Lorcaserin plus lifestyle modification for weight loss maintenance: Rationale and design for a randomized controlled trial

Mindful Eating, General Mindful Awareness, and Acceptance as Predictors of Weight Loss

Objectives

The goal of the present study was to determine whether baseline mindful eating, general mindful awareness, or acceptance was most strongly associated with short- and long-term weight loss in a lifestyle modification program.

Methods

Data were from 178 participants (baseline BMI=40.9±5.9 kg/m², age=44.2±11.2 years; 87.6% female; 71.3% black) who enrolled in a two-phase trial. All participants attended an initial 14-week lifestyle modification program that included a meal replacement diet. Participants who had lost ≥5% of initial weight (N=137) were then randomized to 52 weeks of lifestyle modification with lorcaserin or placebo. Linear mixed models examined whether mindful eating (Mindful Eating Questionnaire) and general mindful awareness and acceptance (Philadelphia Mindfulness Scale) predicted short-term weight loss at week 14 in the full sample and long-term weight loss at the end of the trial in the subsample of randomized participants.

Results

In the full sample, higher baseline acceptance predicted greater short-term weight losses (p=.004). At week 14, individuals low in acceptance (-1SD) lost an average of 8.7 kg (SE=0.6) compared to 11.2 kg (SE=0.6) among those high in acceptance (+1SD). In the subsample of participants who successfully lost weight in phase 1, the independent effect of acceptance on total losses at the end of the trial did not reach statistical significance (p=.058). Neither mindful eating nor general mindful awareness independently predicted weight loss at either time point.

Conclusions

Acceptance was a stronger predictor than either general or eating-specific awareness of weight loss with lifestyle modification.

Early Weight Loss in Behavioral Treatment Predicts Later Rate of Weight Loss and Response to Pharmacotherapy

BACKGROUND

Early weight loss (EWL) in the first 1-2 months of behavioral treatment is a strong predictor of later total weight loss. It is not clear whether participants with lower early losses lose less in ongoing treatment or simply fail to overcome the smaller initial loss. Furthermore, no study has tested whether EWL in behavioral treatment predicts response to a different treatment modality, such as pharmacotherapy.

METHODS

Data were from 170 participants with obesity (baseline BMI = 40.8 ± 5.8 kg/m2, 87.6% female; 71.3% Black) enrolled in a two-phase trial. Data from the weight loss phase, which provided weekly lifestyle counseling and a meal replacement diet, were used to examine the relationship between 4-week EWL and subsequent rate of weight loss in behavioral treatment. Data from the maintenance phase, in which 137 participants who had lost ≥5% of initial weight were randomized to 52 weeks of maintenance counseling with lorcaserin or placebo, were used to determine whether EWL with behavioral treatment affects the benefit of pharmacotherapy.

RESULTS

EWL in the first 4 weeks of behavioral treatment (3.6 ± 1.7%) predicted greater total losses at Week 14 (r2 = 0.61, p < .001) and a faster rate of weight loss in the subsequent 9 weeks of the program (p < .001). During the maintenance phase, lower EWL in behavioral treatment predicted a greater benefit of lorcaserin, in comparison with placebo, for the maintenance of a ≥5% loss at Weeks 24 and 52.

CONCLUSIONS

These findings support recommendations to modify treatment for individuals with low EWL.

Associations between causal attributions for obesity and long-term weight loss

Obesity is a complex disease caused by a wide array of behavioral, biological, and environmental factors. However, obesity is often attributed to oversimplified and stigmatizing causal factors such as laziness, lack of willpower, and failure to take personal responsibility for one's health. Understanding of the causal factors that contribute to obesity among people with obesity may affect their weight management efforts. The current study explored associations between causal attributions for obesity and long-term weight loss, as well as examined potential changes in attributions with weight reduction. The 16-item Causal Attributions for Obesity scale (rated 1-7) was administered to 178 patients seeking behavioral/pharmacological weight-loss treatment. Causal attributions and weight were assessed at baseline, after 14 weeks of a low-calorie diet, and again at weeks 24 and 52 of a subsequent randomized trial (i.e., 66 weeks total). Logistic and linear regression examined effects of baseline causal attribution ratings on weight loss. Higher baseline ratings of personal responsibility attributions predicted 38% reduced odds of achieving ≥10% weight loss at week 52 (p = 0.02). Causal attribution ratings did not change over time or correlate continuously with weight change. Thus, attributing obesity to a failure of personal responsibility may impair long-term weight management efforts for individuals seeking ≥10% weight loss. Targeted techniques are needed to reduce patients' stigmatizing beliefs about the causes of obesity.

A randomized controlled trial of lorcaserin and lifestyle counselling for weight loss maintenance: changes in emotion- and stress-related eating, food cravings and appetite

Anti-obesity medication may help people maintain diet-induced reductions in appetite. The present exploratory analysis assessed the effects of lorcaserin on changes at 24 weeks post-randomization in emotion- and stress-related eating, food cravings and other measures of appetite (i.e. binge eating, cognitive restraint, disinhibition, hunger, preoccupation with eating and fullness). The parent study investigated the efficacy of combined lorcaserin and behavioural treatment in facilitating weight loss maintenance (WLM) in 137 adults (mean age = 46.1 years, 86.1% female, 68.6% black) who had lost ≥5% of initial weight during a 14-week, low-calorie diet (LCD) run-in. Participants were randomly assigned to lorcaserin or placebo and were provided with group WLM counselling sessions. Emotion- and stress-related eating, food cravings and appetite were measured at the start of the LCD (week -14), randomization (0) and week 24. From randomization, lorcaserin-treated participants had significantly greater improvements in emotion- and stress-related eating compared to placebo-treated participants (P = 0.04). However, groups did not differ significantly after randomization in changes in the frequency of food cravings, binge eating or other measures of appetite (Ps > 0.05). Compared to placebo, lorcaserin may improve emotion- and stress-related eating.

"Last Supper" Predicts Greater Weight Loss Early in Obesity Treatment, but Not Enough to Offset Initial Gains

Background: Many participants experience clinically significant fluctuations in weight before beginning a behavioral weight loss program. Pre-treatment weight gain, often referred to as the “last supper” effect, may limit total weight loss from the time of the pre-treatment screening visit and could be an indicator that a participant will respond poorly to behavioral intervention.

Methods: Data were from the weight loss phase of a two-phase weight loss maintenance trial, in which 178 participants with obesity (screening BMI = 40.5 ± 6.0 kg/m², 87.6% female; 71.3% black) were provided with a 14 week lifestyle intervention that included a meal replacement diet. Participants were categorized as having gained >1.15%, remained weight stable, or lost >1.15% of initial weight between the pre-treatment screening visit and the first treatment session (48.7 ± 29.4 days). We first examined whether the weight change groups differed in baseline eating characteristics (e.g., emotional eating, self-regulation, craving frequency) using one-way ANCOVAs. Linear mixed models were then used to compare weight change groups on total weight loss from the screening visit to week 14 and in-treatment weight loss from weeks 1 to 14.

Results: Nearly half of the sample (48.9%) gained >1.15% of initial weight during the pre-treatment period (+2.5 ± 1.2%); 41.0% remained weight stable (+0.2 ± 0.6%); and 10.1% lost >1.15% of initial weight (-2.2 ± 0.9%). There were no significant differences between the groups in baseline eating characteristics. As measured from the screening weight, the weight-gain group had a lower total loss of 6.8%, compared to 7.8% in the weight stable group (p = 0.02) and 9.0% in the weight-loss group (p = 0.003). The weight-gain group lost more weight in the first 4 weeks of treatment, but in-treatment losses did not differ among the groups at week 14.

Conclusion: Pre-treatment weight gain was not an indicator of a poor response to a behavioral weight loss intervention and was associated with greater weight loss early in treatment. However, weight gain during the pre-treatment period may limit the total weight loss that participants achieve from the time that they first enroll in a weight loss program.

Effects of addictive-like eating behaviors on weight loss with behavioral obesity treatment

To examine the relationship between food cravings and food addiction as defined by the Yale Food Addiction Scale (YFAS) and to assess the effects of these variables on weight loss during a 14-week group lifestyle modification program. Data were from 178 participants who were prescribed a 1000-1200 kcal/day portion-controlled diet and provided with weekly group lifestyle modification sessions. Participants completed the Food Craving Inventory and YFAS pre- and post-treatment. Weight was measured weekly. Participants with YFAS-defined food addiction (6.7%) reported more frequent overall food cravings relative to those without food addiction. More frequent food cravings at baseline were associated with less weight loss over the 14 weeks. Analyzed categorically, participants in the highest tertile of baseline food cravings lost 7.6 ± 0.5% of initial weight, which was significantly less compared to those in the lowest tertile who lost 9.1 ± 0.5%. Percent weight loss did not differ significantly between participants with YFAS-defined food addiction (6.5 ± 1.2%) and those who did not meet criteria (8.6 ± 0.3%). Addictive-like eating behaviors significantly declined from pre- to post-treatment. Participants with frequent food cravings lost less weight than their peers. Targeted interventions for food cravings could improve weight loss in these individuals. Few participants met YFAS-defined criteria for food addiction. Addictive-like eating behaviors tended to decline during behavioral weight loss, but neither baseline nor change in YFAS scores predicted weight loss.

Short- and Long-Term Changes in Health-Related Quality of Life with Weight Loss: Results from a Randomized Controlled Trial

OBJECTIVE

The objective of this study was to determine the effects of weight loss and weight loss maintenance (WLM) on weight-specific health-related quality of life in a 66-week trial.

METHODS

Adults with obesity (N = 137, 86.1% female, 68.6% black, mean age = 46.1 years) who had lost ≥ 5% of initial weight in a 14-week intensive lifestyle intervention/low-calorie diet (LCD) program were randomly assigned to lorcaserin or placebo for an additional 52-week WLM program. The Impact of Weight on Quality of Life-Lite (IWQOL-Lite) scale (including five subscales), Patient Health Questionnaire-9 (depression), and Perceived Stress Scale were administered at the start of the 14-week LCD program, randomization, and week 52 of the randomized controlled trial (i.e., 66 weeks total).

RESULTS

Significant improvements in all outcomes, except weight-related public distress, were found following the 14-week LCD program (P values < 0.05). Improvements were largely maintained during the 52-week randomized controlled trial, despite weight regain of 2.0 to 2.5 kg across treatment groups. Participants who lost ≥ 10% of initial weight achieved greater improvements in physical function, self-esteem, sexual life, and the IWQOL-Lite total score than those who lost < 5% and did not differ from those who lost 5% to 9.9%.

CONCLUSIONS

Improvements in weight-specific health-related quality of life were achieved with moderate weight loss and were sustained during WLM.

Everyday discrimination in a racially diverse sample of patients with obesity

Weight discrimination affects a significant proportion of individuals with obesity and contributes to poor mental and physical health. Prior research on weight discrimination has been limited by a lack of racial diversity in samples and has not considered other potential forms of discrimination that individuals with obesity may experience. The current study assessed different reasons for discrimination in a racially diverse sample of treatment-seeking individuals with obesity (N = 122, 66.4% black, mean body mass index = 38.5 ± 6.2 kg/m² ). Results showed that over half of participants reported experiencing at least one form of repeated discrimination, and 30% reported two or more reasons for discrimination. Race and weight were the most commonly reported reasons for repeated, everyday instances of discrimination. Among participants who reported experiencing weight discrimination (28.7%), over 80% reported experiencing at least one other form of discrimination, with 60% reporting discrimination due to race. These findings indicate that individuals with obesity may face multiple forms of discrimination in their daily lives. Further research is needed to understand how all forms of discrimination contribute to obesity-related health problems.

A Randomized Trial of Lorcaserin and Lifestyle Counseling for Maintaining Weight Loss Achieved with a Low-Calorie Diet

OBJECTIVE

Improving the maintenance of lost weight remains a critical challenge, which can be addressed by long-term behavioral and/or pharmacological interventions.

METHODS

This study investigated the efficacy of combined behavioral and pharmacological treatment in facilitating weight loss maintenance (WLM) in 137 adults (86.1% female; 68.6% black; BMI = 37.0 ± 5.6 kg/m² ) who had lost ≥ 5% of initial weight during a 14-week low-calorie diet (LCD) program (mean = 9.3 ± 2.9%). Participants were randomly assigned to lorcaserin (10 mg twice a day) or placebo and were provided 16 group WLM counseling sessions over 52 weeks.

RESULTS

At 24 weeks post randomization, more lorcaserin-treated than placebo-treated participants maintained a ≥ 5% loss (73.9% vs. 57.4%; P = 0.033), and the lorcaserin-treated participants lost an additional 2.4 ± 0.8 kg versus a 0.6 ± 0.8 kg gain for placebo (P = 0.010). However, at week 52, groups did not differ on either co-primary outcome; 55.1% and 42.6%, respectively, maintained ≥ 5% loss (P = 0.110), with gains from randomization of 2.0 ± 0.8 kg and 2.5 ± 0.8 kg (P = 0.630), respectively. From the start of the LCD, groups maintained reductions of 7.8% and 6.6%, respectively (P = 0.318).

CONCLUSIONS

Combined behavioral and pharmacological treatment produced clinically meaningful long-term weight loss in this group of predominantly black participants. Lorcaserin initially improved upon weight loss achieved with WLM counseling, but this advantage was not maintained at 1 year.

Sociocultural and Familial Factors Associated with Weight Bias Internalization

BACKGROUND/AIMS

Sociocultural and familial factors associated with weight bias internalization (WBI) are currently unknown. The present study explored the relationship between interpersonal sources of weight stigma, family weight history, and WBI.

METHODS

Participants with obesity (N = 178, 87.6% female, 71.3% black) completed questionnaires that assessed the frequency with which they experienced weight stigma from various interpersonal sources. Participants also reported the weight status of their family members and completed measures of WBI, depression, and demographics. Participant height and weight were measured to calculate body mass index (BMI).

RESULTS

Linear regression results (controlling for demographics, BMI, and depression) showed that stigmatizing experiences from family and work predicted greater WBI. Experiencing weight stigma at work was associated with WBI above and beyond the effects of other sources of stigma. Participants who reported higher BMIs for their mothers had lower levels of WBI.

CONCLUSION

Experiencing weight stigma from family and at work may heighten WBI, while having a mother with a higher BMI may be a protective factor against WBI. Prospective research is needed to understand WBI's developmental course and identify mechanisms that increase or mitigate its risk.

A randomized trial of lifestyle modification and taranabant for maintaining weight loss achieved with a low-calorie diet

Improving the maintenance of weight loss remains a critical challenge for obesity researchers. The present 1-year, randomized, placebo-controlled trial evaluated the safety and efficacy of weight maintenance counseling combined with either placebo or the cannabinoid-1 receptor inverse agonist, taranabant, for sustaining prior weight loss achieved on a low-calorie diet (LCD). Seven hundred eighty-four individuals who had lost ≥ 6% of body weight during six initial weeks of treatment with an 800 kcal/day liquid LCD were randomly assigned to placebo or once-daily taranabant in doses of 0.5, 1, or 2 mg. All participants were provided monthly, on-site behavioral weight maintenance counseling, as well as monthly phone calls. The primary end point was change in body weight from randomization to week 52. The randomized participants lost an average of 9.6 kg (9.5% of initial weight) during the 6-week LCD. The model-adjusted mean change in body weight during the subsequent 1 year was +1.7 kg for placebo, compared with -0.1, -0.6, and -1.2 kg for the taranabant 0.5, 1, and 2 mg doses, respectively (all P values ≤ 0.007 vs. placebo). The incidences of psychiatric-related adverse events, including irritability, were higher for taranabant 1 and 2 mg vs. placebo (P ≤ 0.038). In addition to reporting data on the safety and efficacy of taranabant, this study provides a method for studying the combination of lifestyle modification and pharmacotherapy for weight maintenance after diet-induced weight loss.