Utility and validity of the eating behavior inventory in clinical obesity research: a review of the literature

The past, present, and future of behavioral obesity treatment

Over the last century, hundreds of evaluations have been conducted to examine weight-management interventions related to diet, physical activity, and behavior therapy. These investigations have contributed to a growing body of knowledge that has consistently advanced the field of obesity treatment, while also revealing some persistent challenges. This narrative review summarizes key findings from randomized controlled trials conducted in adults that have combined diet, physical activity, and behavior therapy, an approach variously referred to as behavioral treatment, comprehensive lifestyle modification, or intensive lifestyle intervention. The review shows that current behavioral approaches induce average reductions in baseline body weight of 5 to 10% at 6 to 12 months. Such losses have proven effective in reducing the risk of type 2 diabetes in persons with impaired glucose tolerance and in improving other obesity-related complications. These benefits have also been associated with reductions in healthcare costs. Despite these advances, behavioral treatment is challenged by the need for larger losses to achieve optimal improvements in health, by difficulties associated with maintaining weight loss, and by barriers limiting access to treatment. New anti-obesity medications, when combined with behavioral obesity treatment, hold promise of addressing the first two issues.

Changes in weight control behaviors and hedonic hunger in a commercial weight management program adapted for individuals with type 2 diabetes

BACKGROUND

A WW (formerly Weight Watchers) program adapted for persons with type 2 diabetes mellitus (T2DM) previously was found to be more effective than standard care (SC) intervention for weight loss, improved glycemic control, and weight- and diabetes-related quality of life measures. With data from the same national trial, this study examined whether WW adapted for persons with T2DM also increased engagement in weight control behaviors and decreased hedonic hunger, each of which could contribute to improved diabetes management.

INTERVENTION AND METHODS

Individuals with T2DM (n = 563) and overweight or obesity participated in a 12-month, 16-site, randomized trial of WW with diabetes counseling or SC. Hierarchical linear modeling (HLM) evaluated whether 12-month changes in weight control behaviors (Eating Behavior Inventory; EBI) and hedonic hunger (Power of Food Scale; PFS) differed by treatment condition. If a significant treatment effect was found, 12-month changes in EBI/PFS were regressed on 12-month changes in HbA_1c and percent weight loss to explore potential treatment differences in these associations.

RESULTS

EBI scores increased significantly over the 12-months (p < 0.001), with greater improvements in WW than SC (p < 0.001). PFS decreased significantly in the 12-months (p < 0.001), with no differences between treatment groups (p = 0.15). HLM analyses that followed up on the significant treatment effect for 12-month change in EBI revealed no significant differences by treatment condition for the relationship between change in EBI scores and change in HbA_1c (p = 0.14) or percent weight loss (p = 0.32). Across all participants, 12-month improvements in EBI and PFS were related to improved HbA_1c (r = 0.22; -0.13, respectively) and greater percent weight loss (r = 0.41; -0.18, respectively) (ps < 0.01).

CONCLUSIONS

WW with diabetes counseling produced greater engagement in weight control behaviors in those with T2DM than did SC. Across both groups, improved weight control behaviors and hedonic hunger were related to improved glycemic control and weight loss.

Patients' reasons for weight loss and their relations to clinical weight loss outcomes in a comprehensive lifestyle intervention

OBJECTIVE

Research suggests that individuals seeking weight loss treatment do so for a variety of reasons. Limited work has explored relations of reasons for weight loss to patient characteristics or to weight loss outcomes. The current study examined these relations.

METHODS

The sample consisted of 588 patients in a 15-week fee-for-service weight loss programme. Prior to the intervention, patients completed questionnaires including items on reasons for weight loss, demographic characteristics, and a variety of weight-based characteristics. Patients' weight change outcomes were expressed as percent weight loss and also categorized into one of three previously described weight loss trajectories.

RESULTS

The results of chi-squared and t-test analyses suggested that endorsement of health concerns, mobility concerns, or another person's recommendation was associated with higher body mass index (BMI) and older age. These reasons were more likely to be endorsed by White patients than Black patients and by male patients than female patients. Endorsement of doctor recommendation was more likely to be seen among Black patients than White patients. There was no significant relation of any weight loss reason with weight loss outcome.

CONCLUSIONS

While certain reasons for weight loss were more often cited by certain patient groups, no specific reason predicted a better or worse outcome.

Access to a scale and self-weighing habits among public housing residents

Having access to a scale is essential for individuals to engage in self-weighing; however, few studies examine scale access, particularly among low-income individuals. Our objectives were to (i) determine how many public housing residents have access to a scale and (ii) describe their self-weighing habits. We conducted a cross-sectional survey of public housing residents in Baltimore, MD, from August 2014 to August 2015. Participants answered questions about their access to a scale ('yes'/'no') and daily self-weighing habits ('no scale/never or hardly ever' vs. 'some/about half/much of the time/always'). We used t-tests or chi-square tests to examine the association of scale access with respondent characteristics. Overall, 266 adults participated (48% response rate). Mean age was 45 years with 86% women, 95% black and 54% with obesity. Only 32% had access to a scale; however, 78% of those with this access reported engaging in some self-weighing. Residents who lacked access to a scale were younger (P = 0.03), and more likely to be unemployed/disabled (P = 0.01) or food insecure (P < 0.01). While few public housing residents have access to a scale, those who do report daily self-weighing with some regularity. Financial hardship may influence scale access in this population, as potential proxies of this status were associated with no scale access.

Effect of mindfulness meditation on short-term weight loss and eating behaviors in overweight and obese adults: A randomized controlled trial

Background

There is a significant health crisis with rates of obesity continuing to increase despite research and clinical standard behavioral weight loss programs (SBWP). Mindfulness meditation (MM), with demonstrated benefits on physical, psychological health, and self-regulation behaviors was explored with SBWP.

Methods

Forty-six adults (BMI=32.5±3.7 kg/m2; age=45.2±8.2 years, 87 % female, 21.7 % African American) were randomly assigned to a 6-month SBWP only (n=24) or SBWP+MM (n=22) at a university-based physical activity and weight management research center in a northeastern US city. Participants were instructed to decrease intake (1200–1500 kcal/day), increase physical activity (300 min/wk), and attend weekly SBWP or SBWP+MM sessions. SBWP+MM had the same SBWP lessons with addition of focused MM training. Outcome measures collected at 0, 3, and 6 months included: weight, Block Food Frequency Questionnaire, Eating Behavior Inventory, Eating Inventory and Paffenbarger Physical Activity Questionnaire. Data were analyzed using linear mixed modeling for efficacy analysis of weight (primary) and eating, exercise and mindfulness (secondary outcomes).

Results

Retention rate was 76.1 % (n=35). A significant group by time interaction (p=0.03) was found for weight, with weight loss favoring SBWP+MM (−6.9 kg+2.9) over SBWP (−4.1 kg+2.8). Eating behaviors (p=0.02) and dietary restraint (p=0.02) improved significantly in SBWP+MM, compared to SBWP. MM enhanced weight loss by 2.8 kg potentially through greater improvements in eating behaviors and dietary restraint.

Conclusions

These findings support further study into the use of MM strategies with overweight and obese adults. The use of this low-cost, portable strategy with standard behavioral interventions could improve weight management outcomes.

Effect of Intensity and Program Delivery on the Translation of Diabetes Prevention Program to Worksites: A Randomized Controlled Trial of Fuel Your Life

OBJECTIVE

The aim of this study was to evaluate the effectiveness of the Fuel Your Life program, an adaptation of the Diabetes Prevention Program (DPP), utilizing implementation strategies commonly used in worksite programs-telephone coaching, small group coaching, and self-study.

METHODS

The primary outcomes of body mass index and weight were examined in a randomized control trial conducted with city/county employees.

RESULTS

Although the majority of participants in all three groups lost some weight, the phone group lost significantly more weight (4.9 lb), followed by the small groups (3.4 lb) and the self-study (2.7 lb). Of the total participants, 28.3% of the phone group, 20.6% of the small group, and 15.7% of the self-study group lost 5% or more of their body weight.

CONCLUSIONS

Fuel Your Life (DPP) can be effectively disseminated using different implementation strategies that are tailored to the workplace.

Racial Differences in Weight Loss Mediated by Engagement and Behavior Change

Objective

We set out to determine if a primarily Internet-delivered behavioral weight loss intervention produced differential weight loss in African American and non-Hispanic White women, and to identify possible mediators.

Design

Data for this analysis were from a randomized controlled trial, collected at baseline and 4-months.

Setting

The intervention included monthly face-to-face group sessions and an Internet component that participants were recommended to use at least once weekly.

Participants

We included overweight or obese African American and non-Hispanic White women (n=170), with at least weekly Internet access, who were able to attend group sessions.

Intervention

Monthly face-to-face group sessions were delivered in large or small groups. The Internet component included automated tailored feedback, self-monitoring tools, written lessons, video resources, problem solving, exercise action planning tools, and social support through message boards.

Main Outcome Measure

Multiple linear regression was used to evaluate race group differences in weight change.

Results

Non-Hispanic White women lost more weight than African American women (-5.03% vs.-2.39%, P=.0002). Greater website log-ins and higher change in Eating Behavior Inventory score in non-Hispanic White women partially mediated the race-weight loss relationship.

Conclusions

The weight loss disparity may be addressed through improved website engagement and adoption of weight control behaviors.

Theoretical and Behavioral Mediators of a Weight Loss Intervention for Men

OBJECTIVE

Men are currently underrepresented in weight loss trials despite similar obesity rates, which limit our understanding about the most effective elements of treatment for men. The purpose of this study was to test the theoretical (autonomous motivation, self-efficacy, outcome expectancies, and self-regulation) and behavioral (calorie intake, physical activity, self-weighing) mediators of a men-only, Internet-delivered weight loss intervention focused on innovative and tailored treatment elements specifically for men.

METHOD

Data comes from a 6-month randomized trial (N = 107) testing the intervention compared to a waitlist control group. Changes in the theoretical mediators between baseline and 3 months were tested as mediators of the intervention effect on weight change at 6 months in both single and multiple mediator models. Changes in behaviors between baseline and 6 months were tested in the same manner.

RESULTS

The intervention produced greater weight losses compared to the control group (-5.57 kg ± 6.6 vs. -0.65 kg ± 3.3, p < 0.001) and significant changes (p's < 0.05) in most of the theoretical and behavior mediators. In multiple mediator models, changes in diet-related autonomous motivation, self-efficacy, and self-regulation all significantly mediated the relationship between the intervention and weight loss. The intervention effect was also mediated by changes in dietary intake and self-weighing frequency.

CONCLUSIONS

By testing the theoretical mediators of this intervention in a multiple mediator context, this study contributes to current knowledge related to the development of weight loss interventions for men and suggests that interventions should target diet-focused constructs.

Byte by Bite: Use of a mobile Bite Counter and weekly behavioral challenges to promote weight loss

The goal of this study was to examine the usability and feasibility of the mobile Bite Counter (a watch-like device that detects when a user consumes food or beverage) and the impact of weekly behavioral challenges on diet and physical activity outcomes. Overweight (mean BMI 31.1±4.9 kg/m²) adults (n=12) were recruited to participate in a four-week study to test both the usability and feasibility of using the device as part of a behavioral weight loss intervention. Participants were instructed to self-monitor number of bites/day using the Bite Counter, attend weekly group sessions, and listen to weekly podcasts. Participants were given weekly challenges: use a daily bite limit goal (wk1), turn off Bite Counter when fruits/vegetables are consumed (wk2), self-monitor kilocalories vs. bites (wk3), and receive a 10 bites/day bonus for every 30 minutes of exercise (wk4). Participants lost a mean of -1.2±1.3 kg. Only the wk3 challenge produced significant differences in kcal change (wk3 1302±120 kcal/day vs. baseline 2042±302 kcal/d, P<0.05). Bite Counter use was significantly correlated with weight loss (r= -0.58, P<0.05). Future studies should examine the use of the Bite Counter and impact of behavioral challenges over a longer period of time in a controlled study.

Weighing every day matters: daily weighing improves weight loss and adoption of weight control behaviors

BACKGROUND

Daily weighing is emerging as the recommended self-weighing frequency for weight loss. This is likely because it improves adoption of weight control behaviors.

OBJECTIVE

To examine whether weighing every day is associated with greater adoption of weight control behaviors compared with less frequent weighing.

DESIGN

Longitudinal analysis of a previously conducted 6-month randomized controlled trial.

PARTICIPANTS/SETTING

Overweight men and women in Chapel Hill, NC, participated in the intervention arm (N=47).

INTERVENTION

The intervention focused on daily weighing for weight loss using an e-scale that transmitted weights to a study website, along with weekly e-mailed lessons and tailored feedback on daily weighing adherence and weight loss progress.

MAIN OUTCOME MEASURES

We gathered objective data on self-weighing frequency from the e-scales. At baseline and 6 months, weight change was measured in the clinic and weight control behaviors (total items=37), dietary strategies, and calorie expenditure from physical activity were assessed via questionnaires. Calorie intake was assessed using an online 24-hour recall tool.

STATISTICAL ANALYSES

We used χ(2) tests to examine variation in discrete weight control behaviors and linear regression models to examine differences in weight, dietary strategies, and calorie intake and expenditure by self-weighing frequency.

RESULTS

Fifty-one percent of participants weighed every day (n=24) over 6 months. The average self-weighing frequency among those weighing less than daily (n=23) was 5.4±1.2 days per week. Daily weighers lost significantly more weight compared with those weighing less than daily (mean difference=-6.1 kg; 95% CI -10.2 to -2.1; P=0.004). The total number of weight control behaviors adopted was greater among daily weighers (17.6±7.6 vs 11.2±6.4; P=0.004). There were no differences by self-weighing frequency in dietary strategies, calorie intake, or calorie expenditure.

CONCLUSIONS

Weighing every day led to greater adoption of weight control behaviors and produced greater weight loss compared with weighing most days of the week. This further implicates daily weighing as an effective weight loss tool.

Prospect theory and body mass: characterizing psychological parameters for weight-related risk attitudes and weight-gain aversion

We developed a novel decision-making paradigm that allows us to apply prospect theory in behavioral economics to body mass. 67 healthy young adults completed self-report measures and two decision-making tasks for weight-loss, as well as for monetary rewards. We estimated risk-related preference and loss aversion parameters for each individual, separately for weight-loss and monetary rewards choice data. Risk-seeking tendency for weight-loss was positively correlated with body mass index in individuals who desired to lose body weight, whereas the risk-seeking for momentary rewards was not. Risk-seeking for weight-loss was correlated to excessive body shape preoccupations, while aversion to weight-gain was correlated with self-reports of behavioral involvement for successful weight-loss. We demonstrated that prospect theory can be useful in explaining the decision-making process related to body mass. Applying prospect theory is expected to advance our understanding of decision-making mechanisms in obesity, which might prove helpful for improving healthy choices.

'Fit Moms/Mamás Activas' internet-based weight control program with group support to reduce postpartum weight retention in low-income women: study protocol for a randomized controlled trial

BACKGROUND

High postpartum weight retention is a strong independent risk factor for lifetime obesity, cardiovascular disease, and type 2 diabetes in women. Interventions to promote postpartum weight loss have met with some success but have been limited by high attrition. Internet-based treatment has the potential to overcome this barrier and reduce postpartum weight retention, but no study has evaluated the effects of an internet-based program to prevent high postpartum weight retention in women.

METHODS/DESIGN

Fit Moms/Mamás Activas targets recruitment of 12 Women, Infants and Children (WIC) Supplemental Nutrition Program clinics with a total of 408 adult (>18 years), postpartum (<1 year) women with 14.5 kg or more weight retention or a body mass index of 25.0 kg/m(2) or higher. Clinics are matched on size and randomly assigned within county to either a 12-month standard WIC intervention or to a 12-month WIC enhanced plus internet-based weight loss intervention. The intervention includes: monthly face-to-face group sessions; access to a website with weekly lessons, a web diary, instructional videos, and computer-tailored feedback; four weekly text messages; and brief reinforcement from WIC counselors. Participants are assessed at baseline, six months, and 12 months. The primary outcome is weight loss over six and 12 months; secondary outcomes include diet and physical activity behaviors, and psychosocial measures.

DISCUSSION

Fit Moms/Mamás Activas is the first study to empirically examine the effects of an internet-based treatment program, coupled with monthly group contact at the WIC program, designed to prevent sustained postpartum weight retention in low-income women at high risk for weight gain, obesity, and related comorbidities.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (identifier: NCT01408147 ) on 29 July 2011.

Dietary intake, eating behaviors, and quality of life in women with polycystic ovary syndrome who are trying to conceive

The Healthy Eating for Reproductive Health study was conducted among 18 (45% non-white) mostly obese (BMI 39.9 ± 6.1) women with polycystic ovary syndrome (PCOS) who were experiencing infertility and interested in losing weight. A variety of markers were measured at baseline: body mass index (BMI), diet, physical activity, eating behaviors (using an Eating Behavior Inventory, a questionnaire which assesses both positive and negative eating behaviors associated with weight status, with a higher score indicating adoption of eating behaviors which have been shown in prior weight-loss research to promote a healthy weight (EBI) and the Three-Factor Eating Questionnaire, which assesses cognitive and behavioral components of eating among overweight adults), and a quality of life (PCOS Health-Related Quality of Life (PCOSQ)) index, which assesses satisfaction around five 'domains': emotional health, presence of body hair, infertility, weight, and menstrual problems). A comparison group of overweight women without PCOS (n = 28) was used to examine differences in measured outcomes between women with and without PCOS. Participants' habitual diets were high in fat and saturated fat and low in fiber, folate, and iron and contained significantly lower amounts of carbohydrate, iron, and whole grains compared with women without PCOS who had enrolled in a behavioral weight loss programme. Participants had a low EBI (indicating that most were not adopting eating behaviors associated with achieving a healthy weight), disinhibition (indicating participants had a tendency to overeat in the presence of highly palatable foods or were susceptible to emotional cues for eating, such as stress), and hunger scores (indicating participants did not report being susceptible to hunger, prompting overeating) and moderate dietary restraint (indicating they were not consistently attempting to restrict food intake consciously). PCOSQ scores were lowest for infertility and weight domains (indicating low satisfaction with current infertility and weight status); however all domains received low scores (emotional health, body hair, and menstrual problems). Higher energy intakes (kcal/day) were associated with a lower EBI score (r = - 0.60, P = 0.02), lower dietary restraint (r =- 0.50, P = 0.04), and higher disinhibition (r = 0.63, P = 0.01). Greater energy expenditure (kcal/day) was associated with lower PCOSQ scores for body weight (r =-0.54, P = 002) and infertility (r =- 0.51, P = 0.003) domains. Results suggest that overweight women with PCOS-related infertility have poor dietary intake, particularly in terms of whole grains, fiber, and iron, and eating behaviors inconsistent with achieving a healthy body weight, as well as low scores for PCOS-related quality of life.

Development and validation of the weight control strategies scale

OBJECTIVE

To develop and validate the Weight Control Strategies Scale (WCSS), a self-report instrument to assess the use of specific behaviors thought to facilitate weight loss.

DESIGN AND METHODS

Factor analysis was conducted on 323 overweight and obese adults (mean age = 48.7 ± 10.9 years, mean body mass index = 35.4 ± 4.9 kg/m(2) , 74% female) enrolled in three different behavioral weight loss trials who completed the WCSS prior to starting treatment. To evaluate construct validity, additional data on dietary intake, physical activity, treatment session attendance, and weight change were obtained from a subsample of participants before and after participation in a 48-week weight loss program.

RESULTS

Principal components analysis with varimax rotation revealed a four-component solution for the WCSS, representing the following subscales: Dietary Choices, Self-monitoring Strategies, Physical Activity, and Psychological Coping (α from 0.79 to 0.89). Longitudinal analyses showed that WCSS subscale scores increased during treatment (P < 0.01). In adjusted models, changes in WCSS total and subscale scores were associated with post-treatment weight loss (P < 0.01). Additionally, changes in WCSS Dietary Choices and Physical Activity subscales were related to post-treatment changes in total daily kilocalorie consumption (P = 0.019) and weekly kilocalorie expenditure through physical activity (P < 0.001), respectively.

CONCLUSIONS

Findings support the validity and reliability of the WCSS in a weight loss treatment-seeking sample.

Does the type of weight loss diet affect who participates in a behavioral weight loss intervention? A comparison of participants for a plant-based diet versus a standard diet trial

Studies have found that people following plant-based eating styles, such as vegan or vegetarian diets, often have different demographic characteristics, eating styles, and physical activity (PA) levels than individuals following an omnivorous dietary pattern. There has been no research examining if there are differences in these characteristics among people who are willing to participate in a weight loss intervention using plant-based dietary approaches as compared to a standard reduced calorie approach, which does not exclude food groups. The present study compared baseline characteristics (demographics, dietary intake, eating behaviors (Eating Behavior Inventory), and PA (Paffenbarger Physical Activity Questionnaire)) of participants enrolling in two different 6-month behavioral weight loss studies: the mobile Pounds Off Digitally (mPOD) study, which used a standard reduced calorie dietary approach and the New Dietary Interventions to Enhance the Treatments for weight loss (New DIETs) study, which randomized participants to follow one of five different dietary approaches (vegan, vegetarian, pesco-vegetarian, semi-vegetarian, or omnivorous diets). There were no differences in baseline demographics with the exception of New DIETs participants being older (48.5±8.3years versus 42.9±11.2, P=0.001) and having a higher Body Mass Index (BMI, 35.2±5.3kg/m(2) versus 32.6±4.7kg/m(2), P=0.001) than mPOD participants. In age- and BMI-adjusted models, there were no differences in EBI scores or in any dietary variables, with the exception of vitamin C (85.6±5.9mg/d mPOD versus 63.4±7.4mg/d New DIETs, P=0.02). New DIETs participants reported higher levels of intentional PA/day (180.0±18.1kcal/d) than mPOD participants (108.8±14.4kcal/d, P=0.003), which may have been the result of New DIETs study recommendations to avoid increasing or decreasing PA during the study. The findings of this study demonstrate that using plant-based dietary approaches for weight loss intervention studies does not lead to a population which is significantly different from who enrolls in a standard, behavioral weight loss study using a reduced calorie dietary approach.

Feasibility and effectiveness of an automated bilingual text message intervention for weight loss: pilot study

Background

Little is known about the feasibility and acceptability of tailored text message based weight loss programs for English and Spanish-language speakers.

Objective

This pilot study evaluated the feasibility, acceptability, and estimated impact of a tailored text message based weight loss program for English and Spanish-language speakers. The purpose of this pilot study was to inform the development of a full-scale randomized trial.

Methods

There were 20 overweight or obese participants (mean age 40.10, SD 8.05; 8/20, 40% male; 9/20, 45% Spanish-speakers) that were recruited in San Diego, California, from March to May 2011 and evaluated in a one-group pre/post clinical trial. For 8 weeks, participants received and responded to 3-5 text messages daily sent from a fully automated text messaging system. They also received printed weight loss materials and brief 10-15 minute weekly counseling calls. To estimate the impact of the program, the primary outcome was weight (kg) measured during face-to-face measurement visits by trained research staff. Pre and post differences in weight were analyzed with a one-way repeated measures analysis of variance. Differences by language preference at both time points were analyzed with t tests. Body mass index and weight management behaviors also were examined. Feasibility and acceptability were determined by recruitment success, adherence (ie, percentage of replies to interactive text messages and attrition), and participant satisfaction.

Results

Participants who completed the final assessment (N=18) decreased body weight by 1.85 kg (F_1,17=10.80, P=.004, CI_∆ 0.66-3.03, η²=0.39). At both time points, there were no differences in weight by language preference. Participants responded to 88.04% (986/1120) of interactive text messages, attrition rate was 10% (2/20), and 94% (19/20) of participants reported satisfaction with the program.

Conclusions

This fully automated text message based weight program was feasible with English and Spanish-speakers and may have promoted modest weight loss over an 8-week period.

Trial Registration

Clinicaltrials.gov NCT01171586; http://clinicaltrials.gov/ct2/show/NCT01171586 (Archived by WebCite at http://www.webcitation.org/6Ksr6dl7n).

Dietary adherence and satisfaction with a bean-based high-fiber weight loss diet: a pilot study

Objective. Dietary fiber can reduce hunger and enhance satiety, but fiber intake during hypocaloric weight loss diets typically falls short of recommended levels. We examined the nutritional effects and acceptability of two high-fiber hypocaloric diets differing in sources of fiber: (a) beans or (b) fruits, vegetables, and whole grains. Methods. Subjects were 2 men, 18 women, mean age = 46.9, and mean BMI = 30.6. Subjects completed 3-day food diaries in each of the two baseline weeks. Subjects were then randomized to four weeks on one of two 1400-calorie diets including 25–35 g fiber primarily from 1.5 cups beans/day or from fruits, vegetables, and whole grains. Recommended fiber-rich foods were provided. Subjects kept weekly 3-day food diaries and were assessed weekly. Results. Diet conditions did not differ on outcome measures. Both diets increased fiber intake from 16.6 g/day (SD = 7.1) at baseline to (treatment average) 28.4 g/day (SD = 6.5) (P < 0.001). Fiber intake was consistent over treatment. Caloric intake dropped from 1623.1 kcal/day (SD = 466.9) (baseline) to 1322.2 kcal/day (SD = 275.8) (P = 0.004). Mean weight loss was 1.4 kg (SD = 1.5; P < 0.001). Energy density and self-reported hunger decreased (P's < 0.01) while self-reported fullness increased (P < 0.05). Both diets were rated as potentially acceptable as long as six months. Conclusions. Both diets significantly increased fiber intake by 75%, increased satiation, and reduced hunger. Results support increasing fiber in weight loss diets with a variety of fiber sources.

Relations of hedonic hunger and behavioral change to weight loss among adults in a behavioral weight loss program utilizing meal-replacement products

Greater self-regulatory behavior usage is associated with greater weight loss within behavioral weight loss treatments. Hedonic hunger (i.e., susceptibility to environmental food cues) may impede successful behavior change and weight loss. Adult men and women (N = 111, body mass index M ± SD = 35.89 ± 6.97 kg/m(2)) were assessed before and after a 15-week lifestyle change weight loss program with a partial meal-replacement diet. From pre- to post-treatment, reported weight control behavior usage improved and hedonic hunger decreased, and these changes were inversely related. Individuals with higher hedonic hunger scores at baseline showed the greatest weight loss. Similarly, participants with lower baseline use of weight control behaviors lost more weight, and increased weight control behavior usage was associated with greater weight loss-particularly among individuals with low baseline hedonic hunger. Further study is warranted regarding the significance of hedonic hunger in weight loss treatments.

Comparison of traditional versus mobile app self-monitoring of physical activity and dietary intake among overweight adults participating in an mHealth weight loss program

OBJECTIVE

Self-monitoring of physical activity (PA) and diet are key components of behavioral weight loss programs. The purpose of this study was to assess the relationship between diet (mobile app, website, or paper journal) and PA (mobile app vs no mobile app) self-monitoring and dietary and PA behaviors.

MATERIALS AND METHODS

This study is a post hoc analysis of a 6-month randomized weight loss trial among 96 overweight men and women (body mass index (BMI) 25-45 kg/m(2)) conducted from 2010 to 2011. Participants in both randomized groups were collapsed and categorized by their chosen self-monitoring method for diet and PA. All participants received a behavioral weight loss intervention delivered via podcast and were encouraged to self-monitor dietary intake and PA.

RESULTS

Adjusting for randomized group and demographics, PA app users self-monitored exercise more frequently over the 6-month study (2.6±0.5 days/week) and reported greater intentional PA (196.4±45.9 kcal/day) than non-app users (1.2±0.5 days/week PA self-monitoring, p<0.01; 100.9±45.1 kcal/day intentional PA, p=0.02). PA app users also had a significantly lower BMI at 6 months (31.5±0.5 kg/m(2)) than non-users (32.5±0.5 kg/m(2); p=0.02). Frequency of self-monitoring did not differ by diet self-monitoring method (p=0.63); however, app users consumed less energy (1437±188 kcal/day) than paper journal users (2049±175 kcal/day; p=0.01) at 6 months. BMI did not differ among the three diet monitoring methods (p=0.20).

CONCLUSIONS

These findings point to potential benefits of mobile monitoring methods during behavioral weight loss trials. Future studies should examine ways to predict which self-monitoring method works best for an individual to increase adherence.

Preoperative lifestyle intervention in bariatric surgery: initial results from a randomized, controlled trial

OBJECTIVE

To document preoperative outcomes of a behavioral lifestyle intervention delivered to patients prior to bariatric surgery in comparison to treatment as usual (insurance-mandated physician supervised diet).

DESIGN AND METHODS

After completing a baseline assessment, candidates for surgery were randomized to a 6-month, evidence-informed, manualized lifestyle intervention (LIFESTYLE, n = 121) or to preoperative care as usual (USUAL CARE, n = 119). At 6 months, 187 participants remained candidates for bariatric surgery and were included in the analyses.

RESULTS

LIFESTYLE participants lost significantly more weight than those receiving USUAL CARE [8.3 ± 7.8 kg vs. 3.3 ± 5.5 kg, F(1,183) = 23.6, P < 0.0001], with an effect size of 0.72. Additionally, logistic regression modeling indicated that LIFESTYLE patients were significantly more likely to lose at least 5% of initial body weight than those in USUAL CARE [OR (95% CI) = 2.94 (1.253, 6.903)], as were participants who were heavier [OR (95% CI) = 1.07 (1.001-1.14) for each unit increase in BMI] or with larger improvements in eating behaviors [OR (95% CI) = 1.1 (1.049, 1.145) for each unit increase on the Eating Behavior Inventory).

CONCLUSIONS

A behavioral lifestyle intervention for severely overweight individuals leads to clinically significant weight loss prior to bariatric surgery. Post-surgery follow-up will allow us to examine the impact of the preoperative intervention on postoperative outcomes.

The Eating Habits Confidence Survey: Reliability and Validity in Overweight and Obese Postmenopausal Women

Background and Purpose: Psychometric properties of the Eating Habits Confidence Survey (EC) were evaluated in a sample of 86 overweight and obese postmenopausal women. Methods: Inter-item correlations and coefficient alphas of the total and subscale scores were conducted. Correlations of the EC to the Eating Self-Efficacy Scale (ESES), Eating Behavior Inventory (EBI), and Binge Eating Scale (BES) were examined as approaches to concurrent and contrast validity. Results: Cronbach’s alphas were adequate for total (.83) and subscale (.64–.80) scores. Only the EC subscale “sticking to it” correlated with the other eating scales. This correlation demonstrates concurrent validity with the other scales that reflected persistence in healthy eating, and contrast validity with them in that the other scales measured different issues under the rubric of eating self-efficacy and behaviors. Conclusions: Thus, the EC performed well among a different demographic than those used during its development. This inexpensive and easily administered survey manifests credible validity and reliability. Nevertheless, evidence for its validity and reliability needs to be accrued when it is used in diverse populations.

Fruit and vegetable intake and eating behaviors mediate the effect of a randomized text-message based weight loss program

INTRODUCTION

We hypothesized that fruit/vegetable intake and eating behaviors mediate the relationship between experimental condition and weight loss in a randomized trial evaluating a text-message based weight loss program.

METHODS

Overweight/obese individuals from San Diego, CA (N = 52 with complete data) were randomly assigned in 2007 into one of two groups for four months: 1) the intervention group that received 2-5 weight management text-messages p/day; 2) the usual-care comparison group. Three 24-hour recalls assessed fruit/vegetable intake change and the eating behavior inventory (EBI) measured change in eating behaviors. Regression path models tested intervention mediation.

RESULTS

Direct effects of the intervention were found for change in body weight (b = -3.84, R(2) = 0.074), fruit/vegetable intake (b = 2.00, R(2) = 0.083), and EBI scores (b = 7.15, R(2) = 0.229) (ps < 0.05). The treatment group to weight change path was not statistically significant (b = -0.673, R(2) = 0.208) when fruit/vegetable intake change and EBI score change were specified as intervention mediators in the model. The total indirect effect was 3.17 lb indicating that the indirect paths explained 82.6% of the total effect on weight change.

DISCUSSION

Fruit/vegetable intake and eating behaviors mediated the intervention's effect on weight change. The findings suggest that sending text-messages that promote healthy eating strategies resulted in moderate short-term weight loss.

Changes in weight control behaviors and hedonic hunger during a 12-week commercial weight loss program

Greater use of key self-regulatory behaviors (e.g., self-monitoring of food intake and weight) is associated with greater weight loss within behavioral weight loss treatments, although this association is less established within widely-available commercial weight loss programs. Further, high hedonic hunger (i.e., susceptibility to environmental food cues) may present a barrier to successful behavior change and weight loss, although this has not yet been examined. Adult men and women (N=111, body mass index M±SD=31.5±2.7kg/m(2)) were assessed before and after participating in a 12-week commercial weight loss program. From pre- to post-treatment, reported usage of weight control behaviors improved and hedonic hunger decreased, and these changes were inversely associated. A decrease in hedonic hunger was associated with better weight loss. An improvement in reported weight control behaviors (e.g., self-regulatory behaviors) was associated with better weight loss, and this association was even stronger among individuals with high baseline hedonic hunger. Findings highlight the importance of specific self-regulatory behaviors within weight loss treatment, including a commercial weight loss program developed for widespread community implementation. Assessment of weight control behavioral skills usage and hedonic hunger may be useful to further identify mediators of weight loss within commercial weight loss programs. Future interventions might specifically target high hedonic hunger and prospectively examine changes in hedonic hunger during other types of weight loss treatment to inform its potential impact on sustained behavior change and weight control.

Text4Diet: a randomized controlled study using text messaging for weight loss behaviors

OBJECTIVE

Text-messaging shows promise as a health intervention. This randomized controlled trial evaluated a daily text-messaging weight loss intervention.

METHODS

Overweight and obese adults (n=170) in California were randomized to receive daily interactive and personally weight-relevant text-messages or monthly e-newsletters. Participants were measured at baseline, 6 and 12 months. Group differences were assessed in weight loss. Relation of text-messaging adherence to weight loss and change in pedometer steps was examined.

RESULTS

There were no group differences in weight loss over 6 (1.53 lb vs 3.72 lb) or 12 months (2.27 lb vs 3.64 lb; control vs intervention). Text-messaging adherence was moderately strong (60-69%). Participants with greater adherence lost more weight at 6 (p=.039) and 12 months (p=.023) than those who were less adherent. Intervention participants' steps increased almost 3000 steps/day over time (p<.05), and higher step counts were associated with greater weight loss (p<.05). Text-messaging satisfaction was moderate to high, and pedometer-related satisfaction was associated with greater weight loss (p<.05).

CONCLUSIONS

Although text-messaging had no effect on weight, adherence was associated with improvement in weight-related behaviors and weight outcomes. Text-messages could be a useful adjunct to weight loss treatments.

The comparison of a technology-based system and an in-person behavioral weight loss intervention

The purpose of this study was to compare a technology-based system, an in-person behavioral weight loss intervention, and a combination of both over a 6-month period in overweight adults. Fifty-one subjects (age: 44.2 ± 8.7 years, BMI: 33.7 ± 3.6 kg/m(2)) participated in a 6-month behavioral weight loss program and were randomized to one of three groups: standard behavioral weight loss (SBWL), SBWL plus technology-based system (SBWL+TECH), or technology-based system only (TECH). All groups reduced caloric intake and progressively increased moderate intensity physical activity. SBWL and SBWL+TECH attended weekly meetings. SBWL+TECH also received a TECH that included an energy monitoring armband and website to monitor energy intake and expenditure. TECH used the technology system and received monthly telephone calls. Body weight and physical activity were assessed at 0 and 6 months. Retention at 6 months was significantly different (P = 0.005) between groups (SBWL: 53%, SBWL+TECH: 100%, and TECH: 77%). Intent-to-treat (ITT) analysis revealed significant weight losses at 6 months in SBWL+TECH (-8.8 ± 5.0 kg, -8.7 ± 4.7%), SBWL (-3.7 ± 5.7 kg, -4.1 ± 6.3%), and TECH (-5.8 ± 6.6 kg, -6.3 ± 7.1%) (P < 0.001). Self-report physical activity increased significantly in SBWL (473.9 ± 800.7 kcal/week), SBWL+TECH (713.9 ± 1,278.8 kcal/week), and TECH (1,066.2 ± 1,371 kcal/week) (P < 0.001), with no differences between groups (P = 0.25). The TECH used in conjunction with monthly telephone calls, produced similar, if not greater weight losses and changes in physical activity than the standard in-person behavioral program at 6 months. The use of this technology may provide an effective short-term clinical alternative to standard in-person behavioral weight loss interventions, with the longer term effects warranting investigation.

Tweets, Apps, and Pods: Results of the 6-month Mobile Pounds Off Digitally (Mobile POD) randomized weight-loss intervention among adults

BACKGROUND

Previous interventions have shown promising results using theory-based podcasts to deliver a behavioral weight-loss intervention.

OBJECTIVE

The objective of our study was to examine whether a combination of podcasting, mobile support communication, and mobile diet monitoring can assist people in weight loss.

METHODS

In this 6-month, minimal contact intervention, overweight (n = 96, body mass index 32.6 kg/m(2)) adults were recruited through television advertisements and email listservs and randomly assigned to Podcast-only or Podcast+Mobile groups. Both groups received 2 podcasts per week for 3 months and 2 minipodcasts per week for months 3-6. In addition to the podcasts, the Podcast+Mobile group was also instructed to use a diet and physical activity monitoring application (app) on their mobile device and to interact with study counselors and other participants on Twitter.

RESULTS

Weight loss did not differ by group at 6 months: mean -2.7% (SD 5.6%) Podcast+Mobile, n = 47; mean -2.7% (SD 5.1%) Podcast, n = 49; P = .98. Days/week of reported diet monitoring did not differ between Podcast+Mobile (mean 2.3, SD 1.9 days/week) and Podcast groups (mean 1.9, SD 1.7 days/week; P = .28) but method of monitoring did differ. Podcast+Mobile participants were 3.5 times more likely than the Podcast group to use an app to monitor diet (P = .01), whereas the majority of Podcast participants reported using the Web (14/41, 34%) or paper (12/41, 29%). There were more downloads per episode in the Podcast+Mobile group (1.4/person) than in the Podcast group (1.1/person; P < .001). The number of podcasts participants reported downloading over the 6-month period was significantly moderately correlated with weight loss in both the Podcast+Mobile (r = -.46, P = .001) and the Podcast (r = -.53, P < .001) groups. Podcast+Mobile participants felt more user control at 3 months (P = .02), but not at 6 months, and there was a trend (P = .06) toward greater elaboration among Podcast+Mobile participants. There were significant differences in reported source of social support between groups. More Podcast participants relied on friends (11/40, 28% vs 4/40, 10%; P = .045) whereas Podcast+Mobile participants relied on online sources (10/40, 25% vs 0/40; P = .001).

CONCLUSIONS

Results confirm and extend previous findings showing a minimally intensive weight-loss intervention can be delivered via podcast, but prompting and mobile communication via Twitter and monitoring app without feedback did not enhance weight loss.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01139255; http://clinicaltrials.gov/ct2/show/NCT01139255 (Archived by WebCite at http://www.webcitation.org/625OjhiDy).

Practices associated with weight loss versus weight-loss maintenance results of a national survey

BACKGROUND

Few studies have examined the weight-control practices that promote weight loss and weight-loss maintenance in the same sample.

PURPOSE

To examine whether the weight control practices associated with weight loss differ from those associated with weight-loss maintenance.

METHODS

Cross-sectional survey of a random sample of 1165 U.S. adults. The adjusted associations of the use of 36 weight-control practices in the past week with success in weight loss (≥10% lost in the past year) and success in weight-loss maintenance (≥10% lost and maintained for ≥1 year) were examined.

RESULTS

Of the 36 practices, only 8 (22%) were associated with both weight loss and weight-loss maintenance. Overall, there was poor agreement (kappa=0.22) between the practices associated with weight loss and/or weight-loss maintenance. For example, those who reported more often following a consistent exercise routine or eating plenty of low-fat sources of protein were 1.97 (95% CI=1.33, 2.94) and 1.76 (95% CI=1.25, 2.50) times more likely, respectively, to report weight-loss maintenance but not weight loss. Alternatively, those who reported more often doing different kinds of exercises or planning meals ahead of time were 2.56 (95% CI=1.44, 4.55) and 1.68 (95% CI=1.03, 2.74) times more likely, respectively, to report weight loss but not weight-loss maintenance.

CONCLUSIONS

Successful weight loss and weight-loss maintenance may require two different sets of practices. Designing interventions with this premise may inform the design of more effective weight-loss maintenance interventions.

Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight

BACKGROUND AND PURPOSE

The objective of this review was to construct an updated evidence-based clinical practice guideline on the use of physical activity and diet for the management of osteoarthritis (OA) in adults (>18 years of age) who are obese or overweight (body mass index ≥25 kg/m(2)).

DATA SOURCES

Articles were extracted from the following databases: MEDLINE, EMBASE (Current Contents), SPORTDiscus, SUM, Scopus, CINAHL, AMED, BIOMED, PubMed, ERIC, the Cochrane Controlled Trials, and PEDro.

STUDY SELECTION

The Ottawa Panel and research assistance team strictly applied the inclusion and exclusion criteria from previous Ottawa Panel publications.

DATA EXTRACTION

An a priori literature search was conducted for articles related to obesity and OA of the lower extremities that were published from January 1, 1966, to November 30, 2010. Inclusion criteria and the methods to grade the recommendations were created by the Ottawa Panel.

RECOMMENDATIONS

were graded based on the strength of evidence (A, B, C, C+, D, D+, or D-) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies). In agreement with previous Ottawa Panel methods, Cochrane Collaboration methods were utilized for statistical analysis. Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group. There were a total of 79 recommendations from 9 articles. From these recommendations, there were 36 positive recommendations: 21 grade A and 15 grade C+. There were no grade B recommendations, and all recommendations were of clinical benefit.

LIMITATIONS

Further research is needed, as more than half of the trials were of low methodological quality.

CONCLUSIONS

This review suggests that physical activity and diet programs are beneficial, specifically for pain relief (9 grade A recommendations) and improved functional status (6 grade A and 7 grade C+ recommendations), for adults with OA who are obese or overweight. The Ottawa Panel was able to demonstrate that when comparing physical activity alone, diet alone, physical activity combined with diet, and control groups, the intervention including physical activity and diet produced the most beneficial results.

Contribution of behavior intervention components to 24-month weight loss

Sustaining weight loss at the long term is difficult.

PURPOSE

To examine if eating behaviors, physical activity levels, and program participation influence ones ability to achieve ≥5%, ≥7%, and ≥10% weight loss during a period of 24 months.

METHODS

Data from 170 overweight and obese women (body mass index = 32.7 ± 4.2 kg·m(-2)) were analyzed in this study. All women followed a standard 24-month behavioral weight loss program in which they were instructed to decrease caloric intake and increase physical activity levels. Eating behaviors, body weight, and physical activity levels were assessed at baseline and at 6 and 24 months. Program participation was evaluated by the percentage of group meetings attended and the percentage of telephone calls completed with an interventionist. Three separate stepwise linear regression analyses were performed to identify variables that were predictive of ≥5%, ≥7%, and ≥10% weight loss at 24 months.

RESULTS

The percentage of telephone calls completed and change in weight loss eating behaviors predicted ≥5% (r2 = 0.16), ≥7% (r2 = 0.14), and ≥10% weight loss (r2 = 0.10) at 24 months. However, the change in physical activity levels from baseline to 24 months was only predictive of weight losses ≥10% (r2 = 0.11).

CONCLUSIONS

Behavioral factors, such as adopting healthy eating behaviors and telephone contact time, are important components that assist individuals in achieving weight losses ≥5%. However, high levels of physical activity play a more prominent role in sustaining weight losses ≥10%. Therefore, innovative strategies to enhance long-term exercise adherence should be developed.

Using positive deviance for determining successful weight-control practices

Based on positive deviance (examining the practices of successful individuals), we identified five primary themes from 36 strategies that help to maintain long-term weight loss (weight control) in 61 people. We conducted in-depth interviews to determine what successful individuals did and/or thought about regularly to control their weight. The themes included weight-control practices related to (a) nutrition: increase water, fruit, and vegetable intake, and consistent meal timing and content; (b) physical activity: follow and track an exercise routine at least 3x/week; (c) restraint: practice restraint by limiting and/or avoiding unhealthy foods; (d) self-monitor: plan meals, and track calories/weight progress; and (e) motivation: participate in motivational programs and cognitive processes that affect weight-control behavior. Using the extensive data involving both the practices and practice implementation, we used positive deviance to create a comprehensive list of practices to develop interventions for individuals to control their weight.

Vagus nerve stimulation acutely alters food craving in adults with depression

Vagus nerve stimulation (VNS) is now available as a treatment for epilepsy and treatment-resistant depression. The vagus nerve plays a central role in satiety and short-term regulation of food intake and research suggests a relationship between VNS and weight loss. The underlying mechanisms of this relationship are unknown. The purpose of the current study was to determine whether acute cervical VNS might temporarily alter food cravings. Thirty-three participants were recruited for three groups; depression VNS, depression non-VNS, and healthy controls. Participants viewed 22 computerized images of foods twice in one session and completed ratings for food cravings after each image. The VNS participants' devices were turned on for one viewing of an image and off for the other (randomized order). Participants were blind to VNS condition (on versus off). Acute VNS device activation was associated with a significant change in cravings-ratings for sweet foods. A significant proportion of variability in VNS-related changes in cravings was accounted for by patients' clinical VNS device settings, acute level of depression, and body mass. Further studies are warranted addressing how acute or chronic VNS might modify eating behavior and weight.