Pretreatment, psychological, and behavioral predictors of weight outcomes among lifestyle intervention participants in the Diabetes Prevention Program (DPP)

Making the Most of Familismo to Curb the Diabetes Epidemic: Early Evidence of Success Delivering the Same Intervention to Latinas at Risk for and With Diabetes

Background/objectives

In the USA, diabetes disproportionately affects Hispanics/Latinx, continuing to contribute to health disparities. To address the diabetes epidemic, separate programs for pre-diabetes and diabetes are promoted nationwide. However, engagement by Hispanics/Latinx in either program is lagging. Recent evidence suggests that offering a single community health worker delivered intervention that includes both groups and allows family members to participate may be more effective and in harmony with Latino cultural values, especially if offered to Latino women (Latinas) who traditionally are in charge of food preparation. Our objective was to explore the results of an intervention delivered to low-income Latinas at various dysglycemic levels (diabetic and pre-diabetic).

Methods

In this quasi-experimental mixed-methods cohort study we longitudinally assessed biometric outcomes and health behaviors among obese Latinas at risk for-and with-diabetes, participating in the same intervention. Data were collected at baseline and 3 months post-intervention. Focus group discussions and interviews provided qualitative data to help contextualize findings.

Results

Participants at different levels of the dysglycemic spectrum benefited equally from the intervention across most measures. Among participants whose relatives had diabetes, weight loss exceeded that of participants without diagnosed relatives. Domestic partners' support, attending the program in a group setting, and previous diagnoses from a healthcare professional were associated with better results.

Conclusions

Our findings indicate that a community health worker-delivered intervention for Hispanics/Latinx with-and at-risk for-diabetes is feasible and could be more effective in reducing Hispanics/Latinx' diabetes burden. Health educators and clinicians should consider tapping into the collective nature of the Latinx/Hispanic culture to encourage healthy behaviors among individuals whose family members have diabetes, regardless of their dysglycemic status. We recommend replicating this study with a more rigorous randomized design, a larger number of participants and longer-term follow-up.

Effect of a comprehensive lifestyle intervention program on body weight and health behavior in women with breast cancer: Results from a randomized controlled trial

BACKGROUND

Both overweight/obesity and a Western lifestyle are associated with a poorer prognosis in women with breast cancer. The primary aim of this analysis was to examine the effect of a telephone-delivered lifestyle intervention program on reducing body weight and waist circumference, decreasing cardiovascular risk factors and improving lifestyle.

DESIGN

Data is derived from an open-label, randomized, controlled phase III study that evaluated two chemotherapy regimens and the impact of a 2-year lifestyle intervention on disease-free survival and secondary outcomes in women with intermediate-risk to high-risk breast cancer. Initially, 2292 women with a body mass index (BMI) between 24 and 40 kg/m2 were randomized into one of two arms of the lifestyle intervention study. After accounting for dropout, 1785 participants remained: 776 in the intervention group (IG) who received a telephone-delivered lifestyle intervention supported by mailed materials, and 1009 in the low-level intervention group (LLIG) who received only mailed educational materials with general recommendations for a healthy lifestyle. Body weight, waist circumference, dietary intake, physical activity, and cardiovascular disease risk parameters were measured repeatedly throughout the intervention and a subsequent 2-year follow-up period. Linear mixed models for repeated measures were used to assess differences in study outcomes between the LLIG and IG at each measured time point.

RESULTS

IG participants showed a mean weight loss of -2.7 kg (kg) (versus +0.4 kg, LLIG) at 6 months, -2.8 kg (vs. +0.8 kg, LLIG) at 12 months and -1.8 kg at 24 months (versus +0.9 kg, LLIG). Significant between-group differences for weight loss and reduced waist circumference were observed at all time points until the end of the lifestyle intervention (all p-values < 0.0001), including post-intervention. Reduced energy intake and a higher alternate healthy eating index (AHEI) score in the IG was detected during the lifestyle intervention (AHEI at 24 months: IG 49.1% versus LLIG 42.0%, p < 0.001). Modest significant improvements in several cardiovascular risk factors were observed during the intervention, including fasting plasma glucose, HbA1c, systolic and diastolic blood pressure, and lipids.

CONCLUSIONS

A mainly telephone-delivered lifestyle intervention program can reduce body weight and waist circumference, improve diet quality, and decrease cardiometabolic risk in women with overweight/obesity and newly diagnosed, human epidermal growth factor receptor 2 (HER2)/neu-negative, intermediate-risk to high-risk breast cancer. Weight loss, reduced waist circumference and improved dietary patterns were maintained for up to two years post-intervention.

TRIAL REGISTRATION

The protocol was registered under the EU Clinical Trials Register, https://www.clinicaltrialsregister.eu/, identifier: 2008-005453-38.

Exploring Determinants of Successful Weight Loss with the Use of a Smartphone Healthcare Application: Secondary Analysis of a Randomized Clinical Trial

Dietary and physical activity interventions through smartphone healthcare applications (apps) have recently surged in popularity as effective methods for weight loss. However, the specific factors contributing to successful weight loss remain uncertain. We conducted an analysis of baseline characteristics and app usage frequencies over three months among 68 Japanese adults with overweight and obesity who were assigned to the intervention group in a previous randomized controlled trial. Logistic regression analysis revealed a negative association (OR: 0.248; p = 0.018) between having a walking habit at baseline and successful weight loss, defined as a 3% reduction in initial weight. Additionally, slower walking speeds and family medical history were identified as potential predictors of successful weight loss. These findings offer insights into the profile of individuals who achieve success in weight loss through our smartphone app, providing valuable guidance for the development of future healthcare apps.

Obesity treatment-associated transfer of exercise-related self-regulation to eating-related self-regulation changes in women

Obesity in the United States has risen to 42 percent of its adult population and is similarly problematic in many other countries. Although the U.S. government has provided education on healthy eating and the need to exercise regularly, behavioral obesity treatments have largely failed to sustain reductions in weight. Self-regulation, and the incorporation of exercise for its psychological impacts on eating, has sometimes been targeted. While there has been sporadic investigation into the carry-over of exercise-related self-regulation to eating-related self-regulation, the present aim is to further inquiry in that area to inform future treatment content for improved effects. Women enrolled in community-based obesity treatments with either a self-regulation (n = 106) or education (n = 54) focus were assessed on changes in exercise- and eating-related self-regulation, negative mood, completed exercise, and weight. Improvements were significantly greater in the self-regulation-focused group. After controlling for initial change in eating-related self-regulation, change in that measure from Month 3 to 6 was significantly predicted by change in exercise-related self-regulation during the initial 3 treatment months. This suggested a carry-over effect. A stronger predictive relationship was associated with the self-regulation-focused treatment. In further analyses, paths from changes in exercise→negative mood→self-regulation of both exercise and eating were significant. Increase in eating-related self-regulation was significantly associated with weight loss over 6, 12, and 24 months. The self-regulation-focused group had stronger relationships, again. Findings suggested utility in targeting exercise-related self-regulation to impact later change in eating-related self-regulation, and the use of exercise-associated mood improvement to bolster participants' self-regulation capabilities.

Facilitators and Barriers to Weight Loss Among Patients With Idiopathic Intracranial Hypertension

BACKGROUND

Little is known about motivation for weight loss and barriers to weight loss among patients with idiopathic intracranial hypertension (IIH). Such information is crucial for developing tailored weight management recommendations and novel interventions.

METHODS

We administered a survey to patients with IIH presenting to neuro-ophthalmology clinics at The University of Michigan Kellogg Eye Center (Michigan, USA) and St. Thomas' Hospital (London, England). Participants rated importance and motivation to lose weight (1-10 scale; 10 = extremely important/motivated). Facilitators and barriers to weight loss were assessed using open-ended survey questions informed by motivational interviewing methodology. Open-ended responses were coded by 2 team members independently using a modified grounded theory approach. Demographic data were extracted from medical records. Descriptive statistics were used to analyze quantitative responses.

RESULTS

Of the 221 (43 Michigan and 178 London) patients with IIH (Table 1), most were female (n = 40 [93.0%] Michigan and n = 167 [94.9%] London). The majority of patients in the United States were White (n = 35 [81.4%] Michigan), and the plurality were Black in the United Kingdom (n = 67 [37.6%] London]) with a mean (SD) BMI of 38.9 kg/m2 (10.6 kg/m2) Michigan and 37.5 kg/m2 (7.7 kg/m2) London. Participants' mean (SD) level of importance to lose weight was 8.5 (2.2) (8.1 [2.3] Michigan and 8.8 [2.1] London), but their mean (SD) level of motivation to lose weight was 7.2 (2.2) (6.8 [2.4] Michigan and 7.4 [2.1] London). Nine themes emerged from the 992 open-ended coded survey responses grouped into 3 actionable categories: self-efficacy, professional resources (weight loss tools, diet, physical activity level, mental health, and physical health), and external factors (physical/environmental conditions, social influences, and time constraints). Most responses (55.6%; n = 551) were about barriers to weight loss. Lack of self-efficacy was the most discussed single barrier (N = 126; 22.9% total, 28.9% Michigan, and 20.4% London) and facilitator (N = 77; 17.5% total, 15.9% Michigan, and 18.7% London) to weight loss. Other common barriers were related to physical activity level (N = 79; 14.3% total, 13.2% Michigan, and 14.8% London) and diet (N = 79; 14.3% total, 9.4% Michigan, and 16.3% London). Commonly reported facilitators included improvements in physical activity level (N = 73; 16.6% total, 18.5% Michigan, and 15.1% London) and dietary changes (N = 76; 17.2% total, 16.4% Michigan, and 17.9% London).

CONCLUSIONS

Patients with IIH believe weight loss is important. Self-efficacy was the single most mentioned important patient-identified barrier or facilitator of weight loss, but professional resource needs and external factors vary widely at the individual level. These factors should be assessed to guide selection of weight loss interventions that are tailored to individual patients with IIH.

Understanding mHealth Adoption and Lifestyle Improvement: An Empirical Test of the Antecedents and Mediating Mechanisms

The potential of using mobile phones for health care service delivery has been well acknowledged. Despite that mobile health (mHealth) related research has proliferated in the past decade, mHealth is still in the fledgling stage with a low adoption rate. There is a research gap in understanding factors influencing mHealth adoption and examining the effects of mHealth use on health outcomes. The purpose of this study was thus to explore influential factors of mHealth use, and test mediation pathways through which mHealth use impacts healthy lifestyle behaviors (e.g. sleep, exercise, and social participation). Survey results from 432 online participants illustrate that performance expectancy, social influence, support conditions, and perceived reliability were significantly associated with mHealth use. However, the impact of effort expectancy on mHealth use was statistically nonsignificant. Moreover, the results indicate that mHealth use can not only contribute to the improvement of healthy lifestyle behaviors directly but also exert an impact through the mediating effect of health competence. Knowing what factors motivate people's mHealth use and how mHealth use contributes to lifestyle improvement can help trigger interventions to boost mHealth adoption and improve public health. Implications and limitations are discussed.

A review of the impact of social disruptions on food security and food choice

At times of severe social disruption, be that war, conflict, pandemic, or economic downturn, both the availability and consumption of healthy dietary patterns can be adversely affected with any effects often outlasting the initial social disruption. For instance, when the COVID-19 pandemic hit and lockdown restrictions followed, households were reported to consume unhealthy diets. In some cases, this seemed to be a response to the situation and a coping mechanism. In contrast, in other cases, it was a consequence of limited food availability or access, with some communities finding that fresh foods became difficult to source due to the disruption in global supply chains. The example presented by the impact of conflict in Ukraine, which has also disrupted global food supply chains, at a macrolevel, food systems and at a microlevel, individual and community shows that food choices may respond to different global events in similar ways. Therefore, in this review, a range of events/disruptions are considered, beyond pandemics and wars, including climate disasters (e.g., fire, famine, and floods) that have been shown to impact food supply and consequently, food security. The importance of this can be seen as inadequate and nutritionally poor diets have a concomitant effect on health, which extends beyond the initial period of societal stress and disruption of food supply chains. Hence, the impact of such disruptions on consumer behavior which includes food choice needs to be corroborated. Therefore, this review aims to discuss the impact of such disruptions on consumer behavior and food choices. Additionally, this review provides some practical strategies that can be used to ensure the availability of healthy diets.

Impact of an augmented intervention on self-regulatory, dietary and physical activity outcomes in a diabetes prevention trial among adults with prediabetes

Self-regulation can facilitate modifications in lifestyle to promote behavioral change. However, little is known about whether adaptive interventions promote improvement in self-regulatory, dietary, and physical activity outcomes among slow treatment responders. A stratified design with an adaptive intervention for slow responders was implemented and evaluated. Adults ≥ 21 years old with prediabetes were stratified to the standard Group Lifestyle Balance intervention (GLB; n = 79) or the adaptive GLB Plus intervention (GLB + ; n = 105) based on first-month treatment response. Intake of total fat was the only study measure that significantly differed between groups at baseline (P = 0.0071). GLB reported greater improvement in self-efficacy for lifestyle behaviors, goal satisfaction with weight loss, and very active minutes of activity than GLB + (all P < 0.01) at 4-months. Both groups reported significant improvement in self-regulatory outcomes and reduction in energy and fat intake (all P < 0.01). An adaptive intervention can improve self-regulation and dietary intake when tailored to early slow treatment responders.

Initial weight loss and early intervention adherence predict long-term weight loss during the Promoting Successful Weight Loss in Primary Care in Louisiana lifestyle intervention

OBJECTIVE

This study tested whether initial weight change (WC), self-weighing, and adherence to the expected WC trajectory predict longer-term WC in an underserved primary-care population with obesity.

METHODS

Data from the intervention group (n = 452; 88% women; 74% Black; BMI 37.3 kg/m2 [SD: 4.6]) of the Promoting Successful Weight Loss in Primary Care in Louisiana trial were analyzed. Initial (2-, 4-, and 8-week) percentage WC was calculated from baseline clinic weights and daily at-home weights. Weights were considered adherent if they were on the expected WC trajectory (10% at 6 months with lower [7.5%] and upper [12.5%] bounds). Linear mixed-effects models tested whether initial WC and the number of daily and adherent weights predicted WC at 6, 12, and 24 months.

RESULTS

Percentage WC during the initial 2, 4, and 8 weeks predicted percentage WC at 6 (R2  = 0.15, R2  = 0.28, and R2  = 0.50), 12 (R2  = 0.11, R2  = 0.19, and R2  = 0.32), and 24 (R2  = 0.09, R2  = 0.11, and R2  = 0.16) months (all p < 0.01). Initial daily and adherent weights were significantly associated with WC as individual predictors, but they only marginally improved predictions beyond initial weight loss alone in multivariable models.

CONCLUSIONS

These results highlight the importance of initial WC for predicting long-term WC and show that self-weighing and adherence to the expected WC trajectory can improve WC prediction.

Psychological and Behavioral Predictors of Weight Loss in the Reach Ahead for Lifestyle and Health-Diabetes Lifestyle Intervention Cohort

BACKGROUND

Understanding the effect lifestyle intervention (LI) has on important psychological and behavioral variables that are associated with weight loss can help inform LI design, content, and delivery.

OBJECTIVE

The aim was to determine the modifiable psychological and behavioral factors that are associated with percent weight loss (%WL) and their relative importance in predicting %WL at 12, 24, and 36 months in the REAL HEALTH-Diabetes randomized controlled trial LI.

DESIGN

This is a secondary analysis of LI arms of the REAL HEALTH-Diabetes randomized controlled trial LI cohort over a 24-month intervention period and 12-month follow-up period. Patient-reported outcomes were measured using validated questionnaires that were either self-administered or administered by a research coordinator.

PARTICIPANTS/SETTING

Adults with type 2 diabetes and overweight/obesity (N = 142) from community health centers, primary care, and local endocrinology practices affiliated with Massachusetts General Hospital in Boston, MA, between 2015 and 2020, were randomized to LI and were included in the analysis.

INTERVENTION

The LI was a lower intensity adaptation of Look Action for Health in Diabetes's (HEALTH) evidence-based LI delivered either in-person or via telephone. Registered dietitians delivered 19 group sessions during the first 6 months followed by 18 monthly sessions.

MAIN OUTCOME MEASURES

The association of psychological (diabetes-related distress, depression, autonomous motivation, diet and exercise self-efficacy, and social support for healthy behaviors) and behavioral (fat-related diet and dietary self-regulation) variables with %WL.

STATISTICAL ANALYSIS

Baseline and 6-month change scores in psychological and behavioral variables were modeled as predictors of %WL at 12, 24, and 36 months using linear regression. Random forests were used to compare the relative importance of changes in the variables in predicting %WL.

RESULTS

Six-month improvement in autonomous motivation, exercise self-efficacy, diet self-efficacy, and dietary self-regulation were associated with %WL at 12 and 24 months, but not at 36 months. Improvement in fat-related diet behavior and depressive symptoms were the only variables associated with %WL at all three timepoints. Autonomous motivation, dietary self-regulation, and low-fat diet behaviors were the three most important predictors of %WL during the 2-year LI.

CONCLUSIONS

The REAL HEALTH-Diabetes randomized controlled trial LI resulted in 6-month improvements in modifiable psychological and behavioral factors that were associated with %WL. LI programs for weight loss should focus on skills and strategies to promote autonomous motivation, flexible dietary self-regulation, and habituation of low-fat eating habits during the intervention period.

The effect of emotion regulation on emotional eating among undergraduate students in China: The chain mediating role of impulsivity and depressive symptoms

This study aimed to examine the relationship between difficulties in emotion regulation and emotional eating and the role of impulsivity and depressive symptoms in mediating this chain. Four hundred ninety-four undergraduate students participated in the study. A self-designed questionnaire was used in the survey from February 6 to 13, 2022, to finish our purpose, including the Emotional Eating Scale (EES-R), Depression Scale (CES-D), Short Version of the Impulsivity Behavior Scale (UPPS-P) and Difficulties in Emotion Regulation Scale (DERS). The results showed that 1) difficulties in emotion regulation, impulsivity, depressive symptoms, and emotional eating were correlated; 2) impulsivity and depressive symptoms separately mediated the relationship between difficulties in emotion regulation and emotional eating; 3) impulsivity and depressive symptoms played a chain mediating role between difficulties in emotion regulation and emotional eating. The current study provided a better understanding of the psychologically related pathway of emotional eating. The results would be helpful for prevention and intervention of emotional eating among undergraduate students.

Appetite, Energy Expenditure, and the Regulation of Energy Balance

At usual weight, energy intake and expenditure are coupled and covary to maintain body weight (energy stores). A change in energy balance, especially weight loss, invokes discoordinated effects on energy intake and output that favor return to previous weight. These regulatory systems reflect physiological changes in systems regulating energy intake and expenditure rather than a lack of resolve. The biological and behavioral physiology of dynamic weight change are distinct from those of attempts at static weight maintenance of an altered body weight. This suggests that optimal therapeutic approaches to losing or gaining vs. sustaining weight changes are different for most individuals.

Eating behavior dimensions and 9-year weight loss maintenance: a sub-study of the Finnish Diabetes prevention study

BACKGROUND

Behavioral processes through which lifestyle interventions influence risk factors for type 2 diabetes (T2DM), e.g., body weight, are not well-understood. We examined whether changes in psychological dimensions of eating behavior during the first year of lifestyle intervention would mediate the effects of intervention on body weight during a 9-year period.

METHODS

Middle-aged participants (38 men, 60 women) with overweight and impaired glucose tolerance (IGT) were randomized to an intensive, individualized lifestyle intervention group (n = 51) or a control group (n = 47). At baseline and annually thereafter until nine years body weight was measured and the Three Factor Eating Questionnaire assessing cognitive restraint of eating with flexible and rigid components, disinhibition and susceptibility to hunger was completed. This was a sub-study of the Finnish Diabetes Prevention Study, conducted in Kuopio research center.

RESULTS

During the first year of the intervention total cognitive (4.6 vs. 1.7 scores; p < 0.001), flexible (1.7 vs. 0.9; p = 0.018) and rigid (1.6 vs. 0.5; p = 0.001) restraint of eating increased, and body weight decreased (-5.2 vs. -1.2 kg; p < 0.001) more in the intervention group compared with the control group. The difference between the groups remained significant up to nine years regarding total (2.6 vs. 0.1 scores; p = 0.002) and rigid restraint (1.0 vs. 0.4; p = 0.004), and weight loss (-3.0 vs. 0.1 kg; p = 0.046). The first-year increases in total, flexible and rigid restraint statistically mediated the impact of intervention on weight loss during the 9-year study period.

CONCLUSIONS

Lifestyle intervention with intensive and individually tailored, professional counselling had long-lasting effects on cognitive restraint of eating and body weight in middle-aged participants with overweight and IGT. The mediation analyses suggest that early phase increase in cognitive restraint could have a role in long-term weight loss maintenance. This is important because long-term weight loss maintenance has various health benefits, including reduced risk of T2DM.

Weight management in young adults with type 1 diabetes: The advancing care for type 1 diabetes and obesity network sequential multiple assignment randomized trial pilot results

AIMS

Co-management of weight and glycaemia is critical yet challenging in type 1 diabetes (T1D). We evaluated the effect of a hypocaloric low carbohydrate, hypocaloric moderate low fat, and Mediterranean diet without calorie restriction on weight and glycaemia in young adults with T1D and overweight or obesity.

MATERIALS AND METHODS

We implemented a 9-month Sequential, Multiple Assignment, Randomized Trial pilot among adults aged 19-30 years with T1D for ≥1 year and body mass index 27-39.9 kg/m2 . Re-randomization occurred at 3 and 6 months if the assigned diet was not acceptable or not effective. We report results from the initial 3-month diet period and re-randomization statistics before shutdowns due to COVID-19 for primary [weight, haemoglobin A1c (HbA1c), percentage of time below range <70 mg/dl] and secondary outcomes [body fat percentage, percentage of time in range (70-180 mg/dl), and percentage of time below range <54 mg/dl]. Models adjusted for design, demographic and clinical covariates tested changes in outcomes and diet differences.

RESULTS

Adjusted weight and HbA1c (n = 38) changed by -2.7 kg (95% CI -3.8, -1.5, P < .0001) and -0.91 percentage points (95% CI -1.5, -0.30, P = .005), respectively, while adjusted body fat percentage remained stable, on average (P = .21). Hypoglycaemia indices remained unchanged following adjustment (n = 28, P > .05). Variability in all outcomes, including weight change, was considerable (57.9% were re-randomized primarily due to loss of <2% body weight). No outcomes varied by diet.

CONCLUSIONS

Three months of a diet, irrespective of macronutrient distribution or caloric restriction, resulted in weight loss while improving or maintaining HbA1c levels without increasing hypoglycaemia in adults with T1D.

Two-year effect of semaglutide 2.4 mg on control of eating in adults with overweight/obesity: STEP 5

OBJECTIVE

This study evaluated the effect of once-weekly semaglutide 2.4 mg on 2-year control of eating.

METHODS

In STEP 5, adults with overweight/obesity were randomized 1:1 to semaglutide 2.4 mg or placebo, plus lifestyle modification, for 104 weeks. A 19-item Control of Eating Questionnaire was administered at weeks 0, 20, 52, and 104 in a subgroup of participants. P values were not controlled for multiplicity.

RESULTS

In participants completing the Control of Eating Questionnaire (semaglutide, n = 88; placebo, n = 86), mean body weight changes were -14.8% (semaglutide) and -2.4% (placebo). Scores significantly improved with semaglutide versus placebo for Craving Control and Craving for Savory domains at weeks 20, 52, and 104 (p < 0.01); for Positive Mood and Craving for Sweet domains at weeks 20 and 52 (p < 0.05); and for hunger and fullness at week 20 (p < 0.001). Improvements in craving domain scores were positively correlated with reductions in body weight from baseline to week 104 with semaglutide. At 104 weeks, scores for desire to eat salty and spicy food, cravings for dairy and starchy foods, difficulty in resisting cravings, and control of eating were significantly reduced with semaglutide versus placebo (all p < 0.05).

CONCLUSIONS

In adults with overweight/obesity, semaglutide 2.4 mg improved short- and longer-term control of eating associated with substantial weight loss.

Medically tailored meals for food insecurity and type 2 diabetes: Protocol for the Food as Medicine for Diabetes (FAME-D) trial

BACKGROUND

Food insecurity is associated with worse glycemic management for individuals with type 2 diabetes mellitus (T2DM), but whether medically tailored meals (MTM), a food insecurity intervention, can improve glycemic management is unclear.

OBJECTIVE

To describe the protocol for a trial assessing whether an MTM plus lifestyle intervention improves hemoglobin A1c (HbA1c) and participant-reported outcomes, relative to a food subsidy (money that can be spent on foods participants choose), for adults with both T2DM and food insecurity.

METHODS

The Food as Medicine for Diabetes (FAME-D) randomized clinical trial (goal n = 200) is a pragmatic trial with an active comparator. Participants, who will have T2DM and report food insecurity, will be randomly assigned to a 6-month MTM plus telephone-delivered lifestyle change intervention, or a 6-month food subsidy ($40/month). The primary outcome is HbA1c at 6 months. Secondary outcomes include HbA1c at 12 months to assess whether the intervention effect (if any) is sustained, along with weight, food insecurity, diabetes distress, and health-related quality of life. Qualitative analyses of semi-structured interviews will help understand why, how, and under what circumstances the intervention achieved its observed results.

CONCLUSION

Results from FAME-D will help inform clinical management of food insecurity when it co-occurs with T2DM. Further, results may be useful as healthcare payors are considering coverage for MTM interventions.

CLINICALTRIALS

gov: NCT04828785.

Results of a 2-year lifestyle intervention for type 2 diabetes: the Reach Ahead for Lifestyle and Health-Diabetes randomized controlled trial

OBJECTIVE

The Reach Ahead for Lifestyle and Health (REAL HEALTH)-Diabetes study assessed the comparative effectiveness of two Look AHEAD (Action for Health in Diabetes)-adapted lifestyle intervention (LI) arms targeting weight loss in type 2 diabetes compared with medical nutrition therapy (MNT) referral. At 1 year, LI had greater weight loss than MNT. This study reports outcomes at 24 (end of LI) and 36 months.

METHODS

Participants (N = 211) with type 2 diabetes and BMI > 25 kg/m2 were randomly assigned to in-person LI, telephone conference call LI, or MNT. The primary outcome was percentage weight change. Secondary outcomes included 5% and 10% weight loss, glycated hemoglobin (HbA1c), and patient-reported outcomes.

RESULTS

Participants were 61.7 (SD 10.2) years old; 55% were female; 77% were non-Hispanic White; and had mean (SD) weight of 98 (18.9) kg and mean (SD) HbA1c of 7.7% (1.2%). Mean (SD) weight change at 24 and 36 months was -4.4% (5.9%) and -4.4% (5.4%) in in-person LI, -4.0% (5.8%) and -5.3% (6.4%) in telephone LI, and -3.1% (5.2%) and -5.8% (7.1%) in MNT, with no statistically significant difference in weight or HbA1c at 24 and 36 months. Compared with MNT, LI arms had favorable changes in patient-reported outcomes related to learned dietary skills.

CONCLUSIONS

There were no differences in weight outcomes among LI participants compared with referral to MNT at the end of intervention or 1 year after its conclusion.

Validation of Tools to Assess Predictors of Successful Weight Loss Outcome in Individuals With Overweight and Obesity

OBJECTIVE

To develop and validate questionnaires to assess the behavioral, psychosocial, and environmental predictors of successful weight loss outcomes.

DESIGN

Mixed method study. Questionnaires were developed using 5 steps: item generation by literature review and preexisting questionnaires, expert evaluation, pilot testing, factor analysis, and internal consistency.

SETTING

Adults with obesity recruited via web-based survey hyperlink.

PARTICIPANTS

One hundred participants with a mean body mass index of 28.7 ± 4.4 kg/m².

VARIABLES MEASURED

The questionnaires were generated using 221 items. Establishing content, face and construct validity, and internal consistency.

ANALYSIS

Content validity was analyzed using content validity index and content validity ratio, internal consistency through Cronbach α (CA), and structural validity by factor analysis via principal varimax rotation.

RESULTS

All three questionnaires had good content validity. The Behavioral Predictor Questionnaire had good internal consistency (CA, 0.7) and excellent structural validity (69.7%). Psychosocial Predictors Questionnaire (CA, 0.8, 67.5%) and Environmental Predictors Questionnaire (CA: 0.8, 72.2%) had excellent internal consistency and structural validity.

CONCLUSION AND IMPLICATION

Questionnaires seem to be practical, valid, and reliable tools for baseline assessment of individual-specific factors related to weight loss success.

Participant Characteristics Associated with Changes in Mental Health in a Trial of Behavioural Weight Management Programmes: Secondary Analysis of the WRAP Trial

INTRODUCTION

On average, aspects of mental health improve following behavioural weight management programmes, yet this is not the case for all participants. It is important to identify those at risk of harm to provide more effective psychological support. We aimed to identify participant characteristics associated with changes in depression and anxiety in participants of a behavioural weight management programme.

METHODS

In the Weight loss Referrals for Adults in Primary care trial, 1,267 adults with body mass index ≥28 kg/m2 were randomized to brief intervention, or WW (formerly weight watchers) for 12-weeks or 52-weeks and followed for 5 years. We used linear and multinomial regression to explore the association between participant characteristics and changes in depression and anxiety (measured by the hospital anxiety and depression scale). Where possible, the impact of missing data was investigated using multiple imputation.

RESULTS

Higher baseline anxiety was associated with decreases in anxiety symptoms and increases in depression symptoms from baseline to follow-up. Higher baseline depression was associated with decreases in depression symptoms and increases in anxiety symptoms from baseline to follow-up. The magnitude of the associations was small. No further characteristics were consistently associated with changes in mental health.

DISCUSSION

Evidence suggests that baseline depression and anxiety may indicate how depression and anxiety symptoms change during and after attending WW. Measurement of depression and anxiety at the start of a behavioural weight management programme and subsequent monitoring may facilitate timely psychological support if a deterioration in mental health is identified. Further research in large and diverse participant samples is required to clarify the findings.

Health Behavior Change Following Stroke: Recommendations for Adapting the Diabetes Prevention Program-Group Lifestyle Balance Program

Objective. History of stroke increases risk for recurrent stroke, which is a significant issue faced by survivors. The Diabetes Prevention Program-Group Lifestyle Balance (DPP-GLB) program is an effective lifestyle modification intervention for ameliorating cardiovascular risk factors but has not been adapted to account for common stroke-related deficits. The purpose of this study was to determine appropriate adaptations to the DPP-GLB for adults with stroke. Design and Methods. In this phenomenological qualitative study, a total of 15 community-dwelling adults with stroke and 10 care-partners participated in 4 focus groups to review DPP-GLB curriculum materials and provide recommendations for adaptation. Focus groups were recorded and transcribed. Inductive content analysis was used to identify key themes. Results. Three themes were identified. First, physical, cognitive, sensory, and psychosocial stroke-related deficits could affect DPP-GLB participation. Second, existing DPP-GLB characteristics could facilitate participation by adults with stroke. Third, stroke-specific adaptations were recommended, including modified session content and format, adapted physical activity and dietary recommendations, and inclusion of care-partners. Conclusion. Current DPP-GLB content and structure may be insufficient to meet the unique needs of adults with stroke. The suggested adaptations should be incorporated into a stroke-specific curriculum and tested for preliminary efficacy for reducing recurrent stroke risk.

Effects of 6-month episodic future thinking training on delay discounting, weight loss and HbA1c changes in individuals with prediabetes

People with prediabetes are at risk for type 2 diabetes. They may discount the future delay discounting (DD), and not engage in preventive health behaviors. Episodic future thinking (EFT) can reduce DD when future scenarios are cued, but research is needed to assess long-term effects of EFT and when EFT is not cued. This study tested EFT training compared to control for people with prediabetes enrolled in a 6-month weight loss program on DD, weight, HbA1c, and physical activity. Results showed a reliable EFT effect on reducing DD in cued (p = 0.0035), and uncued DD tasks (p = 0.048), and significant overall changes in weight (p < 0.001), HbA1c (p, 0.001) and physical activity (p = 0.003), but no significant differences in these outcomes by group (p’s > 0.05). Sixty-eight percent of the sample ended below the prediabetes HbA1c range. These results suggest that DD can be modified over extended periods, and the effects of EFT can be observed without EFT cues. However, these data do not suggest that changes in weight, HbA1c or physical activity were due to EFT training. The study was initiated before the COVID-19 pandemic which provided the opportunity to compare differences for people treated in-person or remotely. Analyses showed no differences in DD, weight, HBA1c or physical activity outcomes were observed between in-person and remote treatment, suggesting telehealth is a scalable approach to treating prediabetes.

Identification of instruments for evaluation of behavioural and psychological parameters associated with obesity management: A systematic review with narrative synthesis of the findings

BACKGROUND AND AIMS

To identify instruments used to evaluate the predictors of successful weight loss across weight loss trials.

METHODS

We searched PubMed, PsychInfo, Cochrane Reviews and Scopus for weight loss trials reporting instruments published in the last 16 years.

RESULTS

A total of 46 significant behavioral and psychological predictors were identified, of which 32 instruments were finally selected. SF-36 questionnaire and Obesity Related Problem Scale for psychosocial health, TREMORE scale for motivation, Social Support Scale for support, Weight Efficacy Lifestyle Scale for self-efficacy and Body Shape Questionnaire for body image had moderate quality. Barriers to healthy eating questionnaire scale and Dutch Eating Behavior also had moderate quality.

CONCLUSION

Use of uniform instruments with optimum quality can benefit clinical and community-based researchers to generate reliable datasets.

The Breast Cancer Weight Loss trial (Alliance A011401): A description and evidence for the lifestyle intervention

The Breast Cancer Weight Loss (BWEL) trial is a randomized controlled trial designed to determine whether weight loss after a breast cancer diagnosis can reduce the risk of cancer recurrence in women with overweight or obesity. The BWEL trial will compare the efficacy of a telephone-based weight-loss intervention plus health education materials versus health education materials alone on invasive disease-free survival in 3,181 women with stage II or III breast cancer and BMI > 27 kg/m² . This report provides a detailed description of the goals and methods of the lifestyle intervention and the evidence supporting the intervention used in the BWEL trial. The intervention's primary goal for participants is to achieve and maintain a weight loss ≥ 10% of baseline weight through increased physical activity and caloric restriction. The evidence supporting the diet, physical activity, and behavioral components of this telephone-based weight-loss intervention, as well as strategies to promote participant engagement and retention, is described. The intervention is provided through 42 sessions delivered by trained health coaches over a 2-year period. If the BWEL lifestyle intervention is successful in improving cancer outcomes, then weight loss will be incorporated into the care of thousands of breast cancer patients.

Self-efficacy proxy predicts frailty incidence over time in non-institutionalized older adults

BACKGROUND

Physical frailty is defined as a syndrome of decreased physiologic reserve conferring vulnerability to functional decline, mortality, and other adverse outcomes upon experiencing stressors. Self-efficacy, which is confidence in one's ability to perform well in a domain of life, is modifiable. Self-efficacy is associated with improved health behavior and decreased chronic disease burden. Its relationship to frailty is unknown. The purpose of this study was to evaluate whether a general self-efficacy proxy predicts incident frailty.

METHODS

A nationally representative sample of 4825 U.S. older adults aged 65 and older living in the community or non-nursing home care setting enrolled in the National Health and Aging Trends Study from 2011 to 2018 was used. Self-efficacy was dichotomized into low and high groups using the one-item self-efficacy proxy measure. The Physical Frailty Phenotype was used to categorize participants as frail and non-frail. A discrete time hazard model using data from eight rounds was used to obtain incident hazard ratios of frailty in two models. Model 1 was adjusted for age, race, sex, education, and income. Model 2 contained Model 1 covariates and added disability and comorbidities.

RESULTS

Among people without frailty at baseline, risk of developing frailty over 7 years was increased by 41% among those with low versus high self-efficacy after adjustment for sociodemographics (P = 0.002), and by 27% after further adjustment for disability and comorbidities (P = 0.032).

CONCLUSION

This study generates a rationale to further explore self-efficacy in frailty research. Self-efficacy may be a key modifiable element to incorporate into multimodal physical frailty interventions.

Rethinking emotional eating: Retrospective and momentary indices of emotional eating represent distinct constructs

Emotional eating (EE) has been proposed as a key weight loss barrier. However, most investigations of EE rely on retrospective self-reports, which may have poor construct validity. This study evaluated concordance between a common self-report EE measure and a novel method for assessing momentary EE using ecological momentary assessment (EMA). We further assessed the utility of both measures for predicting both BMI and weight outcomes. Participants with overweight or obesity enrolled in a weight loss trial (N = 163) completed a self-report measure of EE and underwent an EMA protocol that assessed momentary emotions and eating behaviors. Momentary EE was derived from EMA data using generalized linear mixed-effects models. Linear regression models examined associations between both EE measures and concurrent BMI as well as weight losses over 30 months. Retrospectively self-reported EE and momentary EE were negatively correlated with one another (r = -0.27). Higher momentary EE and higher retrospectively reported EE both predicted higher concurrent BMI, and higher retrospectively reported EE predicted poorer weight loss outcomes at all time points (p < 0.05). By contrast, higher momentary EE predicted improved weight outcomes at 1-year and 2-year follow-up (p < 0.05). Our findings extend prior research suggesting that retrospective self-report EE measures capture a different construct than intended and suggest that momentary EE could predict improved weight loss outcomes.

Heterogeneity of Treatment Effects Among Patients With Type 2 Diabetes and Elevated Body Mass Index in a Study Comparing Group Medical Visits Focused on Weight Management and Medication Intensification

BACKGROUND

Illuminating heterogeneity of treatment effect (HTE) within trials is important for identifying target populations for implementation.

OBJECTIVE

The aim of this study was to examine HTE in a trial of group medical visits (GMVs) for patients with type 2 diabetes and elevated body mass index.

RESEARCH DESIGN AND MEASURES

Participants (n=263) were randomized to GMV-based medication management plus low carbohydrate diet-focused weight management (WM/GMV; n=127) or GMV-based medication management alone (GMV; n=136) for diabetes control. We used QUalitative INteraction Trees, a tree-based clustering method, to identify subgroups with greater improvement in hemoglobin A1c (HbA1c) and weight from either WM/GMV or GMV. Subgroup predictors included 32 baseline demographic, clinical, and psychosocial factors. Internal validation was conducted to estimate bias in the range of mean outcome differences between arms.

RESULTS

QUalitative INteraction Trees analyses indicated that for patients who had not previously attempted weight loss, WM/GMV resulted in better glycemic control than GMV (mean difference in HbA1c improvement=1.48%). For patients who had previously attempted weight loss and had lower cholesterol and blood urea nitrogen, GMV was better than WM/GMV (mean difference in HbA1c improvement=1.51%). No treatment-subgroup effects were identified for weight. Internal validation resulted in moderate corrections in mean HbA1c differences between arms; however, differences remained in the clinically significant range.

CONCLUSION

This work represents a novel step toward targeting care approaches for patients to maximize benefit based on individual patient characteristics.

Weight Loss Barriers and Dietary Quality of Intermittent and Continuous Dieters in Women with a History of Gestational Diabetes

Weight-loss after gestational diabetes (GDM) lowers the risk of type-2 diabetes (T2DM). Intermittent energy restriction (IER) produces comparable weight-loss to continuous energy restriction (CER), but long-term adherence remains difficult in this population. This exploratory secondary analysis of a 12-month trial comparing IER to CER following GDM examined weight-loss and dietary quality associated with barriers to weight-loss or T2DM risk perception as assessed in a Likert scale questionnaire at baseline. The participants had a median (IQR) BMI of 32.6 (9.4) kg/m² and 3 (4) years postpartum (n = 121). Forty-five percent (n = 54) of the participants thought they were at a high risk of developing T2DM. Greater affordability of healthy food was related with greater weight-loss at 3 months (p = 0.044, n = 85). At 12 months, there was no significant relationship between weight-loss and the barriers to weight-loss (p > 0.05). CER had superior improvement in dietary quality at 12 months (CER 11 ± 10, IER 6 ± 5.6, n = 42, p = 0.05). Under the Theoretical Domains Framework, the barriers were predominantly related to behavioral regulation (n = 83, 69%; n = 76, 63%) and environmental context and resources (n = 67, 56%). Interventions for diabetes prevention in this population should include behavioral regulation strategies, consider the family home environment, and ensure that the risk of T2DM is conveyed. Women choosing IER may benefit from education to improve their dietary quality.

Psychological and behavioral pathways between perceived stress and weight change in a behavioral weight loss intervention

Black women have a higher prevalence of obesity and tend to have suboptimal outcomes in behavioral weight loss programs for reasons that are not fully understood. Studies have shown a potential relationship between perceived psychological stress and weight loss in behavioral interventions. This study sought to assess whether baseline stress was directly or indirectly associated with 6-month weight change among Black women participating in a behavioral weight loss study. Indirect pathways of interest included depressive symptoms and dietary intake. A secondary analysis of data (n = 409) collected from a cluster, randomized behavioral weight loss trial was conducted. Demographics, anthropometry, surveys, and dietary data were collected at baseline and 6 months. Path analysis was used to test for direct and indirect effects of baseline stress on 6-month weight change while controlling for sociodemographic factors and intervention group. Baseline stress was not directly associated with 6-month weight change nor was it indirectly associated via depressive symptoms in the adjusted model. However, each of the direct paths linking baseline stress to weight loss were statistically significant. Stress was not associated with 6-month weight change via dietary intake. Baseline stress was positively associated with 6-month depressive symptoms which in turn was associated with less weight change. Depressive symptoms may offer an additional psychosocial target to consider when designing behavioral weight loss interventions for Black women.

Obese patients' characteristics and weight loss outcomes in cardiac rehabilitation: An observational study of registry data

AIM

Cardiac rehabilitation (CR) guidelines advocate weight loss for obese patients but mean weight loss is small. We sought to determine the extent to which obese patients' characteristics prior to CR predict weight loss.

METHODS

An observational, pre- and post CR study of routine practice using the UK National Audit of Cardiac Rehabilitation dataset was undertaken. Backward, stepwise, multiple linear regression analysis was used to identify characteristics prior to CR that predicted weight change in obese patients.

RESULTS

In 29,601 obese patients undertaking CR, mean weight loss was 0.9 kg (SD 4.3; p < 0.001) in men (74% of sample) and 0.5 kg (SD 3.9; p < 0.001) in women. Smoking cessation since the cardiac event independently predicted less weight loss by 1.2 kg (95% CI; 0.9, 1.5 kg; p < 0.001). Diabetes, cardiac surgery, living in a deprived area, being female, low fitness levels and pain independently predicted less weight loss during CR. Higher initial weight, greater age and being employed predicted increased weight loss.

CONCLUSION

This is the first study to identify how the characteristics of obese patients independently predict different amounts of weight loss during CR in free-living individuals. It is also the largest, registry-based study to investigate predictors of weight loss in obese patients in CR. Knowledge of the extent to which obese patients' characteristics predict more or less weight loss can aid: the generation of guidelines; agreement of realistic goals with patients; and tailoring of weight management support.

Predictors of successful weight loss outcomes amongst individuals with obesity undergoing lifestyle interventions: A systematic review

Understanding the predictors of weight loss with lifestyle interventions can help to ascertain the probable outcomes of individuals with obesity who undergo such interventions. This systematic review assessed the evidence of predictors of successful weight loss among individuals who are overweight or with obesity undergoing lifestyle interventions. Four electronic databases (PubMed, Cochrane Reviews, PsychInfo and Wiley) were searched to find relevant literature published in the past 20 years. A total of 1351 titles were identified in the initial search, of which 23 studies were finally included. Predictors were synthesized in the domains of socio-demographic factors, anthropometric parameters, psychological and behavioural factors and intervention-based factors. The overall quality of evidence on predictors was then appraised using an adapted GRADE approach. Patient-specific factors such as being male, older in age, having existing cardiometabolic comorbidities and limited fat intake were significantly associated with weight loss success. Amongst intervention specific predictors, greater initial weight loss and higher adherence to lifestyle advice were associated with greater weight loss success. In this review, initial weight loss came out to be as the most important predictor of successful weight loss outcome.

Greater Average Meal Planning Frequency Predicts Greater Weight Loss Outcomes in a Worksite-Based Behavioral Weight Loss Program

BACKGROUND

Planning in behavioral weight loss (BWL) programs helps participants enact changes in eating and exercise, although the direct impact on weight loss is unclear.

PURPOSE

To examine how meal and exercise planning frequencies change in a BWL program and their relations to weight loss outcomes.

METHODS

Participants (N = 139) in a 40 week worksite-based BWL program completed a questionnaire regarding meal and exercise planning frequency at Weeks 0, 10, 20, 30, and 40 and were weighed weekly. Growth curve models were used to determine trajectories in meal and exercise planning frequency and to assess the role of an individual's average meal and exercise planning (between-person effect) and individual variation in planning (within-person effect) on body mass index (BMI).

RESULTS

The best-fitting model, a linear random effect with a quadratic fixed-effect model, demonstrated that meal and exercise planning frequency increased over the course of the program with slowing growth rates. Between participants, higher average meal planning frequency (B = -0.029, t = -3.60), but not exercise planning frequency, was associated with greater weight loss. Within participants, exercise planning, but not meal planning, predicted a higher than expected BMI (B = 3.17, t = 4.21).

CONCLUSIONS

Frequent meal planning should be emphasized as a continued, as opposed to intermittent, goal in BWL programs to enhance weight loss. Average exercise planning frequency does not impact weight loss in BWL programs; however, acute increases in exercise planning frequency may be a popular coping strategy during a weight loss setback or, alternatively, may lead to increased calorie consumption and weight gain.

Predictors of Gestational Weight Gain Examined As a Continuous Outcome: A Prospective Analysis

Background: Excess gestational weight gain (GWG) is common and adversely affects both mothers and offspring, including increasing the risk of maternal and childhood obesity. GWG is typically examined categorically, with women grouped into categories of those who gain above, within, and below guideline recommendations. Examining GWG as a continuous variable, rather than categorically, allows for a consideration of GWG at a finer level of detail, increasing precision. Methods: We collected exposure data among 970 pregnant women in early gestation using a standardized questionnaire in Ontario, Canada, from 2015 to 2017. Maternal weight and height were extracted from antenatal records. Continuous GWG was calculated using four methods: percentage of ideal weight gain, excess GWG, GWG adequacy ratio, and GWG z-score. We used the stepwise linear regression analyses to select variables associated with GWG. Results: We found that a common set of variables (parity, prepregnancy body mass index, planned pregnancy weight gain, smoking, pregnancy-related food cravings, and fast food intake) significantly predicted GWG in a manner consistent across the four GWG outcomes. Certain psychological factors, including the perception of families' and friends' attitudes toward the food cravings of pregnant women, emotion suppression, compensatory health beliefs coupled with eating unhealthy foods, frequent prepregnancy dietary restraint in carbohydrates, sugar, and meals, preferred prepregnancy body size image, agreeable and conscientious personalities, and depression, also were related with GWG. Conclusions: Our findings demonstrate that psychological factors play an important role in the magnitude of GWG, providing key avenues to inform interventions to support healthy weight gain in pregnancy.

Delivering the Same Intervention to Hispanic/Latinos With Pre-diabetes and Diabetes. Early Evidence of Success in a Longitudinal Mixed Method Study

BACKGROUND

Despite nationwide efforts to address the diabetes epidemic and reduce prevalence disparities, higher rates persist among the poor, especially those with limited literacy. Currently, individuals with abnormal glycemia who have pre-diabetes and diabetes qualify for different programs. However, evidence suggests that, for low-income Hispanic/Latinos, offering a single intervention to all those with abnormal glycemia may provide a more culturally acceptable and effective approach. Our objective was to explore the feasibility of such an intervention led by community health workers (CHWs) among low-income Hispanic/Latinos with diabetes and at risk for diabetes.

METHODS

Using a quasi-experimental mixed method design, we assessed weight, glycosylated hemoglobin, diabetes knowledge, and behavior changes of Hispanic/Latinos participants with pre-diabetes and diabetes living in Southern California. Biometric measurements, blood tests, and surveys were collected at baseline and 3 months post-intervention. Interviews and focus group discussions provided qualitative data.

RESULTS

Although the program was less costly, results exceeded those reported for low-income H/L attending the National Diabetes Prevention Program and did not differ between pre-diabetes and diabetes groups. Instead, including individuals at different stages of the dysglycemic spectrum seemed to have enhanced the intervention. Physician referral and attendance of family/friends were associated with better outcomes.

CONCLUSION

Our findings indicate that a joint prevention/self-management intervention led by CHWs for low-income Hispanic/Latinos with diabetes and with pre-diabetes is feasible and cost-effective, providing results that could help reduce the success gap. Incorporating suggestions and replicating this study on a larger scale could help determine whether or not results are reproducible.

Eating self-efficacy changes in individuals with type 2 diabetes following a structured lifestyle intervention based on the transcultural Diabetes Nutrition Algorithm (tDNA): A secondary analysis of a randomized controlled trial

OBJECTIVE

Eating self-efficacy behavior is an important predictor of successful lifestyle intervention. This secondary analysis evaluated the changes in eating self-efficacy behavior in patients with type 2 diabetes (T2D) and overweight/obesity following structured lifestyle intervention based on the Malaysian customized transcultural Diabetes Nutrition Algorithm (tDNA).

METHODS

Patients with T2D and overweight/obesity (n = 230) were randomized either into the tDNA group which included a structured low-calorie meal plan using normal foods, incorporation of diabetes-specific meal replacements, and an exercise prescription or usual T2D care (UC) for 6 months. Patients in the tDNA group also received either counseling with motivational interviewing (tDNA-MI) or conventional counseling (tDNA-CC). The UC group received standard dietary and exercise advice using conventional counseling. Eating self-efficacy was assessed using a locally validated Weight Efficacy Lifestyle (WEL) questionnaire. All patients were followed up for additional 6 months' post-intervention.

RESULTS

There was a significant change in WEL scores with intervention over one-year [Group X Time effect: F = 51.4, df = (3.4, 318.7), p<0.001]. Compared to baseline, WEL scores improved in both the tDNA groups with significantly higher improvement in the tDNA-MI group compared to the tDNA-CC and UC groups at 6 months (tDNA-MI: 25.4±2.1 vs. tDNA-CC: 12.9±2.8 vs. UC: -6.9±1.9, p<0.001). At 12 months' follow-up, both the tDNA groups maintained improvement in the WEL scores, with significantly higher scores in the tDNA-MI group than tDNA-CC group, and the UC group had decreased WEL scores (tDNA-MI: 28.9±3.1 vs. tDNA-CC: 11.6±3.6 vs. UC: -13.2±2.1, p<0.001). Patients in the tDNA-MI group with greater weight loss and hemoglobin A1C reduction also had a higher eating self-efficacy, with a similar trend observed in comparative groups.

CONCLUSION

Eating self-efficacy improved in patients with T2D and overweight/obesity who maintained their weight loss and glycemic control following a structured lifestyle intervention based on the Malaysian customized tDNA and the improvement was further enhanced with motivational interviewing.

CLINICAL TRIAL

This randomized clinical trial was registered under National Medical Research Registry, Ministry of Health Malaysia with registration number: NMRR-14-1042-19455 and also under ClinicalTrials.gov with registration number: NCT03881540.

Rationale and description of a lifestyle intervention programme to achieve moderate weight loss in women with non-metastatic breast cancer: the lifestyle intervention part of the SUCCESS C Study

Objective

There is growing evidence from observational studies that lifestyle factors such as obesity, an unhealthy diet and lack of physical activity are associated with poor long-term outcome in women with breast cancer. The primary objective of the lifestyle modification part of the Simultaneous Study of Docetaxel Based Anthracycline Free Adjuvant Treatment Evaluation, as well as Life Style Intervention Strategies (SUCCESS C) Trial is to investigate the effect of an individualised lifestyle intervention programme aiming at moderate weight loss on disease-free survival in women with HER2/neu-negative breast cancer. Secondary objectives include the effect of the intervention on body weight, cardiovascular risk and quality of life.

Methods

The SUCCESS C Trial is an open-label, multicentre, randomised controlled phase III study using a 2×2 factorial design in women with newly diagnosed HER2/neu-negative intermediate-risk to high-risk breast cancer. The first randomisation served to compare disease-free survival in patients treated with two different chemotherapy regimens (3642 participants). The second randomisation served to compare disease-free survival in patients with a body mass index of 24–40 kg/m² (2292 participants) receiving either a telephone-based individualised lifestyle intervention programme for moderate weight loss or general recommendations for a healthy lifestyle for 2 years. Outcome analyses will be conducted after 5 years of follow-up.

Perspective

This study will provide information on the efficacy and safety of a comprehensive lifestyle intervention programme on disease-free survival in a large cohort of women with breast cancer. EU Clinical Trials Identifier: 2008-005453-38.

A Qualitative Study on the Perspectives of Latinas Enrolled in a Diabetes Prevention Program: Is the Cost of Prevention Too High?

Introduction: Latinas are among the groups most affected by diabetes health disparities, yet they often benefit less from diabetes interventions even when these are culturally adapted. The purpose of this qualitative study was to explore readiness of Latinas enrolled in a diabetes prevention program to adopt recommended preventive behaviors, and to identify factors associated with the adoption and maintenance of these recommended lifestyle changes. Insights gained will be used to inform future efforts at reducing diabetes disparities and the burden of chronic diseases among Latinas. Methods: Nine focus group discussions (FGDs) and 3 key informant interviews (KIIs) were conducted after the completion of a culturally adapted diabetes prevention program led by Latino community health workers. A grounded theory approach by Charmaz informed by the transtheoretical model guided the questions. Discussions and interviews were audio-taped with participants’ permission, transcribed, coded, and themed. Results: Forty low-income Latinas contributed to FGDs and KIIs. Baseline readiness to engage in new behaviors varied. Negative personal and family health events and physician referral impacted most readiness to enroll and to adopt preventive behaviors. Built environment, financial constraints, and threat of social alienation constituted major barriers to behavior adoption and maintenance, while physician involvement, awareness of diabetes complications, and social support partially mitigated these impediments. Conclusions: Our results suggest that timing of enrollment, physician-patient dynamics, and the emotional personal/family cost of behavior modification should all be considered when planning diabetes prevention programs for low-income Latinas. Besides appropriately timing referrals to accessible culturally informed prevention programs, health educators and health care providers should be aware of the potentially negative impact of behavior modification on family dynamics and be prepared to address resulting repercussions. Future research on Latinas should also include and report data on physician involvement, family context, and social determinants of health for more consistent program comparisons.

Mindfulness-based emotional eating awareness training: taking the emotional out of eating

PURPOSE

Emotional eating is important to study and address because it predicts poor outcome in weight loss interventions. Interventions have only touched the surface in terms of addressing emotional eating. Mindfulness approaches can address emotional eating by modification of emotion regulation and appetitive traits. The current study involved development of an emotional eating-specific mindfulness intervention and assessment of its effect on appetitive traits associated with emotional eating.

METHODS

Participants (n = 14; age M = 29 years; 90% female) completed baseline and end-of-intervention self-report measures of emotional eating, food-cue reactivity, mindfulness, intuitive eating, emotional impulse regulation, stress, and a behavioural measure of inhibitory control. During the 6-week intervention, mindfulness meditation skills were taught weekly embedded in a psycho-educational curriculum about emotional eating.

RESULTS

Paired t tests, controlled for type 1 error, revealed significant improvements in food-cue reactivity, intuitive eating, emotional impulse regulation, inhibitory control and stress (ps < 0.05; d: 0.58-1.54). Changes in emotional eating approached significance (p = 0.075, d = 0.66).

CONCLUSION

The intervention purposefully did not focus on weight loss and recruited participants who had self-declared difficulties with emotional eating. The positive outcomes suggest that intervening with mindfulness training before weight loss is attempted has the potential to change psychological factors that underpin overeating and undermine weight loss efforts. The study provides proof of principle as a basis to design a randomized control trial to assess rigorously the effectiveness of the intervention as a precursor to a weight loss intervention.

LEVEL OF EVIDENCE

Level IV, uncontrolled trial.

Understanding and effectively addressing disparities in obesity: A systematic review of the psychological determinants of emotional eating behaviours among Black women

Emotional eating may be a particularly important contributor to differences in body weight and weight loss response to behavioural interventions among non-Hispanic Black women. We performed a systematic review on the impact of psychological factors (stress, anxiety, depression, and discrimination) upon emotional eating and weight among non-Hispanic Black women, applying the Preferred Reporting Items for Systematic Reviews and Meta-analysis for relevant studies. The initial search yielded 4593 articles with 15 accepted for review. Based on this review, there is a suggestion that negative emotions, in particular, perceived stress, may be predictive of emotional eating among non-Hispanic Black women. Results from the only two longitudinal studies identified by the review indicate that stress influences emotional eating, and emotional eating predicts weight gain over time. Findings from this review highlight the need for more studies that examine various negative emotions that may lead to emotional eating and weight gain among non-Hispanic Black women. Findings from this review also highlight the need for more rigorous studies to differentiate the effects of emotional eating from that of the physiologic (ie, activation of the hypothalamic-pituitary axis) responses to stress and its impact on high-risk groups.

Psychological Factors of Long-Term Dietary and Physical Activity Adherence among Chinese Adults with Overweight and Obesity in a Community-Based Lifestyle Modification Program: A Mixed-Method Study

There is a paucity of research on factors influencing long-term adherence to lifestyle modification. We conducted a mixed-method study to explore the psychological factors of dietary and physical activity (PA) adherence among Chinese adults with overweight and obesity at 10 months after enrollment of a community-based lifestyle modification program in Hong Kong. We recruited Chinese adults newly enrolled in a culturally adapted lifestyle modification program and followed them for 10 months. For the quantitative study, primary outcomes were dietary and PA adherence scores while secondary outcomes included knowledge, self-efficacy, motivation and stage of change. For the qualitative study, data were collected using semi-structured interviews and observation. A total of 140 participants completed the 10-month follow-up. They reported moderate level of dietary adherence but low level of PA adherence at 10 months. Multivariable regression analyses revealed that greater improvement in nutrition knowledge and diet stage of change predicted higher dietary adherence while greater improvement in PA self-efficacy and PA stage of change predicted higher PA adherence. Qualitative data on 26 participants suggest that participants' knowledge and self-efficacy but not motivation were enhanced during the program. The findings of this study enhanced our understanding on factors influencing long-term adherence to lifestyle changes.

Lessons Learned from an ACT-Based Physician-Delivered Weight Loss Intervention: A Pilot RCT Demonstrates Limits to Feasibility

Background: Acceptance and Commitment Therapy (ACT) interventions have shown to be effective in facilitating weight loss for emotional eaters, however, the lack of accessibility of these interventions limits their impact. The present study aimed to increase the accessibility of an ACT intervention for emotional eaters through delivery by physicians.

Methods: This two-arm pilot randomized controlled trial tested the effectiveness and feasibility of a brief ACT intervention for emotional eaters compared with standard care at a weight loss clinic in Toronto, Canada. Primary outcomes were changes in weight and emotional eating. Treatment satisfaction was also assessed.

Results: Participants in neither condition lost weight. Both conditions displayed decreases in emotional eating, but no condition interaction was found. Both patients and physicians reported high treatment satisfaction with the ACT intervention. However, there were high attrition rates and variability in intervention completion times.

Conclusion: The ACT intervention led to reductions in emotional eating and was well received by patients and physicians alike. However, the present study identified high attrition as a limitation to the feasibility of this mode of intervention delivery. Future interventions may be more effectively delivered in primary care settings by encouraging further brevity and exploring delivery by other health professionals. Trial registration: ClinicalTrials.gov NCT03611829. Registered 26 July 2018. Retrospectively registered.

Psychometric properties of a nationwide survey for adults with and without diabetes: the "disease knowledge and information needs - diabetes mellitus (2017)" survey

BACKGROUND

In order to close existing information gaps on diabetes-related health perceptions, diabetes knowledge, and information-seeking behaviors among adults in Germany, a representative population-based survey targeting the German-speaking population 18 years and older with and without diabetes was conducted. The aim of the present work was to analyze the psychometric properties of the multi-item scales, applied in the survey in order to provide guidance for decisions on the use of these measurements for future research.

METHODS

Based on data from participants who completed the final survey (N = 1479 with known diabetes; N = 2327 without known diabetes) reliability and unidimensionality of multi-item scales were tested using Cronbach's Alpha and confirmatory factor analysis (CFA).

RESULTS

Psychometric properties and model fit varied across scales. Cronbach's alpha values ranged from very good to unacceptable. Model fit indices suggested evidence of a single underlying factor in some but not all scales. Adequate reliability and at least mediocre model fit were found for diabetes distress and patient-provider-relationship in people with diabetes and for perceived level of information in individuals without diabetes. Scales revealing inacceptable reliability values or not suggesting unidimensionality were e.g. diabetes-related stigmatization in both individuals with and without diabetes, self-efficacy in individuals with diabetes, and perceived personal control in those without diabetes.

CONCLUSION

Based on results of the current study, some of the scales applied in the survey can be recommended for present and future analyses of the survey data and for future surveys (e.g. diabetes distress, patient-provider-relationship in people with diabetes). Other scales should be interpreted and used with caution (e.g. depressive symptoms in people with diabetes) while others should be reformulated, interpreted only as single items, or need further investigation (e.g. diabetes-related stigmatization in people with and without diabetes). Findings provide researchers the opportunity to evaluate diabetes-specific scales in population-based studies of adults with and without diabetes.

The Influence of Chronic Stress and Emotions on Eating Behavior Patterns and Weight among Young African American Women

This study examines the influence of chronic stress, varied positive and negative emotions on eating behaviors, and weight among 91 community-dwelling African American women 18-40 years old. Study measures include hair cortisol, Differential Emotional Scale IV, Eating Behavior Pattern Questionnaire, demographic form, waist circumference, and Body Mass Index (BMI). Analysis revealed positive emotions of interest (r_s = .27, p = .011) and surprise (r_s = .23, p = .029) were associated with low fat eating. Negative emotions of anger (r_s = .23, p = .035), shyness (r_s = .29, p = .006), and guilt (r_s = .24, p = .022) were positively associated with emotional eating. Mediation analysis suggests that emotional eating mediates anger (indirect effect = 0.136), shyness (0.144), guilt (0.187), and BMI among young African American women. Chronic stress and positive and negative emotions impact eating behaviors and should be considered for successful weight management among African American women.

Self-compassion, physical health, and health behaviour: a meta-analysis

This meta-analysis investigated relationships between self-compassion and (1) physical health and (2) health-promoting behaviour in a large pooled sample (N = 29,588) sourced from 94 peer-reviewed articles. As hypothesised, omnibus analyses revealed positive associations between self-compassion and both physical health (r = .18) and health behaviour (r = .26). Moderation analyses using 290 effects found that both associations varied according to health domain, participant age, intervention duration, and self-compassion measure. Self-compassion predicted outcomes in most health domains, with the strongest effects observed on global physical health, functional immunity, composite health behaviour, sleep, and danger avoidance. It did not predict frailty, maladaptive bodily routines, and substance abuse. Multi-session interventions designed to boost self-compassion predicted increased physical health and health behaviour, thereby supporting causal links between self-compassion and health outcomes. The effects of single-session inductions were non-significant. The mean effect of self-compassion on physical health was non-significant for young participants (12.00-19.99) and its effect on health behaviour was weakest among older participants (40.00+). Results support the proposition that self-compassion can promote better physical health. Practical implications of these findings are discussed.

"I Try to Keep That Sugar Down." Experiences of Homebound Older Adults With Type 2 Diabetes: Barriers to Self-Management

Objectives: To study the experiences and challenges of type 2 diabetes (T2D) self-management among homebound older adults who regularly receive home-delivered meals and services.Methods: Participants (n = 31) were recruited by telephone screening and were selected by purposive sampling. Semi-structured interviews were subsequently conducted within participants' homes. The interpretive methodology utilized in this study was developed to systematically assess T2D self-management.Results: Thematic analysis shows that participants felt mostly responsible for their health status, but attributed any noncompliance to lack of social and economic assistance. Most of the seniors in this study felt competent, but often did not have the opportunity to engage in protective measures due to a number of economic, physical, and social barriers.Conclusions: These results contribute to a better understanding of how to approach, support, and motivate homebound older adults with T2D while addressing challenges. Findings offer insight into the development of diabetes self-management education (DSME) and interventions for this population.

Association Between Purpose in Life and Glucose Control Among Older Adults

Background

Greater purpose in life is associated with lower rates of certain chronic diseases. Whether purpose in life can protect against development of prediabetes or type 2 diabetes is unknown.

Purpose

To examine the association between purpose in life and blood glucose control among adults ≥50 years.

Methods

We conducted a longitudinal cohort study of 3,907 participants of the Health and Retirement Study who at baseline did not have type 2 diabetes or prediabetes. Baseline purpose in life was measured using the Ryff and Keyes' Scales of Psychological Well-Being and grouped into tertiles (high, medium, and low). We used multivariable linear regression to examine the association between baseline purpose in life and HbA1c over 4 years. Multivariable logistic regression was used to examine the association between baseline purpose and incident prediabetes or type 2 diabetes over the same period.

Results

After adjusting for sociodemographic factors, body mass index, physical activity, and physical and mental health factors, HbA1c was 0.07 percentage points lower among participants with high purpose than those with low purpose (95% confidence interval [CI] -0.12 to -0.02; p = .011). Participants with high purpose had lower odds of developing prediabetes or type 2 diabetes than those with low purpose (adjusted odds ratio 0.78; 95% CI 0.62 to 0.98; p = .037).

Conclusions

Among older adults, greater purpose in life is associated with a lower incidence of prediabetes or type 2 diabetes. Strategies to promote greater purpose in life should be tested as a part of type 2 diabetes prevention efforts.

Determinants of successful lifestyle change during a 6-month preconception lifestyle intervention in women with obesity and infertility

PURPOSE

To identify demographic, (bio)physical, behavioral, and psychological determinants of successful lifestyle change and program completion by performing a secondary analysis of the intervention arm of a randomized-controlled trial, investigating a preconception lifestyle intervention.

METHODS

The 6-month lifestyle intervention consisted of dietary counseling, physical activity, and behavioral modification, and was aimed at 5-10% weight loss. We operationalized successful lifestyle change as successful weight loss (≥ 5% weight/BMI ≤ 29 kg/m2), weight loss in kilograms, a reduction in energy intake, and an increase in physical activity during the intervention program. We performed logistic and mixed-effect regression analyses to identify baseline factors that were associated with successful change or program completion.

RESULTS

Women with higher external eating behavior scores had higher odds of successful weight loss (OR 1.10, 95% CI 1.05-1.16). Women with the previous dietetic support lost 0.94 kg less during the intervention period (95% CI 0.01-1.87 kg). Women with higher self-efficacy reduced energy intake more than women with lower self-efficacy (p < 0.01). Women with an older partner had an increased energy intake (6 kcal/year older, 95% CI 3-13). A high stage of change towards physical activity was associated with a higher number of daily steps (p = 0.03). A high stage of change towards weight loss was associated with completion of the intervention (p = 0.04).

CONCLUSIONS

Determinants of lifestyle change and program completion were: higher external eating behavior, not having received previous dietetic support, high stage of change. This knowledge can be used to identify women likely to benefit from lifestyle interventions and develop new interventions for women requiring alternative support.

TRIAL REGISTRATION

The LIFEstyle study was registered at the Dutch trial registry (NTR 1530; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1530 ).

Models Integrating Genetic and Lifestyle Interactions on Two Adiposity Phenotypes for Personalized Prescription of Energy-Restricted Diets With Different Macronutrient Distribution

Aim: To analyze the influence of genetics and interactions with environmental factors on adiposity outcomes [waist circumference reduction (WCR) and total body fat loss (TFATL)] in response to energy-restricted diets in subjects with excessive body weight.

Materials and Methods: Two hypocaloric diets (30% energy restriction) were prescribed to overweight/obese subjects during 16 weeks, which had different targeted macronutrient distribution: a low-fat (LF) diet (22% energy from lipids) and a moderately high-protein (MHP) diet (30% energy from proteins). At the end of the trial, a total of 201 participants (LF diet = 105; MHP diet = 96) who presented good/regular dietary adherence were genotyped for 95 single nucleotide polymorphisms (SNPs) previously associated with weight loss through next-generation sequencing from oral samples. Four unweighted (uGRS) and four weighted (wGRS) genetic risk scores were computed using statistically relevant SNPs for each outcome by diet. Predictions of WCR and TFATL by diet were modeled through recognized multiple linear regression models including genetic (single SNPs, uGRS, and wGRS), phenotypic (age, sex, and WC, or TFAT at baseline), and environment variables (physical activity level and energy intake at baselines) as well as eventual interactions between genes and environmental factors.

Results: Overall, 26 different SNPs were associated with differential adiposity outcomes, 9 with WCR and 17 with TFATL, most of which were specific for each dietary intervention. In addition to conventional predictors (age, sex, lifestyle, and adiposity status at baseline), the calculated uGRS/wGRS and interactions with environmental factors were major contributors of adiposity responses. Thus, variances in TFATL-LF diet, TFATL-MHP diet, WCR-LF diet, and WCR-MHP diet were predicted by approximately 38% (optimism-corrected adj. R² = 0.3792), 32% (optimism-corrected adj. R² = 0.3208), 22% (optimism-corrected adj. R² = 0.2208), and 21% (optimism-corrected adj. R² = 0.2081), respectively.

Conclusions: Different genetic variants and interactions with environmental factors modulate the differential individual responses to MHP and LF dietary interventions. These insights and models may help to optimize personalized nutritional strategies for modeling the prevention and management of excessive adiposity through precision nutrition approaches taking into account not only genetic information but also the lifestyle/clinical factors that interplay in addition to age and sex.

Offering a Health Empowerment Program in a Faith-Based Community Clinic

Introduction. Given the excess burden of overweight/obesity in low-income communities, the objective of this pilot study was to examine the feasibility and effectiveness of a healthy living program (Health Empowerment Program) for improving physical activity, eating habits, and mental health outcomes. Adapted from the Diabetes Prevention Program (DPP), a 7-week biopsychosocial intervention that included spirituality was created. Methods. Participants (n = 153) recruited from a faith-based neighborhood health center were assessed using self-report measures for depressive and anxiety symptoms, self-regulation, physical activity, and eating habits at baseline, postintervention, and 3-month follow-up. Results. Participants had significant decreases in depressive symptoms (β = -1.21; SE = 0.27; P < .001) and anxiety symptoms (β = -0.69; SE = 0.24; P = .005) and significant increases in self-regulation (β = 2.42; SE = 0.82; P = .003), time spent in physical activity (β; = 3.56; SE = 1.48; P = .016), and total healthy eating habits (β = 0.97; SE = 0.16; P < .001). Conclusion. Although including spirituality in a healthy living program is feasible and is associated with improvements in outcomes, future research needs to consider how best to incorporate a modified DPP into community settings allowing access to all community members.