Behavioral Interventions for Obesity: Recognizing Our Progress and Future Challenges

A vegan diet improves insulin resistance in individuals with obesity: a systematic review and meta-analysis

BACKGROUND

A vegan diet has benefits on weight reduction and on the parameters of glucose and lipid metabolism. This meta-analysis aimed to investigate the efficacy of plant-based diets on insulin resistance and blood lipids in patients with obesity.

METHODS

PubMed, Embase, and the Cochrane Library were searched for available papers published up to March 2021. The primary outcome was insulin resistance which was assessed by Homeostasis Model Assessment Insulin Resistance (HOMA-IR), other metabolic parameters measures including the pre/post-diet changes in triglycerides, HDL-cholesterol, total cholesterol, LDL-cholesterol. All analyses were performed using the random-effects model.

RESULTS

Six studies (seven datasets) were included. Compared with baseline, the plant-based diet improved the HOMA-IR (SMD = 1.64, 95%CI 0.95, 2.33; I2 = 91.8%, Pheterogeneity < 0.001), total cholesterol (SMD = 2.51, 95% CI 0.88, 4.13; I2 = 98.0%, Pheterogeneity < 0.001), HDL-cholesterol (SMD = 1.55, 95% CI 0.66, 2.44; I2 = 92.0%, Pheterogeneity < 0.001), and LDL-cholesterol (SMD = 2.50, 95% CI 1.30, 3.70; I2 = 94.4%, Pheterogeneity < 0.001), but not the triglycerides (SMD = - 0.62, 95% CI - 1.92, 0.68; I2 = 97.8%, Pheterogeneity < 0.001). The sensitivity analyses showed that the results were robust.

CONCLUSIONS

In obese individuals with insulin resistance, a vegan diet improves insulin resistance and dyslipidemia, except for triglycerides.

Psychometric Evaluation of the Barriers to Healthy Eating Scale: Results from Four Independent Weight Loss Studies

OBJECTIVE

The purpose of this study was to evaluate the psychometric properties of the 22-item Barriers to Healthy Eating (BHE) scale in four independent weight loss studies conducted over 13 years.

METHODS

Principal axis factoring with promax rotation was performed to reveal the underlying factor structure. Internal consistency was assessed using Cronbach α, and convergent validity was assessed by correlating the baseline BHE with the Weight Efficacy Lifestyle questionnaire total and subscale scores. Predictive validity was examined by the association of BHE change with weight loss over 6 months.

RESULTS

The four studies had similar gender (82.9%-89.9% female) and race (70.5%-81.4% white) distributions. Factor analyses suggested removal of two items and a three-factor structure: self-control and motivation (10 items), daily mechanics (7 items), and social support (3 items). The Cronbach α for the 20-item BHE ranged from 0.849 to 0.881 across the four studies. The BHE and Weight Efficacy Lifestyle questionnaire total and subscale scores were all negatively correlated with each other, showing good convergent validity (r = 0.120-0.544, P < 0.05). BHE change was associated with weight loss from 0 to 6 months (r = 0.282-0.450, P < 0.05).

CONCLUSIONS

The BHE scale showed very good psychometric properties over time, supporting its use in measuring barriers to one's ability to adopt or maintain a healthy eating plan.

Findings From a Randomized Trial of Weight Gain Prevention Among Overweight Puerto Rican Young Adults

OBJECTIVE

Assess impact of multimodality weight gain prevention intervention.

METHODS

Randomized clinical trial among 39 overweight young Puerto Rico college students using 10 weekly peer-support sessions promoting dietary, physical activity, and other lifestyle changes enhanced by stress-reduction and mindfulness approaches. Body mass index (BMI) and self-reported behaviors were measured at baseline and at 10 weeks and 6 months after baseline.

RESULTS

At the completion of the intervention, BMIs in the experimental arm were 0.8 units lower than at baseline (z = -3.0; P = .008) and 1.2 lower at 6 months after baseline (z = -4.1; P < .001); BMIs in the control arm were 0.7 higher (z = 2.7; P = .02) at 10 weeks and 0.8 higher at 6 months (z = 3.1; P = .005). Group × time interaction confirmed that BMI differed significantly over time between arms (χ² = 26.9; degrees of freedom = 2; P < .001). Analysis of behavioral changes was mostly inconclusive although the experimental arm reported a considerable increase in walking at 10 weeks. Qualitative data suggested that yoga and mindfulness components were particularly useful for motivating participants to maintain healthier lifestyle patterns.

CONCLUSIONS

Body mass index in the experimental arm decreased at the end of intervention and was maintained at 6 months' follow-up.

Fit & quit: An efficacy trial of two behavioral post-cessation weight gain interventions

While smoking cessation leads to significant improvements in both mortality and morbidity, post-cessation weight gain partially attenuates this benefit. Even though post-cessation weight gain is small (4.7 kg on average), it is a stated reason to delay cessation attempts and is associated with smoking relapse. Fit & Quit is a randomized, controlled efficacy trial that aims to examine the ability of a weight stability intervention and a weight loss intervention to reduce post-cessation weight gain. For this purpose, Fit & Quit will randomize participants to three conditions: (a) Small Changes, a weight gain prevention intervention; (b) Look AHEAD Intensive Lifestyle Intervention; and (c) a lower-intensity bibliotherapy intervention. All conditions will receive a highly efficacious behavioral (i.e., rate reduction skills, motivational interviewing) and pharmacological (i.e., varenicline) smoking cessation program. A total of 400 participants will be recruited and randomized to the three interventions. Participants will be recruited in waves, with 10 waves of approximately 40 participants per wave. The primary outcomes of this study include post-cessation weight gain and cessation status at 12-month follow-up. Fit & Quit will integrate and adapt the strongest evidence-based interventions available for weight management and smoking cessation. Fit & Quit is highly innovative in the areas of the target population, study design, and use of technology. For these reasons, we expect that Fit & Quit will make a significant public health contribution to curtailing the important cessation barrier of post-cessation weight gain.

Experiences of Barriers and Motivators to Weight-Loss among Saudi People with Overweight or Obesity in Qassim Region - A Qualitative Study

BACKGROUND

Obesity has become a global health threat. Saudi Arabia ranks among the countries with high obesity and overweight rates. This study aims to explore experiences of Saudi people with overweight or obesity with a particular focus on the perceived barriers and motivators to weight loss.

MATERIAL AND METHODS

We used a qualitative approach to recruiting a purposive sample using maximum variation sampling technique. Those who had previously attempted weight loss at least once were included in the study. In-depth interviews were conducted, transcribed and/ or audiotaped. Interviews continued until saturation was reached. The qualitative content analysis was performed.

RESULTS

A total of 19 males and 18 females participated in this study with a mean Body Mass Index (BMI) of 32.6 kg/m2. Their main triggers to weight loss were concerns about overall health and the desire to improve their looks. Declining motivation, lack of family support and unhealthy eating during social gatherings were perceived as the main barriers. Motivating factors included concerns about health, family support, and availability of exercise facilities.

CONCLUSION

Factors responsible for a successful weight- loss is context-specific. This study has shown several barriers as well as motivators, which play an important role in weight reduction and maintenance.

Behavioral Medicine Review: Strategic Management of Diabetes Risk

There is widespread public health concern about the upsurge in diabetes and its cardiometabolic comorbidities. Unfortunately, too many patients still do not receive best practices care. This review discusses some key contributing dynamics as well as considerations for progress toward the more comprehensive, strategic management of diabetes and its associated risks.

The Biggest Loser Thinks Long-Term: Recency as a Predictor of Success in Weight Management

Only a minority of participants in behavioral weight management lose weight significantly. The ability to predict who is likely to benefit from weight management can improve the efficiency of obesity treatment. Identifying predictors of weight loss can also reveal potential ways to improve existing treatments. We propose a neuro-psychological model that is focused on recency: the reliance on recent information at the expense of time-distant information. Forty-four weight-management patients completed a decision-making task and their recency level was estimated by a mathematical model. Impulsivity and risk-taking were also measured for comparison. Weight loss was measured in the end of the 16-week intervention. Consistent with our hypothesis, successful dieters (n = 12) had lower recency scores than unsuccessful ones (n = 32; p = 0.006). Successful and unsuccessful dieters were similar in their demographics, intelligence, risk taking, impulsivity, and delay of gratification. We conclude that dieters who process time-distant information in their decision making are more likely to lose weight than those who are high in recency. We argue that having low recency facilitates future-oriented thinking, and thereby contributes to behavior change treatment adherence. Our findings underline the importance of choosing the right treatment for every individual, and outline a way to improve weight-management processes for more patients.

Engaging rural women in healthy lifestyle programs: insights from a randomized controlled trial

BACKGROUND

The obesity epidemic is well established, particularly in rural settings. Programs promoting healthy lifestyles for rural women are urgently needed; however, participant engagement is challenging. In the context of a large randomized controlled trial targeting the prevention of weight gain in rural women, we explored successful recruitment strategies and aimed to understand participants' barriers, enablers and reasons for program participation.

METHODS

We recruited women (aged 18-55 years) from the general rural Australian population. A mixed-methods approach was applied to explore factors that influenced program participation, including quantitative questionnaires for all participants (n = 649) and qualitative semi-structured interviews conducted for a subgroup of participants (n = 45). Data were collected at three time points: baseline, 6 and 12 months post program commencement.

RESULTS

We recruited 649 rural women through a community communication and partnering strategy, a program marketing campaign and mobilization of social networks. Program participants were diverse across education and income levels and were representative of the wider Australian regional population. Factors that influenced program engagement were divided into personal (perceived program benefits and program accessibility) and social (peer persuasion and support). Identified enablers included convenience of the program location, perceived program utility, such as weight management and optimization of lifestyle choices, as well as attending the program with peer support. Barriers to engagement, which are likely exacerbated in rural communities included lack of anonymity, self-consciousness and segregated social networks in rural settings. Participants reported that eliciting local support and maximizing publicity is fundamental to improving future program engagement.

CONCLUSION

Multiple program promotion strategies including communication, marketing and partnering, as well as mobilization of social networks and peer persuasion, enabled engagement of rural women into a healthy lifestyle program. These recruitment strategies are consistent with successful strategies utilized previously to recruit urban-dwelling women into lifestyle programs. Future engagement efforts in rural settings could be enhanced by hosting multiple sessions within existing socio-cultural networks and assuring participants that they will not need to share their personal health information with others in their community.

TRIAL REGISTRATION

Australia & New Zealand Clinical Trial Registry. Trial number ACTRN12612000115831. Date of registration 24 January 2012.

Systematic development of a text-driven and a video-driven web-based computer-tailored obesity prevention intervention

Background

This paper describes the systematic development of a text-driven and a video-driven web-based computer-tailored intervention aimed to prevent obesity among normal weight and overweight adults. We hypothesize that the video-driven intervention will be more effective and appealing for individuals with a low level of education.

Methods and Design

The Intervention Mapping protocol was used to develop the interventions, which have exactly the same educational content but differ in the format in which the information is delivered. One intervention is fully text-based, while in the other intervention in addition to text-based feedback, the core messages are provided by means of videos. The aim of the interventions is to prevent weight gain or achieve modest weight loss by making small changes in dietary intake or physical activity. The content of the interventions is based on the I-Change Model and self-regulation theories and includes behavior change methods such as consciousness raising, tailored feedback on behavior and cognitions, goal setting, action and coping planning, and evaluation of goal pursuit. The interventions consist of six sessions. In the first two sessions, participants will set weight and behavioral change goals and form plans for specific actions to achieve the desired goals. In the remaining four sessions, participants’ will evaluate their progress toward achievement of the behavioral and weight goals. They will also receive personalized feedback on how to deal with difficulties they may encounter, including the opportunity to make coping plans and the possibility to learn from experiences of others. The efficacy and appreciation of the interventions will be examined by means of a three-group randomized controlled trial using a waiting list control group. Measurements will take place at baseline and six and twelve months after baseline. Primary outcome measures are body mass index, physical activity, and dietary intake.

Discussion

The present paper provides insight into how web-based computer-tailored obesity prevention interventions consisting of self-regulation concepts and text-driven and video-driven messages can be developed systematically. The evaluation of the interventions will provide insight into their efficacy and will result in recommendations for future web-based computer-tailored interventions and the additional value of using video tailoring.

Trial registration

NTR3501.

School-based obesity policy, social capital, and gender differences in weight control behaviors

OBJECTIVES

We examined the associations among school-based obesity policies, social capital, and adolescents' self-reported weight control behaviors, focusing on how the collective roles of community and adopted policies affect gender groups differently.

METHODS

We estimated state-level ecologic models using 1-way random effects seemingly unrelated regressions derived from panel data for 43 states from 1991 to 2009, which we obtained from the Centers for Disease Control and Prevention's Youth Risk Behavior Surveillance System. We used multiplicative interaction terms to assess how social capital moderates the effects of school-based obesity policies.

RESULTS

School-based obesity policies in active communities were mixed in improving weight control behaviors. They increased both healthy and unhealthy weight control behaviors among boys but did not increase healthy weight control behaviors among girls.

CONCLUSIONS

Social capital is an important contextual factor that conditions policy effectiveness in large contexts. Heterogeneous behavioral responses are associated with both school-based obesity policies and social capital. Building social capital and developing policy programs to balance outcomes for both gender groups may be challenging in managing childhood obesity.

Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study

BACKGROUND

Excessive weight gain during pregnancy is a major risk factor for postpartum weight retention and future weight gain and obesity in women, but few adequately powered randomized controlled trials have examined the efficacy of a behavioral weight-control intervention during pregnancy.

OBJECTIVE

This study examined whether a behavioral intervention during pregnancy could decrease the proportion of women who exceeded the 1990 Institute of Medicine (IOM) recommendations for gestational weight gains and increase the proportion of women who returned to pregravid weights by 6 mo postpartum.

DESIGN

This study was a randomized, assessor-blind, controlled trial. Participants were pregnant (13.5 wk gestation), normal-weight (NW; n = 201) and overweight or obese (OW/OB; n = 200) women whose average age was 28.8 y. Participants were randomly assigned within the 1990 IOM weight category (NW compared with OW/OB) to standard care (n = 200) or to a behavioral intervention to prevent excessive gestational weight gain (n = 201). The intervention included one face-to-face visit; weekly mailed materials that promoted an appropriate weight gain, healthy eating, and exercise; individual graphs of weight gain; and telephone-based feedback. The retention at the 6-mo postpartum assessment was 82%.

RESULTS

Intent-to-treat analyses showed that the intervention, compared with standard care, decreased the percentage of NW women who exceeded IOM recommendations (40.2% compared with 52.1%; P = 0.003) and increased the percentages of NW and OW/OB women who returned to their pregravid weights or below by 6 mo postpartum (30.7% compared with 18.7%; P = 0.005).

CONCLUSION

A low-intensity behavioral intervention during pregnancy reduced excessive gestational weight gains in NW women and prevented postpartum weight retention in NW and OW/OB women. This trial was registered at clinicaltrials.gov as NCT01117961.

Comparison of education-only versus group-based intervention in promoting weight loss: a randomised controlled trial

AIM

To compare the effectiveness of education-only versus group-based intervention in promoting weight loss.

METHODS

Between April and October 2009, a 6-month randomised controlled trial was conducted at Mito Kyodo General Hospital in Japan (UMIN000001259). The participants were 188 overweight adults (145 women, 43 men) aged 40-65 years. They were randomly assigned to one of three groups: control, moderate or intensive intervention. A single motivational lecture was provided to all three groups, educational materials (textbooks, notebooks, and a pedometer) to the moderate and intensive intervention groups, and group-based support to the intensive intervention group. Amount of weight loss was the primary outcome measure. Secondary outcome measures were components of metabolic syndrome.

RESULTS

Mean ± SD weight loss of participants in the control, moderate and intensive intervention groups was 2.9 ± 4.1, 4.7 ± 4.0 and 7.7 ± 4.1 kg, respectively. Bonferroni post-hoc comparisons revealed all between-group differences to be significant (p < 0.05). Waist circumference decreased in the intensive intervention group more than in the other groups, whereas no significant differences were observed in the other secondary outcome measures.

CONCLUSION

Education-only intervention is a cost-effective method to promote weight loss. Adding group-based intervention further promotes weight loss.

Adherence to a behavioral weight loss treatment program enhances weight loss and improvements in biomarkers

OBJECTIVES

To describe participants' adherence to multiple components (attendance, energy intake, fat gram, exercise goals, and self-monitoring eating and exercise behaviors) of a standard behavioral treatment program (SBT) for weight loss and how adherence to these components may influence weight loss and biomarkers (triglycerides, low density lipoproteins [LDL], high density lipoprotein, and insulin) during the intensive and less-intensive intervention phases.

METHODS

A secondary analysis of a randomized clinical trial consisting of a SBT with either fat-restricted standard or lacto-ovo vegetarian diet. The 12-month intervention was delivered in 33 group sessions. The first six months reflected the intensive phase; the second six months, the less-intensive intervention phase. We conducted the analysis without regard to treatment assignment. Eligible participants included overweight/obese adults (N = 176; mean body mass index = 34.0 kg/m(2)). The sample was 86.9% female, 70.5% White, and 44.4 +/- 8.6 years old. The outcome measures included weight and biomarkers.

RESULTS

There was a significant decline in adherence to each treatment component over time (P < 0.0001). In the first six months, adherence to attendance, self-monitoring and the energy goal were significantly associated with greater weight loss (P < 0.05). Adherence to attendance and exercise remained significantly associated with weight loss in the second six months (P < 0.05). Adherence to attendance, self-monitoring and exercise had indirect effects through weight loss on LDL, triglycerides, and insulin (P < 0.05).

CONCLUSIONS

We observed a decline in adherence to each treatment component as the intervention intensity was reduced. Adherence to multiple treatment components was associated with greater weight loss and improvements in biomarkers. Future research needs to focus on improving and maintaining adherence to all components of the treatment protocol to promote weight loss and maintenance.

A comparison of maintenance-tailored therapy (MTT) and standard behavior therapy (SBT) for the treatment of obesity

OBJECTIVE

To evaluate a maintenance-tailored therapy (MTT) compared to standard behavior therapy (SBT) for treatment of obesity.

MAIN OUTCOME MEASURE

change in body weight.

METHOD

A non-blinded, randomized trial comparing effectiveness of MTT and SBT in facilitating sustained weight loss over 18 months; 213 adult volunteers> or =18 years participated. SBT had fixed behavioral goals, MTT goals varied over time. Study conducted at the University of Minnesota, School of Public Health, January 2005 through September 2007.

RESULTS

Mean (SD) weight losses at 6, 12, and 18 months were 5.7 (5.0) kg, 8.2 (8.6) kg and 8.3 (8.9) kg for MTT and 7.4 (3.9) kg, 10.7 (8.2) kg and 9.3 (8.8) kg for SBT. Total weight loss did not differ by group at 18 months, but the time pattern differed significantly (p<0.001). The SBT group lost more weight in the first 6 months. Both groups lost similar amounts between 6 and 12 months; MTT had stable weight between 12 and 18 months, while SBT experienced significant weight gain.

CONCLUSIONS

The MTT approach produced sustained weight loss for an unusually long period of time and not achieved in previous trials of behavioral treatment for weight loss. The MTT approach, therefore, deserves further study.

Behavioral Medicine Review: Strategic Management of Diabetes Risk

There is widespread public health concern about the upsurge in diabetes and its cardiometabolic comorbidities. Unfortunately, too many patients still do not receive best practices care. This review discusses some key contributing dynamics as well as considerations for progress toward the more comprehensive, strategic management of diabetes and its associated risks.

Effects of a vegetarian diet and treatment preference on biochemical and dietary variables in overweight and obese adults: a randomized clinical trial

BACKGROUND

A vegetarian diet may lead to numerous health benefits, including weight loss.

OBJECTIVE

We examined the joint effects of personal preference of dietary treatment and a calorie-restricted, low-fat lactoovovegetarian diet (LOV-D) compared with a standard calorie-restricted, low-fat omnivorous diet (STD-D) on changes in weight, total cholesterol, ratio of LDL to HDL cholesterol (LDL:HDL cholesterol), triacylglycerols, insulin resistance, and macronutrient intake during an 18-mo study.

DESIGN

This was a randomized clinical trial of 176 overweight and obese adults who were recruited and randomly assigned first to 1 of 2 preference conditions (yes or no). If assigned to Preference-No, they were randomly assigned to 1 of the 2 diet conditions (STD-D or LOV-D). If assigned to Preference-Yes, they were assigned to the diet they indicated as preferred at screening. The 12-mo intervention was followed by a 6-mo maintenance phase.

RESULTS

Participants were mainly women (86.9%) and white (70.5%); 75% completed the 18-mo study. A significant interaction between preference and dietary treatment was not observed for any of the outcome variables. However, participants in the Preference-No groups significantly decreased their triacylglycerols (P = 0.04). The only effect observed for diet was a borderline significant decrease in LDL:HDL cholesterol for the LOV-D group (P = 0.06). Within the LOV-D groups, those who were 100% adherent to the LOV-D had significant and marginally significant reductions in monounsaturated fat (P = 0.02) and total fat (P = 0.05) intakes at 18 mo.

CONCLUSIONS

Our findings suggest that neither prescribing a vegetarian diet nor allowing persons to choose their preferred diet had a significant effect on outcome measures. However, all participants had a significant reduction in total energy and fat intakes and an increase in energy expenditure, which was reflected in reduced body weight. This clinical trial was registered at www.clinicaltrials.gov as NCT00330629.

A randomized clinical trial of a standard versus vegetarian diet for weight loss: the impact of treatment preference

BACKGROUND

With obesity rampant, methods to achieve sustained weight loss remain elusive.

OBJECTIVE

To compare the long-term weight-loss efficacy of 2 cal and fat-restricted diets, standard (omnivorous) versus lacto-ovo-vegetarian, and to determine the effect of a chosen diet versus an assigned diet.

DESIGN, SUBJECTS

A randomized clinical trial was conducted with 176 adults who were sedentary and overweight (mean body mass index, 34.0 kg/m(2)). Participants were first randomly assigned to either receive their preferred diet or be assigned to a diet group and second, were given their diet of preference or randomly assigned to a standard weight-loss diet or a lacto-ovo-vegetarian diet. Participants underwent a university-based weight-control program consisting of daily dietary and exercise goals plus 12 months of behavioral counseling followed by a 6-month maintenance phase.

MEASUREMENTS

Percentage change in body weight, body mass index, waist circumference, low- and high-density lipoprotein, glucose, insulin and macronutrient intake.

RESULTS

The program was completed by 132 (75%) of the participants. At 18 months, mean percentage weight loss was greater (P=0.01) in the two groups that were assigned a diet (standard, 8.0% (s.d., 7.8%); vegetarian, 7.9% (s.d., 8.1%)) than in those provided the diet of their choice (standard, 3.9% (s.d., 6.1%); vegetarian, 5.3% (s.d., 6.2%)). No difference was observed in weight loss between the two types of diet. Over the 18-month program, all groups showed significant weight loss.

CONCLUSIONS

Participants assigned to their dietary preference did not have enhanced treatment outcomes. However, all groups lost weight with losses ranging from 4 to 8% at 18 months.

Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes

BACKGROUND

Multiple-risk-factor interventions offer a promising means for addressing the complex interactions between lifestyle behaviors, psychosocial factors, and the social environment. This report examines the long-term effects of a multiple-risk-factor intervention.

METHODS

Postmenopausal women (N = 279) with type 2 diabetes participated in the Mediterranean Lifestyle Program (MLP), a randomized, comprehensive lifestyle intervention study. The intervention targeted healthful eating, physical activity, stress management, smoking cessation, and social support. Outcomes included lifestyle behaviors (i.e., dietary intake, physical activity, stress management, smoking cessation), psychosocial variables (e.g., social support, problem solving, self-efficacy, depression, quality of life), and cost analyses at baseline, and 6, 12, and 24 months.

RESULTS

MLP participants showed significant 12- and 24-month improvements in all targeted lifestyle behaviors with one exception (there were too few smokers to analyze tobacco use effects), and in psychosocial measures of use of supportive resources, problem solving, self-efficacy, and quality of life.

CONCLUSION

The MLP was more effective than usual care over 24 months in producing improvements on behavioral and psychosocial outcomes. Directions for future research include replication with other populations.

Opportunities and challenges in the prevention and control of cancer and other chronic diseases: children's diet and nutrition and weight and physical activity

OBJECTIVE

The purpose of this article is to review the role of behavioral research in disease prevention and control, with a particular emphasis on lifestyle- and behavior-related cancer and chronic disease risk factors--specifically, relationships among diet and nutrition and weight and physical activity with adult cancer, and tracking developmental origins of these health-promoting and health-compromising behaviors from childhood into adulthood.

METHOD

After reviewing the background of the field of cancer prevention and control and establishing plausibility for the role of child health behavior in adult cancer risk, studies selected from the pediatric published literature are reviewed. Articles were retrieved, selected, and summarized to illustrate that results from separate but related fields of study are combinable to yield insights into the prevention and control of cancer and other chronic diseases in adulthood through the conduct of nonintervention and intervention research with children in clinical, public health, and other contexts.

RESULTS

As illustrated by the evidence presented in this review, there are numerous reasons (biological, psychological, and social), opportunities (school and community, health care, and family settings), and approaches (nonintervention and intervention) to understand and impact behavior change in children's diet and nutrition and weight and physical activity.

CONCLUSIONS

Further development and evaluation of behavioral science intervention protocols conducted with children are necessary to understand the efficacy of these approaches and their public health impact on proximal and distal cancer, cancer-related, and chronic disease outcomes before diffusion. It is clear that more attention should be paid to early life and early developmental phases in cancer prevention.

Successful control of dyslipidemia in patients with metabolic syndrome: focus on lifestyle changes

Approaches to controlling dyslipidemia in patients with metabolic syndrome must take into consideration a patient's individual characteristics and underlying lipid disorder. Some patients will require pharmacologic therapy, whereas others can be controlled with lifestyle changes alone. The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines recommend that patients with at least 3 of the following clinical variables be designated as having metabolic syndrome: abdominal obesity as reflected in increased waist circumference; a low high-density lipoprotein cholesterol (HDL-C) level; an elevated triglyceride level; elevated blood pressure or treatment with antihypertensive medications; and/or elevated fasting plasma glucose or treatment with antidiabetic medications. Unless patients with metabolic syndrome change their lifestyle, existing cardiovascular and metabolic risk factors will worsen or new risk factors will develop. This helps explain why these patients are at increased risk for developing type 2 diabetes mellitus (DM) and coronary heart disease (CHD). The lifestyle changes recommended by NCEP ATP III for controlling dyslipidemia (i.e., elevated levels of triglycerides and decreased levels of HDL-C) in patients with metabolic syndrome or type 2 DM include (1) reduced intake of saturated fats and dietary cholesterol, (2) intake of dietary options to enhance lowering of low-density lipoprotein cholesterol, (3) weight control, and (4) increased physical activity. If lifestyle changes are not successful for individuals at high risk of developing CHD, or for those who currently have CHD, a CHD risk equivalent, or persistent atherogenic dyslipidemia, then pharmacotherapy may be necessary as defined by NCEP ATP III guidelines.

The risk of preeclampsia rises with increasing prepregnancy body mass index

PURPOSE

To explore the dose-dependent relation between prepregnancy body mass index (BMI) and the risk of preeclampsia after adjusting for measured confounders.

METHODS

We studied 1179 primiparous women who enrolled at < 16 weeks' gestation into a prospective cohort study of the pathogenesis of preeclampsia. Multivariable logistic regression was used to quantify the independent effect of prepregnancy BMI on the risk of preeclampsia after adjusting for race and smoking status. BMI was specified as a restricted quadratic spline.

RESULTS

Preeclampsia risk rose strikingly from a BMI of 15 to 30 kg/m(2). Compared with women with a BMI of 21, the adjusted risk of preeclampsia doubled at a BMI of 26 (odds ratio 2.1 [95% confidence interval, 1.4, 3.4]), and nearly tripled at a BMI of 30 (2.9 [1.6, 5.3]). Women with a BMI of 17 had a 57% reduction in preeclampsia risk compared with women with a BMI of 21 (0.43 [0.25, 0.76]), and a BMI of 19 was associated with a 33% reduction in risk (0.66 [0.50, 0.87]).

CONCLUSIONS

These results indicate that preeclampsia risk rises through most of the BMI distribution. The dramatic elevation in overweight prevalence in the United States may increase preeclampsia incidence in the future.

Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain

Weight loss is difficult to achieve and maintaining the weight loss is an even greater challenge. The identification of factors associated with weight loss maintenance can enhance our understanding for the behaviours and prerequisites that are crucial in sustaining a lowered body weight. In this paper we have reviewed the literature on factors associated with weight loss maintenance and weight regain. We have used a definition of weight maintenance implying intentional weight loss that has subsequently been maintained for at least 6 months. According to our review, successful weight maintenance is associated with more initial weight loss, reaching a self-determined goal weight, having a physically active lifestyle, a regular meal rhythm including breakfast and healthier eating, control of over-eating and self-monitoring of behaviours. Weight maintenance is further associated with an internal motivation to lose weight, social support, better coping strategies and ability to handle life stress, self-efficacy, autonomy, assuming responsibility in life, and overall more psychological strength and stability. Factors that may pose a risk for weight regain include a history of weight cycling, disinhibited eating, binge eating, more hunger, eating in response to negative emotions and stress, and more passive reactions to problems.

A review of psychosocial pre-treatment predictors of weight control

Prompted by the large heterogeneity of individual results in obesity treatment, many studies have attempted to predict weight outcomes from information collected from participants before they start the programme. Identifying significant predictors of weight loss outcomes is central to improving treatments for obesity, as it could help professionals focus efforts on those most likely to benefit, suggest supplementary or alternative treatments for those less likely to succeed, and help in matching individuals to different treatments. To date, however, research efforts have resulted in weak predictive models with limited practical usefulness. The two primary goals of this article are to review the best individual-level psychosocial pre-treatment predictors of short- and long-term (1 year or more) weight loss and to identify research needs and propose directions for further work in this area. Results from original studies published since 1995 show that few previous weight loss attempts and an autonomous, self-motivated cognitive style are the best prospective predictors of successful weight management. In the more obese samples, higher initial body mass index (BMI) may also be correlated with larger absolute weight losses. Several variables, including binge eating, eating disinhibition and restraint, and depression/mood clearly do not predict treatment outcomes, when assessed before treatment. Importantly, for a considerable number of psychosocial constructs (e.g. eating self-efficacy, body image, self-esteem, outcome expectancies, weight-specific quality of life and several variables related to exercise), evidence is suggestive but inconsistent or too scant for an informed conclusion to be drawn. Results are discussed in the context of past and present conceptual and methodological limitations, and several future research directions are described.

Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies. A statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition

Overweight and obesity are important risk factors for type 2 diabetes. The marked increase in the prevalence of overweight and obesity is presumably responsible for the recent increase in the prevalence of type 2 diabetes. Lifestyle modification aimed at reducing energy intake and increasing physical activity is the principal therapy for overweight and obese patients with type 2 diabetes. Even moderate weight loss in combination with increased activity can improve insulin sensitivity and glycemic control in patients with type 2 diabetes and prevent the development of type 2 diabetes in high-risk persons (ie, those with impaired glucose tolerance). The American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition have joined together to issue this statement on the use of lifestyle modification in the prevention and management of type 2 diabetes.

Pretreatment predictors of attrition and successful weight management in women

OBJECTIVE

This study analyzed baseline behavioral and psychosocial differences between successful and nonsuccessful participants in a behavioral weight management program. Success was defined by commonly used health-related criteria (5% weight loss). Noncompletion was also used as a marker of a failed attempt at weight control.

SUBJECTS

A total of 158 healthy overweight and obese women (age, 48.0+/-4.5 y; BMI, 31.0+/-3.8 kg/m(2); body fat, 44.5+/-5.3%).

INTERVENTION

Subjects participated in a 16-week lifestyle weight loss program consisting of group-based behavior therapy to improve diet and increase physical activity, and were followed for 1 y after treatment.

METHODS

At baseline, all women completed a comprehensive behavioral and psychosocial battery assessing dieting/weight history, dietary intake and eating behaviors, exercise, self-efficacy, outcome evaluations, body image, and other variables considered relevant for weight management. Participants who maintained a weight loss of 5% or more at 16 months (or 10% or more of initial fat mass) were classified as successful. Nonsuccessful participants were those who dropped out and completers who had not lost weight at follow-up.

RESULTS

Of all participants, 30% (n=47) did not complete initial treatment and/or missed follow-up assessments (noncompleters). Noncompletion was independently associated with more previous weight loss attempts, poorer quality of life, more stringent weight outcome evaluations, and lower reported carbohydrate intake at baseline. In logistic regression, completion status was predicted correctly in 84% of all cases (chi(2)=45.5, P<0.001), using baseline information only. Additional predictors of attrition were initial weight, exercise minutes, fiber intake, binge eating, psychological health, and body image. A large variation in weight loss/maintenance results was observed (range: 37.2 kg for 16-month weight change). Independent baseline predictors of success at 16 months were more moderate weight outcome evaluations, lower level of previous dieting, higher exercise self-efficacy, and smaller waist-to-hip ratio. Success status at follow-up was predicted correctly in 74% of all starting cases (chi(2)=33.6, P<0.001).

CONCLUSION

Psychosocial and behavioral variables (eg, dieting history, dietary intake, outcome evaluations, exercise self-efficacy, and quality of life) may be useful as pretreatment predictors of success level and/or attrition in previously overweight and mildly obese women who volunteer for behavioral weight control programs. These factors can be used in developing readiness profiles for weight management, a potentially important tool to address the issue of low success/completion rates in the current management of obesity.