Behavioral transitions and weight change patterns within the PREMIER trial

Feasibility of the flipped classroom approach for health education in a clinical weight loss program

Aim

To assess the feasibility of the flipped classroom pedagogy in a clinical weight loss program and its impact on 6-month weight change.

Methods

Adults with overweight/obesity enrolled in a 6-month program with a structured diet (portion-controlled meals and fruits/vegetables) and exercise plan (≥150mins/week), plus weekly, 1-h group education sessions. Sessions used a flipped classroom approach: educational content was delivered beforehand via podcast/video and book readings and session time involved application-based activities (e.g., case studies, games). Satisfaction surveys were completed at 3 months. Weight change was assessed using paired t-tests (SAS 9.4, significance 0.05).

Results

Eighteen participants completed 6 months (retention 94%). Participants maintained diet adherence and exercise at 3 months (∼84% diet adherence, ∼153mins exercise/week) and 6 months (∼83% diet adherence, ∼158mins exercise/week), as well as attendance to behavioral sessions (3 months: 77%; 6mo: 71%). Satisfaction surveys showed high program enjoyment (∼8.1/10). Mean weight change at 3 and 6 months was -6.5 ± 4.2% and - 9.3 ± 5.0% (both p < 0.01), respectively.

Conclusion

The flipped classroom pedagogy was feasible for delivery in a clinical weight loss program and supported significant 6-month weight loss.

Innovation

This is the first evaluation of the flipped classroom in a clinical setting and supports the investigation of this pedagogy in weight management.

Attendance, Weight Loss, and Participation in a Behavioural Diabetes Prevention Programme

BACKGROUND

Weight loss in diabetes prevention programmes has been shown to be associated with participants' age, socio-economic status, and ethnicity. However, little is known about how these differences relate to attendance and whether such differences can be mediated by other potentially modifiable factors. Differential effectiveness across these factors may exacerbate health inequalities.

METHOD

Prospective analysis of participant data collected by one provider of the standardised national NHS diabetes prevention programme in England. Mediation analysis was performed via a structural equation model to examine whether the number of attended sessions mediated the associations of age, socio-economic status, and ethnicity with follow-up weight. The group-level factor of number of attended sessions was examined using multiple linear regression as a benchmark; multilevel linear regression using three levels (venue, coach, and group); and fixed effects regression to account for venue-specific and coach-specific characteristics.

RESULTS

The associations of age, socio-economic status, and ethnicity with follow-up weight were all mediated by the number of attended sessions. Group size was associated with attendance in an inverted 'U' shape, and the number of days between referral and group start was negatively associated with attendance. Time of day, day of the week, and the number of past groups led by the coach were not associated with attendance.

CONCLUSION

Most of the differences in weight loss initially attributed to socio-demographic factors are mediated by the attendance of the diabetes prevention programme. Therefore, targeted efforts to improve uptake and adherence to such programmes may help alleviate inequalities.

What matters for weight loss in behavioral trials in the Latinx community: Learnings from three randomized controlled trials

BACKGROUND

Nearly half of Latinx adults in the US are obese, making effective weight loss interventions crucial to prevent associated chronic conditions.

OBJECTIVE

To identify factors associated with increased session attendance and clinically significant weight loss among Latinx adults.

PARTICIPANTS

Latinx participants from the Vivamos Activos (n = 207), Vida Sana (n = 191), and HOMBRE (n = 424 Latinx men) randomized clinical trials.

DESIGN

Post-hoc analysis of randomized controlled trial data.

INTERVENTION

Culturally-adapted behavioral weight loss interventions based on the Diabetes Prevention Program among Latinx adults over 12 months.

MAIN OUTCOME MEASURE

Demographic, clinical, and psychosocial predictors of session attendance and 5% weight loss at 12-months.

STATISTICAL ANALYSIS PERFORMED

Bi-variable associations between baseline characteristics and outcomes were tested with chi-square and t-tests. Those with p-value< 0.15 were then included in stepwise logistic regressions.

RESULTS

Participants (N = 822) were middle age with diverse socioeconomic backgrounds. Older age in the Vivamos Activos and Vida Sana trials, and lower acculturation in the HOMBRE trial were significant predictors of increased session attendance. Factors associated with 5% weight loss varied by trials. These included younger age (OR 0.96 95% CI 0.92, 0.99) in Vivamos Activos, higher acculturation (OR 1.88 95% CI 1.05, 3.37) in Vida Sana, and higher education (OR 3.20 95% CI 1.3, 7.03) and greater body image dissatisfaction (OR 1.29, 95% CI 1.04, 1.6), and lower acculturation (0.69 95% CI 0.5, 0.96) in HOMBRE.

CONCLUSIONS

Few and conflicting baseline characteristics were associated with session attendance and clinically significant weight loss, suggesting that alternative approaches to optimizing interventions are needed.

Efficacy of a Commercial Weight Management Program Compared With a Do-It-Yourself Approach: A Randomized Clinical Trial

IMPORTANCE

Given the prevalence of obesity, accessible and effective treatment options are needed to manage obesity and its comorbid conditions. Commercial weight management programs are a potential solution to the lack of available treatment, providing greater access at lower cost than clinic-based approaches, but few commercial programs have been rigorously evaluated.

OBJECTIVE

To compare the differences in weight change between individuals randomly assigned to a commercial weight management program and those randomly assigned to a do-it-yourself (DIY) approach.

DESIGN, SETTING, AND PARTICIPANTS

This 1-year, randomized clinical trial conducted in the United States, Canada, and United Kingdom between June 19, 2018, and November 30, 2019, enrolled 373 adults aged 18 to 75 years with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 25 to 45. Assessors were blinded to treatment conditions.

INTERVENTIONS

A widely available commercial weight management program that included reduced requirements for dietary self-monitoring and recommendations for a variety of DIY approaches to weight loss.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the difference in weight change between the 2 groups at 3 and 12 months. The a priori hypothesis was that the commercial program would result in greater weight loss than the DIY approach at 3 and 12 months. Analyses were performed on an intention-to-treat basis.

RESULTS

The study include 373 participants (272 women [72.9%]; mean [SD] BMI, 33.8 [5.2]; 77 [20.6%] aged 18-34 years, 74 [19.8%] aged 35-43 years, 82 [22.0%] aged 44-52 years, and 140 [37.5%] aged 53-75 years). At 12 months, retention rates were 88.8% (166 of 187) for the commercial weight management program group and 95.7% (178 of 186) for the DIY group. At 3 months, participants in the commercial program had a mean (SD) weight loss of -3.8 (4.1) kg vs -1.8 (3.7) kg among those in the DIY group. At 12 months, participants in the commercial program had a mean (SD) weight loss of -4.4 (7.3) kg vs -1.7 (7.3) kg among those in the DIY group. The mean difference between groups was -2.0 kg (97.5% CI, -2.9 to -1.1 kg) at 3 months (P < .001) and -2.6 kg (97.5% CI, -4.3 to -0.8 kg) at 12 months (P < .001). A greater percentage of participants in the commercial program group than participants in the DIY group achieved loss of 5% of body weight at both 3 months (40.7% [72 of 177] vs 18.6% [34 of 183]) and 12 months (42.8% [71 of 166] vs 24.7% [44 of 178]).

CONCLUSIONS AND RELEVANCE

Adults randomly assigned to a commercial weight management program with reduced requirements for dietary self-monitoring lost more weight and were more likely to achieve weight loss of 5% at 3 and 12 months than adults following a DIY approach. This study contributes data on the efficacy of commercial weight management programs and DIY weight management approaches.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03571893.

Testing the short-term effectiveness of primary care referral to online weight loss programmes: A randomised controlled trial

Guidelines ask health professionals to offer brief advice to encourage weight loss for people living with obesity. We tested whether referral to one of three online programmes could lead to successful weight loss. A total of 528 participants aged ≥18 years with a body mass index of ≥30 kg/m² were invited via a letter from their GP. Participants were randomised to one of three online weight loss programmes (NHS Weight Loss Plan, Rosemary Online or Slimming World Online) or to a control group receiving no intervention. Participants self-reported weight at baseline and 8 weeks. The primary outcome was weight change in each of the active intervention groups compared with control. We also compared the proportion of participants losing ≥5% or ≥10% of body weight. For Rosemary, Online mean weight loss was modestly greater than control (-1.5 kg [95% confidence interval (CI) -2.3 to -0.6]) and more than three times as many participants in this group lost ≥5% (relative risk [RR] = 3.64, 95% CI: 1.63-8.1). For Slimming World, mean weight loss was not significantly different from control (-0.8 kg [95%CI -1.7 to 0.1]), twice as many participants lost ≥5% (RR = 2.70, 1.17-6.23). There was no significant difference in weight loss for participants using the NHS Weight Loss Plan (-0.4 kg, [95% CI -1.3 to 0.5]), or the proportion losing ≥5% (RR = 2.09, 0.87-5.01). Only one of three online weight loss programmes was superior to no intervention and the effect size modest among participants living with obesity.

The degree of engagement of overweight/obese adult women in the recommended activities of the Chilean "Vida Sana" program is directly correlated with its effectiveness

INTRODUCTION

Introduction: the Chilean Ministry of Health implements the Vida Sana (VS) program with the objective of reducing risk factors for chronic diseases in overweight/obese (OW/OB) individuals, aged 2-64. Objective: to determine the effectiveness of VS in OW/OB women (20-44 yrs) in terms of their engagement in the recommended activities. These consist of participating in a minimum number each of three core activities (psychologist consultations, lifestyle workshops, and physical activity sessions) during 6 months, to obtain a 5 % weight loss and improved physical fitness (PF). Methods: a retrospective study involving secondary analyses of the 2017 VS database (n = 5,179 OW/OB women). We determined effectiveness by: a) comparing changes in weight and PF in participants who achieved one or both outcomes, using t-tests and tests of proportions, and b) assessing the probability of achieving the program´s goal, according to participation in 1, 2, or 3 core activities, individually and jointly, using the OR (95 % CI) and trend analysis. Results: around 32 %, 88 %, and 29 % of women achieved 5 % weight loss, improved PF, and both, respectively. The high percentage of women who improved PF was due to a permissive criterion. Although 20 % of women attained the program´s goal with 0 engagement, among participants, the ORs (95 % CI) for achieving the program´s goal when engaging in 1, 2, or 3 core activities were 1.55 (CI 1.2-2.03), 2.34 (1.76-3.11), and 3.5 (2.21-5.53), respectively. Conclusion: effectiveness parallels degree of engagement in the recommended activities of VS. A characterization of a program´s participation rate is crucial for improving its effectiveness.

Utility of self-rated adherence for monitoring dietary and physical activity compliance and assessment of participant feedback of the Healthy Diet and Lifestyle Study pilot

Background

We examined the utility of self-rated adherence to dietary and physical activity (PA) prescriptions as a method to monitor intervention compliance and facilitate goal setting during the Healthy Diet and Lifestyle Study (HDLS). In addition, we assessed participants’ feedback of HDLS. HDLS is a randomized pilot intervention that compared the effect of intermittent energy restriction combined with a Mediterranean diet (IER + MED) to a Dietary Approaches to Stop Hypertension (DASH) diet, with matching PA regimens, for reducing visceral adipose tissue area (VAT).

Methods

Analyses included the 59 (98%) participants who completed at least 1 week of HDLS. Dietary and PA adherence scores were collected 8 times across 12 weeks, using a 0–10 scale (0 = not at all, 4 = somewhat, and 10 = following the plan very well). Adherence scores for each participant were averaged and assigned to high and low adherence categories using the group median (7.3 for diet, 7.1 for PA). Mean changes in VAT and weight from baseline to 12 weeks are reported by adherence level, overall and by randomization arm. Participants’ feedback at completion and 6 months post-intervention were examined.

Results

Mean ± SE, dietary adherence was 6.0 ± 0.2 and 8.2 ± 0.1, for the low and high adherence groups, respectively. For PA adherence, mean scores were 5.9 ± 0.2 and 8.5 ± 0.2, respectively. Compared to participants with low dietary adherence, those with high adherence lost significantly more VAT (22.9 ± 3.7 cm² vs. 11.7 ± 3.9 cm² [95% CI, − 22.1 to − 0.3]) and weight at week 12 (5.4 ± 0.8 kg vs. 3.5 ± 0.6 kg [95% CI, − 3.8 to − 0.0]). For PA, compared to participants with low adherence, those with high adherence lost significantly more VAT (22.3 ± 3.7 cm² vs. 11.6 ± 3.6 cm² [95% CI, − 20.7 to − 0.8]). Participants’ qualitative feedback of HDLS was positive and the most common response, on how to improve the study, was to provide cooking classes.

Conclusions

Results support the use of self-rated adherence as an effective method to monitor dietary and PA compliance and facilitate participant goal setting. Study strategies were found to be effective with promoting compliance to intervention prescriptions.

Trial registration

ClinicalTrials.gov Identifier: NCT03639350. Registered 21st August 2018—retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00786-3.

Differences in treatment response to a total diet replacement intervention versus a food-based intervention: A secondary analysis of the OPTIWIN trial

OBJECTIVE

For every weight loss treatment, there are usually groups of people who lose less than expected. This study sought to determine if response rates to a total diet replacement (TDR) differed from those of a calorie-restricted, food-based (FB) diet.

METHODS

Data from OPTIWIN, a 12-month multicenter trial in adults with a BMI of 30-55 kg/m2, with 26-week weight-loss and weight-maintenance phases, were utilized. Participants (n = 330) were randomized to the OPTIFAST programme (OP) or to a reduced-energy FB diet. Treatment non-responders were defined as those who lost <3% of initial weight at months 6 or 12.

RESULTS

There were 103 (76%) responders in the OP compared with 78 (57%) in the FB group at 12 months. The odds of treatment response at 12 months among participants who were non-responders at 3 months was not significantly different between the OP and FB groups (p = 0.64). Race, type 2 diabetes status and previous weight loss attempts were significantly associated with responder status. OP responders had higher meal plan adherence and non-caloric fluid intake compared with FB responders.

CONCLUSION

Early treatment response is more likely and better sustained with TDR compared with an FB diet. Individual and treatment level factors appear to influence early treatment response to behavioural interventions for weight reduction.

Greater Attendance at a Community Weight Loss Programme over the First 12 Weeks Predicts Weight Loss at 2 Years

BACKGROUND

There is considerable heterogeneity in long-term weight loss among people referred to obesity treatment programmes. It is unclear whether attendance at face-to-face sessions in the early weeks of the programme is an independent predictor of long-term success.

OBJECTIVE

To investigate whether frequency of attendance at a community weight loss programme over the first 12 weeks is associated with long-term weight change.

METHODS

Participants were randomised to receive brief support only (control, n = 211), or a weight loss programme for 12 weeks (n = 530) or 52 weeks (n = 528). This study included participants with data on session attendance over the first 12 weeks (n = 889) compared to the control group. The association between attendance (continuously) and weight loss was explored using a linear model. A multi-level mixed-effects linear model was used to investigate whether attendance (categorised as 0, 1, 2-5, 6-9, and 10-12 sessions) was associated with weight loss at 3, 12, and 24 months compared to the control.

RESULTS

For every session attended in the first 12 weeks, the average weight loss was -0.259 kg/session at 24 months (p = 0.005). Analysis by attendance group found only those attending 10-12 sessions had significantly greater weight loss (-7.5 kg [95% CI -8.1 to -6.9] at 12 months; -4.7 kg [95% CI -5.3 to -4.1] at 24 months) compared to the control group (-3.4 [95% CI -4.5 to -2.4] at 12 months, -2.5 [95% CI -3.5 to -1.5] at 24 months). Early attendance was higher for people ≥70 years, but there was no evidence of a difference by gender, ethnicity, education, or income.

CONCLUSIONS

Greater attendance at a community weight loss programme in the first 12 weeks is associated with enhanced weight loss up to 24 months. Regular attendance at a programme could be used as a criterion for continued provision of weight loss services to maximise the cost-effectiveness of interventions.

Depressive symptom severity as a predictor of attendance in the HOME behavioral weight loss trial

OBJECTIVE

We examined whether total depressive symptoms and symptom clusters predicted behavioral weight loss attendance among economically disadvantaged adults in a randomized controlled trial.

METHODS

150 adults with obesity were randomized to 12 months of in-person, video conference, or enhanced usual care weight loss groups. We categorized percent session attendance in the intervention arms into three levels: no attendance, poorer attendance, and better attendance.

RESULTS

Higher baseline Patient Health Questionnaire-8 (PHQ-8) score was associated with a greater odds of being in the poorer versus better attendance group (OR = 1.94, 95% CI: 1.02-3.69, p = .04). A similar relationship between PHQ-8 score and odds of being in the no attendance versus better attendance group was observed but was not statistically significant (OR = 1.63, 95% CI: 0.94-2.81, p = .08). Both cognitive/affective and somatic clusters contributed to the depressive symptoms-attendance relationships.

CONCLUSION

Greater depressive symptoms at the start of a behavioral weight loss program may predict poorer subsequent session attendance. Screening for and addressing depression may improve intervention uptake. ClinicalTrials.gov Identifier: NCT02057952.

Identifying psychological predictors of adherence to a community-based lifestyle modification program for weight loss among Chinese overweight and obese adults

BACKGROUND/OBJECTIVES

Existing evidence on lifestyle modification programs for weight loss is limited by the high attrition rate of such programs. Identifying predictors of adherence to a lifestyle modification program could result in program improvement. However, little is known about behavior-specific adherence and its psychological predictors. This study aimed to examine the psychological predictors of adherence after one-month participation in a community-based lifestyle modification program among Chinese overweight and obese adults in Hong Kong.

SUBJECTS/METHODS

A total of 205 Chinese overweight and obese adults aged 38.9 ± 10.5 years completed the study. Data were collected at baseline and after one month using self-reported questionnaires, which assessed knowledge (self-developed scale), motivation (Treatment Self-Regulation Questionnaire), stage of change (Stage of Exercise Scale) and self-efficacy (Self-Rated Abilities for Health Practices Scale). At one month, a 4-day dietary recall and the International Physical Activity Questionnaire-Short Form were used to assess dietary and physical activity (PA) adherence. Food and PA diaries were examined to indicate self-monitoring. Program attendance was tracked between baseline and one-month follow-up.

RESULTS

After one month, participants reported high dietary adherence, attendance, and adherence to self-monitoring but low PA adherence. Multiple regression analyses suggested that diet self-efficacy (baseline) and nutrition knowledge (one-month change) were independent predictors of dietary adherence score at one month, whereas autonomous PA motivation (baseline) and PA self-efficacy (both baseline and one-month change) were independent predictors of PA adherence score at one month. No significant psychological predictor was identified for attendance or self-monitoring.

CONCLUSIONS

The results suggest that the effect of psychological factors on adherence differs between diet and PA adherence outcomes. To promote adherence, practitioners should assess self-efficacy, knowledge, and motivation at the beginning of a weight-loss program and explore behavior-specific strategies to improve knowledge and self-efficacy. The results of this study have direct implications for program improvements.

Determinants of weight loss maintenance: a systematic review

BACKGROUND

Discerning the determinants of weight loss maintenance is important in the planning of future interventions and policies regarding overweight and obesity. We have therefore systematically synthesized recent literature on determinants of weight loss maintenance for individuals with overweight and obesity.

METHODS

With the use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, prospective studies were identified from searches in PubMed and PsycINFO from 2006 to 2016. We included articles investigating adults with overweight and obesity undergoing weight loss without surgery or medication. Included articles were scored on their methodological quality, and a best-evidence synthesis was applied to summarize the results.

RESULTS

Our search resulted in 8,222 articles of which 67 articles were selected. In total, 124 determinants were identified of which 5 were demographic, 59 were behavioural, 51 were psychological/cognitive and 9 were social and physical environmental determinants. We found consistent evidence that demographic determinants were not predictive of weight loss maintenance. Behavioural and cognitive determinants that promote a reduction in energy intake, an increase in energy expenditure and monitoring of this balance are predictive determinants.

CONCLUSION

This review identifies key determinants in weight loss maintenance. However, more research regarding cognitive and environmental determinants of weight loss maintenance is needed to advance our knowledge on determinants of weight loss maintenance.

An Overview of Factors Associated with Adherence to Lifestyle Modification Programs for Weight Management in Adults

This review aims to provide an overview of the factors associated with adherence reported in existing literature on lifestyle modification programs for weight management among the adult population. An electronic search was performed using PubMed, Medline, PsycINFO and PsycARTICLE to identify studies that examined the factors of adherence to lifestyle modification programs with explicit definition of adherence indicators. We identified 19 studies published between 2004 and 2016. The most commonly used indicator of adherence was attrition, followed by attendance, self-monitoring and dietary adherence. A broad array of factors has been studied but only few studies exploring each factor. Limited evidence suggested older age, higher education, healthier eating and physical activity behaviours, higher stage of change at baseline and higher initial weight loss may predict better adherence. On the other hand, having depression, stress, strong body shape concern, more previous weight loss attempts and being unemployed may predict poor adherence. Inconsistent findings were obtained for self-efficacy, motivation and male gender. This review highlights the need for more rigorous studies to enhance our knowledge on factors related to adherence. Identification of the factors of adherence could provide important implication for program improvement, ultimately improving the effectiveness and the cost-effectiveness of lifestyle modification program.

Strategies for Sustained Weight Management: Perspectives From African American Patients With Type 2 Diabetes

Purpose The purpose of this study was to identify effective strategies for sustained weight management used by African American patients with obesity and type 2 diabetes. Methods In this study, nominal group technique was used to identify effective strategies for weight management used by 12 African Americans with overweight/obesity and type 2 diabetes who successfully lost or maintained their weight after completing DECIDE (Decision-making Education for Choices In Diabetes Everyday), a 9-module, literacy-adapted diabetes and cardiovascular disease (CVD) education and problem-solving training program. Results Participants generated a list of 101 strategies that covered 4 domains: nutrition, physical activity, cognitive-behavioral strategies, and other. Self-monitoring and relying on social support were the top 2 strategies for weight maintenance. Conclusion Future obesity studies should consider including friends/family as well as electronic tools to facilitate self-monitoring and regular practice of behavioral strategies for long-term success.

Do individual, online motivational interviewing chat sessions enhance weight loss in a group-based, online weight control program?

OBJECTIVE

To examine whether the addition of online motivational interviewing (MI) chats to a Web-based, group behavioral obesity treatment program augments weight loss outcomes relative to the Web-based weight control program alone.

METHODS

Healthy individuals (N = 398, 24% minority) with overweight/obesity were randomized to a 36-session group Internet behavioral weight control treatment (BT) or the same group Internet treatment plus six individual MI chat sessions (BT + MI). Both conditions received weekly synchronous online chat group sessions for 6 months followed by 12 monthly group chats. Participants in both groups received identical behavioral lessons and individualized therapist feedback on progress toward meeting exercise and calorie goals. BT + MI also received six individual MI sessions delivered by a separate MI counselor via Web chat. Weight loss was measured at 6 and 18 months.

RESULTS

There were no significant differences in weight loss between BT (-5.5 ± 6.0 kg) and BT + MI (-5.1 ± 6.3 kg) at 6 months or at 18 months (-3.3 ± 7.1 kg vs. -3.5 ± 7.7 kg for BT and BT + MI, respectively). Attendance at group chats did not differ between groups, nor did self-monitoring patterns, suggesting comparable engagement in the weight control program in both conditions.

CONCLUSIONS

Online MI chat sessions were not a viable strategy to enhance Web-based weight control treatment outcomes.

Nutrition Interventions for Obesity

Obesity is a common disorder with complex causes. The epidemic has spurred significant advances in the understanding of nutritional approaches to treating obesity. Although the primary challenge is to introduce a dietary intake that creates an energy deficit, clinicians should also consider targeted risk factor modification with manipulation of the nutrient profile of the weight-reducing diet. These strategies produce significant weight loss and improvements in cardiometabolic risk factors. Future research is needed to better understand how to personalize nutrient prescriptions further to promote optimal risk modification and maintenance of long-term energy balance in the weight-reduced state.

Weight loss intervention adherence and factors promoting adherence: a meta-analysis

BACKGROUND

Adhering to weight loss interventions is difficult for many people. The majority of those who are overweight or obese and attempt to lose weight are simply not successful. The objectives of this study were 1) to quantify overall adherence rates for various weight loss interventions and 2) to provide pooled estimates for factors associated with improved adherence to weight loss interventions.

METHODS

We performed a systematic literature review and meta-analysis of all studies published between January 2004 and August 2015 that reviewed weight loss intervention adherence.

RESULTS

After applying inclusion and exclusion criteria and checking the methodological quality, 27 studies were included in the meta-analysis. The overall adherence rate was 60.5% (95% confidence interval [CI] 53.6-67.2). The following three main variables were found to impact adherence: 1) supervised attendance programs had higher adherence rates than those with no supervision (rate ratio [RR] 1.65; 95% CI 1.54-1.77); 2) interventions that offered social support had higher adherence than those without social support (RR 1.29; 95% CI 1.24-1.34); and 3) dietary intervention alone had higher adherence than exercise programs alone (RR 1.27; 95% CI 1.19-1.35).

CONCLUSION

A substantial proportion of people do not adhere to weight loss interventions. Programs supervising attendance, offering social support, and focusing on dietary modification have better adherence than interventions not supervising attendance, not offering social support, and focusing exclusively on exercise.

Impact of food supplementation on weight loss in randomised-controlled dietary intervention trials: a systematic review and meta-analysis

Dietary trials provide evidence for practice and policy guidelines, but poor adherence may confound results. Food supplementation may improve adherence to dietary interventions, but the impact of supplementation on study outcomes is not known. The aim of this review was to examine the impact of food supplementation on weight loss in dietary intervention trials. The databases Scopus, PubMed and the Cochrane Library were searched for dietary intervention trials published between January 2004 and March 2015 using the following keyword combinations: ‘trial’ OR ‘intervention’, ‘food’ OR ‘diet’, ‘weight loss’ and ‘adherence’ OR ‘adherence’. Studies were included if food was provided to at least one study group and both ‘weight change’ and ‘adherence’ were reported. Random effects meta-analyses were conducted to assess weighted mean differences (WMD) in body weight (change or final mean values). The included studies formed two groups: trials involving an intervention group supplemented with a food and a control without food supplementation (food v. no food), and trials in which food was provided to all subjects (food v. food) (PROSPERO registration: CRD42015017563). In total, sixteen studies were included. Significant weight reduction was reported in the food v. no food studies (WMD −0·74 kg; 95 % CI −1·40, −0·08; P=0·03, I2=63 %). A non-significant increase in weight was found among the food v. food studies (WMD 0·84 kg; 95 % CI −0·60, 2·27; P=0·25, I2=0 %). Food supplementation appeared to result in greater weight loss in dietary trials. Energy restrictions and intensity of interventions were other significant factors influencing weight loss.

Longitudinal Weight Loss Patterns and their Behavioral and Demographic Associations

BACKGROUND

Identification of weight change patterns may allow tailored interventions to improve long-term weight loss.

PURPOSE

To identify patterns of weight change over 18 months, and assess participant characteristics and intervention adherence factors associated with weight change patterns in a sample of 359 overweight/obese adults.

METHODS

Weight loss (0-6 months) was achieved with reduced energy intake and increased physical activity (PA). Maintenance (7-18 months) provided adequate energy to maintain weight and continued PA.

RESULTS

Latent profile analysis identified three weight change profiles. During weight loss/maintenance, participants in profiles 2 and 3 (18-month weight loss ∼14 %) attended more behavioral sessions and performed more PA compared with profile 1 (18-month weight loss <1 %). Self-efficacy for both weight management and exercise barriers were higher in profiles 2 and 3 compared with profile 1 following weight loss and during maintenance.

CONCLUSION

Weight change patterns can be identified and are associated with both participant characteristics and intervention adherence.

The SELF trial: A self-efficacy-based behavioral intervention trial for weight loss maintenance

OBJECTIVE

The SELF Trial examined the effect of adding individual self-efficacy (SE) enhancement sessions to standard behavioral weight loss treatment (SBT).

METHODS

Participants were randomly assigned to SBT or SBT plus SE sessions (SBT+SE). Outcome measures were weight loss maintenance, quality of life, intervention adherence, and self-efficacy at 12 and 18 months.

RESULTS

The sample (N = 130) was female (83.08%) with a mean (SD) body mass index of 33.15 (4.11) kg m(2) . There was a significant time effect for percent weight change (P = 0.002) yet no significant group or group-by-time effects. The weight loss for the SBT+SE group was 8.38% (7.48) at 12 months and 8.00% (7.87) at 18 months, with no significant difference between the two time points (P = 0.06). However, weight loss for the SBT group was 6.95% (6.67) at 12 months and 5.96% (7.35) at 18 months, which was significantly different between the two time points (P = 0.005), indicating that the SBT group had significant weight regain.

CONCLUSIONS

Both groups achieved clinically significant weight loss. The group receiving an intervention targeting enhanced self-efficacy had greater weight loss maintenance whereas the SBT group demonstrated significant weight regain possibly related to the greater attention provided to the SBT+SE group.

Predictors of initial weight loss among women with abdominal obesity: a path model using self-efficacy and health-promoting behaviour

AIM

To identify predictors of initial weight loss among women with abdominal obesity by using a path model.

BACKGROUND

Successful weight loss in the initial stages of long-term weight management may promote weight loss maintenance.

DESIGN

A longitudinal study design.

METHODS

Study participants were 75 women with abdominal obesity, who were enrolled in a 12-month Community-based Heart and Weight Management Trial and followed until a 6-month assessment. The Weight Efficacy Lifestyle, Exercise Self-Efficacy and Health Promoting Lifestyle Profile-II measured diet self-efficacy, exercise self-efficacy and health-promoting behaviour respectively. All endogenous and exogenous variables used in our path model were change variables from baseline to 6 months. Data were collected between May 2011-May 2012.

FINDINGS

Based on the path model, increases in both diet and exercise self-efficacy had significant effects on increases in health-promoting behaviour. Increases in diet self-efficacy had a significant indirect effect on initial weight loss via increases in health-promoting behaviour. Increases in health-promoting behaviour had a significant effect on initial weight loss.

CONCLUSION

Among women with abdominal obesity, increased diet self-efficacy and health-promoting behaviour were predictors of initial weight loss. A mechanism by which increased diet self-efficacy predicts initial weight loss may be partially attributable to health-promoting behavioural change. However, more work is still needed to verify causality. Based on the current findings, intensive nursing strategies for increasing self-efficacy for weight control and health-promoting behaviour may be essential components for better weight loss in the initial stage of a weight management intervention.

Effect of a 12-week weight management program on the clinical characteristics and dietary intake of the young obese and the contributing factors to the successful weight loss

BACKGROUND/OBJECTIVES

The objectives were to investigate the effect of a 12-wk intervention with behavioral modification on clinical characteristics and dietary intakes of young and otherwise healthy obese and to identify factors for successful weight loss. The goal was to lose 0.5 kg per week by reducing 300-500 kcal/day and by increasing physical activities.

SUBJECTS AND METHODS

Forty four obese subjects (BMI > 25) and 19 normal weight subjects (BMI 18.5-23) finished the 12-week intervention. Obese subjects participated in 5 group educations and 6 individual counseling sessions. Normal weight subjects attended 6 individual counseling sessions for evaluations of dietary intake and exercise pattern. Anthropometric and clinical characteristics and 3-day dietary records were evaluated at baseline and week12.

RESULTS

Weight and serum triglyceride and free fatty acid concentrations in obese group decreased significantly with intervention. Intakes of energy, fat, and cholesterol decreased significantly in the obese. Active participation, realistic weight loss goal setting, and weight gain after high school graduation not during childhood were identified as key factors for successful weight loss.

CONCLUSIONS

The 12-week intervention with behavioral modification resulted in reduced energy and fat intakes and led to significant weight loss and improvements of clinical characteristics in the obese. The finding that those who became obese during childhood lost less weight indicates the importance of 'early' intervention.

A randomized trial comparing weight loss treatment delivered in large versus small groups

Background

Behavioral interventions for obesity are commonly delivered in groups, although the effect of group size on weight loss has not been empirically evaluated. This behavioral weight loss trial compared the 6- and 12-month weight changes associated with interventions delivered in a large group (LG) or small groups (SG).

Methods

Obese adults (N = 66; mean age = 50 years; mean BMI = 36.5 kg/m²; 47% African American; 86% women) recruited from a health maintenance organization were randomly assigned to: 1) LG treatment (30 members/group), or 2) SG treatment (12 members/group). Conditions were comparable in frequency and duration of treatment, which included 24 weekly group sessions (months 1–6) followed by six monthly extended care contacts (months 7–12). A mixed effects model with unstructured covariance matrix was applied to analyze the primary outcome of weight change while accounting for baseline weight and dependence among participants’ measurements over time.

Results

SG participants lost significantly more weight than LG participants at Month 6 (−6.5 vs. -3.2 kg; p = 0.03) and Month 12 (−7.0 vs. -1.7 kg; p < 0.002). SG participants reported better treatment engagement and self-monitoring adherence at Months 6 and 12, ps < 0.04, with adherence fully mediating the relationship between group size and weight loss.

Conclusions

Receiving obesity treatment in smaller groups may promote greater weight loss and weight loss maintenance. This effect may be due to improved adherence facilitated by SG interactions. These novel findings suggest that the perceived efficiency of delivering behavioral weight loss treatment to LGs should be balanced against the potentially better outcomes achieved by a SG approach.

The long-term effects of lifestyle change on blood pressure: One-year follow-up of the ENCORE study

BACKGROUND

There is a paucity of data describing the sustained benefits of lifestyle interventions on health behaviors and blood pressure (BP).

METHODS

We examined the persistence of changes in health habits and BP in the ENCORE study, a trial in which 144 overweight individuals with above-normal BP were randomized to one of the following 16-week interventions: Dietary Approaches to Stop Hypertension (DASH) diet alone (DASH-A), DASH diet plus a behavioral weight management intervention (DASH-WM), or Usual Care. Follow-up assessments were conducted 8 months after the end of treatment.

RESULTS

At 16 weeks, systolic BP was reduced by 16.1 (95% confidence interval (CI) = 13.0-19.2) mm Hg in the DASH-WM group, 11.2 (95% CI = 8.1-14.3) mm Hg in the DASH-A group, and 3.4 (95% CI = 0.4-6.4) mm Hg in the Usual Care group. A decrease in BP persisted for 8 months, with systolic BP lower than baseline by 11.7 (95% CI = 8.1-15.3) mm Hg in the DASH-WM group, 9.5 (95% CI = 6.7-12.1) mm Hg in the DASH-A group, and 3.9 (95% CI = 0.5-7.3) mm Hg in the Usual Care group (P < 0.001 for active treatments vs. Usual Care). DASH-WM subjects lost 8.7 kg during the intervention and remained 6.3 kg lighter on follow-up examination. Changes in diet content were sustained in both DASH intervention groups. Among those who participated in DASH-WM, however, caloric intake was no longer lower, and only 21% reported still exercising regularly 8 months after completing the intervention.

CONCLUSIONS

Changes in dietary habits, weight, and BP persisted for 8 months after completion of the 16-week ENCORE program, with some attenuation of the benefits. Additional research is needed to identify effective methods to promote long-term maintenance of the benefits of lifestyle modification programs.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT00571844.

Examining behavioral processes through which lifestyle interventions promote weight loss: results from PREMIER

OBJECTIVE

To examine the behavioral processes through which lifestyle interventions impacted weight loss.

METHODS

The analyses were limited to overweight and obese Black and White adults randomized to a PREMIER lifestyle intervention (N = 501). Structural equation modeling was conducted to test the direct and indirect relationships of session attendance, days of self-monitoring diet and exercise, change in diet composition and exercise, and 6-month weight change.

RESULTS

Greater session attendance was associated with increased self-monitoring, which was in turn significantly related to reduction in percent energy from total fat consumed. Change in percent energy from fat and self-monitoring was associated with 6-month percent change in weight. Both a decrease in fat intake and increase in self-monitoring are potential mediators of the relationship between attendance and weight change.

CONCLUSIONS

The findings provide a reasonable model that suggests regular session attendance and use of behavioral strategies like self-monitoring are associated with improved behavioral outcomes that are associated with weight loss.

Examining social influence on participation and outcomes among a network of behavioral weight-loss intervention enrollees

Research suggests that social networks, social support, and social influence are associated with weight trajectories among treatment- and non-treatment-seeking individuals. This study examined the impact of having a social contact who participated in the same group behavioral weight-control intervention in the absence of specific social support training on women engaged in a weight-loss program. Participants (n = 92; 100% female; 54% black; mean age: 46 ± 10 years; mean BMI: 38 ± 6) were grouped based upon whether or not they reported a social contact enrolled previously/concurrently in our behavioral weight-control studies. Primary outcomes were 6-month weight change and treatment adherence (session attendance and self-monitoring). Half of the participants (53%) indicated that they had a social contact; black women were more likely to report a social contact than white women (67.3% versus 39.5%; P < 0.01). Among participants with a social contact, 67% reported at least one contact as instrumental in the decision to enroll in the program. Those with a contact lost more weight (5.9 versus 3.7 kg; P = 0.04), attended more group sessions (74% versus 54%; P < 0.01), and submitted more self-monitoring journals (69% versus 54%; P = 0.01) than those without a contact. Participants' weight change was inversely associated with social contacts' weight change (P = 0.04). There was no association between participant and contact's group attendance or self-monitoring. Social networks may be a promising vehicle for recruiting and engaging women in a behavioral weight-loss program, particularly black women. The role of a natural social contact deserves further investigation.

Surgery for Severe Obesity

Bariatric surgery has been demonstrated to be an effective treatment for patients with severe obesity, producing improvements in many comorbid conditions, including type 2 diabetes, hypertension, obstructive sleep apnea, and dyslipidemia. The loss of body weight and resolution of comorbidities have been more recently found to be the result of functional and metabolic changes produced by the surgical procedures. Nonetheless, bariatric surgery is still considered to be a tool that is supported by health behaviors characteristic of all weight loss programs—that is, adoption of healthy eating patterns, engagement in robust physical activity, and implementation of constructive coping strategies. In addition, patients who undergo bariatric surgery face challenges that are particular to this population, including adjustment to rapid and significant reduction in body weight, forced alterations in eating behavior, and risk of alcohol misuse. This state-of-the-art review focuses on the research and resultant recommendations regarding lifestyle management for patients who have undergone bariatric surgery.

Short- and long-term eating habit modification predicts weight change in overweight, postmenopausal women: results from the WOMAN study

BACKGROUND

Standard behavioral obesity treatment produces poor long-term results. Focusing on healthy eating behaviors rather than energy intake may be an alternative strategy. In addition, important behaviors might differ for short- vs long-term weight control.

OBJECTIVE

Our aim was to describe and compare associations between changes in eating behaviors and weight after 6 and 48 months.

DESIGN

We performed secondary analysis of data collected during a randomized weight-loss intervention trial with 48-month follow-up.

PARTICIPANTS

We studied 481 overweight and obese postmenopausal women enrolled in the Women on the Move through Activity and Nutrition (WOMAN) Study.

MAIN OUTCOME MEASURES

We measured changes in weight from baseline to 6 and 48 months.

STATISTICAL ANALYSES PERFORMED

Linear regression models were used to examine the associations between 6- and 48-month changes in eating habits assessed by the Conner Diet Habit Survey and changes in weight. Analyses were conducted in the combined study population and stratified by randomization group.

RESULTS

At 6 months in the combined population, weight loss was independently associated with decreased desserts (P<0.001), restaurant eating (P=0.042), sugar-sweetened beverages (P=0.009), and fried foods (P<0.001), and increased fish consumption (P=0.003). Results were similar in intervention participants; only reduced desserts and fried foods associated with weight loss in controls. At 48 months in the combined population, weight loss was again associated with decreased desserts (P=0.003) and sugar-sweetened beverages (P=0.011), but also decreased meats/cheeses (P=0.024) and increased fruits/vegetables (P<0.001). Decreased meats/cheeses predicted weight loss in intervention participants; desserts, sugar-sweetened beverages, and fruits/vegetables were independently associated in controls.

CONCLUSIONS

Changes in eating behaviors were associated with weight change, although important behaviors differed for short- and long-term weight change and by randomization group. Future studies should determine whether interventions targeting these behaviors could improve long-term obesity treatment outcomes.