Personality, attrition and weight loss in treatment seeking women with obesity

Determinants of completion and early dropout in an adult weight management service: a prospective observational study

BACKGROUND

High attrition rates in weight management interventions (WMIs) undermine their effectiveness but are poorly understood. This study aimed to identify determinants of completion and early dropout in National Health Service (NHS) WMIs.

METHODS

In this prospective observational study, 329 patients recruited at initial consultation appointments satisfied the eligibility criteria: age ≥18 years and body mass index (BMI) ≥30 kg/m2 . Multivariate logistic regression analyses were performed to identify the odds ratios (OR, given with 95% confidence interval) of completion and early dropout.

RESULTS

Intervention completion rate was 39.8% (131 of 329). Variables that increased the likelihood of completion included engagement in support sessions, OR10.6 (4.7-23.6, p < 0.001); male sex, OR2.5 (1.4-4.5, p = 0.002); osteoarthritis, OR1.9 (1.1-3.3, p = 0.014); and one or more missed intervention appointments marked as 'could not attend' (notified nonattendance), OR1.8 (1.1-2.9, p = 0.032). Odds of early dropout were higher for participants with anxiety and depression OR2.0 (1.0-4.0, p = 0.039). Dietetic 1:1 participants were less likely to drop out early compared with group programme participants, OR0.3 (0.2-0.7, p = 0.002), but were less likely to complete the full intervention, OR0.5 (0.3-0.9, p = 0.02). Age, BMI, social deprivation and travel distance were among the variables not associated with completion or early dropout.

CONCLUSIONS

This study provides further evidence of the importance of support for participants of WMIs and the need for services to consider how support networks can be incorporated. Patients with poorer mental health may be more likely to drop out early and consequently benefit less from WMIs. Future research should qualitatively explore why these factors contribute to attrition to improve WMI effectiveness.

In Patients with Obesity, Are Affective Temperaments Associated with Attrition? An Evaluation during and before the SARS-CoV-2 Pandemic

Timely data on attrition from weight loss programs for patients with obesity during the SARS-CoV-2 pandemic are lacking, so we aimed to contribute to filling this gap in the literature by comparing attrition during or outside of the SARS-CoV-2 pandemic and its possible association with patients' affective temperaments, psychopathology, and clinical variables. Two-hundred and eleven outpatients with obesity were recruited and completed the Temperament Evaluation of Memphis, Pisa, and San Diego Auto-questionnaire, Binge Eating Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Those who dropped out during the pandemic period were mostly men, with younger age of weight gain, and with a larger waist circumference than completers. Patients with obesity who dropped out outside of the SARS-CoV-2 pandemic showed marked levels of depression, anxiety, binge eating episodes, and higher affective temperaments (but the hyperthymic one) when compared to their counterparts. The cyclothymic temperament slightly increased attrition (OR = 1.13, 95% CI 1.00-1.27 p = 0.05) outside the pandemic, while during the pandemic, male gender (OR = 3.50, 1.04-11.7, p = 0.04) was associated with attrition. These findings suggested that male patients with obesity are at particular risk of drop-out from weight-loss treatment during the SARS-CoV-2 pandemic; contrariwise, outside the pandemic, affective temperaments could be a useful baseline assessment for defining the attrition risk in these patients.

Predictors of attrition from a weight loss program. A study of adult patients with obesity in a community setting

PURPOSE

Obesity unit attrition is frequent and contributes to treatment failure. Many studies evaluating attrition predictors were part of randomized trials, and different terminology and criteria were used in the engagement field. We aimed to investigate the factors potentially implicated in early (< 12 weeks) and late (> 12 weeks) attrition from an obesity unit in a community setting METHODS: This was a retrospective cohort study of 250 patients with obesity who were followed-up at our obesity unit. Our program included at least 6 meetings in 12 months. Sociodemographic and anthropometric data, and psychometric questionnaires were collected from all participants.

RESULTS

One-hundred thirty-four (53.6%) participants dropped out. Those individuals showed lower BMI, lower overall health status, and increased depression scores. In a multiple regression model, BMI (inversely; OR = 0.90; 95%CI 0.84-0.96) and depression score (directly, OR = 1.05; 1.00-1.10) were associated with attrition risk. Early dropouts (n = 47) had lower weights, smaller waist circumferences and worse mental health scores than late dropouts (n = 87) and more frequently lived alone. When compared to completers, early dropouts had lower weights, BMIs, waist circumferences, overall health and mental status scores, increased depression scores and percentage of individuals living alone. In a multiple regression, lower BMI (OR = 0.83; 0.75-0.92), lower mental status score (OR = 3.17; 1.17-8.59) and living alone (OR = 2.25; 1.02-4.97) were associated with early attrition risk.

CONCLUSION

Lower BMI and increased depression score were associated with attrition. Early attrition was associated with lower weight, decreased mental well-being, and living alone. Individuals with these characteristics might need tailored approaches to enhance their engagement.

LEVEL OF EVIDENCE

Level V, retrospective descriptive study.

Lifetime Weight Course as a Phenotypic Marker of Severity and Therapeutic Response in Patients with Eating Disorders

The association between lifetime weight fluctuations and clinical characteristics has been widely studied in populations with eating disorders (ED). However, there is a lack of literature examining the potential role of weight course as a transdiagnostic factor in ED so far. Therefore, the aim of this study is to compare ED severity and treatment outcomes among four specific BMI profiles based on BMI-trajectories across the lifespan: (a) persistent obesity (OB-OB; (n = 74)), (b) obesity in the past but currently in a normal weight range (OB-NW; n = 156), (c) normal weight throughout the lifespan (NW-NW; n = 756), and (d) current obesity but previously at normal weight (NW-OB; n = 314). Lifetime obesity is associated with greater general psychopathology and personality traits such as low persistence and self-directedness, and high reward dependence. Additionally, greater extreme weight changes (NW-OB and OB-NW) were associated with higher psychopathology but not with greater ED severity. Higher dropout rates were found in the OB-OB group. These results shed new light on the BMI trajectory as a transdiagnostic feature playing a pivotal role in the severity and treatment outcome in patients with ED.

Motivational Interviewing Adapted to Group Setting for the Treatment of Relapse in the Behavioral Therapy of Obesity. A Clinical Audit

Motivational interviewing (MI) is devised to change unhealthy behaviors by increasing motivation. We adapted MI to a group format for the treatment of relapse during the behavioral treatment of obesity and performed a clinical audit to evaluate its effectiveness in stopping weight regain. The program was structured in seven weekly sessions, plus a 6-month follow-up. Patients (n = 86) completed a questionnaire on motivation to change in both healthy diet and physical activity, and a self-reported measurement of calorie intake and physical activity at baseline, at program end and at 6-month follow-up. The attendance to the program was high, with only 13 patients (15%) not completing the program and 24% not attending the 6-month follow-up. By the end of follow up, the prevalence of patients in either precontemplation or contemplation was reduced from over 60% at enrollment to approximately 20%, whereas the sum of patients in action or maintenance stages was increased from 9.5% in healthy diet and 14% in physical activity to 39.7% and 41.3%, respectively. These changes translated into significant behavioral changes (mean calorie intake, −13%; total physical activity, +125%; sedentary time, −8%) and finally into reduced body weight ( −3%). We conclude that MI programs adapted for groups may be used to stop relapse in individuals following a behavioral intervention for obesity.

Expected benefits and motivation to weight loss in relation to treatment outcomes in group-based cognitive-behavior therapy of obesity

PURPOSE

We aimed to determine cognitive drivers, expected to play a role in target reach and/or attrition in obesity programs.

METHODS

We recorded the expected benefits of weight loss, weight targets, primary motivation for weight loss, perceived treatment needs, readiness and self-confidence to be successful and a battery of psychopathology questionnaires in 793 subjects with obesity (68% women; mean age 48.7; 46% obesity class III) enrolled into a group-based cognitive-behavioral treatment program. Their relevance on attrition and successful weight loss outcome were tested by logistic regression analysis.

RESULTS

The expected benefits of weight loss scored very high in all physical, psychological and social areas, with differences between genders. Attrition rate was 24, 41 and 65% at 6-, 12-, and 24-month follow-up. Average weight loss was 5.8 ± 7.1 kg (- 4.8%) at 6 months, with 17% of cases (32% of continuers) maintaining weight loss > 10% at 24 months. After adjustment for confounders, attrition was reduced by concern for present health, motivation/consciousness of the importance of physical activity and need for support; treatment discontinuation was favored by concern for body image, by expectations for drug treatment or bariatric surgery, and by high-challenging weight loss targets. Male gender, higher BMI and concern for present health predicted weight loss > 10%, whereas concern for body appearance was associated with lower probability of attaining the desired weight loss targets.

CONCLUSION

A more precise definition of needs and expectations might help tailor treatment to individual patients, but attrition rates and target reach remain difficult to predict.

LEVEL OF EVIDENCE

Level V, descriptive studies.

Are Personality Characteristics as Measured by the Temperament and Character Inventory (TCI) Associated with Obesity Treatment Outcomes? A Systematic Review

PURPOSE OF REVIEW

Some personality traits seem to be associated with obesity, but there is little information available regarding their association with obesity treatment outcomes. The aim of this systematic review was therefore to assess the associations between personality traits-evaluated by means of the Temperament and Character Inventory (TCI)-and outcomes of obesity treatment, including attrition, weight loss, and weight loss maintenance. The PubMed database was searched, and studies were screened as per the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, and data were collated using a narrative approach.

RECENT FINDINGS

Of the 886 articles retrieved, 9 studies assessing personality traits by means of the TCI in participants with obesity met the inclusion criteria and were reviewed. This approach revealed three main findings: (i) only one study found that attrition rate-during a 6-month behavioral weight loss program-is predicted by low reward dependence scores at baseline; (ii) two studies found that lower novelty-seeking and higher self-directedness scores at baseline positively predict short-term weight-loss magnitude; and (iii) four studies found that higher persistence and lower novelty-seeking scores at baseline predicted weight maintenance at 12 and 24 months. Novelty-seeking and self-directedness traits appear to be predictors of short-term weight loss (≤ 6 months), and persistence and novelty-seeking traits may be related to long-term weight loss maintenance (≥ 12 months), although great uncertainty still exists regarding predictors of attrition.

Does self-control modify the impact of interventions to change alcohol, tobacco, and food consumption? A systematic review

Low self-control is associated with increased consumption of alcohol, tobacco, and unhealthy food. This systematic review aimed to assess whether individual differences in self-control modify the effectiveness of interventions to reduce consumption of these products, and hence their potential to reduce consumption amongst those whose consumption is generally greater. Searches of six databases were supplemented with snowball searches and forward citation tracking. Narrative synthesis summarised findings by: consumption behaviour (alcohol, tobacco, food); psychological processes targeted by the intervention (reflective, non-reflective, or both); and study design (experiment, cohort, or cross-sectional). Of 54 eligible studies, 22 reported no evidence of modification, 18 reported interventions to be less effective in those with low self-control, and 14 reported interventions to be more effective in those with low self-control. This pattern did not differ from chance. Whilst self-control often influenced intervention outcomes, there was no consistent pattern of effects, even when stratifying studies by consumption behaviour, intervention type, or study design. There was a notable absence of evidence regarding interventions that restructure physical or economic environments. In summary, a heterogeneous, low-quality evidence base suggests an inconsistent moderating effect of low self-control on the effectiveness of interventions to change consumption behaviours.

Long-term weight loss maintenance for obesity: a multidisciplinary approach

The long-term weight management of obesity remains a very difficult task, associated with a high risk of failure and weight regain. However, many people report that they have successfully managed weight loss maintenance in the long term. Several factors have been associated with better weight loss maintenance in long-term observational and randomized studies. A few pertain to the behavioral area (eg, high levels of physical activity, eating a low-calorie, low-fat diet; frequent self-monitoring of weight), a few to the cognitive component (eg, reduced disinhibition, satisfaction with results achieved, confidence in being able to lose weight without professional help), and a few to personality traits (eg, low novelty seeking) and patient-therapist interaction. Trials based on the most recent protocols of lifestyle modification, with a prolonged extended treatment after the weight loss phase, have also shown promising long-term weight loss results. These data should stimulate the adoption of a lifestyle modification-based approach for the management of obesity, featuring a nonphysician lifestyle counselor (also called "lifestyle trainer" or "healthy lifestyle practitioner") as a pivotal component of the multidisciplinary team. The obesity physicians maintain a primary role in engaging patients, in team coordination and supervision, in managing the complications associated with obesity and, in selected cases, in the decision for drug treatment or bariatric surgery, as possible more intensive, add-on interventions to lifestyle treatment.