A behavioral taxonomy of obese female participants in a weight-loss program

A taxonomy of impacts on clinical and translational research from community stakeholder engagement

Background

Community engagement is increasingly recognized as a valuable tool in clinical and translational research; however, the impact of engagement is not fully understood. No standard nomenclature yet exists to clearly define how research changes when community stakeholders are engaged across the research spectrum. This severely limits our ability to assess the value of community engagement in research. To address this gap, we developed a taxonomy for characterizing and classifying changes in research due to community engagement.

Methods

Using an iterative process, we (a) identified areas of potential impact associated with community engagement from author experience, (b) categorized these in taxonomic bins based on research stages, (c) conducted semi‐structured interviews with researchers and community stakeholders, (d) validated the codebook in a sample dataset and (e) refined the taxonomy based on the validation. Community stakeholders were involved in every step of the process including as members of the primary study team.

Results

The final taxonomy catalogues changes into eleven domains corresponding to research phases. Each domain includes 2‐4 dimensions depicting concepts within the domain's scope and, within each dimension, 2‐10 elements labelling activities through which community engagement could change research.

Conclusions

Community engagement has great potential to enhance clinical and translational research. This taxonomy provides a common vocabulary and framework for understanding the impact of community engagement and suggests metrics for assessing the value of community engagement in research.

Predictors of emotional eating during adolescents' transition to college: does body mass index moderate the association between stress and emotional eating?

OBJECTIVE

This study sought to (1) examine perceived stress and resources to cope with stress as predictors of emotional eating during the transition to college and (2) determine whether body mass index (BMI) moderated the emotional eating-stress relationship.

PARTICIPANTS

Participants were 97 college freshmen (73% female; BMI: M = 25.3 kg/m(2), SD = 5.7 kg/m(2)). Research was conducted in September 2012.

METHODS

Participants completed the Perceived Stress Scale, Emotional Eating Scale, and Eating and Appraisal Due to Emotions and Stress Questionnaire during the first month of college. Height and weight were measured objectively.

RESULTS

BMI moderated the relationship between perceived stress and emotional eating. Higher stress predicted greater emotional eating for the lower BMI groups, but not the highest group. Greater resources to cope with stress predicted lower emotional eating.

CONCLUSIONS

Greater perceived stress and poorer resources to cope with stress may contribute to emotional eating during the transition to college. The relationship between perceived stress and emotional eating may vary by BMI.

The assessment of eating behaviour in children who are obese: a psychological approach. A position paper from the European childhood obesity group

OBJECTIVE

This paper introduces health professionals to the different psychological models thought to influence eating behaviour in the absence of hunger in children who are obese and to propose a method of assessing these behaviours in practice.

METHODS

Clinical researchers from the European Childhood Obesity Group (ECOG) adopted an evidence-based approach to examine the literature concerning the assessment of eating behaviour in children who are obese. Studies published in English were filtered out of the medical and psychological literature from 1960 to the present, and the resulting bibliography was searched for relevant articles. Key themes from the current evidence were compiled and classified according to the underpinning psychological models. Based on the current evidence and the authors' combined clinical experience, a three-staged approach to assessment was agreed by consensus.

RESULTS

Valid and reliable tools for assessing and monitoring each of the three identified models (Dietary Restraint Theory, Emotional Eating and the Diathesis-Stress Model) are suggested for use in clinical practice, and the ECOG three-staged approach to assessing eating behaviours in the absence of hunger is described.

CONCLUSIONS

This paper presents practical guidance on how to assess eating behaviour in the absence of hunger in children who are clinically obese and suggests a focus for future research.

Differences in Eating Style between Overweight and Normal-Weight Youngsters

Differences in eating styles between overweight and normal-weight youngsters were investigated with a child version of the Dutch Eating Behavior Questionnaire (DEBQ). Subjects were children ( n = 1458; M: 10.1; SD = 1.3) and adolescents ( n = 1016; M: 14.9; SD =1.5). Overweight adolescent girls scored high on emotional eating while overweight adolescent boys displayed more external eating. In overweight children, already 10.5 per cent displayed emotional eating and 38.4 per cent reported external eating. All overweight youngsters reported restrained attitudes. Eating styles were positively associated with indicators of eating pathology. The results suggest the use of appropriate norms that take into account the child's age, gender and overweight status.

Psychological profile to become and to stay obese

OBJECTIVE

The presentation will successively deal with the psychological models to explain for the onset or maintenance of child obesity.

DESIGN

Five psychological perspectives on childhood obesity are selected. The boundary model of Herman and Polivy (1980) was brought forward as an explanation model for understanding the overeating behaviour in obese people. Others describe obese children as over-responsive to external cues and this over-responsiveness is seen as a personality trait. Learning theories put forward how (dysfunctional) learning mechanisms can explain also why obese people eat in front of food cues, without feeling hungry. Finally, obesity can be seen as an expression of a family pathology or an emotional problem.

CONCLUSIONS

Psychological explanation models are still subject of discussion. Personality variables, eating behaviour, restraint attitudes, psychopathlogy and emotional factors, learning mechanisms as well as the role of the family are to be considered in an assessment process. It may help to better empathize with both parent and child. Furthermore, it can help to tailor the treatment program to the individual needs of an obese child. Further research is needed to find out whether already during the intake psychological indicators can be found that are predictors of negative therapy outcome.

Self-reported eating behaviors of extremely obese persons seeking bariatric surgery: a factor analytic approach

OBJECTIVE

To summarize the self-reported eating behaviors of persons seeking bariatric surgery and to provide reliability data for a clinical instrument that assesses those eating behaviors.

RESEARCH METHODS AND PROCEDURES

Adults (552) with extreme obesity (mean +/- standard deviation BMI = 52.4 +/- 10.1 kg/m(2)) completed the Weight and Lifestyle Inventory (WALI) before undergoing bariatric surgery. The WALI is a self-report instrument that includes 24 items that assess the eating behaviors to which respondents attribute their excess weight. These items were entered into a principal components analysis with promax rotation. Relationships of factor scores to demographic and psychosocial variables were examined. Test-retest reliability data were obtained from a smaller sample (n = 58) of less obese participants (BMI = 34.4 +/- 4.0 kg/m(2)) who completed the WALI twice within 2 weeks, before beginning a non-surgical weight loss program.

RESULTS

The principal components analysis yielded five factors with acceptable internal consistency and test-retest reliability. These included: eating in response to negative affect, eating in response to positive affect and social cues, general overeating and impaired appetite regulation, overeating at early meals, and snacking. Each factor was related to symptoms of binge eating disorder, and every factor except the second one was associated with depressive symptoms. Factor scores were unrelated or weakly associated with demographic characteristics.

DISCUSSION

The eating behaviors of persons seeking bariatric surgery can be assessed reliably and parsimoniously with the WALI. The predictive utility of the factors obtained in this study remains to be examined.

Effects of academic examination stress on eating behavior and blood lipid levels

The influence of academic examination stress on eating behavior and lipid profiles and the moderating effect of dietary restraint, trait anxiety, and social support availability was assessed in university students. One hundred and seventy-nine students were divided into exam-stress groups (51 women, 64 men) and control groups (48 women, 16 men) and were assessed at baseline and then within 2 weeks of exams or an equivalent point for the control group. Perceived stress, emotional well-being, and fasting lipid profiles were measured, and dietary information was collected by interview. The exam-stress group reported significant increases in perceived stress and deterioration in emotional well-being at the exam sessions compared with baseline sessions. No general effects of exam stress on food intake were observed, and there was no interaction between stress and dietary restraint. However, students in the exam-stress group with high trait anxiety and low social support showed significant increases in total energy intake between baseline and exam sessions, whereas individuals with low trait anxiety and high social support showed a reduction in energy intake. Students with high trait anxiety and low social support showed increases between baseline and exam sessions in the amount of fat and saturated fat consumed. Women in the exam-stress group taking oral contraceptives showed a significant increase in total cholesterol between baseline and exam sessions. The results are discussed in relation to the effects of naturally occurring episodic stress on health behavior and on lipid profiles.

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.

An Ecological Momentary Assessment of Relapse Crises in Dieting

Much of the research on relapse crises in dieting has focused on isolated lapse events and relied heavily on retrospective self-report data. The present study sought to overcome these limitations by using ecological momentary assessment (EMA) techniques to examine situations of dietary temptation and lapse with a sample of obese, formerly sedentary, postmenopausal women (N = 37) during the final week of a weight-loss intervention. Mood was associated with reports of dietary lapse. Abstinence-violation effects were more strongly associated with dietary lapses than temptations. Finally, coping responses distinguished dietary temptations from lapses. Education on the factors associated with relapse crises in dieting may be imperative for weight loss success and maintenance.

Weight loss readiness in middle-aged women: psychosocial predictors of success for behavioral weight reduction

Accurate prediction of weight loss success and failure has eluded researchers for many years. Thus, we administered a comprehensive psychometric battery before a 4-month lifestyle behavioral weight reduction program and analyzed weight changes during that period to identify baseline characteristics of successful and unsuccessful participants, among 112 overweight and obese middle-aged women (age, 47.8 +/- 4.4 years; BMI, 31.4 +/- 3.9 kg/m2). Mean weight and percentage fat losses among the 89 completers were -5.4 kg and -3.4%, respectively (p < .001). A higher number of recent dieting attempts and recent weight loss, more stringent weight outcome evaluations, a higher perceived negative impact of weight on quality of life, lower self-motivation, higher body size dissatisfaction, and lower self-esteem were associated with less weight loss and significantly distinguished responders from nonresponders among all participants. These findings are discussed as to their usefulness (i) to screen individuals before treatment, (ii) to provide a better match between interventions to participants, and (iii) to build a weight loss readiness questionnaire.

Measurement of attitudes toward obese people among a Canadian sample of men and women

A new scale for examining attitudes toward obese people had 44 items selected from previously published scales designed to indicate attitudes toward obese people. Reliability analysis yielded a Cronbach coefficient alpha of .92 for the total sample. A factor analysis yielded four factors. Employing the Body Mass Index as an indicator of obesity, the attitudes of 239 men and women were examined. Women were significantly more positive than men in their attitude toward obese people. When examining Body Mass Index as a factor, comparisons of obese and nonobese women indicated obese women were more positive on the Diet and Exercise factor of the scale. Suggestions for improvement and research are offered.

Impact of moods and social context on eating behavior

The relationship of moods and social context to energy and nutrient intakes was examined to ascertain if these variables interact or function independently. The subjects were 78 predominantly white, obese women participating in weight-loss studies. Mean age was 36.7 (SD=7.6) and mean Body Mass Index was 32.1 (SD=3.6). Subjects completed 2-week baseline food diaries recording everything they ate, including moods and people present during the meals. Meals eaten in positive and negative moods were significantly larger than meals eaten in a neutral mood. Meals eaten with other people were significantly larger than meals eaten alone. There were no significant moods by social context interactions for total energy intake. Moods and social context functioned additively to increase the risk of over-eating. Macro nutrient analysis revealed only a main effect for social context. Percentage of calories from fat and protein were greater, whereas the percentage of carbohydrate was less in social context meals compared to meals eaten alone. Clinicians should conduct a functional analysis to assess exposure to the frequency and types of risky situations. Teaching people to cope more effectively with social situations and moods may increase the efficacy of weight loss and maintenance programs.

Caloric intake patterns of nonpurge binge-eating women

Daily caloric intake of nonpurge binge-eating women was monitored over 28 days using food diaries to determine how caloric intake patterns were related to binge eating. The majority of participants had extreme fluctuations in daily caloric intake. Caloric intake for both nonbinge days and days preceding the highest-calorie binge days was significantly lower than caloric intake on binge days and highest-calorie binge days. The lower caloric intake was not low enough to cause physiological deprivation. Although there was not physiological deprivation of calories, the individual may have felt that she ate less than desired, which may have contributed to subsequent binge eating.

Weight control self-efficacy types and transitions affect weight-loss outcomes in obese women

Matching obesity treatments to heterogeneous clients is a recent evolution in the development of more effective weight-control programs, yet most interventions emphasize the external features of treatments rather than the internal belief structures of individuals. The purpose of this study was to determine whether Q methodology would identify distinct types of weight-control self-efficacy beliefs in obese women that would be linked to outcomes of a weight-loss program. Fifty-four women (45 +/- 9 yrs, Mean +/- SD) 136 +/- 10% over ideal body weight participated in a 9-month nutritional/behavioral weight loss program. Two major self-efficacy categories emerged through factor analysis of Q sorts: assureds and disbelievers. The assureds (n = 28) had the strongest self-efficacy beliefs and at baseline reported significantly (p < .01) greater self-esteem and less depression than the disbelievers (n = 26). By posttreatment, the assureds had lost significantly more weight (10 +/- 6 vs. 7 +/- 7 kg). Regrouping the data for analysis by posttreatment self-efficacy types demonstrated transitions in the self-efficacy beliefs of the women during treatment. Those who were disbelievers at baseline but became assureds posttreatment (n = 7) lost twice as much weight as the women who started and finished as disbelievers (n = 19) (10 +/- 7 kg vs. 5 +/- 5 kg). The posttreatment assureds (n = 32) lost significantly more weight than the disbelievers (n = 22) (10 +/- 6 vs. 6 +/- 5 kg), and reported better self esteem, mood, and eating patterns. Thus, assessment of intrinsic belief systems, particularly weight-control self-efficacy, may provide new directions for designing interventions that target distinctly different needs of obese women to affect greater weight loss and more positive affective states.

Situational obstacles to dietary adherence for adults with diabetes

OBJECTIVE

To develop a taxonomy of everyday situations that create obstacles for adherence to dietary management in patients with diabetes.

SUBJECTS

Twenty-six adults with diabetes (12 with insulin-dependent diabetes mellitus and 14 with non-insulin-dependent diabetes mellitus) were recruited from an outpatient diabetes clinic.

MAIN OUTCOME MEASURES

Subjects were interviewed to identify problem situations that create obstacles for dietary adherence. The resulting 69 situations were judged for the presence or absence of 32 environmental features using a reliable coding system.

STATISTICAL ANALYSIS

A hierarchical cluster analysis was used to identify homogeneous groups of dietary adherence obstacles.

RESULTS

Twelve types of problem situations were identified: negative emotions, resisting temptation, eating out, feeling deprived, time pressure, tempted to relapse, planning, competing priorities, social events, family support, food refusal, and friends' support.

CONCLUSIONS

The resulting taxonomy provides an outline for the detailed assessment of obstacles to dietary adherence. An individual's ability to cope with this array of obstacles to dietary adherence should be assessed so treatment can be individualized.

Situational obstacles to adherence for adolescents with diabetes

Twenty adolescents with insulin-dependent diabetes mellitus were interviewed to obtain samples of problem situations that create obstacles to dietary adherence. The resulting 57 situations were analyzed using a reliable coding system to determine the presence or absence of 28 stimulus features. A hierarchical cluster analysis was used to identify 10 relatively homogeneous categories of obstacles to dietary adherence: being tempted to stop trying; negative emotional eating; facing forbidden foods; peer interpersonal conflict; competing priorities; eating at school; social events and holidays; food cravings; snacking when home, alone, or bored; and social pressure to eat. Diabetes educators should consider an individual's ability to cope with this array of obstacles to adherence when individualizing treatment. Dietary intervention then can be personalized to address specific situational obstacles.

Toward an empirically derived typology of obese persons: derivation in a nonclinical sample

The purpose of this research was to empirically derive a typology of obese persons and validate a typology derived in earlier research (Allison & Heshka [1991] International Journal of Obesity). Biological, behavioral, and psychological variables were assessed through survey among 719 (641 females, 78 males) obese members of The National Association to Advance Fat Acceptance (NAAFA). All variables were subjected to principal components analyses which extracted 12 biological and 12 psychological components. A two-cluster solution from a k-means clustering on biological components was replicated via Ward's method. Agreement between the solutions was significant (Phi = .33, Kappa = .19, p < .05). The solution was validated through entering psychological component scores into discriminant analysis. One significant function (p < .001) substantially separated the clusters. A component measuring early onset/familial history powerfully discriminated between the clusters. Early onset obese were more obese, more active, and restricted caloric intake to a greater degree. Late onset obese were more likely to be "settled down," engage in substance abuse, eat at night, and have diabetes (p < .05). Results were substantially consistent with those of prior research.

Binge eating in the obese

This review will first describe problems in the definition of the term binge eating, especially in the absence of purging (vomiting, laxative abuse). We highlight current approaches in the classification of obesity, and then provide an overview of the available literature on differences between obese binge eaters and obese non-binge eaters. Many studies indicate that binge eating is common among the female obese, with a frequency ranging from 23 to 46% among those seeking treatment for weight reduction. Despite differences in the definitions of binge eating and variability among the samples investigated, there is strong evidence that binge eaters represent a distinct subgroup among the obese. Binge eating obese exhibit significantly more eating and weight-related pathology, as well as more psychopathology compared to their non-binge eating obese counterparts.