Early dropout predictive factors in obesity treatment

Dropout in cognitive behavioral treatment in adults living with overweight and obesity: a systematic review

Obesity is a chronic, complex, and multifactorial disease resulting from the interaction of genetic, environmental, and behavioral factors. It is characterized by excessive fat accumulation in adipose tissue, which damages health and deteriorates the quality of life. Although dietary treatment can significantly improve health, high attrition is a common problem in weight loss interventions with serious consequences for weight loss management and frustration. The strategy used to improve compliance has been combining dietary prescriptions and recommendations for physical activity with cognitive behavioral treatment (CBT) for weight management. This systematic review determined the dropout rate and predictive factors associated with dropout from CBT for adults with overweight and obesity. The data from the 37 articles selected shows an overall dropout rate between 5 and 62%. The predictive factors associated with attrition can be distinguished by demographics (younger age, educational status, unemployed status, and ethnicity) and psychological variables (greater expected 1-year Body Mass Index loss, previous weight loss attempts, perceiving more stress with dieting, weight and shape concerns, body image dissatisfaction, higher stress, anxiety, and depression). Common reasons for dropping out were objective (i.e., long-term sickness, acute illness, and pregnancy), logistical, poor job conditions or job difficulties, low level of organization, dissatisfaction with the initial results, lack of motivation, and lack of adherence. According to the Mixed Methods Appraisal quality analysis, 13.5% of articles were classified as five stars, and none received the lowest quality grade (1 star). The majority of articles were classified as 4 stars (46%). At least 50% of the selected articles exhibited a high risk of bias. The domain characterized by a higher level of bias was that of randomization, with more than 60% of the articles having a high risk of bias. The high risk of bias in these articles can probably depend on the type of study design, which, in most cases, was observational and non-randomized. These findings demonstrate that CBT could be a promising approach for obesity treatment, achieving, in most cases, lower dropout rates than other non-behavioral interventions. However, more studies should be conducted to compare obesity treatment strategies, as there is heterogeneity in the dropout assessment and the population studied. Ultimately, gaining a deeper understanding of the comparative effectiveness of these treatment strategies is of great value to patients, clinicians, and healthcare policymakers. Systematic review registration: PROSPERO 2022 CRD42022369995 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022369995.

Late bedtime is associated with lower weight loss in patients with severe obesity after sleeve gastrectomy

BACKGROUND

Previous research has shown that sleep can play a role in obesity and weight loss. However, the association of sleep with weight loss in patients with severe obesity after bariatric surgery remains unexplored. We aimed to evaluate the role of sleep in weight loss evolution in a cohort of patients who underwent sleeve gastrectomy.

METHODS

A cohort of 252 patients with severe obesity (75.7% women; age [mean ± SD] 47.7 ± 10.8 years; BMI 44.2 ± 5.9 kg/m²) was followed for 1 year after surgery. Anthropometric, biochemical, physical activity, sleep (bedtime, wakeup time, and sleep duration) and dietary intake variables were collected pre- and post-surgery (1 year). Linear and non-linear regression models were used to examine the associations between sleep variables and weight loss. Participants were grouped into 'early' and 'late' sleepers according to a bedtime threshold (before or after 24:00 h), and the differences in weight loss, physical activity, meal timing, and dietary intake between groups were studied.

RESULTS

1-h increments in bedtime were linearly associated with less excess weight loss (EWL) [-2.23%; 95%CI: -3.37; -0.70; p = 0.005] 1 year after the sleeve gastrectomy. Late sleepers lost less weight (-5.64% of EWL [95%CI: -10.11; -1.17]; p = 0.014) when compared to early sleepers and showed a higher energy intake after 21:00 h (8.66% of total energy intake [95% CI: 4.87; 12.46]; p < 0.001).

CONCLUSIONS

Late bedtime is associated with less success of weight loss 1 year after the sleeve gastrectomy. Late sleepers consumed more of their calories closer to bedtime. Our results highlight the relevance of considering recommendations on bedtime and meal timing for patients after bariatric surgery.

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

PURPOSE

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level V, retrospective descriptive study.

Continuous versus Intermittent Dieting for Fat Loss and Fat-Free Mass Retention in Resistance-trained Adults: The ICECAP Trial

INTRODUCTION

Can intermittent energy restriction (IER) improve fat loss and fat-free mass retention compared with continuous energy restriction (CER) in resistance-trained adults?

METHODS

Sixty-one adults (32 women) with a mean (SD) age of 28.7 (6.5) yr, body weight of 77.2 (16.1) kg, and body fat of 25.5% (6.1%) were randomized to 12 wk of 1) 4 × 3 wk of moderate (m) energy restriction interspersed with 3 × 1 wk of energy balance (mIER; n = 30; 15 wk total) or 2) 12 wk of continuous moderate energy restriction (mCER; n = 31). Analyses of all outcome measures were by intention-to-treat.

RESULTS

After accounting for baseline differences, mIER did not result in lower fat mass or body weight, or greater fat-free mass, compared with mCER after energy restriction. Mean (and 97.5% confidence interval for fat mass at the end of mIER versus mCER was 15.3 (12.5-18.0) kg versus 18.0 (14.3-21.7) kg (P = 0.321), that for fat-free mass was 56.7 (51.5-61.9) kg versus 56.7 (51.4-62.0) kg (P = 0.309), and that for body weight (with 95% confidence interval) was 72.1 (66.4-77.9) versus 74.6 (69.3-80.0) (P = 0.283). There were no differences between interventions in muscle strength or endurance or in resting energy expenditure, leptin, testosterone, insulin-like growth factor-1, free 3,3',5-triiodothyronine or active ghrelin, or in sleep, muscle dysmorphia, or eating disorder behaviors. However, participants in mIER exhibited lower hunger (P = 0.002) and desire to eat (P = 0.014) compared with those in mCER, and greater satisfaction (P = 0.016) and peptide YY (P = 0.034).

CONCLUSIONS

Similar fat loss and fat-free mass retention are achieved with mIER and mCER during 12 wk of energy restriction; however, mIER is associated with reduced appetite.

Change in Weight, BMI, and Body Composition in a Population-Based Intervention Versus Genetic-Based Intervention: The NOW Trial

OBJECTIVE

The aim of this study was to compare changes in body fat percentage (BFP), weight, and BMI between a standard intervention and a nutrigenomics intervention.

METHODS

The Nutrigenomics, Overweight/Obesity and Weight Management (NOW) trial is a parallel-group, pragmatic, randomized controlled clinical trial incorporated into the Group Lifestyle Balance^TM (GLB) Program. Statistical analyses included two-way ANOVA and split-plot ANOVA. Inclusion criteria consisted of: BMI ≥ 25.0 kg/m² , ≥18 years of age, English speaking, willing to undergo genetic testing, having internet access, and not seeing another health care provider for weight-loss advice outside of the study. Pregnancy and lactation were exclusion criteria. GLB groups were randomly assigned 1 to 1 (N = 140) so that participants received either the standard 12-month GLB program or a modified 12-month program (GLB plus nutrigenomics), which included the provision of nutrigenomics information and advice for weight management. The primary outcome was percent change in BFP. Secondary outcomes were change in weight and BMI.

RESULTS

The GLB plus nutrigenomics group experienced significantly (P < 0.05) greater reductions in percent and absolute BFP at the 3-month follow-up and percent BFP at the 6-month follow-up compared with the standard GLB group.

CONCLUSIONS

The nutrigenomics intervention used in the NOW trial can optimize change in body composition up to 6 months.

Baseline Psychosocial and Demographic Factors Associated with Study Attrition and 12-Month Weight Gain in the DIETFITS Trial

OBJECTIVE

The purpose of this study was to examine correlates of failure-trial attrition and weight gain-in a randomized clinical weight-loss trial.

METHODS

The Diet Intervention Examining The Factors Interacting with Treatment Success (DIETFITS) trial included 609 adults (18-50 years; BMI 28-40). Participants were randomized to a 12-month healthy low-fat or healthy low-carbohydrate diet for weight loss. At baseline, participants completed psychosocial, demographic, and anthropometric measures. Stepwise logistic regressions identified baseline factors associated with (1) study attrition and (2) among trial completers, weight gain at 12 months.

RESULTS

Having higher baseline food addiction and self-efficacy was linked to treatment failure. Being younger, not having a college education, having higher outcome expectations and quality of life, and having lower social functioning and self-control increased the odds of trial attrition. Identifying as other than non-Hispanic white; not being married or cohabitating; having higher cognitive restraint and self-control; and having lower amotivation, family encouragement, and physical limitations increased the odds of gaining weight by treatment's end.

CONCLUSIONS

Participants' baseline psychosocial and demographic factors may support or impede successful weight loss. Trialists should attend to these factors when designing treatments in order to promote participants' likelihood of completing the trial and achieving their weight-loss goals.

Health Care Providers' Perspectives on Family Compliance and Behavior Change in a Childhood Obesity Program

Background. Evidence suggests that children and adolescents growing up in low-income families and those with underrepresented ethnocultural backgrounds tend to have high prevalence rates of obesity and more difficulty adhering to childhood obesity interventions. However, less is known about how intergenerational, family-based approaches to lifestyle interventions for childhood obesity support sustained behavior change. Aims. The aim of this study was to explore the perspectives of health care providers regarding family adherence and behavior change in a childhood obesity program that served ethnoculturally diverse and low-income families. Method. Semistructured in-person interviews were conducted with 18 providers at one of three hospitals participating in a Canadian family-based childhood obesity program. Data were thematically analyzed using a constant comparative approach. Results. The following key themes emerged as challenges from the provider's perspective for family adherence and behavior modification in the childhood obesity program: divergent views about obesity, complicated lives and logistical priorities, parental role modeling, and intergenerational tensions. Discussion and Conclusion. This examination of providers' perspectives on family adherence and behavior modification relevant to the management of childhood obesity highlight the importance of tailoring childhood obesity programs to the complex and diverse needs of families from diverse backgrounds. Recommendations include methods of service delivery that address logistical challenges and are better suited to extended families, particularly grandparents.

Tipping the scales: Provider perspectives on a multi-disciplinary approach to obesity

IMPACT STATEMENT

Obesity is a major multi-faceted, chronic disease that increases the risk of morbidity and mortality of children and adults particularly impacting high-risk populations and those of lower socioeconomic status. Given provider time constraints, models of care to effectively and efficiently address obesity in primary care are key. Although physician recommendations can exert a powerful influence on behavior, providers often feel powerless to adequately address obesity due to the complexity of physical and behavioral health problems. This mini-review focuses on describing the feasibility and evidence for tackling obesity through provider-led multidisciplinary weight management programs.

Alexithymia Predicts Attrition and Outcome in Weight-Loss Obesity Treatment

Obesity is a psychosomatic condition characterized by a complex interaction of biological and psychological factors and a large body of research has aimed to identify variables limiting efficacy and determining high attrition rates in weight loss programs. In this study, we used the Diagnostic Criteria for Psychosomatic Research (DCPR), designed to broaden the clinician's perspective on patients' problems by providing additional clinical information not found in the more traditional psychiatric classification, to predict psychosomatic variables that may limit efficacy and determine attrition in clinical interventions with people with obesity. We evaluated 82 consecutive participants with obesity at baseline for psychopathology, psychosomatic correlates, psychological distress, and eating-related symptoms before entering a weight loss program. Regression models were used to assess attrition and outcome at a 6-month follow-up and per-protocol and intention-to-treat analyses were performed. DPCR alexithymia significantly predicted attrition (OR = 6.9), and unsuccessful weight-loss (OR = 11.3). These findings suggest that the identification of psychosomatic factors, in addition to psychological and psychopathological factors, may predict adherence to weight-loss programs.

Factors associated with early dropout in an employer-based commercial weight-loss program

OBJECTIVE

Minimizing program dropout is essential for weight-loss success, but factors that influence dropout among commercial programs are unclear. This study's objective was to determine factors associated with early dropout in a commercial weight-loss program.

METHODS

A retrospective analysis of a remotely delivered, employer-based commercial program from 2013 to 2016 was conducted. The dependent variable was 'early dropout', defined as enrollees who disengaged from telephone coaching by month 2's end. Independent variables included demographics, program website engagement and early weight change. Multivariate logistic regression analyses were used to assess for differences in early dropout by several factors, adjusted for employer clustering.

RESULTS

Of the 5,274 participants, 26.8% dropped out early. Having ≥1 chronic condition (odds ratio [OR] 1.41, p < 0.001) and 'weight-loss failure' defined as ≥0% weight change at month 1's end (OR 1.86, p < 0.001) had significantly increased odds of early dropout. Increasing age by 10-year intervals (OR 0.90, p = 0.002) and 'meeting the website login goal' defined as ≥90 logins in 3 months (OR 0.13, p < 0.001) significantly decreased the odds of early dropout.

CONCLUSIONS

Presence of comorbidities, less online engagement and weight-loss failure were associated with early dropout in a commercial program. Strategies to prevent dropout among high-risk participants, such as increased support or program tailoring, should be developed and tested.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level V, descriptive studies.

An Overview of Factors Associated with Adherence to Lifestyle Modification Programs for Weight Management in Adults

This review aims to provide an overview of the factors associated with adherence reported in existing literature on lifestyle modification programs for weight management among the adult population. An electronic search was performed using PubMed, Medline, PsycINFO and PsycARTICLE to identify studies that examined the factors of adherence to lifestyle modification programs with explicit definition of adherence indicators. We identified 19 studies published between 2004 and 2016. The most commonly used indicator of adherence was attrition, followed by attendance, self-monitoring and dietary adherence. A broad array of factors has been studied but only few studies exploring each factor. Limited evidence suggested older age, higher education, healthier eating and physical activity behaviours, higher stage of change at baseline and higher initial weight loss may predict better adherence. On the other hand, having depression, stress, strong body shape concern, more previous weight loss attempts and being unemployed may predict poor adherence. Inconsistent findings were obtained for self-efficacy, motivation and male gender. This review highlights the need for more rigorous studies to enhance our knowledge on factors related to adherence. Identification of the factors of adherence could provide important implication for program improvement, ultimately improving the effectiveness and the cost-effectiveness of lifestyle modification program.

Factors behind nonadherence to diet regimens among obese adults in Tanta, Egypt: a case-control study

BACKGROUND

Nonadherence to diet regimens is a major cause of treatment failure in the field of obesity management. It varies according to the study design and the type of intervention. In weight loss clinical trials, nonadherence rates range from 10 to 80%. Strategies to reduce dropout rates rely on precise identification of factors leading to premature program termination. The aim of this research was to study factors behind nonadherence to diet regimens among obese adults in Tanta, Egypt.

PARTICIPANTS AND METHODS

A retrospective, case-control study was carried out during the year 2014 in an obesity management private clinic in Tanta, Gharbia Governorate, Egypt. The study included two groups of 150 participants each (adherents and nonadherents) matched for sex and BMI. Self-administered questionnaires were used to collect data concerning sociodemographic characteristics, weight changes, dieting, and behavioral, psychological, and medical factors. Personal perspectives on potential factors contributing to nonadherence to diet regimens were also investigated.

RESULTS

Factors significantly associated with probabilities high probability of to loss of adherence to diet regimens were as follows: younger age, urban residence, higher educational levels, obesity of grades I and III, a higher frequency of previous weight loss trials, consumption of fruits and vegetables less than that recommended (<5 times/day), higher weight loss expectations, and binge eating. The most common personal perspectives on causes limiting adherence to diet regimens were as follows: unsatisfactory results (37.3%), difficulties in dieting practices (33.3%), logistics (30.0%), and fading of motives (27.3%).

CONCLUSION AND RECOMMENDATIONS

Obese individuals seeking weight reduction with young age, urban residence, higher educational levels, a higher frequency of previous weight loss trials, higher weight loss expectations, and those with perceived unsatisfactory results are more prone to lose their adherence to diet regimens. Individuals with factors of nonadherence should receive extra care to avoid their withdrawal from diet programs and to improve clinical outcomes.

Determinants of adherence to lifestyle intervention in adults with obesity: a systematic review

Lifestyle intervention programmes are efficacious in the management of obesity but often report poor attendance and adherence rates that hinder treatment effectiveness and health outcomes. The aim of this systematic review is to identify (i) barriers to behaviour change and (ii) predictors of adherence to lifestyle intervention programmes in adults with obesity. Studies were identified by systematically reviewing the literature within Medline, PsycINFO, CINAHL, SPORTDiscus and Web of Science from inception to August 2016. Barriers to behaviour change include poor motivation; environmental, societal and social pressures; lack of time; health and physical limitations; negative thoughts/moods; socioeconomic constraints; gaps in knowledge/awareness; and lack of enjoyment of exercise. The most prominent predictors of adherence include early weight loss success, lower baseline body mass index (BMI), better baseline mood, being male and older age. The findings within this review provide novel insight to clinicians working in obesity and have important implications for lifestyle intervention programme design. Barriers to behaviour change need to be addressed early in treatment, with lifestyle intervention individualized accordingly. Predictors of adherence should also be taken into careful consideration, with negative moods and unrealistic weight loss expectations discussed at the outset. If adherence is improved, treatment effectiveness, health outcomes and the ultimate burden of chronic diseases could also be improved.

Predictors of early attrition and successful weight loss in patients attending an obesity management program

Background

Our objective was to identify factors that are independently associated with early attrition and successful weight loss (WL) in an obesity-management program.

Methods

Participants were 9,498 patients enrolled in treatment at the Wharton Weight Management Clinic for at least 6 months. Predictors of early attrition (<6 months) and successful WL (≥5 %) were analyzed using relative risk (RR) in men and women separately. Pearson’s correlation was used to determine the relationship between WL and treatment time Weight loss and attrition analysis was restricted to patients who had more than two visits (n = 5415).

Results

Older individuals had lower early attrition (RR Range:0.74–0.92, P < 0.05) and greater WL success (RR Range:1.40–1.65, P < 0.05) than younger individuals. Males with hypertension and females with depression had greater early attrition (RR Range:1.09–1.20, P < 0.05) and lower WL success (RR Range:0.48–0.57, P < 0.05) than those without these health conditions. Males with lower education had greater early attrition (RR = 1.11[1.03–1.19]) than males with higher education, but did not differ in WL. Females who smoked had greater early attrition (RR = 1.06[1.01–1.11]) than females who did not smoke, but did not differ in WL. Ethnicity was not related to early attrition, however, females of Black and Other ethnicities had lower WL success compared to White females (RR Range:0.58–0.74, P < 0.05). After adjusting for treatment time, all above associations were no longer significant and treatment time remained as the only independent predictor of WL success (P < 0.0001).

Conclusion

As WL is positively and independently related with treatment time, individuals at risk for early attrition may need alternative treatment options, in order to improve patient retention and improve WL success.