Treatment response to the RENEW weight loss intervention in schizophrenia: impact of intervention setting

Psychotropic Drug-Related Weight Gain and Its Treatment

Psychotropic drug-related weight gain (PDWG) is a common occurrence and is highly associated with non-initiation, discontinuation, and dissatisfaction with psychiatric drugs. Moreover, PDWG intersects with the elevated risk for obesity and associated morbidity that has been amply reported in the psychiatric population. Evidence indicates that differential liability for PDWG exists for antipsychotics, antidepressants, and anticonvulsants. During the past two decades, agents within these classes have become available with significantly lower or no liability for PDWG and as such should be prioritized. Although lithium is associated with weight gain, the overall extent of weight gain is significantly lower than previously estimated. The benefit of lifestyle and behavioral modification for obesity and/or PDWG in psychiatric populations is established, with effectiveness similar to that in the general population. Metformin is the most studied pharmacological treatment in the prevention and treatment of PDWG, and promising data are emerging for glucagon-like peptide-1 (GLP-1) receptor agonists (e.g., liraglutide, exenatide, semaglutide). Most pharmacologic antidotes for PDWG are supported with low-confidence data (e.g., topiramate, histamine-2 receptor antagonists). Future vistas for pharmacologic treatment for PDWG include large, adequately controlled studies with GLP-1 receptor agonists and possibly GLP-1/glucose-dependent insulinotropic polypeptide co-agonists (e.g., tirzepatide) as well as specific dietary modifications.

Lifestyle intervention based on exercise and behavioural counselling and its effect on physical and psychological health in outpatients with schizophrenia spectrum disorders. An exploratory, pragmatic randomized clinical trial

Patients with Schizophrenia Spectrum Disorders (SSD) often lead unhealthy lifestyles. This pragmatic trial evaluated the effectiveness of a lifestyle intervention, consisting of a 12-week aerobic exercise program and behavioural counselling, in SSD outpatients with metabolic syndrome (MetS). It also aimed to assess persistence of potential effects in a 24-month long-term follow-up. Effectiveness was measured in terms of a wide range of outcomes involving physical and psychological health, quality of life, physical activity and changes in motivation to exercise within the context of the self-determination theory. Our primary outcome was waist circumference change. Thirty-three out of 48 participants completed the study. No differences between groups were found in terms of BMI change or other metabolic parameters. However, the active group (AG) showed improvement regarding waist circumference, negative symptomatology and identified motivation to exercise during the study and follow-up. The AG exhibited changes toward a more active pattern of activity after intervention. Moreover, belonging to the AG was a significant predictor for achieving any degree of clinical improvement after 24-month follow-up. Combined interventions of exercise and behavioural counselling in SSD patients with MetS should be considered as an essential part of the integral treatment in the context of mental health services.

Nutrition and Exercise for Wellness and Recovery: A Randomized Controlled Trial of a Community-Based Health Intervention

OBJECTIVE

The purpose of this study was to examine the efficacy of the Nutrition and Exercise for Wellness and Recovery (NEW-R) intervention for improving competency and behaviors related to diet, physical activity, and weight management.

METHODS

Participants with psychiatric disabilities were recruited from four community mental health agencies and a hospital-based psychiatric outpatient clinic and randomly assigned to the NEW-R intervention (N=55) or control condition (N=58). Outcome measures included the Perceived Competence Scale, Health-Promoting Lifestyle Profile (HPLP), and weight change; random-effects regression models were used. A follow-up analysis examined the interactions of group, time, and site.

RESULTS

Fifty of the 55 intervention participants and 57 of the 58 control participants completed the study. The two groups did not differ significantly on any measured baseline characteristic. The intervention group had statistically significant improvements, compared with the control group, in perceived competence for exercise and healthy eating, total HPLP score, and scores on two HPLP subscales (nutrition and spiritual growth). No significant difference between groups was found for weight loss. A study condition × time × site effect was observed: at the three sites where mean weight loss occurred, NEW-R participants lost significantly more weight than did control participants.

CONCLUSIONS

NEW-R offers promise as an intervention that can initiate the change to healthy lifestyle behaviors and boost perceived competence in a healthy lifestyle. It may also be effective for weight loss when administered in supportive settings.

Improving the Physical Health of Psychiatric Hospital Residents: An Evaluation of an Obesity Education Program for Mental Health Professionals

Background: People living with mental health disorders are at increased risk for developing obesity due to poor diet, physical inactivity, and antipsychotic medications. In the United States, the obesity rate is 36% in the general population and more than 50% for people living with mental health disorders. Although mental health clinicians concentrate on managing psychiatric disorders, they seldom recognize the gradual increase in body mass index of their patients. The result is a disconnection between the clinical management of psychiatric disorders and the medical management of obesity. Purpose: This study assessed the effectiveness of an evidence-based education program for improving the obesity management practices of mental health clinicians caring for residents at a state psychiatric hospital. Methods: This was a quasi-experimental study design with a pretest and posttest evaluation. Convenience sampling was used to recruit mental health professionals, or clinicians, at a large psychiatric hospital in the Southern region of the United States. Data was collected with the Advising and Treating Overweight and Obese Patient questionnaire (17 items). Data analysis included descriptive and inferential statistics. The findings were reported in accordance with the TREND and GREET guidelines. Results: The education program was completed by 50 MHCs. The pretest indicated that 76% of MHCs were not involved in helping obese residents manage their weight, but the posttest indicated 90% were involved. There was a significant increase in MHC knowledge about obesity management and reported actions 90-days after the program. MHCs were unable to arrange follow-up visits for residents, a task not directly within their control. Conclusions: Mental health clinicians reported increased knowledge and improved clinical practice after an education program. Because the outcomes were reported at 90-days after the program, further research needs to evaluate the longitudinal impact of this type of program, where the reported behaviors are correlated to process and clinical outcome measures for obesity.

Hybrid and Remote Psychosocial Interventions Focused on Weight and Sedentary Behavior Management Among Patients with Severe Mental Illnesses: a Systematic Review

Severe mental illness could be defined through its diagnosis, disability, and duration, and one of their main characteristics is the high prevalence of some clinical conditions such as obesity and metabolic syndrome. Although the promotion of a healthier lifestyle has been demonstrated as an effective strategy to reduce both body mass index and abdominal circumference in this population, there is a lack of studies focusing on digital intervention in this population. The aim of this systematic review was to evaluate the efficacy of studies that used digital technologies to reduce weight, body mass index (BMI) and abdominal circumference in individuals with severe mental illness. This current review also compared remote and hybrid interventions, the effects of those interventions in metabolic biomarkers as well as in the development of a healthier lifestyle. The main findings included the following: (a) the use of digital devices or strategies might be feasible and useful to reduce sedentary behavior among individuals with severe mental illnesses, 2) most interventions used digital pedometers and mobile phone communication (either text messages or phone calls) as main strategies, 3) all remote interventions and six of nine hybrid interventions found significant outcomes in favor of their interventions. In conclusion, even with a limited number of studies promoting healthier lifestyle through digital interventions among individuals with severe mental illnesses, evidence from studies included in this review showed that they might be useful to improve a healthier lifestyle and increase the frequency of physical activity behavior.

Identifying effective characteristics of behavioral weight management interventions for people with serious mental illness: A systematic review with a qualitative comparative analysis

People with serious mental illness (SMI) have identified barriers to engaging in behavioral weight management interventions (BWMIs). We assessed whether BWMIs that addressed these barriers were more effective. First, we systematically reviewed qualitative literature and used a thematic analysis to identify the characteristics of BWMIs that promote engagement for adults with SMI. Second, we systematically reviewed randomized controlled trials (RCTs) of BWMIs in adults with SMI. Data on the characteristics that promoted engagement and weight outcomes were extracted. We then used a crisp-set qualitative comparative analysis (CsQCA) to identify which characteristics were associated with weight loss. For the qualitative review, 20 studies in 515 people with SMI were analyzed and nine characteristics were reported to promote engagement in BWMIs. For the systematic review, 34 RCTs testing 36 interventions in 4305 participants were included. The active interventions resulted in more weight loss (mean = -4.37 to +1 kg at 6 weeks to 18 months follow-up) compared with controls (-1.64 to +3.08 kg). The CsQCA showed BWMIs that offered regular contact, tools to support enactment, and tailored materials were associated with effectiveness. As these are all supplementary strategies, it may be possible to augment BWMIs available for the general population to engage people with SMI.

In- and outpatient lifestyle interventions on diet and exercise and their effect on physical and psychological health: a systematic review and meta-analysis of randomised controlled trials in patients with schizophrenia spectrum disorders and first episode of psychosis

Patients with non-affective psychosis often lead unhealthy lifestyles. We performed a systematic review and meta-analysis on non-pharmacological RCTs for improvement of diet and physical activity in non-affective psychosis patients, including first-episode psychosis. A variety of outcomes was analysed, including metabolic, psychopathology, cognitive, functional and quality of life outcomes. Fifty-nine studies were included. An improvement in anthropometric measurements (BMI, weight, waist circumference) was observed post-intervention, persisting after follow-up. Post-intervention benefit was found also for psychotic symptoms severity (also persisting after follow-up), many cognitive domains and physical and global functioning and quality of life. Conversely, no effect was observed in relation to most blood metabolites, blood pressure and non-psychotic psychopathology and spontaneous physical activity. Improvement was generally larger for interventions including exercise, especially moderate/vigorous aerobic exercise, but follow-up maintenance was greater for psychotherapy interventions. Sensitivity analyses limited to chronic stages of psychosis and low risk of bias studies produced comparable results. Further studies are needed to design optimized interventions in this vulnerable population.

Outcomes and safety of concomitant topiramate or metformin for antipsychotics-induced obesity: a randomized-controlled trial

BACKGROUND

Although there are some existing data describing the usage of topiramate in patients with antipsychotic-induced obesity, study on its comparison with metformin is limited. This study aimed to explore the effectiveness and safety of concomitant topiramate on antipsychotic-induced obesity as well as its comparison with metformin.

METHODS

62 stabilized outpatients with antipsychotic-induced obesity were randomized into the topiramate group and the metformin group with 16-week treatment. The patients' weight, body mass index (BMI), waist-hip ratio, and their side effects were assessed and compared. Intention-to-treat and completer analyses were performed. Meanwhile, covariance analysis was conducted to control the impact of the significant difference in BMI between the two groups.

RESULTS

The two groups had comparable characteristics, though their difference in baseline BMI was significant. (1) Intention-to-treat analyses: the random missing values were replaced using the last observation carried forward method when intention-to-treat analyses were conducted. Compared with the baseline, the weight, BMI, and waist-hip ratio in the topiramate group markedly decreased at each follow-up, whereas, in the metformin group, only waist-hip ratio significantly decreased at 4 weeks after treatment. Compared with the metformin, only weight and BMI in the topiramate group were significantly decreased at week 4 after treatment, and at week 8-16, weight, BMI and waist-hip ratio were remarkably declined. (2) Completer analyses: compared with the baseline, the weight, BMI, and waist-hip ratio in the topiramate group at week 4-16 were markedly decreased, whereas only waist-hip ratio with metformin was significantly decreased at week 4. Compared with the metformin, all BMI with topiramate were markedly decreased at week 4-16. Moreover, its weight and waist-hip ratio also were notably lowered at week 8. No significant differences in adverse events were found between the two groups.

CONCLUSIONS

Topiramate, similar to metformin in reducing obesity as previously reported, also significantly reduced body weight, BMI, and waist-hip ratio in patients with antipsychotic-induced obesity and demonstrated well tolerance in psychiatric patients. Trial registration The trial was registered at http://www.chictr.org.cn , and the number was ChiCTR-IPR-17013122.

The effectiveness of health behavior change interventions in managing physical health in people with a psychotic illness: A systematic review

PURPOSE

People living with psychotic illness disproportionately experience more comorbidities and have a markedly shorter life expectancy compared to the general population. This review evaluates the effectiveness of health behavior change interventions in improving health outcomes in this group.

DESIGN AND METHODS

All studies included objective physical health measures or health behaviors as the main outcome measures and experimental design with baseline and follow-up quantitative data. Only studies of moderate and strong quality were included. Narrative synthesis was undertaken.

FINDINGS

Included studies utilized a range of methodological designs and outcome measures. The majority reported significant intervention effect on most outcome measures.

PRACTICE IMPLICATIONS

Health behavior change interventions can be effective in improving health outcomes in people with psychotic illness, with the potential benefit of improved psychiatric outcomes.

Occupational therapy intervention addressing weight gain and obesity in people with severe mental illness: A scoping review

BACKGROUND

Individuals diagnosed with severe mental illness have higher rates of obesity than the general population due to a range of factors, including: medication side effects, poor nutrition and reduced physical activity. Obesity is associated with increased mortality and reduced quality of life. Evidence suggests that lifestyle interventions can be effective in addressing this issue. While such interventions would appear to fit within the scope of practice of occupational therapy, there is no publication synthesising the existing literature regarding occupational therapy interventions addressing lifestyle factors associated with obesity.

AIM

To determine what is known from the existing literature about occupational therapy interventions addressing weight gain and obesity in adults diagnosed with severe mental illness.

METHODS

A scoping review was conducted. Searches were performed in online databases, occupational therapy journals and grey literature databases. Thematic analysis occurred across all articles included in the review.

RESULTS

A total of 14 articles were included in the review. Analysis revealed a central theme of supporting occupational performance and participation in health promoting occupations. This central theme consisted of four categories; facilitating client-centred practice, addressing personal performance issues, addressing environmental barriers and providing the 'just right' challenge.

CONCLUSION/SIGNIFICANCE

These findings suggest occupational therapists are providing occupation focused interventions that are aligned with current clinical guidelines. However, more research is required to strengthen evidence-based occupational therapy practice in this important area.

Occupational Therapy for Adults with Overweight and Obesity: Mapping Interventions Involving Occupational Therapists

Background

Worldwide obesity rates are increasing. The effectiveness of occupational therapy in overweight and obese adults has not yet been clarified.

Objectives

The scoping review aimed at examining the evidence on interventions involving occupational therapists in the treatment of adults with overweight and obesity.

Methods

Data on interventions involving occupational therapists and reporting on lifestyle-related outcomes in overweight and obese adults was extracted from the databases Cochrane, PubMed, CINAHL, and Embase, including hand and reference search. The scoping review methodology of Arksey and O'Malley was used. Conclusions were based on numerical and narrative analysis.

Results

Thirteen articles reporting on eleven studies met the inclusion criteria. Several studies showed significant weight loss. However, the studies possessed high heterogeneity and showed insufficient explication of the role and contribution of occupational therapy to the outcomes.

Conclusions

The interventions with involvement of occupational therapists were suggested to help short-term weight loss. Occupational therapists contributed to the outcomes with a holistic approach, educating on the role of activity, providing technological support, and promoting enjoyment of being active. There is a need for further documentation of the effectiveness, role, and contributions of occupational therapy in the treatment of overweight and obese adults in all settings.

Impact of lifestyle modification on some components of metabolic syndrome in persons with severe mental disorders: A meta-analysis

BACKGROUND

Metabolic syndrome (MS) is reportedly associated with high mortality from mostly cardiovascular causes in patients with severe mental disorders (SMD). Lifestyle interventions augment effective management of MS in patients with SMD. The present meta-analysis aims at updating the recent evidence on the effectiveness of lifestyle intervention for MS in patients with SMD.

METHOD

A literature search for English Language publications of randomized controlled trials (RCTs) from 2001 to 2016 comparing lifestyle modification (LM) with treatment as usual (TAU) in the management of MS were identified. Using PRISMA guidelines, 19 RCTs reporting data on 1688 SMD and MS patients and providing data on change in Body Weight, Body Mass Index (BMI) and waist circumference (WC) were included. Using random effects model, standardized mean difference between LM and TAU for the mean baseline-to-endpoint change in body weight, BMI and WC was calculated with a 95% confidence limit, on RevMan 5.3. The study was registered with PROSPERO (CRD42016046847).

RESULTS

LM had significantly superior efficacy in the reducing weight (-0.64, 95% CI -0.89, -0.39, Z = 5.03, overall effect p < 0.00001), BMI (-0.68, 95% CI -1.01, -0.35, Z = 4.05, overall effect p < 0.0001), and WC (-0.60, 95% CI -1.17, -0.03, Z = 2.06; overall effect p = 0.04), compared to TAU. LM was significantly more effective than TAU even in short duration (p = 0.0001) and irrespective of the treatment setting.

CONCLUSION

Interventions targeting LM in persons with SMD and MS are effective in reducing body weight, BMI and WC. It must be routinely recommended to all patients with SMD, ideally during commencement stage of second generation antipsychotic treatment.

Case study of an adaptation and implementation of a Diabetes Prevention Program for individuals with serious mental illness

The Diabetes Prevention Program (DPP) is an evidence-based lifestyle intervention developed to decrease the risk for type 2 diabetes and promote weight loss in individuals at risk for diabetes. Individuals with serious mental illness have a greater risk for developing diabetes compared with the general population. In this article, the authors provide a detailed description of the adaptation process of the DPP for individuals with serious mental illness (DPP-SMI). The adaptation process was based on a cultural adaptation framework for modifying evidence-based interventions. To assess the effectiveness of the DPP-SMI, 11 individuals from a community mental health residential agency completed a 22-session pilot study of the adapted program and provided physiological measures before and after the intervention. As primary outcomes, participants were expected to report decreased body weight and increased physical activity per week. Completers had an average weight loss of 19 lbs (8%) and their physical activity increased from 161 to 405 min per week. These preliminary results together with participants' feedback informed further refinement of the DPP-SMI. This case study supports that individuals with serious mental illness can benefit from the DPP-SMI, which is tailored to meet the unique needs of this population group.

Effectiveness of Interventions for Weight Loss for People With Serious Mental Illness: A Systematic Review and Meta-Analysis

OBJECTIVE

We examined the effectiveness of weight loss interventions in community-based settings for people with serious mental illness (SMI).

METHOD

Four databases were searched for randomized controlled trials published in 2008 or later that met the criteria for the research question and used weight loss as an outcome measure. Data were extracted, and weight loss was analyzed using a meta-analysis. Similarities and differences in interventions were analyzed qualitatively.

RESULTS

Seventeen studies and a total of 1,874 participants with various diagnoses of SMI were included in the meta-analysis. The various lifestyle-focused interventions had a significant effect on weight loss with an overall effect size of -0.308 (p < .001).

CONCLUSION

Community-based interventions for people with SMI are effective for weight loss. Occupational therapists can be involved in the provision of weight loss interventions and in the development and study of intervention components that are most effective.

Lifestyle interventions for weight loss among overweight and obese adults with serious mental illness: A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to estimate effects of lifestyle intervention participation on weight reduction among overweight and obese adults with serious mental illness.

METHOD

We systematically searched electronic databases for randomized controlled trials comparing lifestyle interventions with other interventions or usual care controls in overweight and obese adults with serious mental illness, including schizophrenia spectrum or mood disorders. Included studies reported change in weight [kg] or body mass index (BMI) [kg/m2] from baseline to follow-up. Standardized mean differences (SMD) were calculated for change in weight from baseline between intervention and control groups.

RESULTS

Seventeen studies met inclusion criteria (1968 participants; 50% male; 66% schizophrenia spectrum disorders). Studies were grouped by intervention duration (≤6-months or ≥12-months). Lifestyle interventions of ≤6-months duration showed greater weight reduction compared with controls as indicated by effect size for weight change from baseline (SMD=-0.20; 95% CI=-0.34, -0.05; 10 studies), but high statistical heterogeneity (I2=90%). Lifestyle interventions of ≥12-months duration also showed greater weight reduction compared with controls (SMD=-0.24; 95% CI=-0.36, -0.12; 6 studies) with low statistical heterogeneity (I2=0%).

CONCLUSION

Lifestyle interventions appear effective for treating overweight and obesity among people with serious mental illness. Interventions of ≥12-months duration compared to ≤6-months duration appear to achieve more consistent outcomes, though effect sizes are similar for both shorter and longer duration interventions.

A Randomized, Controlled Multisite Study of Behavioral Interventions for Veterans with Mental Illness and Antipsychotic Medication-Associated Obesity

BACKGROUND

Weight gain and other metabolic sequelae of antipsychotic medications can lead to medication non-adherence, reduced quality of life, increased costs, and premature mortality. Of the approaches to address this, behavioral interventions are less invasive, cost less, and can result in sustained long-term benefits.

OBJECTIVE

We investigated behavioral weight management interventions for veterans with mental illness across four medical centers within the Veterans Affairs (VA) Healthcare System.

DESIGN

We conducted a 12-month, multi-site extension of our previous randomized, controlled study, comparing treatment and control groups.

PARTICIPANTS

Veterans (and some non-veteran women) diagnosed with mental illness, overweight (defined as having a BMI over 25), and required ongoing antipsychotic therapy.

INTERVENTIONS

One group received "Lifestyle Balance" (LB; modified from the Diabetes Prevention Program) consisting of classes and individual nutritional counseling with a dietitian. A second group received less intensive "Usual Care" (UC) consisting of weight monitoring and provision of self-help.

MAIN MEASURES

Participants completed anthropometric and nutrition assessments weekly for 8 weeks, then monthly. Psychiatric, behavioral, and physical assessments were conducted at baseline and months 2, 6, and 12. Metabolic and lipid laboratory tests were performed quarterly.

KEY RESULTS

Participants in both groups lost weight. LB participants had a greater decrease in average waist circumference [F(1,1244) = 11.9, p < 0.001] and percent body fat [F(1,1121) = 4.3, p = 0.038]. Controlling for gender yielded statistically significant changes between groups in BMI [F(1,1246) = 13.9, p < 0.001]. Waist circumference and percent body fat decreased for LB women [F(1,1243) = 22.5, p < 0.001 and F(1,1221) = 4.8, p = 0.029, respectively]. The majority of LB participants kept food and activity journals (92%), and average daily calorie intake decreased from 2055 to 1650 during the study (p < 0.001).

CONCLUSIONS

Behavioral interventions specifically designed for individuals with mental illness can be effective for weight loss and improve dietary behaviors. "Lifestyle Balance" integrates well with VA healthcare's patient-centered "Whole Health" approach. ClinicalTrials.gov identifier NCT01052714.

Randomized Trials of Nurse-Delivered Interventions in Weight Management Research: A Systematic Review

The purpose of this systematic review was to determine whether nurse-delivered weight management interventions improve weight outcomes across the life span. We conducted a comprehensive search of the PubMed, CINAHL, and PsycINFO electronic databases. We graded the trials using an adapted Jadad approach for methodological quality. The search identified a total of 1,159 citations; 23 articles from 20 studies were eligible for this review. Sixty-five percent of the studies reported significant findings related to body mass index (BMI) or weight reduction. Studies that were particularly successful at helping participants reduce weight and/or BMI involved nurses engaged in health promotion activities, operating within multidisciplinary teams and/or providing consultations, physical activity education, and coaching over the phone. Of the studies that involved long-term follow-up assessments, three out of nine studies showed a significant loss in weight or BMI between the intervention and control groups at follow-up times ranging from 12 months to 2 years.

Efficacy of Baduanjin Exercise and Feasibility of Mobile Text Reminders on Follow-up Participation in People With Severe Mental Illness: An Exploratory Study

BACKGROUND

People with severe mental illness (SMI) frequently have poor physical health, which can in part be related to a low level of physical activity. The goal of this exploratory study was to examine the efficacy of a group participating in Baduanjin (a type of traditional Chinese exercise) on the health of individuals with SMI and the feasibility/acceptability of using short message service (SMS) reminder strategies to prompt continued exercise during a follow-up period.

METHOD

Participants (N=11) participated in a Baduanjin group session for 8 weeks and then maintained home-based Baduanjin with SMS reminders for another 8 weeks. Physical and psychological tests were administered to participants.

RESULTS

Significant improvements were found in balance and processing speed and in some domains of the 36-Item Short Form Health Survey (SF-36) after the Baduanjin program. Participants were able to maintain engagement in 80% of the expected practice time during the follow-up period. The acceptability of strategies to support home-based exercise, including SMS reminders, was high.

CONCLUSIONS

This preliminary study suggested the efficacy of Baduanjin and the feasibility of SMS reminders in maintaining follow-up participation in people with SMI. Future studies using a larger sample size and a control group are needed to confirm the findings.

Meal replacements as a weight loss tool in a population with severe mental illness

Weight gain and worsening metabolic parameters are often side effects of antipsychotic medications used by individuals with severe mental illness. To address this, a randomized, controlled research study of a behavioral weight management program for individuals with severe mental illness was undertaken to assess its efficacy. Patients unable to meet weight loss goals during the first portion of the year-long study were given the option of using meal replacement shakes in an effort to assist with weight loss. Specific requirements for use of meal replacement shakes were specified in the study protocol; only five patients were able to use the shakes in accordance with the protocol and lose weight while improving metabolic parameters. Case studies of two subjects are presented, illustrating the challenges and obstacles they faced, as well as their successes. Taking responsibility for their own weight loss, remaining motivated through the end of the study, and incorporating the meal replacement shakes into a daily routine were factors found in common with these patients. Use of meal replacements shakes with this population may be effective.