Outcomes of a traditional weight control program and a nondiet alternative: a one-year comparison

Integrating person-centred care and social justice: a model for practice with larger-bodied patients

Person-centred care (PCC) has been touted as a promising paradigm for improving patients' experiences and outcomes, and the overall therapeutic environment for a range of health conditions, including obesity. While this approach represents an important shift away from a paternalistic and disease-focused paradigm, we argue that PCC must be explicitly informed by a social justice lens to achieve optimal conditions for health and well-being. We suggest that existing studies on PCC for obesity only go so far in achieving social justice goals as they operate within a biomedical model that by default pathologises excess weight and predetermines patients' goals as weight loss and/or management, regardless of patients' embodied experiences and desires. There remains a dearth of empirical research on what social justice-informed PCC looks like in practice with larger patients. This interview study fills a research gap by exploring the perspectives of 1) health practitioners (n=22) who take a critical, social justice-informed approach to weight and 2) larger patients (n=20) served by such practitioners. The research question that informed this paper was: What are the characteristics of social justice-informed PCC that play out in clinical interactions between healthcare practitioners and larger-bodied patients? We identified five themes, namely: 1) Integrating evidence-based practice with compassionate, narrative-based care; 2) Adopting a curious attitude about the patient's world; 3) Centring patients' own wisdom and expertise about their conditions; 4) Working within the constraints of the system to advocate for patients to receive equitable care; 5) Collaborating across professions and with community services to address the multifaceted nature of patient health. The findings illustrate that despite participants' diverse perspectives around weight and health, they shared a commitment to PCC by upholding patient self-determination and addressing weight stigma alongside other systemic factors that affect patient health outcomes.

Cross-cultural validity of the Intuitive Eating Scale-2: Psychometric evaluation in the Greek-Cypriot population

BACKGROUND: Intuitive eating is defined by eating response to physiological hunger and satiety cues rather than situational or emotional cues and it has been linked to psychological well-being. The 23-item Intuitive Eating Scale-2 (IES-2) is commonly used to assess the concept of intuitive eating. OBJECTIVE: To develop the Greek version of the IES-2 questionnaire and to test its psychometric qualities. METHODS: Forward and backward translations into Greek and English were completed. Exploratory Factor Analysis (EFA) was applied to understand the underlying factor structure of the IES-2, whilst internal consistency was assessed by Cronbach’s alpha test. The concurrent validity was assessed by evaluating the correlation among the IES-2 and the Eating Attitudes Test-26 Item (EAT-26) questionnaire. RESULTS: A total of 379 adults (mean age = 34 years) participated. EFA gave a three-factor structure with the total variance explained being 54.4% . Cronbach’s alpha was 0.87 for the IES-2 total score, as well as 0.90, 0.84 and 0.70 for the IES-2 subscales. The revised IES-2 total score was significantly correlated with EAT-26 total score (rs = –0.46, p <  0.01) and BMI (rs = –0.46, p <  0.01). CONCLUSION: In this sample, the Greek version of the IES-2 showed good psychometric qualities and can be regarded a helpful tool for examining adult intuitive eating behaviours.

Intuitive eating, objective weight status and physical indicators of health

INTRODUCTION

Intuitive eating (IE) has emerged as a weight-neutral approach to health promotion for those with overweight/obesity. This weight-neutral paradigm has some support, although research thus far has often neglected to control for potential confounds (i.e. objective weight status and demographics) and foundational studies are lacking. The objective of the current study was to observe the unique association of IE with physical health indicators in a sample of adults, independent of objective weight status.

METHODS

Participants were 248 adults (32 ± 14 years old, 73% female, 64% White) of all weight categories (18.2-55.3 kg m-2), with an average body mass index (BMI) of 30 ± 8 kg m-2. IE was measured with the Intuitive Eating Scale-2 (IES-2). BMI was objectively measured in-lab. Health indicators included blood pressure (BP) and fasting glucose.

RESULTS

A series of hierarchical linear regressions revealed no significant associations between IE and systolic BP (β = -0.076, P = 0.256), diastolic BP (DBP; β = -0.122, P = 0.073) or fasting glucose (β = 0.047, P = 0.500) after controlling for BMI. All effects sizes were small or below (f 2 = 0.00 to -0.04). Sensitivity analyses revealed significantly lower DBP in high intuitive eaters versus low when analysed with a t-test, t(111.651) = 3.602, P < 0.001, Levene corrected; however, after controlling for relevant covariates (i.e. BMI and demographics), analysis of covariance revealed no difference in DBP between groups, F(1, 116) = 0.330, P = 0.567. No significant differences in systolic BP or fasting glucose were observed between low and high intuitive eaters before or after considering covariates.

CONCLUSIONS

In sum, this study investigated associations between IE and common indicators of physical health after controlling for objective weight status. Findings revealed no unique relationship between IE and physical health, and any IE-physical health relationships that were observed were accounted for BMI and/or demographic factors.

Effects of weight-neutral approaches compared with traditional weight-loss approaches on behavioral, physical, and psychological health outcomes: a systematic review and meta-analysis

Context

Weight-neutral approaches for health are emerging therapeutic alternatives to traditional weight-loss approaches. The existing literature base comparing these approaches has not yet been systematically evaluated by a meta-analysis.

Objective

This review aims to determine if weight-neutral approaches are valid alternatives to weight-loss approaches for improving physical, psychological, and behavioral health outcomes.

Data Sources

Embase, Scopus, PsycINFO, PubMed, CINAHL, and the University of Queensland Library databases were searched.

Study Selection

Peer-reviewed, experimental, or quasi-experimental studies that included weight-neutral and weight-loss arms and reported physical, psychological, or behavioral outcomes were eligible. A total of 525 studies were identified through initial database searches, with 10 included in the final analysis after exclusion criteria were applied.

Data Extraction

Screening and eligibility assessment of studies followed the PRISMA protocol. The following outcomes were extracted: weight, body mass index, lipid and glucose variables, blood pressure, eating behavior, self-esteem, depression, quality of life, physical activity, and diet quality.

Data Analysis

Studies were graded per the National Health and Medical Research Council (NHMRC) level-of-evidence tool and the Academy of Nutrition and Dietetics quality-evaluation tool. Effect sizes were examined as a meta-analysis of standardized and mean differences using a random-effects inverse-variance model with 95%CIs. Practice recommendations for each outcome were graded per NHMRC body-of-evidence guidelines.

Conclusions

Weight-neutral approaches resulted in greater improvement in bulimia (P = 0.02), but no significant differences were observed for any other outcome. Weight-neutral approaches may be as effective as weight-loss methods for improving physical, psychological, and behavioral outcomes. Limitations include inconsistent definitions of both approaches and variable time frames of follow-up.

Eating-Related and Psychological Outcomes of Health at Every Size Intervention in Health and Social Services Centers Across the Province of Québec

Purpose:

To report the outcomes of a Health at Every Size (HAES) intervention in a real-world setting.

Design:

Quasi-experimental design evaluating eating behaviors and psychological factors.

Setting:

The HAES intervention is offered in Health and Social Services Centers in Québec (Canada).

Participants:

For this study, 216 women (body mass index [BMI]: 35.76 [6.80] kg/m2) who participated to the HAES intervention were compared to 110 women (BMI: 34.56 [7.30] kg/m2) from a comparison group.

Intervention:

The HAES intervention is composed of 14 weekly meetings provided by health professionals. It focuses on healthy lifestyle, self-acceptance, and intuitive eating.

Measures:

Eating behaviors (ie, flexible restraint, rigid restraint, disinhibition, susceptibility to hunger, intuitive eating, and obsessive-compulsive eating) and psychological correlates (ie, body esteem, self-esteem, and depression) were assessed using validated questionnaires at baseline, postintervention, and 1-year follow-up.

Analysis:

Group, time, and interaction effects analyzed with mixed models.

Results:

Significant group by time interactions were found for flexible restraint ( P = .0400), disinhibition ( P < .0001), susceptibility to hunger ( P < .0001), intuitive eating ( P < .0001), obsessive–compulsive eating ( P < .0001), body-esteem ( P < .0001), depression ( P = .0057), and self-esteem ( P < .0001), where women in the HAES group showed greater improvements than women in the comparison group at short and/or long term.

Conclusion:

The evaluation of this HAES intervention in a real-life context showed its effectiveness in improving eating-, weight-, and psychological-related variables among women struggling with weight and body image.

Validation of an instrument to measure registered dietitians'/nutritionists' knowledge, attitudes and practices of an intuitive eating approach

OBJECTIVE

The purpose of the present study was to develop and assess the construct validity of a tool to measure knowledge, attitudes and practices of registered dietitians/nutritionists (RD/N) regarding an intuitive eating lifestyle.

DESIGN

Cross-sectional study design that utilized a survey administered to a random sample and remaining full population of RD/N.

SETTING

A national survey conducted via online survey software.

SUBJECTS

A random sample of 10 % of all RD/N in the USA (n 8834) was invited to participate. Survey completion rate was 22·2 % (n 1897). After initial validation, the survey was distributed to the remaining 90 % of RD/N to confirm validation.

RESULTS

After removing items with insufficient factor loadings, results were consistent with a four-factor solution: (i) knowledge of intuitive eating; (ii) attitudes towards intuitive eating; (iii) traditional and restrictive practices; and (iv) non-restrictive and intuitive eating practices. Confirmatory factor analysis provided further evidence of the validity of the four factors and the factors had strong reliability.

CONCLUSIONS

Unlike the hypothesized three-factor solution (knowledge, attitudes and practices), validation analysis revealed that the survey measures knowledge of intuitive eating, attitudes towards intuitive eating, use of traditional and restrictive weight-management practices, and use of non-restrictive and intuitive eating practices. With the landscape of weight management and health promotion undergoing a shift towards a health centred, size acceptance approach, this instrument will provide valuable information regarding the current knowledge, attitudes and practices of RD/N and other health promotion professionals.

Weight acceptance versus body dissatisfaction: Effects on stigma, perceived self-esteem, and perceived psychopathology

OBJECTIVE

It is unknown whether weight acceptance or body dissatisfaction impact anti-fat stigma. Therefore, this study utilized a 2×2 between-subject experimental design to examine of the relationship between body acceptance and stigmatization.

METHOD

Participants were university undergraduates (N=394, 70% women, mean age=20.8 years, mean BMI=23.61 kg/m(2)) who were randomly assigned to read vignettes describing an obese or normal-weight target described as either accepting or not accepting of her weight. Participants completed measures of stigma (the Fat Phobia Scale (FPS), the modified Anti-fat Attitudes Scale (AFA)), perceived self-esteem (assessed with the modified Rosenberg Self-Esteem Scale (RSE)), and perceived psychopathology.

RESULTS

Analyses revealed significant main effects for acceptance. Notably, targets who accepted their weight were less stigmatized on the FPS (F(1, 354)=66.82, p<.001) and the AFA willpower subscale (F(1, 373)=37.90, p<.001), and they were perceived as having better self esteem (F(1, 371)=166.16, p<.001) and fewer psychological problems (F(1, 381)=123.19, p<.001) than those who did not accept their weight.

CONCLUSION

Results from this study suggest that size acceptance, even when practiced by obese targets, was significantly less stigmatized than body dissatisfaction and associated with better perceived self esteem and mental health.

Impact of non-diet approaches on attitudes, behaviors, and health outcomes: a systematic review

OBJECTIVE

To determine the overall effect of non-diet, weight-neutral interventions on factors such as weight, biochemical measures, food and activity behavior, body image, and mental health.

DESIGN

Systematic review of intervention literature.

SETTING

Group classes in community and worksite settings (14 studies), and individual counseling (1) and online education (1) in college settings.

PARTICIPANTS

Eighteen research articles (representing 16 studies) evaluating non-diet interventions using quasi-experimental and randomized study designs with either a comparison or control group.

MAIN OUTCOME MEASURES

Anthropometric, physiological, psychological, and dietary intake.

ANALYSIS

Systematic search of 168 articles and review of 18 articles meeting inclusionary criteria.

RESULTS

Non-diet interventions resulted in statistically significant improvements in disordered eating patterns, self-esteem, and depression. None of the interventions resulted in significant weight gain or worsening of blood pressure, blood glucose, or cholesterol, and in 2 studies biochemical measures improved significantly compared with the control or diet group. Primary limitations were inconsistent definitions of non-diet approaches and the use of different assessment instruments for measuring outcomes.

CONCLUSIONS AND IMPLICATIONS

Because of the long-term ineffectiveness of weight-focused interventions, the psychological improvements seen in weight-neutral, non-diet interventions warrant further investigation.

Psychological benefits of weight loss following behavioural and/or dietary weight loss interventions. A systematic research review

It is generally accepted that weight loss has significant physiological benefits, such as reduced risk of diabetes, lowered blood pressure and blood lipid levels. However, few behavioural and dietary interventions have investigated psychological benefit as the primary outcome. Hence, systematic review methodology was adopted to evaluate the psychological outcomes of weight loss following participation in a behavioural and/or dietary weight loss intervention in overweight/obese populations. 36 Studies were selected for inclusion and were reviewed. Changes in self-esteem, depressive symptoms, body image and health related quality of life (HRQoL) were evaluated and discussed. Where possible, effect sizes to indicate the magnitude of change pre- to post- intervention were calculated using Hedges' g standardised mean difference. The results demonstrated consistent improvements in psychological outcomes concurrent with and sometimes without weight loss. Improvements in body image and HRQoL (especially vitality) were closely related to changes in weight. Calculated effect sizes varied considerably and reflected the heterogeneous nature of the studies included in the review. Although the quality of the studies reviewed was generally acceptable, only 9 out of 36 studies included a suitable control/comparison group and the content, duration of intervention and measures used to assess psychological outcomes varied considerably. Further research is required to improve the quality of studies assessing the benefits of weight loss to fully elucidate the relationship between weight loss and psychological outcomes.

Weight science: evaluating the evidence for a paradigm shift

Current guidelines recommend that "overweight" and "obese" individuals lose weight through engaging in lifestyle modification involving diet, exercise and other behavior change. This approach reliably induces short term weight loss, but the majority of individuals are unable to maintain weight loss over the long term and do not achieve the putative benefits of improved morbidity and mortality. Concern has arisen that this weight focus is not only ineffective at producing thinner, healthier bodies, but may also have unintended consequences, contributing to food and body preoccupation, repeated cycles of weight loss and regain, distraction from other personal health goals and wider health determinants, reduced self-esteem, eating disorders, other health decrement, and weight stigmatization and discrimination. This concern has drawn increased attention to the ethical implications of recommending treatment that may be ineffective or damaging. A growing trans-disciplinary movement called Health at Every Size (HAES) challenges the value of promoting weight loss and dieting behavior and argues for a shift in focus to weight-neutral outcomes. Randomized controlled clinical trials indicate that a HAES approach is associated with statistically and clinically relevant improvements in physiological measures (e.g., blood pressure, blood lipids), health behaviors (e.g., eating and activity habits, dietary quality), and psychosocial outcomes (such as self-esteem and body image), and that HAES achieves these health outcomes more successfully than weight loss treatment and without the contraindications associated with a weight focus. This paper evaluates the evidence and rationale that justifies shifting the health care paradigm from a conventional weight focus to HAES.

Promising Practices for the Prevention and Control of Obesity in the Worksite

Purpose.

To identify worksite practices that show promise for promoting employee weight loss.

Data Source.

The following electronic databases were searched from January 1, 1966, through December 31, 2005: CARL Uncover (via Ingenta), CDP, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Library, CRISP, Dissertation Abstracts, EMBASE, ERIC, Health Canada, INFORM (part of ABI/INFORM Proquest), LocatorPlus, New York Academy of Medicine, Ovid MEDLINE, SPORTDiscus, PapersFirst, PsycINFO, PubMed, and TRIP.

Study Inclusion and Exclusion Criteria.

Included studies were published in English, conducted at a worksite, designed for adults (aged ≥18 years), and reported weight-related outcomes.

Data Extraction.

Data were extracted using an online abstraction form.

Data Synthesis.

Studies were evaluated on the basis of study design suitability quality of execution, sample size, and effect size. Changes in weight-related outcomes were used to assess effectiveness.

Results.

The following six promising practices were identified: enhanced access to opportunities for physical activity combined with health education, exercise prescriptions alone, multicomponent educational practices, weight loss competitions and incentives, behavioral practices with incentives, and behavioral practices without incentives.

Conclusions.

These practices will help employers and employees select programs that show promise for controlling and preventing obesity. (Am J Health Promot 2011;25[3]:e12–e26.)

Psychological Impact of a "Health-at-Every-Size" Intervention on Weight-Preoccupied Overweight/Obese Women

The aim of the present study was to assess the impact of a "Health-at-every-size" (HAES) intervention on psychological variables and body weight the weight-preoccupied overweight/obese women. Those women were randomized into three groups (1) HAES, (2) social support (SS), (3) waiting-list (WL), and were tested at baseline, post-treatment and six-month and one-year follow-ups. All participants presented significant psychological improvement no matter if they received the HAES intervention or not. However, even if during the intervention, the three groups showed improvements, during the follow up, the HAES group continued to improve while the other groups did not, even sometimes experiencing some deterioration. Furthermore, in the HAES group only, participant's weight maintenance 12 months after the intervention was related to their psychological improvement (quality of life, body dissatisfaction, and binge eating) during the intervention. Thus, even if, in the short-term, our study did not show distinctive effects of the HAES intervention compared to SS and WL on all variables, in the long-term, HAES group seemed to present a different trajectory as psychological variables and body weight are maintained or continue to improve, which was not the case in other groups. These differential long-term effects still need to be documented and further empirically demonstrated.

The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review

This report presents the results of a systematic review of the effectiveness of worksite nutrition and physical activity programs to promote healthy weight among employees. These results form the basis for the recommendation by the Task Force on Community Preventive Services on the use of these interventions. Weight-related outcomes, including weight in pounds or kilograms, BMI, and percentage body fat were used to assess effectiveness of these programs. This review found that worksite nutrition and physical activity programs achieve modest improvements in employee weight status at the 6-12-month follow-up. A pooled effect estimate of -2.8 pounds (95% CI=-4.6, -1.0) was found based on nine RCTs, and a decrease in BMI of -0.5 (95% CI=-0.8, -0.2) was found based on six RCTs. The findings appear to be applicable to both male and female employees, across a range of worksite settings. Most of the studies combined informational and behavioral strategies to influence diet and physical activity; fewer studies modified the work environment (e.g., cafeteria, exercise facilities) to promote healthy choices. Information about other effects, barriers to implementation, cost and cost effectiveness of interventions, and research gaps are also presented in this article. The findings of this systematic review can help inform decisions of employers, planners, researchers, and other public health decision makers.

Evaluation of a community-based weight control program

Overweight and obesity result from a complex interaction of behavioral, environmental, and genetic factors. The present study reports on the efficacy of a community-based weight control program in 31 overweight and obese adults. TrymGym is a multi-dimensional lifestyle behavior change program for improving both diet and physical activity (PA) related behavior with education and cognitive behavioral training. The program was evaluated using nutritional, physiological, and physical activity-related psychological factors before and after the 12 week program. Paired sample t-tests were conducted to identify significant changes. Body weight (BW) and diastolic blood pressure decreased by 3.6 and 6.4% respectively in completers of the study. Waist and hip circumferences decreased by 4.1 and 5.7% respectively. Caloric intake decreased from 1994+/-146 at baseline to 1768+/-144 in completers of the study. There was also a significant 5.2% decrease in the percentage of calories derived from fat and a 4% increase in percent of calories from protein. Although intake of vitamin C was increased at the end of the study, intake of several other micronutrients at baseline did not meet Dietary Reference Intake recommendations and were further compromised at week 12. Despite a trend toward increased participation in leisure-time and strenuous PA there was a decrease in behavioral intention to participate in future PA. Overall, this community-based weight control program was effective in fostering a significant improvement in BW, anthropometric measurements, participation in PA, and nutritional intake.

Short-term effects of a "health-at-every-size" approach on eating behaviors and appetite ratings

OBJECTIVE

To assess the effects of a "Health-At-Every-Size" (HAES) intervention on eating behaviors and appetite ratings in 144 premenopausal overweight women.

RESEARCH METHODS AND PROCEDURES

Women were randomly assigned to one of the 3 groups: HAES group, social support (SS) group, and control group (N = 48 in each group). Interventions were conducted over a 4-month period, and measurements were taken before and after this period. Eating behaviors (cognitive dietary restraint, disinhibition, and susceptibility to hunger) were evaluated by the Three-Factor Eating Questionnaire. Appetite ratings (desire to eat, hunger, fullness, and prospective food consumption) were assessed by visual analogue scales before and after a standardized breakfast.

RESULTS

More important decreases in susceptibility to hunger and external hunger were observed in the HAES group when compared with the SS group (p=0.05, for susceptibility to hunger) and the control group (p=0.02 and p=0.005, for susceptibility to hunger and external hunger, respectively). In addition, women from the HAES group had more important decreases in postprandial area under the curve for desire to eat (p=0.02) and hunger (p=0.04) when compared with the control group. The change in the desire to eat noted in the HAES group was also different from the one observed in SS group (p=0.02). Women from the HAES group experienced significant weight loss at 4 months (-1.6+/-2.5 kg, p<0.0001), which did not differ significantly from the SS and control groups (p=0.09). An increase in flexible restraint was significantly related to a greater weight loss in both HAES and SS groups (r=-0.39, p<0.01; and r=-0.37, p<0.05, respectively). A decrease in habitual susceptibility to disinhibition was also associated with a greater weight loss in HAES and control groups (r=0.31, p<0.05; and r=0.44, p<0.05, respectively).

DISCUSSION

These results suggest that a HAES intervention could have significant effects on eating behaviors and appetite ratings in premenopausal overweight women, when compared with an SS intervention or a control group.

Weight loss treatment and psychological well-being: a review and meta-analysis

Research suggests that weight loss treatment generally benefits psychological well-being but these effects have never been quantitatively reviewed. A meta-analysis of 117 weight loss treatment tests showed that weight loss treatment was associated with lowered depression and increased self-esteem. Treatment type moderated treatment effects on depression and self-esteem. Actual weight loss moderated treatment effects on self-esteem but not depression; only treatments that produced actual weight loss predicted increased self-esteem whereas improvements in depression were independent of weight loss. The clinical implications of the findings and the possible causal relationships among weight, depression and self-esteem are discussed.

Flavor-nutrient learning in restrained and unrestrained eaters

After we consume a novel food an association can form between its sensory characteristics (e.g., taste properties) and the effect it has on the body (rewarding). Associations of this kind underpin much of our everyday dietary behavior because they mediate both the affective quality of food (flavor-preference learning) and the amount that we choose to consume (learning satiation). Notwithstanding this fact, very few studies have successfully demonstrated the process of dietary learning in human adults. In addition, based on evidence from related research, we explored whether learning is less likely to occur in individuals who have high scores on a measure of dietary restraint. Female participants (N = 44) consumed two differently flavored desserts. Each was presented three times on separate days. One was formulated with a high-energy content (1882 kJ) and the other with a low-energy content (226 kJ). After training, we found little evidence for learned satiation. However, we did observe flavor-preference learning. Specifically, participants acquired a greater liking and desire-to-eat the dessert flavor that was paired with a higher energy density during training. Further analysis revealed that this effect on liking is qualified by dietary restraint. As predicted, unrestrained eaters demonstrated greater differential responding to the two desserts than did restrained eaters. These data provide further evidence for flavor-nutrient learning in adults and they highlight a hitherto unexplored and potentially important difference between restrained and unrestrained eaters.

Does dietary learning occur outside awareness?

Several forms of dietary learning have been identified in humans. These include flavor-flavor learning, flavor-postingestive learning (including flavor-caffeine learning), and learned satiety. Generally, learning is thought to occur in the absence of contingency (CS-US) or demand awareness. However, a review of the literature suggests that this conclusion may be premature because measures of awareness lack the rigor that is found in studies of other kinds of human learning. If associations do configure outside awareness then this should be regarded as a rare instance of automatic learning. Conversely, if awareness is important, then successful learning may be governed by an individual's beliefs and predilection to attend to stimulus relationships. For researchers of dietary learning this could be critical because it might explain why learning paradigms have a reputation for being unreliable. Since most food preferences are learned, asking questions about awareness can also tell us something fundamental about everyday dietary control.