therapeutic patient education in chronic diseases and obesity

OBJECTIVE

To evaluate the clinical, methodological and reporting aspects of systematic reviews and meta-analyses in order to determine the efficacy of therapeutic patient education (TPE).

METHODS

A thorough search of the medical and nursing literature recorded in MedLine database from 1999 to August 2009 was conducted using the keywords: patient education, efficacy, diabetes, asthma, COPD, hypertension, cardiology, obesity, rheumatology, and oncology.

RESULTS

Thirty five relevant meta-analyses were identified and initially selected for critical analyses (598 studies concerning approximately 61,000 patients). The detailed description of the educative intervention was present in 4% of articles whereas in 23% the interventions were briefly described. In the majority of studies, the educative interventions were only named (49%) or totally absent (24%). The majority of studies reported improvement of patient outcomes due to the TPE (64%), 30% of studies reported no effect of TPE and 6% of the analysed reviews and meta-analyses reported worsening of measured outcomes.

CONCLUSION

Patient education could improve patient outcomes. The high benefit from TPE was shown by articles with detailed description of educational intervention as well as by those who report multidimensional and multidisciplinary educational intervention.

PRACTICE IMPLICATIONS

The impact of therapeutic patient education on health outcomes is 50-80%.

Adding cognitive behavioural treatment to either low-carbohydrate or low-fat diets: differential short-term effects

To evaluate the efficacy of adding cognitive behavioural treatment (CBT) to either a low-carbohydrate (LC) diet or a low-fat (LF) diet in the treatment of weight loss of obese women, a randomised clinical intervention study was performed. A total of 105 healthy non-pregnant obese women (average age and BMI of 45.4 (sd 10.4) years and 36 (sd 4.3) kg/m2) were randomly allocated to the CBT or control (C) groups; within each group, women were randomly selected to receive either the LC or LF diet during 6 months. The pre-planned primary trial end-point was the weight loss. Differences between the groups were assessed using one-way ANOVA. There were three women (2.8 %) who dropped out, all of them in the CBT group. No differences in the anthropometric and laboratory characteristics at baseline were noted between women in the CBT (n 52) and control groups (n 50). Intention-to-treat analysis showed that weight loss in the CBT-LC (90 (sd 12.3) to 82.1 (sd 12.1) kg) and C-LC (89.4 (sd 10.0) to 85.8 (sd 9.8) kg) groups reached 8.7 and 4.0 %, respectively (P < 0.0001), and in the CBT-LF (87.9 (sd 11.4) to 79.4 (sd 11.8) kg) and C-LF (88.8 (sd 14.5) to 85.3 (sd 14.3) kg) groups it was 9.7 and 3.9 %, respectively (P < 0.05). Weight loss was higher in the CBT-LF group than in the CBT-LC groups (P = 0.049). The present results showed that adding CBT to either the LF or LC diet produced significantly greater short-term weight loss in obese women compared with diet alone. These finding support the efficacy of CBT in breaking previous dietary patterns and in developing healthier attitudes that reinforce a healthier lifestyle.

Home-centred physical fitness programme in morbidly obese individuals: a randomized controlled trial

Objective: To assess the effectiveness of domiciliary physical fitness programmes in obese individuals.

Design: Nine-month randomized controlled trial.

Setting: Home-based intervention with outpatient visits.

Subjects: Morbidly obese subjects (body mass index (BMI) ≥30) aged 25—65 years suitable for physical activities at home.

Intervention: At the end of a preliminary one-month in-hospital rehabilitation programme (baseline), 52 patients were randomly assigned either to a structured educational programme (intervention group) of daily incremental physical activity at home (walking and skeletal muscle resistance training, with booklets and written instructions) or to a programme of general advice (control group) regarding exercise and long-term fitness.

Main measures: Both groups were evaluated at baseline and every three months for: (1) time, metabolic equivalents (METs), and heart rate reserve (HRR) during a standardized 2-km walking test (2kmWT); (2) anthropometric measures (body weight, BMI, abdominal and neck circumference); (3) the Polar Fitness Test index (PFTI), and (4) time to exhaustion while sustaining consecutive isoload extensions in the dominant leg (isoload LE). Time during 2kmWT was the study primary outcome.

Results: Body weight, BMI and abdominal circumference improved significantly (P<0.05) over time in the intervention group. The cardiopulmonary fitness variables changed significantly (P<0.05) over time in both study groups. However, all variables improved in the intervention patients, while some worsened or remained stable in the controls. Thus, the mean group difference in changes was significant (P<0.05) for 2kmWT time (—77.4 seconds), HRR (11.7%), and PFTI (5.4 points).

Conclusion: This structured domiciliary fitness programme is feasible and provides sustained anthropometric and physiological benefits in some morbidly obese individuals.

Helping clients think through their causal models: application to counseling clients to exercise

This article presents a model for therapy using active investigation of causal attributions made by the client. Causal attributions guide behavior. Often wrong attributions (excuses) force the individual to waste effort and time in making changes that do not lead to desired behavior. Many focus on their motivation and not external causes of their behavior. As a consequence, they relapse into old habits when their motivation waivers. Others gather information that is not causally linked to their behavior, and therefore of little use in understanding the mechanism for change. The role of clinician is envisioned as being to guide the clients to seek causal explanations for their behavior, to correct false attributions, and to help the clients use the causal mechanisms they have found to change their behavior. In theory, at least, it is expected that when causes of the unhealthy behavior are removed, lasting change will occur and the client is less likely to go through cycles of improvement and relapse. This article shows how the clinician can conduct causal analysis of the client's behavior. This model for therapy is in the tradition of solution-focused approaches to helping individuals make psychological and behavioral changes. A case example is also presented, where the client is trying to increase his or her exercise patterns.

Effect of orlistat in obese patients with binge eating disorder

OBJECTIVE

Binge eating disorder represents a significant public health problem, with up to 50% of weight loss program participants displaying this disorder. In previous studies with orlistat, patients with binge eating disorder were excluded. The goal of this study was to assess the efficacy of orlistat in obese patients with binge eating disorder.

RESEARCH METHODS AND PROCEDURES

Eighty-nine patients with clinically diagnosed binge eating disorder and a BMI > or = 30 kg/m2 were randomized in double-blind fashion to 24 weeks of treatment with 120 mg of orlistat or placebo three times daily, in combination with a mildly reduced-calorie diet.

RESULTS

After 24 weeks, the mean weight loss from baseline for orlistat-treated patients was significantly greater than for patients receiving placebo (-7.4% vs. -2.3%; p = 0.0001) (intent-to-treat analysis). The overall Eating Disorder Inventory 2 score at week 24 was significantly lower in patients treated with orlistat than in those in the placebo group (p = 0.011).

DISCUSSION

Orlistat may be considered as part of the management for patients with obesity and binge eating disorder.