# data[].attributes.body
Social factors - habits of family/friends, ease of lifestyle to change (e.g. office job making routine eating harder to break)

Emotional factors - Reasons for current diet change may be emotional (e.g. binge eating disorder)

Cultural factors - Some diets may be embedded in particular cultures, making diet change more difficult. For instance, Indian diets are mostly vegetarian and promote good sources of vegetables and protein, however a British diet is typically very high fat and meat centric

Cognitive factors - Knowledge on how to actually change, how easy do the obese adults think this will be?

Perceived symptoms - Many adults who are yet to experience comorbidities of obesity may be more likely to not notice a problem and continue their current lifestyle. Evident from the BBC documentary 'Who are you calling fat?', many people do not believe the correlation between weight and health.

Accessibility to medical services - Although British adults have access to the NHS, stigma of being overweight may prevent them from seeking help for their comorbidities.

Personality factors - mood, optimism with diet plan etc.

# data[].attributes.headline
Coping mechanisms for specific obese populations:

# data[].attributes.subject
Coping mechanisms for specific obese populations:

# data[].attributes.body
Mentally ill patients:

An overview of treatments for obesity in a population with mental illness Taylor et al. (2011).

Beyond Pharmacotherapy: Understanding the Links Between Obesity and Chronic Mental Illness Taylor et al. (2011).

Pregnant women:

Howard County General Hospital (2015): Obesity and Pregnancy

Children:

Overweight children and adolescents: Impact on psychological and social development. McClanahan, Huff & Omar (2009)

# data[].attributes.body
Poor mental health associated with obesity (particularly anxiety & depression)

# data[].attributes.body
Ability to cope and strategy of coping largely depends on the individuals willingness to change. This drastically varies between individuals. With the incline in medical advancements, we are increasingly seeing people attempt to resolve their weight issues through bariatric surgeries and medical interventions rather than the traditional route of a better diet and increased exercise.

# data[].attributes.headline
Fifty Years of Behavioral/Lifestyle Interventions for Overweight and Obesity: Where Have We Been and Where Are We Going?

# data[].attributes.subject
Fifty Years of Behavioral/Lifestyle Interventions for Overweight and Obesity: Where Have We Been and Where Are We Going?

# data[].attributes.body
Williamson, (2017).

Literature review of obesity treatment since Stuart's 1967 three-dimensional obesity programme ( heavily criticised as results not often long-term):
1.  environmental interventions to strengthen healthy eating and decrease sedentary behavior
2. Structured exercise programs to increase physical activity
3. dietary programs to decrease caloric intake.

Stuart and Davis (1972) Lifestyle modification intervention. Validated method through RTCs. Treatment progressed from individual to group therapy.

Intensive Lifestyle Intervention (ILI) examples:

1. Diabetes Prevention Program (DPP) (1994)

2. Look AHEAD (2006

3. CALERIE (2007)

4. POUNDS Lost (2009)

Conclusions
Over time of using ILIs, therapy has progressively moved to group scenarios, and treatment duration has increased. Interventions are increasingly using computer systems to monitor progress.

Creation of CDC Diabetes Prevention Recognition Program (DPRP - 2015) to recognise successes of ILIs into one recognised programme.

# data[].attributes.attachment_link.readable_text
Disclosure:: Donald A. Williamson is a paid consultant to Real Appeal, Inc. The author declared no conflict of interest.

Abstract

Objective

This paper reviews the literature pertaining to the structure and content of intensive lifestyle interventions (ILIs) for overweight/obesity since Richard Stuart described this new treatment approach in 1967. A consensus opinion has formed that behavioral/lifestyle treatment of overweight and obesity should be viewed as a mainstream intervention for the treatment and prevention of type 2 diabetes and medical complications associated with obesity.

Methods

The development of modern ILIs and demonstration of their efficacy are compared by structure, content, and efficacy of four major randomized controlled trials: Diabetes Prevention Program (DPP), Look AHEAD, POUNDS Lost, and CALERIE.

Results

The results of these studies indicated that modification of lifestyle behaviors related to nutrition and physical activity can yield weight loss and prevention or improvement of a variety of medical conditions associated with obesity in a variety of subpopulations.

Conclusions

Recommendations for the structure and length of behavioral/lifestyle interventions have been recently adopted by agencies and institutions that approve reimbursement for medical services. These recommendations represent a giant step in the effort to recognize ILIs as a mainstream approach for the treatment of obesity and comorbid medical conditions. Nevertheless, they do not adequately represent advances made since the publication of the DPP results.

Introduction

In 1967, Richard Stuart published the first paper to describe the behavioral treatment of overeating, presenting the weight loss results of eight patients with obesity treated during a 12‐month period. Four years later , he described a "three‐dimensional program" of behavioral treatment for obesity with many of the components of modern lifestyle interventions: environmental interventions to strengthen healthy eating and decrease sedentary behavior, structured exercise programs to increase physical activity, and dietary programs to decrease caloric intake. The behavioral intervention was delivered using individual counseling with 16 to 41 sessions aver a 12‐month period . Weight loss was described as being continuous over 12 months, averaging between 0.60 and 0.70 pounds per week , resulting in average 12‐month weight losses between 35 and 40 pounds. Most contemporary professionals were pessimistic about the successful treatment of obesity . In the past 50 years, behavioral/lifestyle treatment for obesity has been intensely studied and has gone through many iterations. There were early concerns that weight loss effects were too short‐lived . Nevertheless, clinical research on this approach has continued. This paper describes the evolution of this research, starting with a discussion about how obesity came to be regarded as a medical problem.

Where Have We Been?

How obesity became recognized as a medical problem

For much of human history, many people were lean or underweight. Nevertheless, the presence of excess adiposity, even in ancient civilizations, has been well documented . By the 18th century, being overweight, or "corpulent," was associated with health and high social standing, though medical consequences of obesity were recognized . During the 20th century, the abundance of food was such that most people could finally achieve a "normal" weight, though stigma was attached to having obesity . Obesity was viewed as a cosmetic problem associated with gluttony, laziness, and low self‐discipline . By 1940, scientists began to note the relationships between obesity, type 2 diabetes, and a variety of cardiovascular disease (CVD) risk factors . In 1988, Gerald M. Reaven formally hypothesized a Syndrome X that linked insulin resistance (a feature of type 2 diabetes) with a range of medical conditions. Syndrome X became known as the metabolic syndrome , which was strongly associated with the presence of overweight and obesity . By 2000, most scientists and clinicians had concluded that obesity was best regarded as a medical problem as opposed to a cosmetic problem . Also, the human race reached a landmark: more than half of the population had overweight or obesity . This phenomenon has been called the global epidemic of obesity . This paper summarizes the evolution of one approach for the treatment of obesity and related problems: intensive lifestyle intervention (ILI).

Evolution of behavioral/lifestyle interventions for obesity‐related medical problems

In 1980, Albert Stunkard published one of the first modern texts on obesity. A variety of treatments were described: diets, exercise, drugs, psychoanalysis, self‐help, gastric bypass, and behavior modification. Stunkard described behavior modification as a "treatment modality that has aroused much initial enthusiasm" . In 1972, Stuart and Davis published the first treatment guide for intensive lifestyle modification for weight management . Over the next 25 years, more than 70 randomized controlled trials (RCTs) were published that validated this approach as effective for weight management, and the length of treatment increased from ∼8 weeks in the 1970s to more than 20 weeks . The initial descriptions of behavioral treatment of obesity used an individual therapy format, but by the mid‐1990s, most ILIs utilized group therapy to deliver the intervention. Most experts concluded that at least 2 years of ILI was needed to prevent weight regain . The health benefits of weight loss had been established, and the National Institutes of Health (NIH) initiated a series of large‐scale, multisite RCTs that investigated the efficacy of lifestyle interventions for weight loss and prevention of obesity‐related problems.

The process of refining and maximizing the effectiveness of lifestyle interventions began with the design and implementation of the Diabetes Prevention Program (DPP) in 1994. The next section summarizes the evolution and effectiveness of ILIs over the past 2 decades, based on four important studies (DPP, Look AHEAD [Action for Health in Diabetes], POUNDS Lost [Preventing Obesity Using Novel Dietary Strategies], CALERIE [Comprehensive Assessment of Long term Effects of Reducing Intake of Energy]) that investigated the effect of ILIs on weight changes and health outcomes. While there are many other studies that could be highlighted, these four studies developed ILIs that built upon each other. For example, the ILI design of Look AHEAD was based primarily on the lifestyle intervention tested in the DPP study . The ILIs of the POUNDS Lost and CALERIE studies were designed using the content and structure of the Look AHEAD and DPP interventions . Table 1 describes the designs, participant characteristics, and outcomes of these four studies.

All outcome data, with the exception of data related to POUNDS Lost, pertain to comparisons with a control arm. All comparisons were statistically significant, P  < 0.05. All data pertaining to changes in weight or improved health reflect within‐group changes from baseline that were statistically significant, P < 0.05. Effect sizes for these statistically significant differences ranged from small (Cohen's d > 0.20) to large (Cohen's d > 0.80). DPP, Diabetes Prevention Program; Look AHEAD, Action for Health in Diabetes; POUNDS Lost, Preventing Obesity Using Novel Dietary Strategies; CALERIE, Comprehensive Assessment of Long term Effects of Reducing Intake of Energy; Tx, treatment, L, low; A, average, prot, protein; WL, average weight loss; % ≥ 5%, percent subjects who lost ≥5% weight; Un, unavailable; QOL; quality of life; CVD, cardiovascular disease.

DPP

The methods of DPP were first reported in 1999 and the primary results were published in 2002 . A description of DPP's ILI was provided in 2002 . DPP found that modest (∼7%) average reductions of body weight that were sustained (∼5%) for 3.2 years could significantly delay the onset of type 2 diabetes in adults who were at high risk for developing diabetes, now called prediabetes . After completion of the initial DDP trial, the DPP Observation Study was initiated, and participants were followed for 10 years. Over the course of those 10 years, the participants in the original ILI gradually regained weight that had been lost. Their final average weight loss was ∼2% below baseline, however. An important finding was that in the initial ILI group, the onset of type 2 diabetes was significantly delayed in comparison to the original placebo group , and CVD risk factors were significantly improved . Thus, the DPP study found that prevention of diabetes and improvement of CVD risk factors with ILI can persist for 10 years. The cost of the ILI was $1,826 during the first year and averaged $305 each year afterward . The ILI was also found to be cost‐effective in comparison to placebo medication after 10 years of follow‐up .

Look AHEAD

Planning for Look AHEAD began in the early 2000s. A description of the Look AHEAD ILI was published in 2006 , and a series of papers were published during the next 8 years, with the 8‐year weight loss outcomes reported in 2014 . The study recruited adults with overweight and obesity who had been diagnosed with type 2 diabetes. In comparison to a control group, the primary findings of Look AHEAD were as follows: ILI resulted in significantly greater weight loss after 1 year (∼9%) and after 8 years (∼5%) of long‐term treatment; weight changes were associated with a wide variety of improved health indicators, ranging from improved CVD risk factors to improved quality of life, but did not reduce the incidence of CVD events such as heart attacks and stroke; improvement of health indicators was sustained for 8 years; and overall medical costs of the ILI arm were significantly lower. During the first year, the ILI cost was $2,865, and it averaged $1,120 during years 5 to 9 . Average weight loss was robust, with equal success over a variety of subgroups.

POUNDS Lost

Planning for POUNDS Lost began in the mid‐2000s, and the primary outcome paper was published in 2009 . This RCT compared four macronutrient diet prescriptions for weight loss, differing in terms of the percentages of carbohydrates, proteins, and fats that were prescribed using diets with four different macronutrient compositions. The same ILI was used in all four treatment arms. The study included medically healthy adults with overweight and obesity. The study duration was 2 years, and no differences in weight changes were observed across the four diets. All four macronutrient diets required caloric restriction and were associated with ∼8% weight loss after 1 year and ∼6% weight loss after 2 years. Improvement of CVD risk factors was observed after 2 years of ILI. Early adherence, e.g., attendance and self‐monitoring, was significantly associated with short‐term and long‐term weight loss .

CALERIE

The CALERIE study was a multisite RCT that compared caloric restriction to a control group over 2 years . The study began in 2007 and included healthy adults who had either normal weight or overweight (BMI 22‐28). A description of the intensive lifestyle intervention of CALERIE was published in 2011 . In comparison to a control group, primary outcomes were as follows: ILI resulted in significantly greater average weight loss after 1 year (∼11%), which was sustained (∼10%) after 2 years; improvement of health indicators (CVD risk factors, quality of life, metabolic measures) was observed for ILI; and some biomarkers for aging were improved.

Summary

Over the past 2 decades, the methodology for delivering highly effective ILIs for overweight and obesity in adults has advanced, exemplified by the four multisite, NIH‐sponsored clinical trials highlighted in this section. Several important conclusions regarding ILIs are warranted from the findings of these four studies: Modest but clinically meaningful weight loss and improved health can be achieved; the types of adults who were responsive were very diverse; weight losses and health improvements were sustained for 2 to 8 years after beginning the initial ILI; variability of results (% achieving 5% weight loss; Table 1) was observed across studies; no significant adverse effects were reported, even in adults without obesity; and initial costs of clinic‐based ILI exceeded $1,000 per year, though these cost estimates may be higher than those of most ILIs .

Evolution of ILI components: DPP, Look AHEAD, POUNDS Lost, and CALERIE

Table 2 summarizes some of the components of the ILIs tested in the four studies. The ILI of the DPP study established the essential elements of studies that followed. As illustrated in Table 2, the studies following DPP introduced additional components to the intervention.

DPP, Diabetes Prevention Program; Look AHEAD, Action for Health in Diabetes; POUNDS Lost, Preventing Obesity Using Novel Dietary Strategies; CALERIE, Comprehensive Assessment of Long term Effects of Reducing Intake of Energy; indiv, individual; MR, meal replacement; CR, caloric restriction; FI, fat intake; C/RG, campaign/refresher groups, FU, follow‐up, sess, session; Y3+, year 3 and beyond; CTS, computer tracking system; ILI, intensive lifestyle intervention.

Duration of core ILI

One difference across the studies is that the number of sessions and the overall duration of the core ILI curriculum systematically increased over time.

Group versus individual counseling

The initial study of a behavioral/lifestyle intervention for obesity utilized individual counseling. Over the next 30 years, studies used group counseling more often . By the initiation of DPP, some ILIs used only individual counseling, some only group counseling, and occasionally some used both. Two of the ILIs summarized in Table 2 emphasized individual counseling, and the other two emphasized group counseling to deliver the core curriculum. The DPP's ILI exclusively used individual counseling (during the first 6 months), and the other three studies used a combination of individual and group counseling, with ratios ranging from two group sessions and two individual sessions per month (CALERIE) to seven group sessions and one individual session every 2 months (POUNDS Lost).

Diet and exercise goals/prescriptions

A strategy that was consistent across the four studies was a diet prescription that restricted caloric intake below baseline caloric intake (usually by about 500‐750 kcal). The DPP study also prescribed strategies to reduce fat intake. Prescriptions for physical activity have generally been expressed as minutes of exercise above routine activity. As shown in Table 2, the exercise prescription varied considerably across the four studies (90‐175 min/wk), including no exercise prescription in the CALERIE study.

Duration of the ILI

As shown in Table 2, the trend toward increasing length of ILI treatment persisted into the 21st century, ranging from 24 weeks for the core DPP ILI and 2 years for the ILIs of the POUNDS Lost and CALERIE studies.

Use of meal replacements

In recent years, ILIs have tended to use meal replacements or provision of prepared foods to facilitate adherence to a calorically restricted diet. Two of the four studies, Look AHEAD and CALERIE, used meal replacements. In Look AHEAD, a meal replacement program was encouraged for much of the first 5 months; after that, meal replacements were used to assist participants who were having difficulty following the prescribed diet. In CALERIE, specially prepared foods were provided for the first 4 weeks. After that, prepared foods or meal replacements were provided for those who struggled to maintain a 25% calorically restricted diet.

Toolbox strategies

All four ILIs employed strategies to individualize the intervention to address specific lifestyle problems that were encountered by participants .

Computer tracking system (CTS)

In the past 2 decades, computer technology has rapidly advanced. All four of these studies utilized some form of CTS to monitor progress and/or adherence. As might be expected, the sophistication of this computer technology improved over the course of these four studies . Methodology for using CTS data to define adherence to an ILI has also been described .

Mathematical models of weight loss

Most modern ILIs have monitored changes in body weight over time to evaluate progress toward weight loss . Several investigators, e.g., Pieper et al. and Thomas et al. , have developed mathematical models of weight loss over time that can be applied to individuals who differ in sex, height, and weight during 2 years of treatment. By comparing actual weight loss to the weight loss predicted by these models , the counselor can evaluate whether weight loss is progressing as expected versus being too slow or too fast. Toolbox strategies can be applied to address deviation from expected weight loss trajectories. Of the four studies, only the CALERIE study employed this strategy.

Use of campaigns/refresher groups during follow‐up

Individual and group counseling can be used during follow‐up, but this strategy is expensive and time consuming. Another approach is to develop "open" groups that can be attended by anyone who has completed year 1. Two studies, DPP and Look AHEAD, used this approach and coined the terms "campaigns" and "refresher groups" . These special open groups were limited to approximately 4 to 8 weeks and focused on specific themes, e.g., resistance training or nighttime eating/snacking. These special groups were conducted two to three times per year and were used as one component of weight maintenance strategies. In contrast, the POUNDS Lost and CALERIE studies continued individual and group counseling sessions during year 2 and did not use campaigns or refresher groups.

Total number of individual and group counseling sessions

For the DPP ILI, it was common to schedule at least 15 individual or group sessions within the first 6 months of the intervention, with a tapering of total sessions over the next 6 months to several years. Examination of the lower sections of Table 1 illustrates how this strategy was employed in each of the four studies. Each of the ILIs following the DPP study utilized more scheduled sessions and included a combination of group and individual counseling.

Summary

Tables 1 and 2 illustrate that from DPP to CALERIE, there was a trend toward increased intensity of the intervention that was accompanied by increased efficacy, as indicated by improved average weight loss. Over the 15 years summarized in Tables 1 and 2, ILIs became more sophisticated, e.g., by using computer technology to track behavioral and weight changes and to provide feedback about adherence. Thus, by 2010, the efficacy of clinic‐based ILIs had been established; but they were costly, inconvenient, and not sustainable as a public health initiative .

Relationship of adherence to ILI components and weight loss

One of the key features of behavioral/lifestyle intervention for obesity is the inclusion of interrelated sessions that are designed to maximize adherence to the components of the program. Enhanced adherence has been found to increase weight loss and health benefits. In the Look AHEAD trial, three behavioral factors were associated with greater weight loss during year 1: session attendance, minutes of self‐reported physical activity, and number of meal replacements consumed . In the POUNDS Lost study, indicators of adherence during the first 6 months of the ILI were highly correlated and significantly predicted weight loss at 6 and 24 months . In a meta‐analysis of community‐based DPP interventions, Ali et al. reported a strong ( r  = 0.90) correlation between program attendance and weight loss. Thus, attendance to sessions has been a consistent and strong predictor of weight loss. To put this into context, the Look AHEAD study reported attendance to sessions in year 1 to be 84% , which translates to approximately 27 sessions attended on average during the first year. The CALERIE study had very high attendance during year 1, with 99% attendance to individual sessions (average = 26 sessions) and 81% attendance to group sessions (average = 18 sessions). Thus, in the CALERIE study, attendance to sessions during the first year averaged 44 sessions.

Where Are We Going?

Recent recommendations about the structure of effective intensive lifestyle interventions

Since the original Stuart paper , hundreds of RCTs and smaller clinical studies have investigated the efficacy of multicomponent ILIs . What are the key components of effective ILI? This question has been addressed in two recent reviews . Both reviews concluded that effective ILI for initial weight loss must be at least 20 weeks in duration with at least 14 contacts during this period. There was general agreement about the content and structure of the ILI. The intervention program should include the following: a calorically restricted diet prescription, regular and intense exercise programs, educational presentations, self‐monitoring (food intake, physical activity, and body weight), feedback from counselors, individual and/or group counseling, and a variety of components to promote adherence to the ILI (e.g., problem‐solving, cognitive restructuring, meal planning, etc.). They also emphasized the potential importance of using meal replacement or structured meal programs. Both reports concluded that ILI could be delivered via face‐to‐face counseling sessions, telephone contact, or using the internet.

Similar conclusions were derived for weight loss maintenance. Both papers concluded that weight loss maintenance ILI should last at least 1 year (after conclusion of the core ILI during the first year) and that contact should be at least monthly to every other week. Also, both reports recommended frequent weighing and the development of weight self‐regulation skills. They also recommended continued calorically restricted diets and intense and regular exercise (>200 min/wk). Individual and/or group counseling was recommended along with a structured program to prevent relapse. The 2013 Guidelines Committee recommended delivery of ILI for weight maintenance via face‐to‐face counseling or via telephone, but did not recommend dissemination via the internet or mobile devices.

Recent developments: official recognition of efficacy of ILIs

CDC Diabetes Prevention Recognition Program

Based on the seminal results of the DPP study , in 2011, the Centers for Disease Control (CDC) developed a pilot program to formally recognize programs that were similar in content and structure to the ILI of the DPP study . This program was named the CDC Diabetes Prevention Recognition Program (DPRP). The final DPRP criteria were published in 2015 . Prior to 2015, there were many calls for the development of sustainable, cost‐effective programs that might delay the onset of type 2 diabetes, as had been reported in the 2002 DDP paper (40‐42,46). The aim of the DPRP was to recognize programs that delivered proven type 2 diabetes prevention lifestyle interventions and therefore promoted the development of sustainable, cost‐effective lifestyle interventions that could be implemented in community settings. Starting in 2015, DPRP programs could be conducted using digital/internet‐based approaches . There are many requirements for DPRP recognition, but for this discussion, several criteria are important. First, participants in the program must be screened to meet a priori criteria for prediabetes. Second, the program curriculum (regardless of delivery mode) has to include 16 sessions in the first 6 months that are directly modeled after the original DPP curriculum. Completion of this phase is defined as attending at least nine of the 16 sessions. Third, during months 7 to 12, the program must include at least one session in each of the 6 months that match the prescribed content from 15 acceptable topics. Completion of this phase is defined as attending at least three of the six sessions. Fourth, the duration of the program must be at least 12 months. In 2016, the CDC disseminated a model curriculum (called Prevent T2) that, if adopted, will partially fulfill the requirements for DPP recognition. A recent report reported promising outcomes‐based results from the first 4 years of the program.

US Preventive Services Task Force (USPSTF) recommendations

The USPSTF makes recommendations about the effectiveness of specific interventions based on evidence and provides a letter grade (A, B, C, D, I) for the quality of the evidence. As a part of the Affordable Care Act, grades of A or B for a service require health insurers to cover, at no cost to the patient, that service, regardless of cost. In 2014 , the USPSTF recommended that ILIs for obesity with additional CVD comorbidity were sufficiently efficacious (grade B) to be covered under Affordable Care Act guidelines. The USPSTF recommended at least 5 to 16 sessions over a 9‐ to 12‐month period and specified the content similar to the core curriculum of the DPP ILI. Furthermore, the recommendation is not made for medically healthy patients who also have overweight or obesity, but it is not limited to people diagnosed with prediabetes (impaired fasting glucose). For example, a patient with overweight and one CVD risk factor, e.g., hypertension or high cholesterol, but who does not meet criteria for prediabetes would qualify for care using the USPSTF recommendations. A recent economic analysis indicated that the recommendations should be cost‐effective, especially for adults with overweight or obesity who have at least one CVD risk factor .

Medicare diabetes prevention program expanded model

Recently, the Centers for Medicare and Medicaid Services approved the use of ILI for treatment of patients with obesity with Medicare Part B who are diagnosed with prediabetes using blood chemistry tests. This new initiative is scheduled to begin in January 2018. To qualify for reimbursement, the program has to offer 1 year of ILI with 16 sessions in months 1 to 6 and 6 sessions in months 7 to 12. Programs must also be fully recognized by the CDC DPRP. Thus, the new Medicare program will treat patients with overweight or obesity who are also diagnosed with prediabetes.

Summary

These three recent developments mean that at least some patients with obesity can receive ILI treatment and the provider can be reimbursed for the services rendered. Thus, for the first time in the history of medicine in the United States, behavioral/lifestyle interventions for certain cases of obesity have been determined to be sufficiently efficacious to warrant payment by health insurers and the US government. This is a monumental moment in the overall struggle to transition behavioral/lifestyle treatment for overweight and obesity from interventions for overeating to mainstream medical care.

Where do we go from here: some remaining questions

The rapidly increasing prevalence of obesity in the United States and most of the world has been amply documented . For years, most people and even most health care providers viewed obesity to be an intractable and essentially untreatable disorder . As obesity became recognized as a medical problem that could be treated using behavioral and medical interventions, this perception has gradually begun to change.

As noted in this overview of the history of ILIs, health care researchers have developed one safe and effective method for achieving at least 5% weight loss for most adults with overweight or obesity from all walks of life. This approach is structured to systematically modify lifestyle behaviors related to nutrition and physical activity. As illustrated in Table 2, the common components of successful ILIs have been established. According to several expert panels, successful ILIs need to be intensive (at least 14 sessions over the first 6 months) and should include programs to develop the skills that are necessary to maintain long‐term adherence to changed habits pertaining to diet and physical activity.

Recently, two expert panels and government services have endorsed ILIs for the prevention of type 2 diabetes , and another recommended ILI for the treatment of comorbid CVD conditions associated with obesity. This recognition is both welcome news and a reflection of the many efforts by scientists over the past 50 years. As we pause and reflect, several cautionary observations are warranted:

1. Recent recognition approves ILIs for the prevention of type 2 diabetes and for the treatment of medical conditions that are common comorbidities of obesity. They do not, however, advocate the use of ILIs for the treatment of comorbidities associated with diagnosed type 2 diabetes or for medically healthy patients with obesity who are likely to progress toward prediabetes and/or the metabolic syndrome .

2. The content and structure of all three recommendations (CDC DPRP, USPSTF, and Centers for Medicare and Medicaid Services) are modeled using the core curriculum of the DPP ILI. As shown in Table 1, major studies planned after DPP all designed ILIs that were even more intensive than the DPP ILI. Also, they systematically enhanced the duration and structure of the new ILIs; e.g., they added the use of meal replacements and the use of mathematical models of weight loss. We do not know whether adding new components and greater intensity to the DPP ILI will produce greater weight loss and/or superior prevention or treatment of disease .

3. All three recent recommendations limit the duration of ILIs to 1 year. They make no recommendation beyond the first year of treatment, despite the fact that the DPP study and most other similar studies of ILIs over the past decade have investigated the impact of lifestyle modification for at least 2 years. There seems to be an implicit assumption in the major studies that sustained weight loss is needed to prevent or treat disease. Furthermore, ILIs of short duration have consistently been found to result in significant weight regain. The necessity of long‐term care needs further study. Does longer treatment generate a superior health outcome? The practical and economic implications of this question loom large.

4. There have been many calls to translate the strategies of studies such as those of DPP and Look AHEAD into sustainable, lower‐cost interventions for the public. This call for real‐world interventions has often been translated into the development of internet‐based or smart phone applications that follow the core curriculum of DPP. Evidence concerning the efficacy of these translational studies has recently emerged. In a recent review of these studies , an expert panel concluded that the weight loss associated with online ILIs with (usually asynchronous) human counseling was lower than that observed in in‐person clinical studies such as those summarized in Tables 1 and 2. The panel also noted that limited evidence concerning the efficacy of fully automated online programs indicated very poor efficacy. These programs generally follow the CDC DPRP guidelines, which, as noted earlier, are not as intense as the core curriculum of DPP or of the other studies conducted after DPP (see Table 1). From a population health perspective, this lower efficacy may be tolerable or even desirable, if these sustainable programs reach larger populations than can be accomplished using clinic‐based, in‐person counseling.

Summary and Future Directions

Over the past 50 years, ILIs for management of weight have progressed from a promising new strategy to accepted mainstream treatment for overweight/obesity and associated medical disorders. This progress comes from the diligence and dedication of the investigators of hundreds of controlled studies .

There is general acceptance that ILIs are best conceptualized as treatment packages that draw synergy from an organized, coordinated set of components . This conclusion begs a question: what are the necessary components of effective ILIs? There have been few scientific efforts to dismantle ILIs, but the question calls for speculation. The CALERE ILI resulted in the highest average weight loss and weight loss maintenance of the four studies summarized in Tables 1 and 2. CALERIE provides the following clues: Computer technology was used to enhance adherence to caloric restriction, participants were screened before enrollment to maximize adherence and retention, increased physical activity was not emphasized, and intense individual and group counseling was continued for 2 years. In another recent study, Martin and colleagues reported the successful use of mathematical models of weight loss without extensive human counseling to induce short‐term weight loss. Similar to CALERIE, this study used mathematical models of weight loss to assess adherence and to reinforce consistent behavior change over time. The results of these two studies suggest that ILI components that enhance adherence, especially to changes in nutrition, and guide weight loss over time should be studied as key features of ILIs.

Another question: Who benefits most from ILIs? The answer to this question may also lead to adherence as a potential answer; those with the best adherence are those who respond most positively . As shown in Table 2, all four studies conducted pre‐enrollment screening interviews and required 2 weeks of self‐monitoring to be eligible for participation. These strategies were designed to identify barriers to adherence and retention. ILIs are generally more effective for older adults (> 65 years) , possibly because they have more time to adhere to the ILI protocol.

Thus, it seems likely that components designed to enhance adherence (before and during the ILI) may be important components of effective ILIs. An important question for the future is how to enhance adherence while simultaneously lowering the intensity and costs of ILIs to make them sustainable in the real world . Artificial intelligence (AI) is often touted as a technical advance that could reduce the use of human counselors and therefore greatly reduce costs and substantially enhance scalability of counseling programs . Use of AI as opposed to human counselors raises an important question: Can AI replace the human capacity to think creatively and respond to the limitless contingencies that arise in the weight management counseling environment? The answer to the question appears to be no; AI is not sufficiently advanced to supplant the need for human counseling. For example, a recent report concluded that 21 of 25 (84%) digital diabetes prevention and management programs (addressing modification of diet, activity, and/or weight) used live human counseling as a part of the intervention. In fact, one of the most intensively studied uses of AI in an ILI includes live human counseling in addition to AI . Use of streaming media may be another answer to this conundrum, and it is more fully developed than AI. Even the use of streaming appears to necessitate the use of human counseling, however . Thus, for the foreseeable future, it is likely that human counselors will be needed to deliver ILIs to maximize adherence . Delivery of effective ILI with only minimal human interaction may be possible, however . Such speculation is exciting but also requires empirical study; let us look to the future.

Acknowledgments

The author expresses gratitude to all of the staff and participants of the key studies that were reviewed in this paper. In particular, the efforts of the principal investigators and the NIH deserve special recognition for guiding this research over the past 2 decades.

Abstract

Objective

This paper reviews the literature pertaining to the structure and content of intensive lifestyle interventions (ILIs) for overweight/obesity since Richard Stuart described this new treatment approach in 1967. A consensus opinion has formed that behavioral/lifestyle treatment of overweight and obesity should be viewed as a mainstream intervention for the treatment and prevention of type 2 diabetes and medical complications associated with obesity.

Methods

The development of modern ILIs and demonstration of their efficacy are compared by structure, content, and efficacy of four major randomized controlled trials: Diabetes Prevention Program (DPP), Look AHEAD, POUNDS Lost, and CALERIE.

Results

The results of these studies indicated that modification of lifestyle behaviors related to nutrition and physical activity can yield weight loss and prevention or improvement of a variety of medical conditions associated with obesity in a variety of subpopulations.

Conclusions

Recommendations for the structure and length of behavioral/lifestyle interventions have been recently adopted by agencies and institutions that approve reimbursement for medical services. These recommendations represent a giant step in the effort to recognize ILIs as a mainstream approach for the treatment of obesity and comorbid medical conditions. Nevertheless, they do not adequately represent advances made since the publication of the DPP results.

Introduction

In 1967, Richard Stuart published the first paper to describe the behavioral treatment of overeating, presenting the weight loss results of eight patients with obesity treated during a 12‐month period. Four years later , he described a "three‐dimensional program" of behavioral treatment for obesity with many of the components of modern lifestyle interventions: environmental interventions to strengthen healthy eating and decrease sedentary behavior, structured exercise programs to increase physical activity, and dietary programs to decrease caloric intake. The behavioral intervention was delivered using individual counseling with 16 to 41 sessions aver a 12‐month period . Weight loss was described as being continuous over 12 months, averaging between 0.60 and 0.70 pounds per week , resulting in average 12‐month weight losses between 35 and 40 pounds. Most contemporary professionals were pessimistic about the successful treatment of obesity . In the past 50 years, behavioral/lifestyle treatment for obesity has been intensely studied and has gone through many iterations. There were early concerns that weight loss effects were too short‐lived . Nevertheless, clinical research on this approach has continued. This paper describes the evolution of this research, starting with a discussion about how obesity came to be regarded as a medical problem.

Where Have We Been?

How obesity became recognized as a medical problem

For much of human history, many people were lean or underweight. Nevertheless, the presence of excess adiposity, even in ancient civilizations, has been well documented . By the 18th century, being overweight, or "corpulent," was associated with health and high social standing, though medical consequences of obesity were recognized . During the 20th century, the abundance of food was such that most people could finally achieve a "normal" weight, though stigma was attached to having obesity . Obesity was viewed as a cosmetic problem associated with gluttony, laziness, and low self‐discipline . By 1940, scientists began to note the relationships between obesity, type 2 diabetes, and a variety of cardiovascular disease (CVD) risk factors . In 1988, Gerald M. Reaven formally hypothesized a Syndrome X that linked insulin resistance (a feature of type 2 diabetes) with a range of medical conditions. Syndrome X became known as the metabolic syndrome , which was strongly associated with the presence of overweight and obesity . By 2000, most scientists and clinicians had concluded that obesity was best regarded as a medical problem as opposed to a cosmetic problem . Also, the human race reached a landmark: more than half of the population had overweight or obesity . This phenomenon has been called the global epidemic of obesity . This paper summarizes the evolution of one approach for the treatment of obesity and related problems: intensive lifestyle intervention (ILI).

Evolution of behavioral/lifestyle interventions for obesity‐related medical problems

In 1980, Albert Stunkard published one of the first modern texts on obesity. A variety of treatments were described: diets, exercise, drugs, psychoanalysis, self‐help, gastric bypass, and behavior modification. Stunkard described behavior modification as a "treatment modality that has aroused much initial enthusiasm" . In 1972, Stuart and Davis published the first treatment guide for intensive lifestyle modification for weight management . Over the next 25 years, more than 70 randomized controlled trials (RCTs) were published that validated this approach as effective for weight management, and the length of treatment increased from ∼8 weeks in the 1970s to more than 20 weeks . The initial descriptions of behavioral treatment of obesity used an individual therapy format, but by the mid‐1990s, most ILIs utilized group therapy to deliver the intervention. Most experts concluded that at least 2 years of ILI was needed to prevent weight regain . The health benefits of weight loss had been established, and the National Institutes of Health (NIH) initiated a series of large‐scale, multisite RCTs that investigated the efficacy of lifestyle interventions for weight loss and prevention of obesity‐related problems.

The process of refining and maximizing the effectiveness of lifestyle interventions began with the design and implementation of the Diabetes Prevention Program (DPP) in 1994. The next section summarizes the evolution and effectiveness of ILIs over the past 2 decades, based on four important studies (DPP, Look AHEAD [Action for Health in Diabetes], POUNDS Lost [Preventing Obesity Using Novel Dietary Strategies], CALERIE [Comprehensive Assessment of Long term Effects of Reducing Intake of Energy]) that investigated the effect of ILIs on weight changes and health outcomes. While there are many other studies that could be highlighted, these four studies developed ILIs that built upon each other. For example, the ILI design of Look AHEAD was based primarily on the lifestyle intervention tested in the DPP study . The ILIs of the POUNDS Lost and CALERIE studies were designed using the content and structure of the Look AHEAD and DPP interventions . Table 1 describes the designs, participant characteristics, and outcomes of these four studies.

All outcome data, with the exception of data related to POUNDS Lost, pertain to comparisons with a control arm. All comparisons were statistically significant, P  < 0.05. All data pertaining to changes in weight or improved health reflect within‐group changes from baseline that were statistically significant, P < 0.05. Effect sizes for these statistically significant differences ranged from small (Cohen's d > 0.20) to large (Cohen's d > 0.80). DPP, Diabetes Prevention Program; Look AHEAD, Action for Health in Diabetes; POUNDS Lost, Preventing Obesity Using Novel Dietary Strategies; CALERIE, Comprehensive Assessment of Long term Effects of Reducing Intake of Energy; Tx, treatment, L, low; A, average, prot, protein; WL, average weight loss; % ≥ 5%, percent subjects who lost ≥5% weight; Un, unavailable; QOL; quality of life; CVD, cardiovascular disease.

DPP

The methods of DPP were first reported in 1999 and the primary results were published in 2002 . A description of DPP's ILI was provided in 2002 . DPP found that modest (∼7%) average reductions of body weight that were sustained (∼5%) for 3.2 years could significantly delay the onset of type 2 diabetes in adults who were at high risk for developing diabetes, now called prediabetes . After completion of the initial DDP trial, the DPP Observation Study was initiated, and participants were followed for 10 years. Over the course of those 10 years, the participants in the original ILI gradually regained weight that had been lost. Their final average weight loss was ∼2% below baseline, however. An important finding was that in the initial ILI group, the onset of type 2 diabetes was significantly delayed in comparison to the original placebo group , and CVD risk factors were significantly improved . Thus, the DPP study found that prevention of diabetes and improvement of CVD risk factors with ILI can persist for 10 years. The cost of the ILI was $1,826 during the first year and averaged $305 each year afterward . The ILI was also found to be cost‐effective in comparison to placebo medication after 10 years of follow‐up .

Look AHEAD

Planning for Look AHEAD began in the early 2000s. A description of the Look AHEAD ILI was published in 2006 , and a series of papers were published during the next 8 years, with the 8‐year weight loss outcomes reported in 2014 . The study recruited adults with overweight and obesity who had been diagnosed with type 2 diabetes. In comparison to a control group, the primary findings of Look AHEAD were as follows: ILI resulted in significantly greater weight loss after 1 year (∼9%) and after 8 years (∼5%) of long‐term treatment; weight changes were associated with a wide variety of improved health indicators, ranging from improved CVD risk factors to improved quality of life, but did not reduce the incidence of CVD events such as heart attacks and stroke; improvement of health indicators was sustained for 8 years; and overall medical costs of the ILI arm were significantly lower. During the first year, the ILI cost was $2,865, and it averaged $1,120 during years 5 to 9 . Average weight loss was robust, with equal success over a variety of subgroups.

POUNDS Lost

Planning for POUNDS Lost began in the mid‐2000s, and the primary outcome paper was published in 2009 . This RCT compared four macronutrient diet prescriptions for weight loss, differing in terms of the percentages of carbohydrates, proteins, and fats that were prescribed using diets with four different macronutrient compositions. The same ILI was used in all four treatment arms. The study included medically healthy adults with overweight and obesity. The study duration was 2 years, and no differences in weight changes were observed across the four diets. All four macronutrient diets required caloric restriction and were associated with ∼8% weight loss after 1 year and ∼6% weight loss after 2 years. Improvement of CVD risk factors was observed after 2 years of ILI. Early adherence, e.g., attendance and self‐monitoring, was significantly associated with short‐term and long‐term weight loss .

CALERIE

The CALERIE study was a multisite RCT that compared caloric restriction to a control group over 2 years . The study began in 2007 and included healthy adults who had either normal weight or overweight (BMI 22‐28). A description of the intensive lifestyle intervention of CALERIE was published in 2011 . In comparison to a control group, primary outcomes were as follows: ILI resulted in significantly greater average weight loss after 1 year (∼11%), which was sustained (∼10%) after 2 years; improvement of health indicators (CVD risk factors, quality of life, metabolic measures) was observed for ILI; and some biomarkers for aging were improved.

Summary

Over the past 2 decades, the methodology for delivering highly effective ILIs for overweight and obesity in adults has advanced, exemplified by the four multisite, NIH‐sponsored clinical trials highlighted in this section. Several important conclusions regarding ILIs are warranted from the findings of these four studies: Modest but clinically meaningful weight loss and improved health can be achieved; the types of adults who were responsive were very diverse; weight losses and health improvements were sustained for 2 to 8 years after beginning the initial ILI; variability of results (% achieving 5% weight loss; Table 1) was observed across studies; no significant adverse effects were reported, even in adults without obesity; and initial costs of clinic‐based ILI exceeded $1,000 per year, though these cost estimates may be higher than those of most ILIs .

Evolution of ILI components: DPP, Look AHEAD, POUNDS Lost, and CALERIE

Table 2 summarizes some of the components of the ILIs tested in the four studies. The ILI of the DPP study established the essential elements of studies that followed. As illustrated in Table 2, the studies following DPP introduced additional components to the intervention.

DPP, Diabetes Prevention Program; Look AHEAD, Action for Health in Diabetes; POUNDS Lost, Preventing Obesity Using Novel Dietary Strategies; CALERIE, Comprehensive Assessment of Long term Effects of Reducing Intake of Energy; indiv, individual; MR, meal replacement; CR, caloric restriction; FI, fat intake; C/RG, campaign/refresher groups, FU, follow‐up, sess, session; Y3+, year 3 and beyond; CTS, computer tracking system; ILI, intensive lifestyle intervention.

Duration of core ILI

One difference across the studies is that the number of sessions and the overall duration of the core ILI curriculum systematically increased over time.

Group versus individual counseling

The initial study of a behavioral/lifestyle intervention for obesity utilized individual counseling. Over the next 30 years, studies used group counseling more often . By the initiation of DPP, some ILIs used only individual counseling, some only group counseling, and occasionally some used both. Two of the ILIs summarized in Table 2 emphasized individual counseling, and the other two emphasized group counseling to deliver the core curriculum. The DPP's ILI exclusively used individual counseling (during the first 6 months), and the other three studies used a combination of individual and group counseling, with ratios ranging from two group sessions and two individual sessions per month (CALERIE) to seven group sessions and one individual session every 2 months (POUNDS Lost).

Diet and exercise goals/prescriptions

A strategy that was consistent across the four studies was a diet prescription that restricted caloric intake below baseline caloric intake (usually by about 500‐750 kcal). The DPP study also prescribed strategies to reduce fat intake. Prescriptions for physical activity have generally been expressed as minutes of exercise above routine activity. As shown in Table 2, the exercise prescription varied considerably across the four studies (90‐175 min/wk), including no exercise prescription in the CALERIE study.

Duration of the ILI

As shown in Table 2, the trend toward increasing length of ILI treatment persisted into the 21st century, ranging from 24 weeks for the core DPP ILI and 2 years for the ILIs of the POUNDS Lost and CALERIE studies.

Use of meal replacements

In recent years, ILIs have tended to use meal replacements or provision of prepared foods to facilitate adherence to a calorically restricted diet. Two of the four studies, Look AHEAD and CALERIE, used meal replacements. In Look AHEAD, a meal replacement program was encouraged for much of the first 5 months; after that, meal replacements were used to assist participants who were having difficulty following the prescribed diet. In CALERIE, specially prepared foods were provided for the first 4 weeks. After that, prepared foods or meal replacements were provided for those who struggled to maintain a 25% calorically restricted diet.

Toolbox strategies

All four ILIs employed strategies to individualize the intervention to address specific lifestyle problems that were encountered by participants .

Computer tracking system (CTS)

In the past 2 decades, computer technology has rapidly advanced. All four of these studies utilized some form of CTS to monitor progress and/or adherence. As might be expected, the sophistication of this computer technology improved over the course of these four studies . Methodology for using CTS data to define adherence to an ILI has also been described .

Mathematical models of weight loss

Most modern ILIs have monitored changes in body weight over time to evaluate progress toward weight loss . Several investigators, e.g., Pieper et al. and Thomas et al. , have developed mathematical models of weight loss over time that can be applied to individuals who differ in sex, height, and weight during 2 years of treatment. By comparing actual weight loss to the weight loss predicted by these models , the counselor can evaluate whether weight loss is progressing as expected versus being too slow or too fast. Toolbox strategies can be applied to address deviation from expected weight loss trajectories. Of the four studies, only the CALERIE study employed this strategy.

Use of campaigns/refresher groups during follow‐up

Individual and group counseling can be used during follow‐up, but this strategy is expensive and time consuming. Another approach is to develop "open" groups that can be attended by anyone who has completed year 1. Two studies, DPP and Look AHEAD, used this approach and coined the terms "campaigns" and "refresher groups" . These special open groups were limited to approximately 4 to 8 weeks and focused on specific themes, e.g., resistance training or nighttime eating/snacking. These special groups were conducted two to three times per year and were used as one component of weight maintenance strategies. In contrast, the POUNDS Lost and CALERIE studies continued individual and group counseling sessions during year 2 and did not use campaigns or refresher groups.

Total number of individual and group counseling sessions

For the DPP ILI, it was common to schedule at least 15 individual or group sessions within the first 6 months of the intervention, with a tapering of total sessions over the next 6 months to several years. Examination of the lower sections of Table 1 illustrates how this strategy was employed in each of the four studies. Each of the ILIs following the DPP study utilized more scheduled sessions and included a combination of group and individual counseling.

Summary

Tables 1 and 2 illustrate that from DPP to CALERIE, there was a trend toward increased intensity of the intervention that was accompanied by increased efficacy, as indicated by improved average weight loss. Over the 15 years summarized in Tables 1 and 2, ILIs became more sophisticated, e.g., by using computer technology to track behavioral and weight changes and to provide feedback about adherence. Thus, by 2010, the efficacy of clinic‐based ILIs had been established; but they were costly, inconvenient, and not sustainable as a public health initiative .

Relationship of adherence to ILI components and weight loss

One of the key features of behavioral/lifestyle intervention for obesity is the inclusion of interrelated sessions that are designed to maximize adherence to the components of the program. Enhanced adherence has been found to increase weight loss and health benefits. In the Look AHEAD trial, three behavioral factors were associated with greater weight loss during year 1: session attendance, minutes of self‐reported physical activity, and number of meal replacements consumed . In the POUNDS Lost study, indicators of adherence during the first 6 months of the ILI were highly correlated and significantly predicted weight loss at 6 and 24 months . In a meta‐analysis of community‐based DPP interventions, Ali et al. reported a strong ( r  = 0.90) correlation between program attendance and weight loss. Thus, attendance to sessions has been a consistent and strong predictor of weight loss. To put this into context, the Look AHEAD study reported attendance to sessions in year 1 to be 84% , which translates to approximately 27 sessions attended on average during the first year. The CALERIE study had very high attendance during year 1, with 99% attendance to individual sessions (average = 26 sessions) and 81% attendance to group sessions (average = 18 sessions). Thus, in the CALERIE study, attendance to sessions during the first year averaged 44 sessions.

Where Are We Going?

Recent recommendations about the structure of effective intensive lifestyle interventions

Since the original Stuart paper , hundreds of RCTs and smaller clinical studies have investigated the efficacy of multicomponent ILIs . What are the key components of effective ILI? This question has been addressed in two recent reviews . Both reviews concluded that effective ILI for initial weight loss must be at least 20 weeks in duration with at least 14 contacts during this period. There was general agreement about the content and structure of the ILI. The intervention program should include the following: a calorically restricted diet prescription, regular and intense exercise programs, educational presentations, self‐monitoring (food intake, physical activity, and body weight), feedback from counselors, individual and/or group counseling, and a variety of components to promote adherence to the ILI (e.g., problem‐solving, cognitive restructuring, meal planning, etc.). They also emphasized the potential importance of using meal replacement or structured meal programs. Both reports concluded that ILI could be delivered via face‐to‐face counseling sessions, telephone contact, or using the internet.

Similar conclusions were derived for weight loss maintenance. Both papers concluded that weight loss maintenance ILI should last at least 1 year (after conclusion of the core ILI during the first year) and that contact should be at least monthly to every other week. Also, both reports recommended frequent weighing and the development of weight self‐regulation skills. They also recommended continued calorically restricted diets and intense and regular exercise (>200 min/wk). Individual and/or group counseling was recommended along with a structured program to prevent relapse. The 2013 Guidelines Committee recommended delivery of ILI for weight maintenance via face‐to‐face counseling or via telephone, but did not recommend dissemination via the internet or mobile devices.

Recent developments: official recognition of efficacy of ILIs

CDC Diabetes Prevention Recognition Program

Based on the seminal results of the DPP study , in 2011, the Centers for Disease Control (CDC) developed a pilot program to formally recognize programs that were similar in content and structure to the ILI of the DPP study . This program was named the CDC Diabetes Prevention Recognition Program (DPRP). The final DPRP criteria were published in 2015 . Prior to 2015, there were many calls for the development of sustainable, cost‐effective programs that might delay the onset of type 2 diabetes, as had been reported in the 2002 DDP paper (40‐42,46). The aim of the DPRP was to recognize programs that delivered proven type 2 diabetes prevention lifestyle interventions and therefore promoted the development of sustainable, cost‐effective lifestyle interventions that could be implemented in community settings. Starting in 2015, DPRP programs could be conducted using digital/internet‐based approaches . There are many requirements for DPRP recognition, but for this discussion, several criteria are important. First, participants in the program must be screened to meet a priori criteria for prediabetes. Second, the program curriculum (regardless of delivery mode) has to include 16 sessions in the first 6 months that are directly modeled after the original DPP curriculum. Completion of this phase is defined as attending at least nine of the 16 sessions. Third, during months 7 to 12, the program must include at least one session in each of the 6 months that match the prescribed content from 15 acceptable topics. Completion of this phase is defined as attending at least three of the six sessions. Fourth, the duration of the program must be at least 12 months. In 2016, the CDC disseminated a model curriculum (called Prevent T2) that, if adopted, will partially fulfill the requirements for DPP recognition. A recent report reported promising outcomes‐based results from the first 4 years of the program.

US Preventive Services Task Force (USPSTF) recommendations

The USPSTF makes recommendations about the effectiveness of specific interventions based on evidence and provides a letter grade (A, B, C, D, I) for the quality of the evidence. As a part of the Affordable Care Act, grades of A or B for a service require health insurers to cover, at no cost to the patient, that service, regardless of cost. In 2014 , the USPSTF recommended that ILIs for obesity with additional CVD comorbidity were sufficiently efficacious (grade B) to be covered under Affordable Care Act guidelines. The USPSTF recommended at least 5 to 16 sessions over a 9‐ to 12‐month period and specified the content similar to the core curriculum of the DPP ILI. Furthermore, the recommendation is not made for medically healthy patients who also have overweight or obesity, but it is not limited to people diagnosed with prediabetes (impaired fasting glucose). For example, a patient with overweight and one CVD risk factor, e.g., hypertension or high cholesterol, but who does not meet criteria for prediabetes would qualify for care using the USPSTF recommendations. A recent economic analysis indicated that the recommendations should be cost‐effective, especially for adults with overweight or obesity who have at least one CVD risk factor .

Medicare diabetes prevention program expanded model

Recently, the Centers for Medicare and Medicaid Services approved the use of ILI for treatment of patients with obesity with Medicare Part B who are diagnosed with prediabetes using blood chemistry tests. This new initiative is scheduled to begin in January 2018. To qualify for reimbursement, the program has to offer 1 year of ILI with 16 sessions in months 1 to 6 and 6 sessions in months 7 to 12. Programs must also be fully recognized by the CDC DPRP. Thus, the new Medicare program will treat patients with overweight or obesity who are also diagnosed with prediabetes.

Summary

These three recent developments mean that at least some patients with obesity can receive ILI treatment and the provider can be reimbursed for the services rendered. Thus, for the first time in the history of medicine in the United States, behavioral/lifestyle interventions for certain cases of obesity have been determined to be sufficiently efficacious to warrant payment by health insurers and the US government. This is a monumental moment in the overall struggle to transition behavioral/lifestyle treatment for overweight and obesity from interventions for overeating to mainstream medical care.

Where do we go from here: some remaining questions

The rapidly increasing prevalence of obesity in the United States and most of the world has been amply documented . For years, most people and even most health care providers viewed obesity to be an intractable and essentially untreatable disorder . As obesity became recognized as a medical problem that could be treated using behavioral and medical interventions, this perception has gradually begun to change.

As noted in this overview of the history of ILIs, health care researchers have developed one safe and effective method for achieving at least 5% weight loss for most adults with overweight or obesity from all walks of life. This approach is structured to systematically modify lifestyle behaviors related to nutrition and physical activity. As illustrated in Table 2, the common components of successful ILIs have been established. According to several expert panels, successful ILIs need to be intensive (at least 14 sessions over the first 6 months) and should include programs to develop the skills that are necessary to maintain long‐term adherence to changed habits pertaining to diet and physical activity.

Recently, two expert panels and government services have endorsed ILIs for the prevention of type 2 diabetes , and another recommended ILI for the treatment of comorbid CVD conditions associated with obesity. This recognition is both welcome news and a reflection of the many efforts by scientists over the past 50 years. As we pause and reflect, several cautionary observations are warranted:

1. Recent recognition approves ILIs for the prevention of type 2 diabetes and for the treatment of medical conditions that are common comorbidities of obesity. They do not, however, advocate the use of ILIs for the treatment of comorbidities associated with diagnosed type 2 diabetes or for medically healthy patients with obesity who are likely to progress toward prediabetes and/or the metabolic syndrome .

2. The content and structure of all three recommendations (CDC DPRP, USPSTF, and Centers for Medicare and Medicaid Services) are modeled using the core curriculum of the DPP ILI. As shown in Table 1, major studies planned after DPP all designed ILIs that were even more intensive than the DPP ILI. Also, they systematically enhanced the duration and structure of the new ILIs; e.g., they added the use of meal replacements and the use of mathematical models of weight loss. We do not know whether adding new components and greater intensity to the DPP ILI will produce greater weight loss and/or superior prevention or treatment of disease .

3. All three recent recommendations limit the duration of ILIs to 1 year. They make no recommendation beyond the first year of treatment, despite the fact that the DPP study and most other similar studies of ILIs over the past decade have investigated the impact of lifestyle modification for at least 2 years. There seems to be an implicit assumption in the major studies that sustained weight loss is needed to prevent or treat disease. Furthermore, ILIs of short duration have consistently been found to result in significant weight regain. The necessity of long‐term care needs further study. Does longer treatment generate a superior health outcome? The practical and economic implications of this question loom large.

4. There have been many calls to translate the strategies of studies such as those of DPP and Look AHEAD into sustainable, lower‐cost interventions for the public. This call for real‐world interventions has often been translated into the development of internet‐based or smart phone applications that follow the core curriculum of DPP. Evidence concerning the efficacy of these translational studies has recently emerged. In a recent review of these studies , an expert panel concluded that the weight loss associated with online ILIs with (usually asynchronous) human counseling was lower than that observed in in‐person clinical studies such as those summarized in Tables 1 and 2. The panel also noted that limited evidence concerning the efficacy of fully automated online programs indicated very poor efficacy. These programs generally follow the CDC DPRP guidelines, which, as noted earlier, are not as intense as the core curriculum of DPP or of the other studies conducted after DPP (see Table 1). From a population health perspective, this lower efficacy may be tolerable or even desirable, if these sustainable programs reach larger populations than can be accomplished using clinic‐based, in‐person counseling.

Summary and Future Directions

Over the past 50 years, ILIs for management of weight have progressed from a promising new strategy to accepted mainstream treatment for overweight/obesity and associated medical disorders. This progress comes from the diligence and dedication of the investigators of hundreds of controlled studies .

There is general acceptance that ILIs are best conceptualized as treatment packages that draw synergy from an organized, coordinated set of components . This conclusion begs a question: what are the necessary components of effective ILIs? There have been few scientific efforts to dismantle ILIs, but the question calls for speculation. The CALERE ILI resulted in the highest average weight loss and weight loss maintenance of the four studies summarized in Tables 1 and 2. CALERIE provides the following clues: Computer technology was used to enhance adherence to caloric restriction, participants were screened before enrollment to maximize adherence and retention, increased physical activity was not emphasized, and intense individual and group counseling was continued for 2 years. In another recent study, Martin and colleagues reported the successful use of mathematical models of weight loss without extensive human counseling to induce short‐term weight loss. Similar to CALERIE, this study used mathematical models of weight loss to assess adherence and to reinforce consistent behavior change over time. The results of these two studies suggest that ILI components that enhance adherence, especially to changes in nutrition, and guide weight loss over time should be studied as key features of ILIs.

Another question: Who benefits most from ILIs? The answer to this question may also lead to adherence as a potential answer; those with the best adherence are those who respond most positively . As shown in Table 2, all four studies conducted pre‐enrollment screening interviews and required 2 weeks of self‐monitoring to be eligible for participation. These strategies were designed to identify barriers to adherence and retention. ILIs are generally more effective for older adults (> 65 years) , possibly because they have more time to adhere to the ILI protocol.

Thus, it seems likely that components designed to enhance adherence (before and during the ILI) may be important components of effective ILIs. An important question for the future is how to enhance adherence while simultaneously lowering the intensity and costs of ILIs to make them sustainable in the real world . Artificial intelligence (AI) is often touted as a technical advance that could reduce the use of human counselors and therefore greatly reduce costs and substantially enhance scalability of counseling programs . Use of AI as opposed to human counselors raises an important question: Can AI replace the human capacity to think creatively and respond to the limitless contingencies that arise in the weight management counseling environment? The answer to the question appears to be no; AI is not sufficiently advanced to supplant the need for human counseling. For example, a recent report concluded that 21 of 25 (84%) digital diabetes prevention and management programs (addressing modification of diet, activity, and/or weight) used live human counseling as a part of the intervention. In fact, one of the most intensively studied uses of AI in an ILI includes live human counseling in addition to AI . Use of streaming media may be another answer to this conundrum, and it is more fully developed than AI. Even the use of streaming appears to necessitate the use of human counseling, however . Thus, for the foreseeable future, it is likely that human counselors will be needed to deliver ILIs to maximize adherence . Delivery of effective ILI with only minimal human interaction may be possible, however . Such speculation is exciting but also requires empirical study; let us look to the future.

Acknowledgments

The author expresses gratitude to all of the staff and participants of the key studies that were reviewed in this paper. In particular, the efforts of the principal investigators and the NIH deserve special recognition for guiding this research over the past 2 decades.

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Fifty Years of Behavioral/Lifestyle Interventions for Overweight and Obesity: Where Have We Been and Where Are We Going?

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Disclosure:: Donald A. Williamson is a paid consultant to Real Appeal, Inc. The author declared no conflict of interest. This paper reviews the literature pertaining to the structure and content of intensive lifestyle interventions (ILIs) for overweight/obesity since Richard Stuart described this new treatment approach in 1967.

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The impact of obesity on quality of life

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The impact of obesity on quality of life

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Taylor et al. (2013).

Mental illness e.g. anxiety and overall quality of life are negatively impacted through obesity. Having a psychiatric illness can in turn prevent successful weight loss programmes and hence this produces a vicious cycle of poor quality of life.

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JavaScript is disabled on your browser. Please enable JavaScript to use all the features on this page.

An important association exists between obesity and mental illness that impacts all aspects of an individual's quality of life. This association can begin early in the developmental trajectory and we do not yet completely understand all the mechanisms linking obesity and mental illness. What we e do know is that physical health factors that often occur secondary to obesity, combined with societal attitudes toward those that are obese coupled with iatrogenic treatment factors linked to psychiatric pharmacotherapy and a number of biologic mediators result in an important and increasing common comorbidity. Recognizing this association is essential for the proper management of both conditions. The following review addresses this issue and provides clinical pearls to help deal with this issue.

View full text

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The impact of obesity on quality of life

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JavaScript is disabled on your browser. Please enable JavaScript to use all the features on this page. An important association exists between obesity and mental illness that impacts all aspects of an individual's quality of life. This association can begin early in the developmental trajectory and we do not yet completely understand all the mechanisms linking obesity and mental illness.

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Defines binge eating disorder (BED), describes symptoms and the connection with obesity

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Defines binge eating disorder (BED), describes symptoms and the connection with obesity

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Effects of Chronic Social Stress on Obesity

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Effects of Chronic Social Stress on Obesity

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Scott, Melhorn & Sakai (2012).

This paper initially discusses John Speakman's hypothesis as reason to why obesity is rising. This explains that maladaptive 'obesity genes' have increased throughout populations due to genetic drift occurring in modern society as humans are less vulnerable to predators; meaning obesity no longer acts as an immediate threat which requires weeding out of the gene pool (2007).

*Refer back to for a detailed biological explanation for the stress pathway and how this effects metabolic dysfunction.

Conclusions drawn are that obesity is increased due to:
1. Modern environment - Modern lifestyle being sedentary and having easy access to nutrient-dense foods
2. PsychoSocial relations - Chronic social stress i.e. from unemployment stress associated with obesity and chronic illnesses due to the biological stress pathway overactivation.
3. BioPsychological - Chronic stress altering food preference and dietary intake. Different for individuals however some stressors encourage 'comfort-food' intake which activates the brain's reward pathway similar to that observed in drug-addiction.

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McLaren (2007).

Finds that a lower socioeconomic status is related to a higher body mass. In developed countries this is highly related to education & occupation.

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Education for health in schools

Unhealthy school lunches?

Policy changes for consumerism

Overweight parent and child correlation

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Who's Responsible For Childhood Obesity? | This Morning

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The Effectiveness of Cognitive Self‐Management as an Adjunct to a Behavioural Intervention for Childhood Obesity: a Research Note

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The Effectiveness of Cognitive Self‐Management as an Adjunct to a Behavioural Intervention for Childhood Obesity: a Research Note

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Duffy & Spence (1993).

Behavioural management plus relaxation placebo or a combined behavioural‐cognitive self‐management approach both had same significant results in weight decrease in 7-13 year olds over a short term period (3/6mth follow ups).

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Abstract

Abstract This study investigated the effectiveness of cognitive self‐management training as an adjunct to the behavioural management of childhood obesity. Twenty‐seven overweight children aged 7-13 years were randomly assigned to either behavioural management plus relaxation placebo or a combined behavioural‐cognitive self‐management approach. Evaluations following the eight treatment sessions revealed a significant reduction in percentage overweight for children in both experimental groups and improvements were maintained at 3‐ and 6‐month follow‐ups Both conditions were also effective in reducing the number of high‐risk foods consumed. No difference in outcome was found between treatments at the post‐treatment assessment or 3‐ and 6‐month follow‐ups. Although a reduction in percentage overweight of around 9% was found for both procedures, subjects in general remained considerably overweight.

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The Effectiveness of Cognitive Self‐Management as an Adjunct to a Behavioural Intervention for Childhood Obesity: a Research Note

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Abstract This study investigated the effectiveness of cognitive self‐management training as an adjunct to the behavioural management of childhood obesity. Twenty‐seven overweight children aged 7-13 years were randomly assigned to either behavioural management plus relaxation placebo or a combined behavioural‐cognitive self‐management approach.

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Mindfulness Intervention for Stress Eating toReduce Cortisol and Abdominal Fat among Overweight and Obese Women: An Exploratory Randomized Controlled Study

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Mindfulness Intervention for Stress Eating toReduce Cortisol and Abdominal Fat among Overweight and Obese Women: An Exploratory Randomized Controlled Study

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Daubenmier et al. (2011).

A mindfulness for stress eating programme saw improvements in  , anxiety, and external-based eating compared to control participants.

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Social factors - Time schedule, family commitments making it more difficult to have personal time to exercise

Emotional factors - physical activity could be channeled as an output of emotional agro.
On the other hand, sensitive emotions in body stigma may prevent physical activity.

Cultural factors - Certain cultures may stigmatise exercise of certain groups - e.g. women

Cognitive factors - Knowledge about types of exercise and their success in weight loss and body transformations.

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The NHS UK describes a chronic condition as a long term health condition requiring ongoing management over a period of years or decades. It is one that cannot be cured but can be controlled with various medications and therapies.

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The NHS UK describes a chronic condition as a long term health condition requiring ongoing management over a period of years or decades. It is one that cannot be cured but can be controlled with various medications and therapies.

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Supporting Information: Long Term Physical Health Condition

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A Long Term Physical Health Condition (also known as a Chronic Condition) is a health problem that requires ongoing management over a period of years or decades.

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Should we officially recognise obesity as a disease?

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Should we officially recognise obesity as a disease?

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The Lancet Diabetes & Endocrinology (2007).

This article highlights how certain regions have already classified obesity as a chronic disease, such as Portugal, Scotland, America and Canada.

It also highlights how for the correct proactive prevention and treatment plans to be implemented by individuals and the wider culture, it is critical obesity is classified as a disease for the appropriate change to occur.

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Should obesity be recognised as a disease?

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Should obesity be recognised as a disease?

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BMJ (2019).

Interesting description of the 'cafeteria diet' experiments held on animals, showcasing the effects modern food can have on healthcare and behaviour.

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1. John P H Wilding , professor of medicine 1,

2. Richard Pile , general practitioner with special interest in cardiology 3

1. 1Obesity and Endocrinology Research, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK

2. 2European Coalition for People living with Obesity, European Association for the Study of Obesity, Teddington, UK

3. Correspondence to: J P H Wilding J.P.H.Wilding@liverpool.ac.uk, R Pile richard.pile@nhs.net

Categorising obesity as a disease will encourage people to seek treatment say John P H Wilding and Vicki Mooney,but Richard Pile thinks medicalisation would be disempowering and reduce motivation

Yes-John P H Wilding and Vicki Mooney

Excess accumulation of body fat (obesity) develops because of abnormal biological regulation of energy balance, has multiple complications, and should be considered a disease. The Oxford Dictionary defines disease as "a disorder of structure or function . . . especially one that produces specific symptoms . . . and is not simply a direct result of physical injury."1 Obesity, in which excess body fat has accumulated to such an extent that health may be adversely affected, meets that definition, and the World Health Organization has considered it a disease since 1936.2

Obesity has rapidly increased in prevalence and now affects 29% of the population in England.3 Metabolic complications include type 2 diabetes, fatty liver disease, and hormone dependent cancers; mechanical complications of joint pain, arthritis, increased obstetric risk, and sleep apnoea are common, and obesity may adversely affect mental health, partly because of stigmatisation.3 Genetic and environmental factors contribute to its aetiology and influence the underlying biology of weight regulation, the sites of fat storage, and the risk of complications.4

Genetics

Studies in twins show that 40-70% of the variability in weight is inherited. More than 200 gene variations influence weight, and those that increase weight are more common in people with severe obesity5 and less likely to be found in people who are thin.6 Most of these genes, including those with variants that cause early onset obesity, are expressed in the brain and involved in appetite regulation.7 Fat distribution, which contributes to risk of metabolic complications, is influenced by genes mostly expressed in adipose tissue.8 Thus body weight, fat distribution, ...

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Should obesity be recognised as a disease?

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Categorising obesity as a disease will encourage people to seek treatment say John P H Wilding and Vicki Mooney , but Richard Pile thinks medicalisation would be disempowering and reduce motivation Excess accumulation of body fat (obesity) develops because of abnormal biological regulation of energy balance, has multiple complications, and should be considered a disease.

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Effect of T'ai Chi Exercise on Biochemical Profiles and Oxidative Stress Indicators in Obese Patients with Type 2 Diabetes

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Effect of T'ai Chi Exercise on Biochemical Profiles and Oxidative Stress Indicators in Obese Patients with Type 2 Diabetes

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Chen et al. (2010).

Practising T'ai Chi had benefits for BMI in obese patients with Type 2 diabetes, whilst conventional exercise had no effect.

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If the address matches an existing account you will receive an email with instructions to reset your password

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Stress in obesity: Cause or consequence?

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Stress in obesity: Cause or consequence?

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Foss & Dyrsrad (2011).

This paper explores the positive feedback interaction between weight gain and stress, as a result of the increased cortisol levels. Suggesting the hypothesis that stress is both a consequence and cause of obesity.

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Abstract

Obesity is a global public health challenge that increases the risk of various diseases including type 2 diabetes mellitus, hypertension and cancer, and will in the future cause further increases in the incidence of chronic disease. Understanding the mechanisms of obesity is critical if we are to prevent and treat this pandemic challenge. Diet and physical activity have traditionally been the major tasks in preventing and treating obesity. However, other mechanisms are now also being considered in the quest for knowledge and understanding of obesity, including the body's stress system and cortisol release. While it seems evident that stress is a cause of obesity, whether stress is also a consequence of obesity has up to now only briefly been discussed. The aim of this article is to elucidate how stress and obesity might be linked and discuss the cause/consequence relationship between the stress response and obesity. Our hypothesis is that stress and obesity interfere by positive feedback. This may be an important issue in both our understanding and coping of obesity.

View full text

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Stress in obesity: Cause or consequence?

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JavaScript is disabled on your browser. Please enable JavaScript to use all the features on this page. Obesity is a global public health challenge that increases the risk of various diseases including type 2 diabetes mellitus, hypertension and cancer, and will in the future cause further increases in the incidence of chronic disease.

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NHS listing of features and serious health problems associated with obesity.

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NHS listing of features and serious health problems associated with obesity.

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Most noticeably: back and joint pain, numerous chronic conditions like type II diabetes and a reduced life expectancy by 3-10 years, depending on severity.

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The term obese describes a person who has excess body fat.
In the UK it's estimated that around 1 in every 4 adults and around 1 in every 5 children aged 10 to 11 are living with obesity.

How to tell if you're living with obesity

The most widely used method to check if you're a healthy weight is body mass index (BMI).

BMI is a measure of whether you're a healthy weight for your height. You can use the NHS BMI healthy weight calculator to find out your BMI.

For most adults, if your BMI is:

below 18.5 - you're in the underweight range

18.5 to 24.9 - you're in the healthy weight range

25 to 29.9 - you're in the overweight range

30 to 39.9 - you're in the obese range

40 or above - you're in the severely obese range

If you have a South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background you'll need to use a lower BMI score to measure overweight and obesity:

23 to 27.4 - you're in the overweight range

27.5 or above - you're in the obese range

BMI score has some limitations because it measures whether a person is carrying too much weight but not too much fat. For example, people who are very muscular, like professional sportspeople, can have a high BMI without much fat.

But for most people, BMI is a useful indication of whether they're a healthy weight.

Another measure of excess fat is waist to height ratio, which can be used as an additional measure in adults who have a BMI under 35.

To calculate your waist to height ratio, measure around your waist just above your belly button, and divide it by your height, measured in the same units (for example, centimetres or inches).

A waist to height ratio of 0.5 or higher means you may have increased health risks.

Risks of living with obesity

Obesity is a serious health concern that increases the risk of many other health conditions.

These include:

Living with overweight and obesity can also affect your quality of life and contribute to mental health problems, such as depression, and can also affect self-esteem.

Causes of obesity

Obesity is a complex issue with many causes. Obesity and overweight is caused when extra calories, particularly those from foods high in fat and sugar, are stored in the body as fat.

Obesity is an increasingly common problem because the environment we live in makes it difficult for many people to eat healthily and do enough physical activity.

Genetics can also be a cause of obesity for some people. Your genes can affect how your body uses food and stores fat.

There are also some underlying health conditions that can occasionally contribute to weight gain, such as an underactive thyroid gland (hypothyroidism), although these types of conditions do not usually cause weight problems if they're effectively controlled with medicines.

Some medicines can also make people more likely to put on weight, including steroids and some medicines for high blood pressure, diabetes or mental health conditions.

Treating obesity

The best way to treat obesity is to eat a healthy reduced-calorie diet and exercise regularly.

To do this, you can:

eat a balanced calorie-controlled diet as recommended by a GP or weight loss management health professional (such as a dietitian)

take up activities such as fast walking, jogging, swimming or tennis for 150 to 300 minutes (2.5 to 5 hours) a week

You may benefit from joining a local weight management programme with group meetings or online support. Your GP can tell you about these.

You may also benefit from receiving support and counselling from a trained healthcare professional to help you better understand your relationship with food and develop different eating habits.

If you're living with obesity and lifestyle and behavioural changes alone do not help you lose weight, a medicine called orlistat may be recommended.

If taken correctly, this medicine works by reducing the amount of fat you absorb during digestion. Your GP will know whether orlistat is suitable for you.

A specialist may prescribe other medicines called liraglutide or semaglutide. They work by making you feel fuller and less hungry.

For some people living with obesity, a specialist may recommend weight loss surgery.

Other obesity-related problems

Living with obesity can cause a number of further problems, including difficulties with daily activities and serious health conditions.

Day-to-day problems related to obesity include:

breathlessness

increased sweating

difficulty doing physical activity

often feeling very tired

joint and back pain

low confidence and self-esteem

feeling isolated

The psychological problems associated with living with obesity can also affect your relationships with family and friends, and may lead to depression.

Serious health conditions

Living with obesity can also increase your risk of developing many potentially serious health conditions, including:

type 2 diabetes

high blood pressure

high cholesterol and atherosclerosis (where fatty deposits narrow your arteries), which can lead to coronary heart disease and stroke

metabolic syndrome, a combination of diabetes, high blood pressure and obesity

several types of cancer, including bowel cancer, breast cancer and womb cancer

gastro-oesophageal reflux disease (GORD), where stomach acid leaks out of the stomach and into the gullet

gallstones

reduced fertility

osteoarthritis, a condition involving pain and stiffness in your joints

sleep apnoea, a condition that causes interrupted breathing during sleep, which can lead to daytime sleepiness with an increased risk of road traffic accidents, as well as a greater risk of diabetes, high blood pressure and heart disease

liver disease and kidney disease

pregnancy complications, such as gestational diabetes or pre-eclampsia, when a woman experiences a potentially dangerous rise in blood pressure during pregnancy

Obesity reduces life expectancy by an average of 3 to 10 years, depending on how severe it is.

Outlook

Managing a complex issue like obesity can be hard. Losing weight takes time and commitment.

The healthcare professionals involved with your care can provide encouragement and advice about how to mange your weight, build healthy lifestyle habits and maintain weight loss achieved.

Completing a weight management programme, regularly monitoring your weight, setting realistic goals, and involving your friends and family with ways to lose weight can also help.

It's important to remember that losing what seems like a small amount of weight, such as 3% or more of your original body weight, and maintaining this for life, can significantly reduce your risk of developing obesity-related complications like diabetes and heart disease.

Social care and support guide

If you:

need help with day-to-day living because of illness or disability

care for someone regularly because they're ill, disabled or because of their age (including family members)

Our guide to care and support explains your options and where you can get support.

Couch to 5K

If it's been a long time since you did any exercise, you should check out the Couch to 5K running plan.

It consists of podcasts delivered over the course of 9 weeks and has been specifically designed for absolute beginners.

To begin with, you start running for short periods of time, and as the plan progresses, gradually increase the amount.

At the end of the 9 weeks, you should be able to run for 30 minutes non-stop, which for most people is around 5 kilometres (3.1 miles).

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Read about obesity and how it can seriously affect your health. Ways to lose weight safely include eating a healthy, reduced-calorie diet and exercising regularly.

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Understanding the complexity of biopsychosocial factors in the public health epidemic of overweight and obesity

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Understanding the complexity of biopsychosocial factors in the public health epidemic of overweight and obesity

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Rosenbaum & White (2016).

Marks’ (2015) Homeostatic Theory of Obesity helps understand the condition. Features of the theory include: social complexities (food production/distribution), behavioural factors (physical activity/consumption) and psychological factors (attachment, sense of cohesion, eudaimonic wellbeing, income, and negative affect).

This is known as a “Circle of Discontent".

This article critiques Marks (2015) research, suggesting other explanations for obesity such as socioeconomic factors.

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Marks' (2015) Homeostatic Theory of Obesity integrates some diverse and valuable literatures into a model aimed toward promoting a better understanding of overweight and obesity. Including some of the social complexities in the obesity epidemic, such as the production and distribution of food (and financial relationships), is a novel perspective. In addition to examining behavioral factors that have demonstrated their importance through empirical study (i.e. physical activity, consumption), Marks proposes that research is needed that focuses on specific social factors and psychological factors including attachment, sense of cohesion, eudaimonic wellbeing, income, and negative affect. The theory emphasizes the role of psychological factors, which have great relevance in understanding the impact of obesity; however, care must be taken to empirically evaluate the psychologically based pathway for obesity etiology that is proposed in the theory's "Circle of Discontent." An integration of the psychological, social, and biological factors, which interact to contribute to the development and maintenance of obesity, remains an important area for continued development as the model presents limited discussion of important biological factors that are critical to development and maintenance of obesity.

The manuscript title "homeostatic theory of obesity" suggests that biological principles of energy balance as applied to intake and expenditure will be discussed as a number of models expanding upon the established energy balance literature have proposed (e.g. Schwartz et al., 2003). The manuscript does not reference the most obvious ways in which well-established biological homeostasis applies to weight (e.g. energy consumed compared to energy need), though, presumably because other sources have already addressed energy balance in obesity at length (interested readers may refer to handbooks such as Wadden and Stunkard (2002) for more on this topic). While it is understandable to assume readers are familiar with energy balance, other biological mechanisms that relate to the psychological and social issues included in the "Circle of Discontent" also remain absent. In doing so, the theory misses an opportunity to lend a truly integrative biopsychosocial lens to this discussion, as the manuscript is otherwise successful in culling from diverse psychological, financial, and public health literatures. Although it may be outside the scope of a behaviorally based theory to discuss biological aspects at length, there are some factors that bridge the disciplines of biological and behavioral obesity research that warrant some mention in the context of this model, such as the role of stress.

Stress responses, exhibited both physiologically and behaviorally, are one example of the link between biological and psychological processes in obesity as stress impacts eating behavior and overweight/obesity risk. The available evidence suggests that due to hormones secreted during stress that promote motivation for food and intake (e.g. glucocorticoids), many individuals overeat in response to chronic stress ( Torres and Nowson, 2007). Because glucocorticoids stimulate appetite and preferentially stimulate fat deposition in the abdomen ( Adam and Epel, 2007), individuals with central adiposity (i.e. "apples" versus "pears") are more prone to intermediary conditions (e.g. dyslipidemia, hyperglycemia, and hypertension) and chronic disease (e.g. Type II Diabetes, stroke, coronary heart disease (CHD)) ( Alberti et al., 2005); in turn, these individuals may be more vulnerable to the psychological and physical stress response ( Björntorp, 2001). Marks' theory proposes the pathways linking overweight/obesity and negative affect; however, additional exploration of the physiological implications of negative affect in obesity (e.g. through stress responses) would foster a more complete biopsychosocial conceptualization.

With the exception of the missed opportunity to address relevant biological elements, the scope of the article is extensive, multifactorial, and underscores the complex challenges of the public health challenges underlying the obesity epidemic. For example, Marks makes reference to the Foresight Report (2007) and its conclusion that over 100 variables may be effective targets for weight control intervention. This highlights the challenge of finding a balance between a complete model and a model that can be easily applied. Marks incorporates a broader subset of psychological factors as potential factors in the development of obesity than what is typical among models of this kind. Specifically, Marks' model re-conceptualizes the role of certain psychological factors in obesity as potential maintenance factors operating within feedback loops.

It may be that such psychologically influenced models are highly applicable among subpopulations of those who have comorbid obesity and eating disorders (e.g. binge eating disorder (BED), eating disorder not otherwise specified, or potentially bulimia nervosa), but may be less applicable to others with obesity whose over-consumption of calories is motivated by factors that are not primarily driven by emotions. These factors might include the drive to consume good tasting foods, or "hedonic" hunger ( Lowe and Butryn, 2007), and environments that place individuals in frequent proximity to an abundance of highly caloric foods, thereby eroding one's self-control resources ( Lowe, 2003). These and other factors suggest that many cases of obesity do not reflect psychological "discontent" and care should be taken for future scientific research to evaluate the Circle of Discontent model in various subgroups across the obesity population.

We also wish to note that while Marks' theory raises issues regarding the relation between negative affect, psychological distress, and over-consumption that have importance in the context of issues closely related to obesity, such as BED ( Heatherton and Baumeister, 1991; Rosenbaum and White, 2013, 2015), these factors may not have as much direct relevance for those with overweight and obesity without comorbid BED or subclinical eating disorder symptoms. Because obesity is a medical disorder, psychological distress is not a hallmark feature of obesity in the same way that it is for eating disorders. While the prospect of psychological factors in the development of obesity is possible, additional research is needed to understand whether an extension of theories of emotional eating and binge eating, which share similarities to Marks' "Circle of Discontent," is supported among a broader subset of individuals with overweight and obesity, as Marks suggests.

In addition to addressing potential psychological issues that may be associated with obesity among some individuals, Marks' theory raises important questions about societal factors. Socioeconomic inequalities have as of yet received less attention in the literature than other potential risk and maintenance factors. While not an official part of the "Circle of Discontent," Marks highlights important socioeconomic factors in the development of obesity that warrant further investigation (e.g. "... overweight and obesity is not just a health issue, it is about social justice, because the least well off suffer significantly higher rates of obesity," p. 2). Indeed, factors that confer risk for stress and social inequality, such as racial and ethnic minority group membership and lower socioeconomic status (SES), are associated with increased obesity risk ( Broady and Meeks, 2015; Sobal and Stunkard, 1989). Worldwide, both obesity and under-nutrition are common among those struggling with socioeconomic burden, creating a "double burden of disease" and increased mortality risk for some communities and households ( World Health Organization, 2015). Although some have called for population-based interventions to address the complex interconnection of obesity risk factors such as gender, race, ethnicity, and SES ( Wang and Beydoun, 2007), few conceptual models of obesity have included these important factors.

The relation among socioeconomic factors, and with obesity, is multifaceted. For instance, poverty and obesity have been linked not just through challenges in acquiring healthy food (e.g. high expense and lower quality of fresh produce and healthy food in lower income neighborhoods ( Darmon and Drewnowski, 2015; Evans et al., 2015), individuals are less likely to own a vehicle to transport groceries ( Ver Ploeg et al., 2015)), but also through limitations in opportunities for physical activity due to unsafe outdoor spaces and limited access to gyms ( Levine, 2011). Given the multifaceted nature of these relations, researchers may be tempted to assume that another discipline would be better equipped to untie the elaborate knots that bind vulnerable groups to obesity risk. Indeed, steps toward addressing the larger social justice issues that set the background for disparities in obesity risk, while sorely needed, may stretch beyond the scope of traditional obesity research; however, rather than waiting for sociology, public health, epidemiology, and other fields to collectively solve this dilemma, it is important for obesity research to encourage creative partnerships and cross-disciplinary collaborations with the above-mentioned fields and others that may help facilitate further progress toward obesity prevention.

We concede that social changes to promote health may be a monumental undertaking. With that in mind, we believe that focusing efforts on factors that have strong empirical support as targets in the development of obesity are needed prior to turning to factors that may have a more theoretical and peripheral role. Research is needed to stimulate the development of new interventions in obesity prevention, weight loss, and weight loss maintenance ( MacLean et al., 2015). Finally, although there may be overlap between risk factors for obesity and eating disorders, we believe it is also important to disambiguate steps that may be have potential utility in eating disorder prevention from those that may be particularly fruitful in obesity prevention. Further investigation is warranted to evaluate the impact of shared pathways in preventing eating disorders and obesity.

In conclusion, Marks presents a complex model for a complex problem. On one hand, we believe that in some respects, the model is incomplete in addressing obesity from an integrative biopsychosocial perspective. Yet, on the other hand, the ambitious, multisystemic intent of this model, along with previous theory-driven arguments ( Smith, 2000), acknowledges the need to expand from nutritional homeostasis models to incorporate more complex behavioral processes that influence overeating. While Marks' model may undervalue biological aspects of obesity, it raises important issues regarding socioeconomic inequalities that contribute to obesity. The theoretical determinants of obesity are multifarious; therefore, without large-scale comprehensive research programs, empirical evaluation of this model may be best suited to interactions among certain components. Furthermore, research aimed toward investigating components that have received less attention in the literature, and have the most likelihood for successful implementation for obesity prevention, such as public health interventions focused on the marketing of highly caloric foods and beverages, is needed. To join others' recent calls for a systems-based approach to public health and clinical interventions, ( Carey and Crammond, 2015; Frood et al., 2013), there is a clear need for multifactorial systemic change to slow the rising obesity epidemic.

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Understanding the complexity of biopsychosocial factors in the public health epidemic of overweight and obesity - Diane L Rosenbaum, Kamila S White, 2016

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Marks' (2015) Homeostatic Theory of Obesity integrates some diverse and valuable literatures into a model aimed toward promoting a better understanding of overweight and obesity. Including some of the social complexities in the obesity epidemic, such as the production and distribution of food (and financial relationships), is a novel perspective.

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‘Just Bloody Fat!’: A Qualitative Study of Body Image, Self-Esteem and Coping in Obese Adults

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‘Just Bloody Fat!’: A Qualitative Study of Body Image, Self-Esteem and Coping in Obese Adults

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Thomas et al. (2012).

This IPA study marks the negative factors obese males and females face in adapting to obesity surrounding poor self-esteem and body image. It also explores the coping strategies of this, commonly being self-isolation and alternatively, finding humour in their situation.

It was noted that females put more blame on themselves while males often attributed the weight gain to external explanations such as providing for their families (working long hours).

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The rise of the 'obesity epidemic' in Western societies has led to an increased public gaze on obese individuals. Yet there is limited research that explores through qualitative methods the increased impact it has had on obese individuals' perceptions of self, body image and coping strategies, using their own words. This paper presents the findings of interviews with a community sample of 142 obese adults in Australia. We examined how obese individuals felt about themselves and their bodies, what influenced these feelings, and the subsequent coping strategies employed. While participants were able to identify many positive characteristics about their inner self, the vast majority used negative language to describe their physical appearance. Many participants described feelings of 'guilt', 'shame' and 'blame' associated with their weight. Coping strategies included striving for perfection in other areas of their life, social isolation, maximising aspects of their appearance and 'fat' acceptance. This study shows that, while different groups of obese adults experience, cope with and compensate for the influence of weight-based stereotyping in many different ways, they still feel an unrelenting otherness and difference associated with their weight.

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'Just Bloody Fat!': A Qualitative Study of Body Image, Self-Esteem and Coping in Obese Adults

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The rise of the 'obesity epidemic' in Western societies has led to an increased public gaze on obese individuals. Yet there is limited research that explores through qualitative methods the increased impact it has had on obese individuals' perceptions of self, body image and coping strategies, using their own words.

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Adolescent Obesity, Overt and Relational Peer Victimization, and Romantic Relationships

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Adolescent Obesity, Overt and Relational Peer Victimization, and Romantic Relationships

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Pearce, Boergers & Prinstei (2012).

For adolescent girls, there was a significantly higher rate of peer relational victimisation for those who are obese in compared to average-rate.

Obese girls and boys both less likely to form romantic relationships and are less satisfied with their dating status in comparison to peers.

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The Role of the Fatosphere in Fat Adults’ Responses to Obesity Stigma: A Model of Empowerment Without a Focus on Weight Loss

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The Role of the Fatosphere in Fat Adults’ Responses to Obesity Stigma: A Model of Empowerment Without a Focus on Weight Loss

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Dickens et al. (2011).

Here the  fat-acceptance movement is explored as an adaption to proactively protecting patients from weight-based stigma before it occurs.

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Obese adults face pervasive and repeated weight-based stigma. Few researchers have explored how obese individuals proactively respond to stigma outside of a dominant weight-loss framework. Using a grounded theory approach, we explored the experiences of 44 bloggers within the Fatosphere-an online fat-acceptance community. We investigated participants' pathways into the Fatosphere, how they responded to and interacted with stigma, and how they described the impact of fat acceptance on their health and well-being. The concepts and support associated with the fat-acceptance movement helped participants shift from reactive strategies in responding to stigma (conforming to dominant discourses through weight loss) to proactive responses to resist stigma (reframing "fat" and self-acceptance). Participants perceived that blogging within the Fatosphere led them to feel more empowered. Participants also described the benefits of belonging to a supportive community, and improvements in their health and well-being. The Fatosphere provides an alternative pathway for obese individuals to counter and cope with weight-based stigma.

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# data[].attributes.attachment_link.title
The Role of the Fatosphere in Fat Adults' Responses to Obesity Stigma: A Model of Empowerment Without a Focus on Weight Loss - Marissa Dickins, Samantha L. Thomas, Bri King, Sophie Lewis, Kate Holland, 2011

# data[].attributes.attachment_link.description
Obese adults face pervasive and repeated weight-based stigma. Few researchers have explored how obese individuals proactively respond to stigma outside of a dominant weight-loss framework. Using a grounded theory approach, we explored the experiences of 44 bloggers within the Fatosphere-an online fat-acceptance community.

# data[].attributes.headline
Oxidative stress and potential interventions to reduce oxidative stress in overweight and obesity

# data[].attributes.subject
Oxidative stress and potential interventions to reduce oxidative stress in overweight and obesity

# data[].attributes.body
Vincent, Innes & Vincent (2007).

Discusses the classic obesity interventions such as acute exercise, fat volume reduction via surgery, pharmacological agents, and dietary modification.

This fails to take into account biopsychosocial factors impacting the success of treatment plans such as mental wellbeing or socioeconomic status and access to lifestyle changes.

# data[].attributes.attachment_link.readable_text
Corresponding Author

The Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA

Dr Heather K. Vincent, Department of Orthopaedics and Rehabilitation, UF & Shands Orthopaedics and Sports Medicine Institute, PO Box 112727, University of Florida, Gainesville, FL 32611, USA. E‐mail:
hvincent@adelphia.net Search for more papers by this author

# data[].attributes.attachment_link.title
Oxidative stress and potential interventions to reduce oxidative stress in overweight and obesity

# data[].attributes.attachment_link.description
Corresponding Author The Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA Dr Heather K. Vincent, Department of Orthopaedics and Rehabilitation, UF & Shands Orthopaedics and Sports Medicine Institute, PO Box 112727, University of Florida, Gainesville, FL 32611, USA. E‐mail: hvincent@adelphia.net Search for more papers by this author

# data[].attributes.headline
Obesity stigmatization and coping: Relation to mental health symptoms, body image, and self- esteem

# data[].attributes.subject
Obesity stigmatization and coping: Relation to mental health symptoms, body image, and self- esteem

# data[].attributes.body
Myers & Rosen (1999).

This article reports the negative comments people with obesity face in stigmatising situations, with the most common being comments from children.

It also reports common self-coping mechanisms, with the most frequent being positive self-talk.

# data[].attributes.attachment_link.readable_text
OBJECTIVE: To create inventories of stigmatizing situations faced by obese people and ways of coping with stigmatization, and to examine how stigma and coping are related to psychological distress in an obese patient population.

DESIGN: Study 1: Items were generated by asking obese people to list stigmatizing situations they had encountered and their ways of coping. Study 2: Obese patients were surveyed about the frequency with which they encountered each form of stigmatization and employed each form of coping. Cross-sectional data on current psychological adjustment were obtained.

SUBJECTS: Study 1: 63 obese patients (body mass index, BMI>40 kg/m ²); 38 obese non-patients, seven professionals who work with obese patients and 32 obese female authors from the print media. Study 2: 112 gastric bypass patients (BMI 33.9-80.9 kg/m ²) and 34 less obese patients (BMI 27.1-57.2 kg/m ²).

MEASUREMENT: Study 1: Collection of stigmatizing situations and coping responses. Study 2: Frequency of stigmatizing experiences and coping responses, psychological symptoms, body image, and self esteem measures.

RESULTS: Study 1 resulted in two objective questionnaires, consisting of 50 situations and 99 responses. Study 2 found that stigmatization is a common experience, and that obese subjects frequently engage in some effort to cope with stigma. More frequent exposure to stigmatization was associated with greater psychological distress, more attempts to cope, and more severe obesity. Certain coping strategies are associated with greater distress.

# data[].attributes.attachment_link.title
Obesity stigmatization and coping: Relation to mental health symptoms, body image, and self-esteem

# data[].attributes.attachment_link.description
OBJECTIVE: To create inventories of stigmatizing situations faced by obese people and ways of coping with stigmatization, and to examine how stigma and coping are related to psychological distress in an obese patient population. DESIGN: Study 1: Items were generated by asking obese people to list stigmatizing situations they had encountered and their ways of coping.

# data[].attributes.body
Kolotkin et al. (2012).

Quality of sexual life is decreased as BMI rises, with women more strongly affected.

# data[].attributes.attachment_link.readable_text
Duke Diet and Fitness Center, Duke University Health System, Durham, North Carolina

Department of Psychiatry and Behavioral Sciences, Division of Medical Psychology, Duke University Health System, Durham, North Carolina
Search for more papers by this author

The costs of publication of this article were defrayed, in part, by the payment of page charges. This article must, therefore, be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

Abstract

Objectives: Reduced sexual quality of life is a frequently reported yet rarely studied consequence of obesity. The objectives of this study were to 1) examine the prevalence of sexual quality‐of‐life difficulties in obese individuals and 2) investigate the association between sexual quality of life and BMI class, sex, and obesity treatment-seeking status.

Research Methods and Procedures: Subjects consisted of 1) 500 participants in an intensive residential program for weight loss and lifestyle modification (BMI = 41.3 kg/m ²), 2) 372 patients evaluated for gastric bypass surgery (BMI = 47.1 kg/m ²), and 3) 286 obese control subjects not seeking weight loss treatment (BMI = 43.6 kg/m ²). Participants completed the Impact of Weight on Quality of Life‐Lite, a measure of weight‐related quality of life. Responses to the four Sexual Life items (assessing enjoyment, desire, performance, and avoidance) were analyzed by BMI, sex, and group.

Results: Higher BMI was associated with greater impairments in sexual quality of life. Obese women reported more impairment in sexual quality of life than obese men for three of four items. Gastric bypass surgery candidates reported more impairment in sexual quality of life than residential patients and controls for most items. In general, residential patients reported levels of impairment greater than or equal to controls.

Discussion: Obesity is associated with lack of enjoyment of sexual activity, lack of sexual desire, difficulties with sexual performance, and avoidance of sexual encounters. Sexual quality of life is most impaired for women, individuals with Class III obesity, and patients seeking gastric bypass surgery.

Introduction

In addition to its medical consequences (, , , ), obesity has been linked to impairments in health‐related quality of life, including reduced physical functioning, psychosocial functioning, and emotional well being (, , , ). Reduced quality of life may be as serious a consequence of obesity as are its adverse effects on morbidity and mortality ().

Our clinical experience suggests that sexual dissatisfaction and/or sexual difficulties are not uncommon among our obese patients. Only a few research studies have examined the relationship between obesity and sexual quality of life. In men, obesity has been associated with lower sexual satisfaction (), increased erectile dysfunction (, ), and penile vascular impairment (). Less is known about obesity and sexual quality of life in women. One study () reported no differences in sexual satisfaction between obese and non‐obese women. However, in the 18‐ to 49‐year‐old cohort, obese women (and men) reported a greater decrease in sexual desire over the preceding 5 years compared with normal‐weight individuals.

The limited numbers of studies on sexual quality of life in obesity, along with anecdotal reports of sexual dissatisfaction/dysfunction by obese patients, suggest that this is an area in need of further study. The objectives of this study were to 1) examine the prevalence of sexual quality‐of‐life difficulties in obese individuals and 2) investigate the association between sexual quality of life and BMI class, sex, and obesity treatment-seeking status.

Research Methods and Procedures

Participants

The sample for this study consisted of obese (BMI ≥ 30 kg/m ²) adult (age ≥ 18 years) individuals from three different groups: 1) 500 participants in an intensive residential program for weight loss and lifestyle modification (); 2) 372 patients evaluated for gastric bypass as part of the Utah Obesity Study (); and 3) 286 individuals from a control group in the Utah Obesity Study who were randomly chosen from a population of severely obese participants but who were not seeking gastric bypass surgery (). Only those participants who completed the four Sexual Life items on the Impact of Weight on Quality of Life‐Lite questionnaire (IWQOL‐Lite) 1 (, ) were included in the current sample.

Procedures

On initial evaluation for their respective programs/studies, participants' heights and weights were obtained by the clinic/study personnel. BMI was calculated as kilograms per meters squared. BMI was categorized as Class I obesity = BMI of 30 to 34.9 kg/m ², Class II obesity = BMI of 35 to 39.9 kg/m ², Class III obesity = BMI of 40+ kg/m ² (). Participants also completed questionnaires that included demographic information (age, sex, and ethnicity) and the IWQOL‐Lite.

Measures

The IWQOL‐Lite is a reliable and valid self‐report measure of weight‐related quality of life (, , , ). The IWQOL‐Lite consists of 31 items that begin with the phrase, "Because of my weight ..." Each item has five response options, ranging from 1) "Never true" to 5) "Always true." The IWQOL‐Lite provides scores in five domains (Physical Function, Self‐Esteem, Sexual Life, Public Distress, and Work) along with a total score. For the purpose of this study, only responses to individual items from the Sexual Life scale were analyzed. The Sexual Life scale consists of four items that assess 1) lack of enjoyment of sexual activity, 2) lack of sexual desire, 3) difficulty with sexual performance, and 4) avoidance of sexual encounters-all items specifically attributed to one's weight.

Statistical Analyses

Separate two‐way ANOVAs with Tukey's honestly significant difference (HSD) post hoc comparisons () were used to compare responses to the four Sexual Life items across BMI categories (Class I, II, and III obesity) and sex. Partial η ² values were calculated to determine the proportion of unique variance accounted for by each factor.

Given previous findings of differences between men and women on IWQOL‐Lite scores (), as well as the sex differences obtained in the current samples, all of the analyses described below were conducted separately by sex. The three participant groups were compared on BMI and age using ANOVA with Tukey's HSD post hoc comparisons and on ethnicity using the χ ² test. Responses to each of the four IWQOL‐Lite Sexual Life items were tabulated by group and sex. Finally, analysis of covariance was used to compare responses to each of the IWQOL‐Lite Sexual Life items by group and sex, controlling for BMI and age. Post hoc comparisons among groups were based on covariate‐adjusted Bonferroni‐corrected contrasts. Again, η ² values were calculated to determine the proportion of unique variance accounted for by group differences.

Results

Demographic and Weight Characteristics

Table 1 presents demographic characteristics and BMI by group and sex. Age was significantly different among groups for both women ( F = 30.00; df = 2, 797; p < 0.001) and men ( F = 6.68; df = 2, 355; p = 0.001). For women, control group participants were significantly older than residential program participants, who were, in turn, significantly older than gastric bypass patients. For men, residential program participants were significantly older than gastric bypass patients.

BMI was also significantly different among groups for both women ( F = 52.83; df = 2, 797; p < 0.001) and men ( F = 13.09; df = 2, 355; p = 0.001). For women, gastric bypass patients had significantly higher BMI than control group participants, who, in turn, had significantly higher BMI than residential treatment participants. For men, gastric bypass patients had significantly higher BMI than both control group and residential program participants.

Although the majority of participants were white, the proportion of white participants differed significantly among groups for women (χ ² = 11.24, df = 2, p = 0.004), with the highest rates in the controls and the lowest rates in the gastric bypass candidates. There were no differences in the proportion of white participants among groups for men (χ ² = 3.24, df = 2, p = 0.198).

Comparisons across BMI Categories and Sex

Table 2 presents Sexual Life item responses by BMI category (Class I, II, and III obesity) and sex. Significant differences by BMI group were obtained for all Sexual Life items except sexual desire. Participants in the Class III obesity group reported less sexual enjoyment, more difficulty with sexual performance, and greater avoidance of sexual encounters in comparison with the other two BMI groups. For two items (enjoyment, performance), the Class II group reported greater impairment than the Class I group; for the remaining item (avoidance), there were no significant differences between the Class I and Class II groups. Women reported greater impairments than men on sexual enjoyment, desire, and avoidance of sexual encounters, but did not differ in terms of difficulties with sexual performance. None of the BMI group‐by‐sex interactions approached significance ( p values ranging from 0.240 to 0.766). For three of the four items (enjoyment, desire, avoidance), sex accounted for a greater portion of the criterion variance than BMI category, whereas for sexual performance, BMI category accounted for a greater portion of the variance.

Sexual Quality‐of‐life Item Responses by Group Separately by Sex

Table 3 presents responses to each of the four IWQOL‐Lite Sexual Life items by group separately for women and men. Across all four items, obese women reported higher frequencies of impairment than obese men. Furthermore, women reported each of these items with approximately equal frequency, whereas men reported some items (e.g., sexual desire and sexual performance) more than others. Female gastric bypass candidates reported much higher frequencies of sexual difficulties than either female residential program participants or controls.

Approximately one third of women (32.8% to 37.6%) reported that they usually or always did not enjoy sexual activity, had little sexual desire, experienced difficulty with sexual performance, and avoided sexual encounters because of their weight. Approximately one half of obese women (54.7% to 61.2%) reported difficulty with these aspects of sexual quality of life at least some of the time.

For obese men, the most commonly reported sexual concern related to weight was difficulty with sexual performance (nearly 50% reported problems at least sometimes), followed by lack of sexual desire (just >40% reported problems at least some of the time). Approximately 15% of obese men (14.5% to 18.2%) reported usually or always experiencing difficulties with sexual enjoyment and avoidance of sexual encounters. However, more than two thirds of men (71.2%) responded "never" or "rarely" to the item, "Because of my weight I do not enjoy sexual activity." Consistent with the findings for women, male gastric bypass candidates reported much higher rates of difficulties in all four aspects of sexual quality of life than the residential program participants or controls.

Comparisons among Treatment‐seeking Groups

Table 4 presents responses for women to the four IWQOL‐Lite Sexual Life items by treatment‐seeking group, controlling for differences in BMI and age. Significant differences were found among groups for all four items, accounting for between 7% (avoidance) and 14% (enjoyment) of the criterion variance. In all cases, female gastric bypass candidates had scores indicating significantly more impairment than the remaining groups. With one exception (sexual enjoyment), women in the residential program reported levels of impairment greater than or equal to female control subjects.

Cell entries represent mean adjusted for BMI and age ± standard deviation. Main effect comparison between groups adjusted for BMI and age.

IWQOL‐Lite, Impact of Weight on Quality of Life‐Lite questionnaire; RP, residential program; GB, gastric bypass; C, controls.

Data for men are presented in Table 5. Significant differences were found among treatment‐seeking groups in all four aspects of sexual quality of life, accounting for between 6% (avoidance) and 12% (enjoyment) of the criterion variance. For items assessing lack of sexual enjoyment and difficulty with sexual performance, men in the gastric bypass group reported more problems than either men in the residential program or male control subjects, who did not differ from each other. In contrast, for items assessing desire and avoidance of sexual encounters, men in the gastric bypass group and men in the residential program did not differ from each other, but reported more impairment than male control subjects.

Cell entries represent mean adjusted for BMI and age ± standard deviation. Main effect comparison between groups adjusted for BMI and age.

IWQOL‐Lite, Impact of Weight on Quality of Life‐Lite questionnaire; RP, residential program; GB, gastric bypass; C, controls.

Discussion

This is a study of the relationship between obesity and sexual quality of life. This is a greatly understudied research area that may have important implications for understanding and treating obese persons. With the increasing prevalence of obesity, sexual issues are likely affecting more people than usually realized. The major findings in this study are that 1) obese individuals report a high frequency of sexual difficulties attributed to their weight (lack of sexual enjoyment, lack of sexual desire, difficulty with sexual performance, and avoidance of sexual encounters); 2) higher BMI is associated with greater impairments in sexual quality of life; 3) sexual quality of life is more impaired for obese women than for obese men; and 4) gastric bypass candidates report greater impairment in sexual quality of life than other obese individuals.

The high rate of sexual difficulties experienced by subjects in this study is consistent with previous findings of reduced sex drive and sexual satisfaction (), as well as negative appearance evaluation (), in obese individuals seeking weight loss treatment. A population study of sexual dysfunction in the United States has reported prevalence rates of 7% to 22% for women (sexual pain, arousal problems, and low desire) and 5% to 21% for men (erectile dysfunction, low desire, and premature ejaculation) (). In contrast, this study of obese persons, albeit not a population study, found much higher rates of impairment in sexual quality of life, particularly for individuals seeking gastric bypass surgery. Although the population study did not examine subjects by BMI, the authors noted that sexual dysfunction was associated with poorer physical and emotional health.

Our finding of greater sexual impairment in women than in men (with the exception of difficulties with sexual performance) is also consistent with previous reports of poorer body image (), higher prevalence of sexual difficulties (), reduced health‐related quality of life (, ), and decreased weight‐related quality of life () in women compared with men. Likewise, our finding that obese persons seeking gastric bypass surgery report the greatest impairments in sexual quality of life and obese community subjects the least is consistent with previous research on differences in weight‐related quality of life across subgroups of obese persons differing in treatment status (). This finding is also consistent with research reporting differences in prevalence of sexual difficulties between patients in primary care settings vs. general community samples ().

The results of this study may have implications for clinicians who treat patients who are obese. Obese persons commonly experience stigmatization, discrimination, and prejudice because of their weight (, ). Additionally, and perhaps related to the above, many obese persons have a negative body image (). Thus, the combination of social stigmatization/prejudice and a negative body image may present social and psychological barriers to having sexual needs met. It is likely that many obese persons who experience diminished sexual quality of life and/or negative body image may wish to discuss these issues with their health care providers. Thus, providers need to create an atmosphere of acceptance and willingness to discuss these issues with their patients. This may be achieved simply by asking patients a few questions during initial screening, listening to patients' concerns with empathy, and putting the concerns into perspective by describing their prevalence in this population (i.e., "normalizing" the concerns). It may also be useful for health care providers to highlight the potential benefits that weight loss and lifestyle change may confer on improved sexual quality of life (, , , , , ). When needed, appropriate referrals and treatments should be recommended-e.g., psychotherapy for body image/self‐esteem issues and medical evaluation and/or treatment for sexual performance issues. Because impairment in sexual quality of life is greatest for women, individuals with Class III obesity, and patients seeking gastric bypass surgery, providers should be particularly mindful of the potential for sexual concerns in these patients.

One of the limitations of this study is that we assessed sexual quality of life using a four‐item scale from a measure of weight‐related quality of life. We recognize that sexual quality of life is a rich and multifactorial construct (including arousal, desire, satisfaction, physical functioning, beliefs and values, comfort with sexual and emotional intimacy, body image, and self‐esteem), and our findings address only the impact attributed to one's weight on sexual enjoyment, sexual desire, difficulty with sexual performance, and avoidance of sexual encounters. Given the paucity of research in this important area and the obvious relevance of this information for clinicians treating obese persons, more research is needed. Fruitful future research directions may include longitudinal studies and in‐depth qualitative research using instruments that are specifically designed to assess sexual functioning from a multidimensional perspective and that are applicable to both obese and non‐obese subjects (, , , ). Additionally, research is needed on the role of weight loss in improving sexual quality of life. Current research on this topic is limited and includes men only. In one study, about one third of obese men with erectile dysfunction reported improved sexual function after weight loss and lifestyle changes (). In another study, obese men (not necessarily with erectile dysfunction) who lost weight showed increased serum testosterone but no significant improvement in sexual function scores ().

Because of our study's cross‐sectional design, we are limited in the causal conclusions we are able to draw with respect to the relationship between obesity and sexual quality of life. Additionally, because of the relatively small number of men in the gastric bypass and control groups, there may be limited statistical power to detect differences among the groups. Finally, geographic differences may have influenced our findings (i.e., gastric bypass patients and control subjects were from Utah, whereas residential subjects came from numerous locations in the United States and abroad).

In summary, we found that obese individuals report a high frequency of sexual difficulties attributed to their weight and that sexual quality of life is particularly impaired for obese women, gastric bypass candidates, and individuals with Class III obesity. If we are to understand more fully the needs of our obese patients, more comprehensive assessment is needed to address the impact of weight on sexual quality of life, body image, and other important aspects of overall quality of life.

Acknowledgement

Portions of this paper were presented in a poster session at the NAASO 2004 meeting in Las Vegas. Dr. Østbye is partially funded by National Institute of Diabetes and Digestive and Kidney Diseases grant number DK‐64, 986. Data provided by the Utah Obesity Study was funded by National Institute of Diabetes and Digestive and Kidney Diseases grant number DK‐55, 006 and by Public Health Service research grant number M01‐RR00064 from the National Center for Research Resources.

Abstract

Objectives: Reduced sexual quality of life is a frequently reported yet rarely studied consequence of obesity. The objectives of this study were to 1) examine the prevalence of sexual quality‐of‐life difficulties in obese individuals and 2) investigate the association between sexual quality of life and BMI class, sex, and obesity treatment-seeking status.

Research Methods and Procedures: Subjects consisted of 1) 500 participants in an intensive residential program for weight loss and lifestyle modification (BMI = 41.3 kg/m ²), 2) 372 patients evaluated for gastric bypass surgery (BMI = 47.1 kg/m ²), and 3) 286 obese control subjects not seeking weight loss treatment (BMI = 43.6 kg/m ²). Participants completed the Impact of Weight on Quality of Life‐Lite, a measure of weight‐related quality of life. Responses to the four Sexual Life items (assessing enjoyment, desire, performance, and avoidance) were analyzed by BMI, sex, and group.

Results: Higher BMI was associated with greater impairments in sexual quality of life. Obese women reported more impairment in sexual quality of life than obese men for three of four items. Gastric bypass surgery candidates reported more impairment in sexual quality of life than residential patients and controls for most items. In general, residential patients reported levels of impairment greater than or equal to controls.

Discussion: Obesity is associated with lack of enjoyment of sexual activity, lack of sexual desire, difficulties with sexual performance, and avoidance of sexual encounters. Sexual quality of life is most impaired for women, individuals with Class III obesity, and patients seeking gastric bypass surgery.

Introduction

In addition to its medical consequences (, , , ), obesity has been linked to impairments in health‐related quality of life, including reduced physical functioning, psychosocial functioning, and emotional well being (, , , ). Reduced quality of life may be as serious a consequence of obesity as are its adverse effects on morbidity and mortality ().

Our clinical experience suggests that sexual dissatisfaction and/or sexual difficulties are not uncommon among our obese patients. Only a few research studies have examined the relationship between obesity and sexual quality of life. In men, obesity has been associated with lower sexual satisfaction (), increased erectile dysfunction (, ), and penile vascular impairment (). Less is known about obesity and sexual quality of life in women. One study () reported no differences in sexual satisfaction between obese and non‐obese women. However, in the 18‐ to 49‐year‐old cohort, obese women (and men) reported a greater decrease in sexual desire over the preceding 5 years compared with normal‐weight individuals.

The limited numbers of studies on sexual quality of life in obesity, along with anecdotal reports of sexual dissatisfaction/dysfunction by obese patients, suggest that this is an area in need of further study. The objectives of this study were to 1) examine the prevalence of sexual quality‐of‐life difficulties in obese individuals and 2) investigate the association between sexual quality of life and BMI class, sex, and obesity treatment-seeking status.

Research Methods and Procedures

Participants

The sample for this study consisted of obese (BMI ≥ 30 kg/m ²) adult (age ≥ 18 years) individuals from three different groups: 1) 500 participants in an intensive residential program for weight loss and lifestyle modification (); 2) 372 patients evaluated for gastric bypass as part of the Utah Obesity Study (); and 3) 286 individuals from a control group in the Utah Obesity Study who were randomly chosen from a population of severely obese participants but who were not seeking gastric bypass surgery (). Only those participants who completed the four Sexual Life items on the Impact of Weight on Quality of Life‐Lite questionnaire (IWQOL‐Lite) 1 (, ) were included in the current sample.

Procedures

On initial evaluation for their respective programs/studies, participants' heights and weights were obtained by the clinic/study personnel. BMI was calculated as kilograms per meters squared. BMI was categorized as Class I obesity = BMI of 30 to 34.9 kg/m ², Class II obesity = BMI of 35 to 39.9 kg/m ², Class III obesity = BMI of 40+ kg/m ² (). Participants also completed questionnaires that included demographic information (age, sex, and ethnicity) and the IWQOL‐Lite.

Measures

The IWQOL‐Lite is a reliable and valid self‐report measure of weight‐related quality of life (, , , ). The IWQOL‐Lite consists of 31 items that begin with the phrase, "Because of my weight ..." Each item has five response options, ranging from 1) "Never true" to 5) "Always true." The IWQOL‐Lite provides scores in five domains (Physical Function, Self‐Esteem, Sexual Life, Public Distress, and Work) along with a total score. For the purpose of this study, only responses to individual items from the Sexual Life scale were analyzed. The Sexual Life scale consists of four items that assess 1) lack of enjoyment of sexual activity, 2) lack of sexual desire, 3) difficulty with sexual performance, and 4) avoidance of sexual encounters-all items specifically attributed to one's weight.

Statistical Analyses

Separate two‐way ANOVAs with Tukey's honestly significant difference (HSD) post hoc comparisons () were used to compare responses to the four Sexual Life items across BMI categories (Class I, II, and III obesity) and sex. Partial η ² values were calculated to determine the proportion of unique variance accounted for by each factor.

Given previous findings of differences between men and women on IWQOL‐Lite scores (), as well as the sex differences obtained in the current samples, all of the analyses described below were conducted separately by sex. The three participant groups were compared on BMI and age using ANOVA with Tukey's HSD post hoc comparisons and on ethnicity using the χ ² test. Responses to each of the four IWQOL‐Lite Sexual Life items were tabulated by group and sex. Finally, analysis of covariance was used to compare responses to each of the IWQOL‐Lite Sexual Life items by group and sex, controlling for BMI and age. Post hoc comparisons among groups were based on covariate‐adjusted Bonferroni‐corrected contrasts. Again, η ² values were calculated to determine the proportion of unique variance accounted for by group differences.

Results

Demographic and Weight Characteristics

Table 1 presents demographic characteristics and BMI by group and sex. Age was significantly different among groups for both women ( F = 30.00; df = 2, 797; p < 0.001) and men ( F = 6.68; df = 2, 355; p = 0.001). For women, control group participants were significantly older than residential program participants, who were, in turn, significantly older than gastric bypass patients. For men, residential program participants were significantly older than gastric bypass patients.

BMI was also significantly different among groups for both women ( F = 52.83; df = 2, 797; p < 0.001) and men ( F = 13.09; df = 2, 355; p = 0.001). For women, gastric bypass patients had significantly higher BMI than control group participants, who, in turn, had significantly higher BMI than residential treatment participants. For men, gastric bypass patients had significantly higher BMI than both control group and residential program participants.

Although the majority of participants were white, the proportion of white participants differed significantly among groups for women (χ ² = 11.24, df = 2, p = 0.004), with the highest rates in the controls and the lowest rates in the gastric bypass candidates. There were no differences in the proportion of white participants among groups for men (χ ² = 3.24, df = 2, p = 0.198).

Comparisons across BMI Categories and Sex

Table 2 presents Sexual Life item responses by BMI category (Class I, II, and III obesity) and sex. Significant differences by BMI group were obtained for all Sexual Life items except sexual desire. Participants in the Class III obesity group reported less sexual enjoyment, more difficulty with sexual performance, and greater avoidance of sexual encounters in comparison with the other two BMI groups. For two items (enjoyment, performance), the Class II group reported greater impairment than the Class I group; for the remaining item (avoidance), there were no significant differences between the Class I and Class II groups. Women reported greater impairments than men on sexual enjoyment, desire, and avoidance of sexual encounters, but did not differ in terms of difficulties with sexual performance. None of the BMI group‐by‐sex interactions approached significance ( p values ranging from 0.240 to 0.766). For three of the four items (enjoyment, desire, avoidance), sex accounted for a greater portion of the criterion variance than BMI category, whereas for sexual performance, BMI category accounted for a greater portion of the variance.

Sexual Quality‐of‐life Item Responses by Group Separately by Sex

Table 3 presents responses to each of the four IWQOL‐Lite Sexual Life items by group separately for women and men. Across all four items, obese women reported higher frequencies of impairment than obese men. Furthermore, women reported each of these items with approximately equal frequency, whereas men reported some items (e.g., sexual desire and sexual performance) more than others. Female gastric bypass candidates reported much higher frequencies of sexual difficulties than either female residential program participants or controls.

Approximately one third of women (32.8% to 37.6%) reported that they usually or always did not enjoy sexual activity, had little sexual desire, experienced difficulty with sexual performance, and avoided sexual encounters because of their weight. Approximately one half of obese women (54.7% to 61.2%) reported difficulty with these aspects of sexual quality of life at least some of the time.

For obese men, the most commonly reported sexual concern related to weight was difficulty with sexual performance (nearly 50% reported problems at least sometimes), followed by lack of sexual desire (just >40% reported problems at least some of the time). Approximately 15% of obese men (14.5% to 18.2%) reported usually or always experiencing difficulties with sexual enjoyment and avoidance of sexual encounters. However, more than two thirds of men (71.2%) responded "never" or "rarely" to the item, "Because of my weight I do not enjoy sexual activity." Consistent with the findings for women, male gastric bypass candidates reported much higher rates of difficulties in all four aspects of sexual quality of life than the residential program participants or controls.

Comparisons among Treatment‐seeking Groups

Table 4 presents responses for women to the four IWQOL‐Lite Sexual Life items by treatment‐seeking group, controlling for differences in BMI and age. Significant differences were found among groups for all four items, accounting for between 7% (avoidance) and 14% (enjoyment) of the criterion variance. In all cases, female gastric bypass candidates had scores indicating significantly more impairment than the remaining groups. With one exception (sexual enjoyment), women in the residential program reported levels of impairment greater than or equal to female control subjects.

Cell entries represent mean adjusted for BMI and age ± standard deviation. Main effect comparison between groups adjusted for BMI and age.

IWQOL‐Lite, Impact of Weight on Quality of Life‐Lite questionnaire; RP, residential program; GB, gastric bypass; C, controls.

Data for men are presented in Table 5. Significant differences were found among treatment‐seeking groups in all four aspects of sexual quality of life, accounting for between 6% (avoidance) and 12% (enjoyment) of the criterion variance. For items assessing lack of sexual enjoyment and difficulty with sexual performance, men in the gastric bypass group reported more problems than either men in the residential program or male control subjects, who did not differ from each other. In contrast, for items assessing desire and avoidance of sexual encounters, men in the gastric bypass group and men in the residential program did not differ from each other, but reported more impairment than male control subjects.

Cell entries represent mean adjusted for BMI and age ± standard deviation. Main effect comparison between groups adjusted for BMI and age.

IWQOL‐Lite, Impact of Weight on Quality of Life‐Lite questionnaire; RP, residential program; GB, gastric bypass; C, controls.

Discussion

This is a study of the relationship between obesity and sexual quality of life. This is a greatly understudied research area that may have important implications for understanding and treating obese persons. With the increasing prevalence of obesity, sexual issues are likely affecting more people than usually realized. The major findings in this study are that 1) obese individuals report a high frequency of sexual difficulties attributed to their weight (lack of sexual enjoyment, lack of sexual desire, difficulty with sexual performance, and avoidance of sexual encounters); 2) higher BMI is associated with greater impairments in sexual quality of life; 3) sexual quality of life is more impaired for obese women than for obese men; and 4) gastric bypass candidates report greater impairment in sexual quality of life than other obese individuals.

The high rate of sexual difficulties experienced by subjects in this study is consistent with previous findings of reduced sex drive and sexual satisfaction (), as well as negative appearance evaluation (), in obese individuals seeking weight loss treatment. A population study of sexual dysfunction in the United States has reported prevalence rates of 7% to 22% for women (sexual pain, arousal problems, and low desire) and 5% to 21% for men (erectile dysfunction, low desire, and premature ejaculation) (). In contrast, this study of obese persons, albeit not a population study, found much higher rates of impairment in sexual quality of life, particularly for individuals seeking gastric bypass surgery. Although the population study did not examine subjects by BMI, the authors noted that sexual dysfunction was associated with poorer physical and emotional health.

Our finding of greater sexual impairment in women than in men (with the exception of difficulties with sexual performance) is also consistent with previous reports of poorer body image (), higher prevalence of sexual difficulties (), reduced health‐related quality of life (, ), and decreased weight‐related quality of life () in women compared with men. Likewise, our finding that obese persons seeking gastric bypass surgery report the greatest impairments in sexual quality of life and obese community subjects the least is consistent with previous research on differences in weight‐related quality of life across subgroups of obese persons differing in treatment status (). This finding is also consistent with research reporting differences in prevalence of sexual difficulties between patients in primary care settings vs. general community samples ().

The results of this study may have implications for clinicians who treat patients who are obese. Obese persons commonly experience stigmatization, discrimination, and prejudice because of their weight (, ). Additionally, and perhaps related to the above, many obese persons have a negative body image (). Thus, the combination of social stigmatization/prejudice and a negative body image may present social and psychological barriers to having sexual needs met. It is likely that many obese persons who experience diminished sexual quality of life and/or negative body image may wish to discuss these issues with their health care providers. Thus, providers need to create an atmosphere of acceptance and willingness to discuss these issues with their patients. This may be achieved simply by asking patients a few questions during initial screening, listening to patients' concerns with empathy, and putting the concerns into perspective by describing their prevalence in this population (i.e., "normalizing" the concerns). It may also be useful for health care providers to highlight the potential benefits that weight loss and lifestyle change may confer on improved sexual quality of life (, , , , , ). When needed, appropriate referrals and treatments should be recommended-e.g., psychotherapy for body image/self‐esteem issues and medical evaluation and/or treatment for sexual performance issues. Because impairment in sexual quality of life is greatest for women, individuals with Class III obesity, and patients seeking gastric bypass surgery, providers should be particularly mindful of the potential for sexual concerns in these patients.

One of the limitations of this study is that we assessed sexual quality of life using a four‐item scale from a measure of weight‐related quality of life. We recognize that sexual quality of life is a rich and multifactorial construct (including arousal, desire, satisfaction, physical functioning, beliefs and values, comfort with sexual and emotional intimacy, body image, and self‐esteem), and our findings address only the impact attributed to one's weight on sexual enjoyment, sexual desire, difficulty with sexual performance, and avoidance of sexual encounters. Given the paucity of research in this important area and the obvious relevance of this information for clinicians treating obese persons, more research is needed. Fruitful future research directions may include longitudinal studies and in‐depth qualitative research using instruments that are specifically designed to assess sexual functioning from a multidimensional perspective and that are applicable to both obese and non‐obese subjects (, , , ). Additionally, research is needed on the role of weight loss in improving sexual quality of life. Current research on this topic is limited and includes men only. In one study, about one third of obese men with erectile dysfunction reported improved sexual function after weight loss and lifestyle changes (). In another study, obese men (not necessarily with erectile dysfunction) who lost weight showed increased serum testosterone but no significant improvement in sexual function scores ().

Because of our study's cross‐sectional design, we are limited in the causal conclusions we are able to draw with respect to the relationship between obesity and sexual quality of life. Additionally, because of the relatively small number of men in the gastric bypass and control groups, there may be limited statistical power to detect differences among the groups. Finally, geographic differences may have influenced our findings (i.e., gastric bypass patients and control subjects were from Utah, whereas residential subjects came from numerous locations in the United States and abroad).

In summary, we found that obese individuals report a high frequency of sexual difficulties attributed to their weight and that sexual quality of life is particularly impaired for obese women, gastric bypass candidates, and individuals with Class III obesity. If we are to understand more fully the needs of our obese patients, more comprehensive assessment is needed to address the impact of weight on sexual quality of life, body image, and other important aspects of overall quality of life.

Acknowledgement

Portions of this paper were presented in a poster session at the NAASO 2004 meeting in Las Vegas. Dr. Østbye is partially funded by National Institute of Diabetes and Digestive and Kidney Diseases grant number DK‐64, 986. Data provided by the Utah Obesity Study was funded by National Institute of Diabetes and Digestive and Kidney Diseases grant number DK‐55, 006 and by Public Health Service research grant number M01‐RR00064 from the National Center for Research Resources.

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Duke Diet and Fitness Center, Duke University Health System, Durham, North Carolina Department of Psychiatry and Behavioral Sciences, Division of Medical Psychology, Duke University Health System, Durham, North Carolina Search for more papers by this author The costs of publication of this article were defrayed, in part, by the payment of page charges.

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Relationship between stress, eating behavior, and obesity

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Relationship between stress, eating behavior, and obesity

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Torres & Nowson (2007).

More common in men, this study correlated weight gain and higher BMI's with chronic life stress.

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Abstract

Stress is thought to influence human eating behavior and has been examined in animal and human studies. Our understanding of the stress-eating relation is confounded by limitations inherent in the study designs; however, we can make some tentative conclusions that support the notion that stress can influence eating patterns in humans. Stress appears to alter overall food intake in two ways, resulting in under- or overeating, which may be influenced by stressor severity. Chronic life stress seems to be associated with a greater preference for energy- and nutrient-dense foods, namely those that are high in sugar and fat. Evidence from longitudinal studies suggests that chronic life stress may be causally linked to weight gain, with a greater effect seen in men. Stress-induced eating may be one factor contributing to the development of obesity. Future studies that measure biological markers of stress will assist our understanding of the physiologic mechanism underlying the stress-eating relation and how stress might be linked to neurotransmitters and hormones that control appetite.

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# data[].attributes.attachment_link.title
Relationship between stress, eating behavior, and obesity

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Stress is thought to influence human eating behavior and has been examined in animal and human studies. Our understanding of the stress-eating relatio...

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Assessment of emotional, externally induced and restrained eating behaviour in nine to twelve-year-old obese and non-obese children

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Assessment of emotional, externally induced and restrained eating behaviour in nine to twelve-year-old obese and non-obese children

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Braet & Strien (1997).

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JavaScript is disabled on your browser. Please enable JavaScript to use all the features on this page.

Abstract

Are there differences in eating behaviour between obese and non-obese children? Using the parent version of the Dutch Eating Behaviour Questionnaire (DEBQ-parent version), the results of the present study suggest an affirmative answer to this question. The scores for obese children were significantly higher on the scales for emotional, external and restrained eating behaviour. Relationships were found between emotional eating and negative feelings of physical competence; between external eating and negative feelings of self-worth; and between both eating styles and various aspects of problem behaviour. No relationship was found between external eating and locus of control. Higher scores on both scales were associated with greater caloric intake. These findings suggest that DEBQ can be used as a screening instrument for assessing eating styles of obese children.

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# data[].attributes.attachment_link.title
Assessment of emotional, externally induced and restrained eating behaviour in nine to twelve-year-old obese and non-obese children

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JavaScript is disabled on your browser. Please enable JavaScript to use all the features on this page. Are there differences in eating behaviour between obese and non-obese children? Using the parent version of the Dutch Eating Behaviour Questionnaire (DEBQ-parent version), the results of the present study suggest an affirmative answer to this question.

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Obesity, Oxidative Stress, Adipose Tissue Dysfunction, and the Associated Health Risks: Causes and Therapeutic Strategies

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Obesity, Oxidative Stress, Adipose Tissue Dysfunction, and the Associated Health Risks: Causes and Therapeutic Strategies

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Manna & Jain (2015).

Oxidative stress seems to be the linking factor between obesity and its associated chronic conditions.

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Coping with weight stigma: development and validation of a Brief Coping Responses Inventory

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Coping with weight stigma: development and validation of a Brief Coping Responses Inventory

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Hayward, Vartanian and Pinkus (2017).

This paper creates a new brief scale to replace the lengthy 99 item Coping Responses Inventory (CRI) with a shorter scale to address weight stigma through 2 coping mechanisms: reappraisal and maladaptive.

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Summary

People who are overweight or obese are frequently stigmatized because of their weight, but there has been limited exploration of how people cope with these experiences. The Coping Responses Inventory (CRI) assesses a wide range of coping strategies in response to weight stigma; however, its length (99 items) may have prevented it from being widely used. The aim of the current research (four studies; total N = 1,391) was to develop and validate a Brief CRI. This 10‐item measure consists of two subscales that assess core coping responses to weight stigma: reappraisal and disengagement coping. Reappraisal coping is an adaptive form of coping that is associated with greater well‐being, whereas disengagement coping reflects a maladaptive form of coping that is associated with poorer well‐being. The Brief CRI provides a quick and effective way to assess coping with weight stigma, and its use has the potential to advance an understanding of the consequences of weight stigma.

Keywords: Coping, obesity, scale, weight stigma

Weight bias is a pervasive problem in Western society; people who are overweight and obese face significant disadvantage in areas of employment, health care, education and interpersonal relationships . Experiences with weight stigma are as common as experiences with stigma based on race , and recent evidence suggests that weight stigma is experienced almost daily among individuals who are overweight or obese , . These stigmatizing experiences are stressful for the targets of weight stigma and produce harmful psychological and behavioural consequences . For example, frequently experiencing weight stigma is associated with greater psychological distress , , unhealthy behaviours, such as binge eating , and exercise avoidance , and increases in cortisol, a hormone involved in the stress response , . Moreover, weight‐based discrimination is associated with an almost 60% increase in mortality risk, even after controlling for body mass index (BMI) and indicators of physical and psychological health .

There is consistent evidence pointing to weight stigma as a stressful experience , but little is known about how people cope with these stigmatizing experiences. A number of potential coping responses have been put forward; however, empirical research on their use and effectiveness is limited. Puhl and Brownell reviewed the theoretical and empirical literature and identified several potential coping responses to weight stigma. People who experience weight stigma may respond by conforming to weight‐based stereotypes, engaging in self‐protection strategies such as attributing negative feedback to the prejudiced views of others, compensating for weight‐related negativity by becoming skilled in other activities (e.g. enhancing their social skills to become more likeable), publicly attributing their obesity and weight‐related behaviours to factors outside of their control (e.g. medication), negotiating their identity (e.g. denying their weight‐based identity or decreasing its importance in threatening situations), confronting the perpetrator of the stigma, engaging in social activism, using avoidance or disengagement strategies (e.g. avoiding places where stigma is more likely to occur), engaging in communal coping or attempting to lose weight. These responses may manifest in a variety of ways, and the extent to which these responses are used is likely to depend on a range of individual and situational factors. Empirical evidence regarding these responses and others is limited.

There is only one measure currently available to assess coping responses to weight stigma. Myers and Rosen devised a 99‐item Coping Responses Inventory (CRI) as a companion measure to their Stigmatizing Situations Inventory (SSI) . The CRI comprises 21 subscales and assesses a wide range of coping strategies in response to weight stigma. Some of the responses identified are cognitive in nature (self‐talk, reappraisal), and others are behavioural (seeking social support, confronting the perpetrator); some are, on face value, positive (self‐love), and others are negative (negative self‐talk, isolating oneself). Studies utilizing this measure have shown that people engage in a wide range of coping behaviours in response to weight stigma, but these studies have not consistently identified subscales that can be categorized as 'adaptive' or 'maladaptive' , . Myers and Rosen identified three CRI subscales that were associated with negative psychological outcomes: negative self‐talk, cry/isolate myself and avoid or leave situation. They did not identify any 'adaptive' coping responses that correlated with better psychological outcomes. Puhl and Brownell used a modified version of the CRI (with an adapted response scale) to examine coping responses among men and women recruited through a weight loss support organization. Contrary to Myers and Rosen, Puhl and Brownell did find some evidence of 'adaptive' coping styles (seeking social support, positive self‐talk) but did not find any evidence of 'maladaptive' coping responses. Further research is needed to determine the types of coping that are consistently adaptive or maladaptive in nature.

Given the length of the CRI, its use may not be practical for many researchers, and this might be one of the reasons why there has been relatively little research examining how people cope with weight stigma. Thus, the aim of the current paper is to develop and validate a brief version of the CRI . In study 1, the full 99‐item measure was subjected to factor analysis in an attempt to identify a smaller number of core coping responses. These coping responses were then correlated with a range of psychological outcomes and with measures of general coping strategies. Study 2 attempted to replicate the findings from study 1; study 3 examined the convergent validity of the Brief CRI; and study 4 validated the Brief CRI with an alternative response scale.

Study 1: item selection

Method

Participants

In all four studies, participants were adults from the USA who identified as overweight or obese and were recruited via Amazon's Mechanical Turk. The advertisement indicated that the research sought individuals who were overweight or obese for an online study about their life experiences but did not mention weight stigma. A separate sample was used for each of the four studies. Because the studies were conducted online, two a priori exclusion criteria were implemented to ensure quality control. Participants were excluded if they failed any of the attention checks (between 1.2% and 5.3% of respondents in each sample) or if they had a BMI < 25 (or incomplete data for height and weight; between 2.8% and 5.6% of the remaining samples). Including these individuals in the analyses does not change the overall pattern of results. In study 1, valid data were available for 455 participants (55.6% women; 78.9% White; M age = 36.78, SD age = 10.84; M BMI = 36.44, SD BMI = 7.55).

Measures

Procedure

After providing informed consent, participants completed the Brief SSI. Next, participants completed the full CRI, the measure of general coping styles and measures of psychological well‐being (presented in random order). Finally, participants reported their age, sex, ethnicity, height and weight and read a debriefing statement.

Results and discussion

Factor analyses and item selection

First, an exploratory factor analysis was conducted on the 99 coping items using extraction and rotation methods that allow for correlated factors (principal axis factoring with direct oblimin). Using Kaiser's Criterion (eigenvalues greater than 1) , 20 potential factors were identified. However, a scree plot revealed that only three factors should be retained (eigenvalues: 20.5, 9.8 and 5.7, respectively). Together, these three factors explained 36.26% of the total variance. The factor analysis was performed again, this time constraining the solution to three factors, and the factor loadings were examined for all items on each subscale. To select items for the brief scale, items that loaded >|.5| on each factor were identified, resulting in a total of 23 items for factor 1, 21 items for factor 2 and seven items for factor 3. In order to keep the measure brief and ensure that each factor included the same number of items, the five items with the highest factor loadings were retained for each factor, with two additional restrictions. First, in order to maintain some breadth of coverage in the shortened measure (i.e. so that any given subscale was not dominated by a particular coping strategy), no more than two items from any one CRI subscale were retained for the new subscales. Second, because some coping items were rarely endorsed (i.e. a mean close to 0 [ Never]), items were required to have a mean frequency greater than 1 (i.e. Once in your life). The resulting factors were as follows: factor 1 ( active coping) reflects acting proactively in some way to reduce the likelihood of experiencing weight stigma in the future or to better cope with those experiences; factor 2 ( reappraisal coping) measures positive thinking in response to stigma and reappraising the experience as the other person's problem; and factor 3 ( disengagement coping) assesses negative self‐talk, withdrawal and avoidance responses. Table shows the items for each subscale, along with their factor loadings, mean (SD), Cronbach's alpha and the CRI subscale to which they originally belonged .

One item on the reappraisal coping factor ('I love myself, even when it seems like other people don't'; from the self‐love subscale of the CRI) loaded positively onto factor 2 at 0.60 but also cross‐loaded negatively onto factor 3 at −0.38. The item was retained because it fit conceptually with the final reappraisal coping subscale, and it had a stronger loading onto factor 2 than it did on factor 3. The item with the next highest loading on factor 2 (0.59) that met the additional criteria and did not cross‐load was 'I just say hello and am friendly'. This item, from the positive response subscale of the CRI, reflects a behavioural coping strategy that does not cohere with the cognitive strategies represented by the other four items on the reappraisal scale. Thus, conceptual clarity was prioritized and the self‐love item was retained. An exploratory factor analysis was conducted on the final 15 items to ensure that the cross‐loading did not persist with the brief measure. Three factors were identified using Kaiser's criterion and scree plot (eigenvalues were 3.67 for the disengagement factor, 3.10 for reappraisal and 2.12 for active). All items loaded cleanly onto their respective subscales (>0.54 on primary factor and <0.28 on all other factors).

The reappraisal and disengagement subscales are face valid and cohesive, whereas the active subscale is less conceptually clear. Although the items all reflect some form of actively responding to stigma, the nature of those responses varies from promoting size‐acceptance to attempting to lose weight. Furthermore, two items on our active coping scale were originally from the 'avoid or leave situation' subscale of the CRI. However, these avoidance items appear to reflect actively changing one's situation to address the problem of weight stigma (changing doctors and quitting jobs in response to stigma), which is conceptually different from the type of 'avoidance' items that load onto our disengagement subscale (avoiding looking in the mirror and avoiding going out in public). Overall, the active coping subscale may be more difficult to interpret than the other two subscales. In fact, it is possible that the items in factor 1 are grouped together more by their rarity than by their content. In support of this suggestion, all 23 items that were originally identified on factor 1 had low mean frequencies. The overall average frequency was 1.09 ( once in your life), with even the most frequently endorsed item from this group ('I tell people it's not right to make remarks about my size') having a mean frequency of only 2.17 ( several times in your life). The items that loaded onto factors 2 and 3 were much more frequent (average frequencies across each factor: 4.57 or more than several times per year and 3.51 or more than about once per year, respectively).

Table reports the association between scores on the Brief CRI subscales and demographic variables (BMI, age and sex), controlling for stigma frequency. Age was negatively correlated with 'active' coping across all samples, but there were no other consistent findings regarding any other demographic variable. Because 75-80% of the samples were White and a diverse range of ethnicities was represented in the 20-25% of participants who did not identify as White, this study was limited in its capacity to investigate meaningful differences in coping style between different ethnic groups. Analyses with ethnicity are therefore not reported.

Convergent validity

First, correlations were conducted between the three coping subscales and subscales of the Brief COPE (Table ). Only subscales that were conceptually related to the subscales identified in the Brief CRI were examined: an active coping subscale ('I've been concentrating my efforts on doing something about the situation I'm in'), a positive reframing subscale ('I've been trying to see it in a different light, to make it seem more positive'), a self‐blame subscale ('I've been blaming myself for things that happened') and a behavioural disengagement subscale ('I've been giving up trying to deal with it'). Surprisingly, the active coping scale was not significantly correlated with the 'active' subscale of the Brief COPE but instead was correlated with disengagement and (to a lesser extent) positive reframing. This pattern further supports the argument that the active subscale is conceptually muddy. Reappraisal coping was positively correlated with positive reframing and with active coping but was negatively correlated with self‐blame and behavioural disengagement. Finally, disengagement coping was positively correlated with self‐blame and behavioural disengagement and was negatively correlated with positive reframing and active coping.

Next, bivariate correlations were conducted between the Brief CRI subscales and the well‐being measures. Because coping frequency is related to how frequently one experiences weight stigma (in the current study, each coping subscale was positively correlated with SSI scores, with active and disengagement coping showing strong correlations) and because frequency of weight stigma itself is associated with well‐being , partial correlations between coping and well‐being, controlling for Brief SSI scores, were also examined (Table ). Unexpectedly, active coping was associated with greater body shape concerns, depression, anxiety and stress, and with lower self‐esteem. However, these relationships changed when controlling for Brief SSI scores: the correlation with body shape concerns changed from positive to negative; the negative correlation with weight bias internalization became significant; and the correlations with depression, stress and self‐esteem were no longer significant. The correlation with anxiety, however, remained significant and positive. Overall, the partial correlations revealed that active coping was associated with body‐related outcomes in the predicted direction but was not consistently correlated with well‐being. These findings reinforce the notion that the active coping subscale is not a cohesive entity.

Reappraisal coping was significantly associated with lower weight bias internalization, lower depression and greater self‐esteem. These relationships held when controlling for Brief SSI scores. Disengagement coping was correlated with higher body shape concerns, internalized weight bias, depression, anxiety and stress, and with lower self‐esteem. These relationships held when controlling for Brief SSI scores. Overall, these findings indicate that reappraisal coping is associated with greater well‐being, whereas disengagement coping is associated with poorer well‐being.

Distribution of data

The active coping subscale was significantly positively skewed (15.44) and suffered from substantial kurtosis issues (11.20). An inverse transformation vastly reduced the skew (2.54) and changed the kurtosis (−6.19); the pattern of results, however, did not substantively change. The reappraisal and disengagement coping scales did not suffer from skewness (0.69 and 1.82, respectively) but had mild kurtosis issues (−3.13 and −3.79). Some level of non‐normality is unsurprising given that the measures assess specific coping responses that are not always likely to be frequent occurrences (e.g. changing doctors, quitting jobs) and that vary widely in nature.

Study 2: replication

Study 2 aimed to replicate the factor structure found in study 1. The final sample consisted of 463 participants (54.2% women; 81.4% White; M age = 37.87, SD age = 11.19; M BMI = 36.41, SD BMI = 7.25). Participants completed the same measures as in study 1, except for one item of the full CRI that was inadvertently omitted ('I try to be with someone who makes me feel attractive'). This item was not included in the Brief CRI of study 1; thus, its omission had no bearing on results. A factor analysis was conducted on the full CRI, constraining the number of factors a priori to three. The same factors were identified: all items on the active subscale loaded highly onto factor 1 (loadings 0.63-0.75); all items from the reappraisal subscale loaded onto factor 2 (0.69-0.79); and all items from the disengagement subscale loaded highly onto factor 3 (0.65-0.78). As in study 1, the item 'I love myself, even when it seems like other people don't' from the reappraisal subscale also cross‐loaded onto factor 3 at −0.37. However, this cross‐loading was no longer observed when only the 15 Brief CRI items were entered into a factor analysis. This analysis revealed a three‐factor solution with all items loading strongly onto their respective factors (>0.57) and weakly on all other factors (<0.28). The three subscales again showed good reliability ( α s > 0.84), and the pattern of correlations with the measure of general coping and with the measures of psychological well‐being largely paralleled those in study 1 (Tables , ).

Studies 3: further validation

In studies 1 and 2, participants completed the items comprising the Brief CRI as part of the full CRI. Following the suggestions of Smith et al. , study 3 tested the validity of the brief measure when it was completed without the parent measure.

Method

Valid and useable data were available for 236 participants (59.3% women; 75.8% White; M age = 36.78, SD age = 11.59; M BMI = 35.73, SD BMI = 7.29), who completed the same measures as in the previous studies with three differences. First, participants completed the Brief CRI instead of the full measure. Second, participants completed the revised Ways of Coping questionnaire (WOC) , as an additional measure of general coping style. The WOC comprises eight subscales, but only those that are most conceptually relevant to the Brief CRI subscales were examined: confrontive coping (e.g. 'I tried to get the person responsible to change his or her mind'), positive reappraisal (e.g. 'I came out of the experience better than when I went in'), accepting responsibility (a measure of self‐blame; e.g. 'I realized I brought the problem on myself') and escape‐avoidance (e.g. 'Avoided being with people in general'). Finally, participants completed the Body Dissatisfaction subscale of the Eating Disorder Inventory as an additional measure of body image concerns.

Results and discussion

Factor structure

Entering the Brief CRI items into a factor analysis revealed a three‐factor solution (as identified by a scree plot and eigenvalues >1) with all items loading cleanly onto their respective subscales (>0.63 on the target factor and <0.22 on all other factors).

Convergent validity

Study 4: replication with modified response scale

Previous researchers have indicated that some participants have difficulty estimating how frequently they have engaged in each coping strategy on the CRI when they were asked to respond using the original 10‐point scale . Thus, study 4 used a response scale that is more 'user friendly'. A final sample of 237 participants (57.8% women; 78.9% White; M age = 35.70, SD age = 10.77; M BMI = 35.47, SD BMI = 7.19) completed the same measures as in study 3, except that the response scale used for the Brief SSI and the Brief CRI was altered to 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, and 4 = Always. A factor analysis revealed a three‐factor solution with all items loading cleanly onto the expected subscales (loadings > 0.60 on target factor and <0.22 on all other factors), except for one item on the active coping subscale ('I quit jobs where I encounter stigma or discrimination') that loaded moderately on both the active coping and disengagement coping factors. The patterns of correlations with the measure of general coping and with the measures of psychological well‐being largely paralleled those in study 3 (Tables , ). Furthermore, the distribution of scores of these modified measures was more normal than it was in the previous studies. Specifically, kurtosis levels were reduced in study 4 for the three coping scales and the SSI (all < |2.04|). The SSI also showed vastly reduced skewness in study 4 (now 1.34, down from 8.27, 8.58 and 6.04 in studies 1-3, respectively). The active coping subscale still suffered from significant skew in study 4 (6.72), but this was substantially lower than in studies 1 and 2 (>15.42) and somewhat lower than in study 3 (8.99). Overall, changing the response scale for the Brief CRI and the Brief SSI to a 5‐point frequency scale did not substantively affect the results and only served to enhance the normality of the distribution.

General discussion

The aim of the current paper was to develop and validate a brief version of Myers and Rosen's CRI, a measure that assesses strategies for dealing with experiences of weight stigma . In study 1 and study 2, the 99‐item, 21‐subscale measure was shortened into three 5‐item subscales reflecting core coping strategies in response to weight stigma: an active coping subscale, a reappraisal coping subscale and a disengagement coping subscale. Across four studies, the reappraisal and disengagement subscales showed good reliability and face validity and demonstrated excellent convergent validity with a range of psychological outcomes and alternative measures of coping in response to general stress. The active coping subscale had consistently good reliability but lacked coherency and produced conflicting findings regarding its validity.

The items in the active coping scale all appear to reflect taking action in response to weight stigma, but some can also be conceptualized as behavioural avoidance (e.g. changing doctors). The strategies on this subscale are also very uncommon (even after initially excluding items with a mean frequency < 1), with responses that are used, on average, only once in a person's life. The factor structure of the active coping subscale was also not replicated in study 4, with one item loading moderately onto the disengagement coping factor. In addition, the majority of the differences in results that were identified in ancillary analyses (i.e. when including all participants) involved the active coping subscale. This speaks to the instability of its relationships with the outcomes of interest. Furthermore, this 'active' subscale was positively correlated with the disengagement subscale of the Brief COPE and the escape‐avoidance subscale of the WOC and did not correlate with the Brief COPE active subscale. Correlations with well‐being outcomes were non‐existent or inconsistent. For these reasons, the validity and interpretability of this 'active' subscale could not be demonstrated, and its use is therefore not recommended.

The items in the reappraisal coping scale all reflect reappraisal of stigmatizing situations in a positive light. This scale showed good convergent validity: it was positively correlated with the positive reframing subscale of the Brief COPE and the positive reappraisal subscale of the Ways of Coping measure and was negatively associated with self‐blame, behavioural disengagement and escape‐avoidance (in study 4 only). Furthermore, reappraisal coping was consistently associated with better psychological outcomes: lower internalized weight bias, body shape concerns, depression, anxiety and stress, and higher self‐esteem. Overall, reappraisal coping, as measured with these five items, appears to be an adaptive strategy that is associated with better outcomes.

The items in the disengagement coping measure tap into several negative responses to weight stigma, including withdrawal, negative self‐talk and avoidance of situations because of fear of experiencing further stigma. The disengagement coping measure showed excellent convergent validity across the four studies. Disengagement coping was positively associated with the avoidance, disengagement and self‐blame subscales of general coping measures and negatively correlated with the active coping and positive reframing subscales. Disengagement coping was also consistently associated with poorer psychological outcomes: greater internalized weight bias, body shape concerns, body dissatisfaction, depression, anxiety and stress, and lower self‐esteem. Overall, then, disengagement coping appears to be a highly maladaptive coping strategy. Furthermore, given the strong association between stigma frequency and disengagement coping, people who experience frequent stigma may be particularly susceptible to adopting this maladaptive response style.

The subscales that were identified in this research showed consistent patterns of associations across four studies with over 1,300 participants who identified as overweight or obese. Each of the studies had approximately equal numbers of men and women, and ancillary analyses revealed that sex did not consistently moderate the relationships between coping and psychological outcomes. Thus, the findings reported in this paper are largely generalizable to both men and women. However, the vast majority of participants in these studies identified as White or Caucasian, and all were living in the USA; thus, it is not known how well these measures will generalize to other samples.

In terms of the brief measure itself, the aim was to retain some of the breadth of the original measure by ensuring that at least three subscales from the original CRI were represented in each Brief CRI subscale. Thus, in the 10‐item measure, six original subscales are represented: positive self‐talk, others problem, self‐love/self‐acceptance, negative self‐talk, cry/isolate myself and avoid/leave situation. However, these measures do not reflect the wide range of possible responses people make when they experience weight stigma. Many of the 15 omitted subscales are likely to have important consequences for well‐being. For example, social support may buffer against the harmful effects of weight stigma on psychological distress ; however, the Brief CRI does not include items reflecting social support as a potential coping strategy. Moreover, the subscales that were identified largely reflect a cognitive style of coping (the only exceptions being the two avoidance items of the disengagement coping subscale). The Brief CRI therefore does not adequately capture behavioural coping, such as responding verbally or physically to the perpetrator of the stigma, eating or dieting, educating others or seeking therapy. This is likely because behavioural forms of coping (such as those identified on the 'active' subscale) are less common responses and are thus somewhat difficult to assess in a general measure such as this one. Researchers who wish to use the Brief CRI should be aware of this limitation. If specific subscales are of interest to researchers, then those researchers would be better served to use the subscales of interest from the full CRI or find alternative measures of specific responses. The specific coping strategies of interest may depend on the type of stigma in question. For example, if the perpetrator of the stigma is close to the victim (e.g. spouse, friend), the coping responses utilized are likely to be different than if the perpetrator is a stranger and different again if the stigma is arising from the media or physical barriers in the environment. Researchers may therefore wish to use the Brief CRI in conjunction with additional specific subscales from the full CRI that are relevant to their specific research questions.

Finally, the self‐report, retrospective nature of these brief measures may to some extent limit their utility. One important avenue for future research will be to examine how well these recalled coping responses correspond with people's actual coping behaviours in response to an episode of stigma. Although research in this area is currently lacking, there is some evidence from the stress and coping literature that people may not be able to accurately and reliably recall their coping responses. For example, a study using an ecological momentary assessment design found that participants' self‐reported coping responses within 1 to 2 h of experiencing a stressful situation were only modestly associated with the coping responses that they retrospectively recalled 48 h later . This lack of correspondence may be due to errors in recall or to the fact that coping may continue after the immediate window has ended and the types of coping used after this time may differ. Both types of assessments - in the moment and retrospective - are crucial in understanding how people cope with weight stigma and whether these coping strategies predict psychological functioning and well‐being.

Across four studies, the present research demonstrated the reliability and validity of a brief version of Myers and Rosen's CRI . The two core coping response subscales that are recommended for assessing coping with weight stigma are reappraisal coping and disengagement coping (see Appendix for the final measure). The reappraisal coping subscale reflects a positive, adaptive response to weight stigma that is consistently associated with improved psychological functioning. The disengagement coping subscale reflects a negative, maladaptive coping response that is strongly associated with poor psychological well‐being. A third strategy, active coping, was also identified, but the use of this subscale cannot be recommended because its validity could not adequately be demonstrated. The final Brief CRI was validated with both the original 10‐item response scale and a modified 5‐item response scale that improved the normality of the distribution. Although the brief 10‐item measure does not encompass all of the possible ways people cope with weight stigma, it provides a quick and efficient way to assess core coping responses - one response that is associated with beneficial outcomes and one response that is associated with harmful outcomes. Future research using the Brief CRI will help to elucidate structural relationships between stigma experiences, coping and psychological well‐being outcomes. The current studies found that stigma frequency is associated with more coping in general but appears to be more strongly associated with disengagement coping. Future studies should attempt to understand the mechanisms underlying these relationships and assess whether disengagement coping exacerbates the harmful effects of stigma on well‐being and whether reappraisal coping mitigates them. Expanding this knowledge may open the door to potential interventions that assist people who are overweight and obese in coping with weight stigma. The present data suggest that any intervention is likely to need to discourage disengagement coping as much as encourage reappraisal coping. Overall, it is hoped that the Brief CRI measure will promote and facilitate future research on coping with weight stigma.

Conflict of Interest Statement

The authors declare no conflict of interest.

Author contributions

L. H. collected and analysed the data. All authors were involved in study conceptualization and design, interpreting the data and writing the paper and had final approval of the submitted article.

Acknowledgements

This research was supported under the Australian Research Council's Discovery Projects funding scheme (project number DP160100904). The Australian Research Council had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript or the decision to submit the paper for publication.

Appendix 1. Brief Coping Responses Inventory

1.

The following questionnaire describes some strategies people use in order to deal with negative situations related to their weight. For example, someone who hears an insult about her appearance may make herself feel better by insulting the person back. Using the following scale, please indicate whether, and how often, you have used each of the following strategies to cope with negative situations related to your weight.

Reappraisal coping subscale (calculate the mean score for the following five items):

1. I try to think about good things that have happened to me.

2. I remind myself that I am a good person and people like me just the way I am.

3. If someone has a problem with how I look, I see it as their problem, not mine.

4. If people do not like me because of my size, I see it as their loss, not mine.

5. I love myself, even when it seems like other people don't.

Disengagement coping subscale (calculate the mean score for the following five items):

1. I feel really bad about myself.

2. I get depressed and isolate myself.

3. I avoid looking in the mirror so that I don't have to think about my weight.

4. I think that no one will ever love me because of my weight.

5. I avoid going out in public because I am afraid people will make comments about my size.

Notes

Hayward L. E., Vartanian L. R., and Pinkus R. T. (2017) Coping with weight stigma: development and validation of a Brief Coping Responses Inventory. Obesity Science & Practice, 3: 373-383. doi: [[ 10.1002/osp4.125. PubMed] PMC free article] [ Google Scholar]

References

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23. Kaiser HF. The application of electronic computers to factor analysis. Educ Psychol Meas 1960; 20: 141-151. [ Google Scholar]

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Coping with weight stigma: development and validation of a Brief Coping Responses Inventory

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People who are overweight or obese are frequently stigmatized because of their weight, but there has been limited exploration of how people cope with these experiences. The Coping Responses Inventory (CRI) assesses a wide range of coping strategies in ...

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How chronic stress can increase obesity

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Here you can see the comorbidities obesity can bring to an individual and the likelihood of resolving these issues once weight has been reduced.

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Cognitive‐behavioral treatment of obese binge eaters

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Cognitive‐behavioral treatment of obese binge eaters

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Smith, Marcus & Kaye (1992)

CBT in obese binge eaters can help reduce bulimic episodes and improve mood.

However did this actually effect weight loss?

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First published:

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Abstract

Obese binge eaters may benefit from cognitive‐behavioral treatment (CBT) approaches that target binge eating. In the present study, eight overweight women participated in a 16‐week group CBT program. The Eating Disorder Examination (EDE), a clinical interview designed to assess the psychopathology specific to eating disorders, was administered pre‐ and post‐treatment. Frequency of bulimic episodes during the 28 days prior to assessment was substantially reduced following treatment. Total days with bulimic episodes decreased from 13.4 to 1.2, with a mean reduction of 81%. As assessed by the EDE, dysfunctional concern for body shape and weight and disturbed attitudes about eating markedly diminished. Mood similarly improved. These find/rigs confirm that obese bingers improve after a CBT program designed to ameliorate binge eating and indicate the utility of the EDE in assessing treatment outcome with these patients.

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Cognitive‐behavioral treatment of obese binge eaters

# data[].attributes.attachment_link.description
First published: Get access to the full version of this article. View access options below. Log in with Open Athens, Shibboleth, or your institutional credentials. If you have previously obtained access with your personal account, Please log in. Obese binge eaters may benefit from cognitive‐behavioral treatment (CBT) approaches that target binge eating.

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This documentary discusses the 'body positive' community, highlighting views of acceptance and giving voice to certain 'toxic' viewpoints which decide size of body is not an indicator of health. Actually stating against scientific evidence that certain comorbidities like Type II diabetes are not caused by being overweight.

This raises problems for interventions as the community are discouraging healthy lifestyle changes. This body positivity movement is particularly strong for young females online, meaning social media may not contribute positively to a healthy lifestyle change for obese patients.

Conversation also discusses the  glorifying of obesity and it's impact on modern culture. In particular, the famously controversial Cosmopolitan magazine cover boasting Tess Holiday, a plus sized obese model. On one hand this cover has been praised for encouraging body positivity, though on the other, shamed for promoting obesity.

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People living with obesity move in together to explore what it means to be larger bodied.

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Psychological interventions for adults who are overweight or obese

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Psychological interventions for adults who are overweight or obese

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Brennan et al. (2018).

Data withdrawn?

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Background

Description of the condition

Overweight and obesity are defined as "conditions of abnormal or excessive fat accumulation in adipose tissue, to the extent that health may be impaired" ( WHO 1998). These conditions are operationally defined as a body mass index (BMI), weight in kilograms divided by the square of height in metres (kg/m²), of ≥ 25 kg/m² and ≥ 30 kg/m² respectively ( WHO 1998). The World Health Organization (WHO) estimates that in 2014, 39% of adults were overweight (38% men and 40% women) and 13% were obese (11% men and 15% women). Worldwide rates of overweight and obesity in adults continue to rise. Rates of extreme obesity are rising most quickly ( WHO 2014). Although the prevalence of overweight and obesity are highest in developed countries, rates in developing countries are rising dramatically as income, urbanisation, and processed food availability increase ( WHO 2014). In higher‐income countries, obesity rates are highest among the poor and those living in rural areas. In contrast, obesity rates in lower‐income countries are highest among those living in urban and more affluent areas. The risk of obesity for women in low‐ and lower‐middle‐income countries is almost double that of men. Rates are similar for men and women in high‐income countries ( WHO 2014).

Excess weight is associated with a range of negative biopsychosocial outcomes; the higher the weight, the greater the risk. The metabolic correlates of overweight and obesity include higher blood pressure, raised cholesterol and triglycerides levels, and greater insulin resistance. Consequently, overweight and obesity are associated with increased risk of cardiovascular disease, type 2 diabetes mellitus, and some cancers (e.g., breast, colon, prostate). Excess weight is also associated with a range of musculoskeletal, respiratory, skin, and fertility conditions that impair health‐related quality of life ( Guh 2009; WHO 2000; WHO 2014). Research examining the psychosocial consequences of overweight and obesity has focused almost exclusively on developed countries. Studies examining the psychological correlates of obesity in the community report mixed findings; however, on balance, they suggest that women who are obese are vulnerable to symptoms of depression (including suicidal ideation) and low self‐esteem ( Luppino 2010). Results are more consistent in those seeking weight loss treatment. Overweight and obese treatment‐seekers demonstrate higher rates of psychopathology, including mood disorders (depression, low self‐esteem, anxiety) and eating disorders (binge eating disorder, night eating syndrome, body image dissatisfaction), as well as impaired health‐related quality of life ( Fontaine 2001; Jia 2005; Wadden 2002b). Heavier individuals are also at increased risk of discrimination in employment, health care, education, the media, and in interpersonal relationships ( Puhl 2003). Combined, these negative biopsychosocial outcomes result in significant impairments in health‐related quality of life (WHO estimates that 35.8 million (2.3%) of global disease‐adjusted life years (DALYs) are caused by overweight or obesity) and loss of productivity ( Fontaine 2001; Robroek 2010). Further, management of weight‐related comorbidities places a significant burden on healthcare systems ( Colagiuri 2010; Hammond 2010; Müller‐Riemenschneider 2008; Wang 2011; WHO 2000).

Traditionally, overweight and obesity were thought to be a consequence of an individual's poor health choices and behaviours resulting in excess energy balance ( Skender 1996; Spiegelman 2001). Thus, early prevention and treatment efforts were targeted at individual behaviour change ( Kremers 2010; Lemmens 2008; Shaw 2005; Shaw 2006; Thomas 2007). There is now improved understanding of the complexity of factors contributing to excess energy balance and weight gain. These include: individual and social psychology, individual physical activity and the activity environment, food consumption and production, human and individual physiology ( Vandenbroeck 2007). As a result of this improved understanding, prevention and intervention efforts are changing to encompass a wider range of contributing factors ( Beauchamp 2014; Franz 2007; Kremers 2010; Lemmens 2008).

The high and increasing prevalence of overweight and obesity highlights the need for prevention efforts. Despite considerable research and intervention efforts targeting obesity prevention, the rate of excess weight continues to rise. Successful prevention efforts aim to first slow, then halt, then reverse increasing rates of overweight and obesity. Therefore, overweight and obesity rates will remain high for some time, even if prevention efforts are successful. Thus, effective treatment approaches are required.

Description of the intervention

Overweight and obesity are treated using 'lifestyle' (diet, exercise), medical (pharmacological), and surgical interventions. Dietary interventions targeting reduced energy and/or relative macronutrient intake result in small weight losses in the short term with weight typically regained in the longer term ( Hession 2009; Thomas 2007). Very low energy diets result in larger weight losses, but weight is typically regained ( Franz 2007; Mann 2007). Exercise interventions targeting increased energy expenditure via cardiovascular and/or resistance training result in small weight losses, and result in marginal improvements in weight loss when combined with dietary interventions ( Jakicic 2001; Shaw 2006). A number of pharmacological treatments have been shown to improve weight loss outcomes ( Franz 2007; Padwal 2003). However, few are currently approved for use in the treatment of obesity. Although surgical interventions are becoming increasingly popular and produce the most substantial and sustained weight loss, they also carry the most risk ( Colquitt 2014).

While psychological interventions are often used in combination with medical interventions ( Douketis 2005), the majority of the research examining psychological interventions examines these interventions used in isolation or in combination with 'lifestyle' interventions ( Sarwer 2014). A range of psychological interventions has been used in the treatment of overweight and obesity. These interventions have typically been adapted from those designed to treat mental health conditions. The overarching objective of this type of intervention is to reduce the psychological barriers to health behaviour change ( Shaw 2005). Which barriers are targeted, and via which mechanisms, vary across types of psychological intervention.

Treatment delivery settings (e.g. hospital, community), delivery modes (e.g. face to face, telephone, online), delivery agent (e.g., psychologist, other health professional, lay person), and intensity and duration, have varied considerably across these interventions ( Shaw 2005). Greater intensity and duration have resulted in greater weight loss and weight maintenance respectively ( Franz 2007). There are few other consistent findings regarding the impact of these treatment characteristics on treatment outcomes.

How the intervention might work

Psychological interventions for overweight and obesity aim to reduce the psychological barriers to health behaviour change and maintenance. The behavioural, cognitive, social and emotional variables that are conceptualised as barriers and therefore targeted in treatment vary depending on the theoretical underpinnings of the intervention. The majority of psychological interventions for overweight and obesity are cognitive behaviourally based, and are typically used in combination with lifestyle interventions ( Shaw 2005). There are three 'waves' of cognitive behavioural interventions. First wave or behaviour therapies target modification of the behaviours and the antecedents and consequences hypothesised to be maintaining a positive energy balance ( Wadden 2002a; Wing 2001). Second wave or cognitive behaviour therapies target modification of the behaviours and thoughts hypothesised to be maintaining a positive energy balance. Cognitive therapies target problematic thoughts hypothesised to be maintaining a positive energy balance ( Cooper 2004; Fabricatore 2007). Third wave cognitive behaviour therapies are a family of interventions (e.g., meta‐cognitive therapy , acceptance and commitment therapy , mindfulness‐based cognitive therapy , dialectical behaviour therapy , and compassion‐focused therapy targeting modification of both behaviours and reactions to/relationships with thoughts hypothesised to be maintaining a positive energy balance ( Öst 2008).

A range of other psychological interventions has been used in the treatment of overweight and obesity ( Shaw 2005). These include relaxation therapy ( Bertisch 2008), psychodynamic therapy ( Wiltink 2007), hypnotherapy ( Kirsch 1995), eye movement desensitisation and reprocessing ( Stapleton 2011), emotion freedom techniques ( Stapleton 2011), interpersonal psychotherapy ( Tanofsky‐Kraff 2014), and emotion‐focused therapy ( Compare 2013). Unfortunately the mechanism of action of these interventions in their treatment of obesity is not always explicitly and/or consistently defined.

Adverse effects of the intervention

The potential adverse effects of obesity interventions have received relatively little research attention ( Shaw 2005; Shaw 2006). To date, the biological impacts of weight loss have been shown to be positive, demonstrating improvements in obesity‐related disease risk factors (e.g., improved insulin resistance) in the short‐ to medium‐term ( Shaw 2005). Similarly, participation in a weight loss intervention has generally been shown to result in improvements in psychological outcomes (e.g., depression, disordered eating) in the short‐ to medium‐term ( Hardeman 2000). Although some studies have found that these improvements are related to the amount of weight lost ( Blaine 2007), others have attributed improvements to other factors such as the social support received while participating in a weight loss intervention ( Elfhag 2005; McLean 2003). Despite widespread recognition of the negative social consequences of obesity (e.g., stigmatisation, discrimination), little is known about the effects of interventions on social outcomes ( Papadopoulos 2015; Puhl 2003).

Why it is important to do this review

The high and increasing prevalence of overweight and obesity ( WHO 2014), combined with the negative biopsychosocial comorbidities of excess weight ( Guh 2009), and the limited effectiveness of prevention efforts to date ( Lau 2007; Lemmens 2008; McTigure 2007; WHO 2000), highlight the need for effective overweight and obesity treatment. There is now a large and increasing body of evidence demonstrating the limited effectiveness of lifestyle interventions in achieving substantial and sustained weight loss ( Shaw 2006; Wu 2009). In recognition of the challenges of achieving substantial and sustained weight loss, psychological interventions increasingly are included in treatment ( Sarwer 2014; Shaw 2005).

The most recent Cochrane Review examining psychological interventions for overweight and obesity was published in 2005 ( Shaw 2005). Over the last 10 years, the field has developed considerably on three fronts. First, the last decade has seen the development of 'third wave' psychological interventions ( Öst 2008). Second, there has been a proliferation of research examining the efficacy, and more recently, the effectiveness of psychological interventions, particularly cognitive behavioural interventions ( Hendrie 2012). Third, this research has considered a broader range of biopsychosocial outcomes and included longer follow‐up periods ( Blaine 2007). As a result, a new review would include a broader range of psychological interventions and consider the impact of various treatment characteristics on treatment outcomes more comprehensively. Furthermore, a review of current literature would also help to clarify a series of inconsistent findings and interpretation of findings that are present in the literature. Although there have been a number of related systematic reviews of psychological interventions for overweight and obesity conducted since 2005, they have considered more specific questions such as methods of delivery of intervention (i.e., web‐based) ( Neve 2010), specific populations (e.g., disabled) ( Hamilton 2007), or specific types of psychotherapy (e.g., hypnosis) ( Pittler 2005). Thus, there is a need for an updated and comprehensive review of psychological interventions for overweight and obesity.

Objectives

To assess the effects of psychological interventions for the treatment of overweight and obese adults. Specific objectives are to examine the efficacy of:

1. All psychological therapies versus minimal or no intervention;

2. All psychological therapies versus an active diet and/or exercise intervention;

3. Behavioural psychological therapies (first, second or third wave) versus other psychological interventions.

Secondary objectives are to examine if the magnitude of intervention effects (objectives 1, 2, and 3) for the primary outcome of BMI are modified by particular intervention characteristics (length of follow‐up), or participant characteristics (degree of excess weight). We also plan to investigate whether the effects of behavioural therapy are modified by the type of behaviour intervention (first, second or third wave).

Declarations of interest

*** TEXT WILL BE DELETED BEFORE PUBLICATION OF THE PROTOCOL ***

Review authors: please note possible conflicts of interests (http://community.cochrane.org/editorial‐and‐publishing‐policy‐resource/conflicts‐interest‐and‐cochrane‐reviews).

For example, 2.2.4. Cochrane Review author also an author on a study listed in the review:

"Cochrane authors who include primary studies (which they had conducted) in their Cochrane Review should declare this in the review in the 'Declarations of interest' section. Authors of primary studies should not extract data from their own study or studies. Instead, another author(s) or an editor(s) should extract these data, and check the interpretation against the study report and any available study registration details or protocol. Also, the relevant authorship of the primary studies should be disclosed in Cochrane's disclosure of potential conflicts of interest form and therefore the Cochrane Review."

References

Additional references

The CONSORT statement. http://www.consort‐statement.org (last accessed 19 may 2016).

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McMaster University, 2015 (developed by Evidence Prime, Inc.). Available from gradepro.org. GRADEpro GDT: GRADEpro Guideline Development Tool. Version accessed dd Month yyyy. Hamilton (ON): McMaster University, 2015 (developed by Evidence Prime, Inc.). Available from gradepro.org.

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# data[].attributes.attachment_link.title
Psychological interventions for adults who are overweight or obese

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Overweight and obesity are defined as "conditions of abnormal or excessive fat accumulation in adipose tissue, to the extent that health may be impaired" ( WHO 1998). These conditions are operationally defined as a body mass index (BMI), weight in kilograms divided by the square of height in metres (kg/m²), of ≥ 25 kg/m² and ≥ 30 kg/m² respectively ( WHO 1998).

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Heavier individuals are also at increased risk of discrimination in employment, health care, education, the media, and in interpersonal relationships (Puhl 2003).

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Should we 'stop sugarcoating' childhood obesity campaigns?

https://abcnews.go.com/Health/Wellness/stop-sugarcoating-child-obesity-ads-draw-controversy/story?id=15273638

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Are junk food advertisements partly responsible for childhood obesity?

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Childhood Obesity: Do junk food adverts really influence children? | Cancer Research UK

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Tells us that when in combination, behavioural therapy and diet/exercise approaches work best in weight reduction treatment.

Since this paper however (2004), there have been many advances in psychological interventions - CBT in particular.

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International Journal of Behavioral Nutrition and Physical Activity

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16k Accesses

27 Citations

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Abstract

Background

Sustainable lifestyle modification strategies are needed to address obesity and cardiovascular risk factors. Intensive, individualised programs have been successful, but are limited by time and resources. We have formulated a group-based lifestyle education program based upon national diet and physical activity (PA) recommendations to manage obesity and cardio-metabolic risk factors. This article describes the content and delivery of this program, with information on compliance and acceptability.

Methods

Overweight/obese adults ( n = 153) with metabolic syndrome were recruited from the community and randomly allocated to intervention (INT) or control (CON). Written copies of Australian national dietary and PA guidelines were provided to all participants. INT took part in a 16-week lifestyle program which provided a curriculum and practical strategies on 1) dietary and PA information based on national guidelines, 2) behavioural self-management tools, 3) food-label reading, supermarkets tour and cooking, 4) exercise sessions, and 5) peer-group support. Compliance was assessed using attendance records and weekly food/PA logs. Participants' motivations, perceived benefits and goals were assessed through facilitated discussion. Program acceptability feedback was collected through structured focus groups.

Results

Although completion of weekly food/PA records was poor, attendance at information/education sessions (77% overall) and exercise participation (66% overall) was high, and compared with CON, multiple markers of body composition and cardio-metabolic health improved in INT. Participants reported that the most useful program components included food-label reading, cooking sessions, and learning new and different physical exercises, including home-based options. Participants also reported finding self-management techniques helpful, namely problem solving and short-term goal setting. The use of a group setting and supportive 'peer' leaders were found to be supportive. More frequent clinical assessment was suggested for future programs.

Conclusion

This group-based lifestyle program achieved improvements in body composition and cardio-metabolic and physical fitness similar to individualised interventions which are more resource intensive to deliver. It confirmed that active training in lifestyle modification is more effective than passive provision of guidelines. Such programs should include social support and self-management techniques. Continued clinical follow up may be required for long-term maintenance in individuals attempting lifestyle behaviour change. Program facilitation by peers may help and should be further investigated in a community-based model.

Background

A randomised, controlled, parallel group intervention trial aimed at improving body composition and cardio-metabolic risk factors was conducted in free-living adults with metabolic syndrome (MetS). The study used a group-based lifestyle modification program of non-energy restricted diet and physical activity (PA) intervention, based on the Australian national guidelines for diet and physical activity (PA). The intervention involved 103 participants and resulted in improvements in body composition, blood pressure, blood lipid levels, physical fitness and dietary intake, the details of which have been described elsewhere [ 1]. The purpose of this article is to provide a detailed description of the intervention used in the study, and to report on the acceptability of the program and the practical implications of applying national recommendations for lifestyle change.

Rationale

Obesity continues to be a major public health issue, and central obesity and MetS are also becoming increasingly prevalent. In Australia, approximately 60% of the population are overweight or obese [ 2], and 30% have central obesity. Increasing levels of obesity, in particular central obesity, are also driving an increase in the prevalence of MetS [ 3]. Consensus on the long-term effectiveness of intervention programs for reducing obesity has not been established [ 4]. Similarly, there is no one agreed treatment for MetS [ 5]. Despite this, lifestyle intervention (weight loss, dietary improvement and PA) is emphasised as first-line therapy for these conditions. National guidelines for appropriate diet and PA are available, but the uptake of these recommendations is unknown.

Current literature suggests that significant effort is required to achieve sustained changes in body composition and metabolic health. Lifestyle intervention combining intensive dietary modification with prescribed levels of PA can reduce the incidence of chronic disease [ 6, 7] but a range of factors can negatively influence the successful adoption and maintenance of positive lifestyle changes [ 8], resulting in difficulty improving lifestyle behaviours. Consequently, many programs demonstrate short term weight loss, for example at 3-6 months, but few show success in maintaining weight loss at 12 months or beyond [ 9- 11] Sustained weight loss and modification of risk factors has been achieved following long-term intensive interventions [ 7, 12] but these methods generally rely on prescribed diet and exercise together with counselling and supervision by dietitians, counsellors, physical trainers, psychologists and behaviourists. The use of highly prescriptive diet and exercise regimes may present difficulties for some people to integrate into their existing lifestyle, and the use of health professionals to work one-on-one with individuals in order to effectively implement this type of program can make such approaches cost and time intensive, and potentially unsustainable at the community level. Evaluations of primary-care based programs and applications of national lifestyle guidelines appear to be practical [ 13- 17], and recent evidence suggests that they may be effective [ 18- 20] but again these types of programs rely heavily on individualised intervention, making their delivery expensive.

The approach we are evaluating in this study involves a program conducted in a group setting, incorporating some of the potentially beneficial aspects of self-management programs (SMP). SMP appear to be effective for chronic disease management [ 21- 23] and might also be useful for the prevention of chronic disease [ 24- 26]. Key features of such programs include shared goal-setting, lifestyle skills teaching, ongoing follow-up and support [ 27] as well as promoting the establishment of peer support networks, which have been suggested as a useful tool for improving compliance with interventions for weight loss [ 28] and diabetes prevention [ 29]. Delivery of this program in a group setting rather than on an individual basis was aimed at reducing the resources required for the delivery of the program.

Methods

Clinical study design

Volunteers were recruited from Whyalla, a regional community of South Australia with rates of overweight and obesity which exceed the State average. Adults in the community responded to media advertisements calling for volunteers to participate in the Shape up for Life lifestyle intervention trial which was aimed at changing lifestyle habit to reduce obesity and improve health. Beginning in 2006, 153 volunteers meeting international criteria [ 30] for MetS were enrolled (111 females, 42 males; aged 45.1 ± 0.8 years). Participants weighed on average at baseline 102.6 ± 2.3 kg, and mean BMI was 36.6 ± 0.7. Mean waist circumference was 115 ± 1 cm. Individuals taking medication for blood pressure, blood lipids or with a diagnosis of diabetes mellitus (type 1 or type 2) were excluded. Eligible participants were randomly allocated to intervention (INT; n = 103); or control (CON; n = 50). There were no significant differences in baseline characteristics between INT and CON. Assessments of anthropometry, body composition, cardiovascular and metabolic health, physical fitness, dietary intake, PA and quality of life were performed at baseline and after 4 and 12 months. The clinical study protocol was approved by the Human Research Ethics Committee of the University of South Australia, and all study participants provided written informed consent prior to participation.

Lifestyle intervention

All participants were provided with standard booklets of the Australian guidelines for healthy eating [ 31] and PA [ 32]. No other intervention was provided to CON. A structured 16 week information and education program and group exercise was conducted for INT. The program, called ' Shape up for Life', ran as group sessions for 2 hours each week.

Key features of the program

The program sessions were framed to translate the various recommendations and advice contained in National guideline documents into 'real life'. Practical strategies were used to aid in the uptake of dietary and physical activity recommendations, given that people are concurrently managing family, work and study; may have limited finances; may be travelling away from home frequently, and may work long and irregular hours (eg. split shifts and night shifts). Sessions were held at different times of the day/night and on different days/nights of the week, to accommodate participants' family and work commitments.

Dietary and physical activity information

Dietary topics covered during information/education sessions are summarised in Table 1. Information for these sessions was drawn from several resources including the Australian Guide to Healthy Eating [ 33] (AGHE), Nutrition Australia 'Healthy living book'[ 34] and factsheets [ 35] and Glycemic index (GI) Australian resources [ 33]. Dietary advice reflected what is advocated by the Australian dietary guidelines (ADG)[ 36], including advice to balance energy intake ( ad libitum) with energy expenditure through daily activity. Participants were not given meal plans or individualised diet counselling, and energy targets were not prescribed. Specific macronutrient and micronutrient requirements were not discussed, except for general recommendations to reduce saturated fat, sodium and alcohol (consistent with ADG). Rather, quality and variety of dietary intake were emphasised. Emphasis was placed upon improving dietary quality through the intake of more nutrient dense foods (that are inherently less energy dense), replacing refined carbohydrates with low GI and fibre-rich options, replacing sources of saturated fats with polyunsaturated fats, reducing salt/sodium intake, and increasing food variety from recommended food groups (mainly vegetables, fruits, grains, nuts and seeds). Participants were encouraged to moderate their intake of alcohol and caffeine, and to drink more water. Health benefits of the standard dietary recommendations were also discussed, including the use of lower GI foods for regulation of blood glucose and satiety; and omega-3 fats for cardiovascular benefit and body fat reduction [ 37]. Some of the practical issues regarding food choices were also discussed, including shopping on a budget, incorporating meat alternatives (if desired), modifying recipes to make healthier meals, trying new foods on family/children, and choosing more appropriate 'fast food' options.

Table 1 Activities in the Shape up for Life program

PA topics are summarised in Table 1. Information regarding physical activity and exercise was drawn from several resources, including National PA guidelines, Active Australia 'getting started' booklet [ 38], Council on the Ageing (COTA) factsheets (accessed online http://www.cota.org.au), and State government of Victoria consumer health fact sheets (accessed online http://www.goforyourlife.vic.gov.au/). Participants were not given specific targets other than to aim to achieve the PA recommendations of the national guidelines. Education topics included: why exercise is important; differentiation between the benefits of different types of exercise (cardiovascular, resistance, flexibility); benefits of moderate intensity aerobic activity; monitoring exercise intensity; using the FITT principle (Frequency, Intensity, Time, Type) to vary and increase activity; and the importance of incidental and transport-related activity. Options for incorporating resistance training into an exercise regimen were also discussed (and demonstrated), including the use of resistance bands, own body weight, dumbbells, bar-bells and resistance machines, highlighting the benefit of improving body composition through increasing lean tissue (fat-free) mass. Participants in INT were provided with free access to a gymnasium during the intervention period to assist with the adoption of exercise guidelines.

Behavioural lifestyle self-management

Lifestyle self-management tools used in the intervention are summarised in Table 2. We encouraged the use of strategies to address some of the barriers to adopting healthy lifestyle habits, achieved mainly by incorporating tools adapted from the Stanford chronic disease SMP, originally developed by Lorig and colleagues [ 39]. One of the essential features that we incorporated was short-term goal setting, or 'action planning', as described by the Stanford model, which teaches participants to break long term goals into smaller, more achievable (action-specific) steps. 'Triggers' affecting food and PA choices were discussed, using an activity adapted from the DPP Lifestyle balance core program, entitled "take charge of what's around you" [ 40]. Another activity called 'obesity prevention', which was inspired by concepts introduced by Swinburn and Egger [ 41], was used to raise awareness of external/environmental obesity-promoting factors (eg. technology, convenience food, limited fresh food access).

Table 2 Lifestyle self-management tools used in Shape up for Life

Another concept that was introduced and referred to throughout the program was a diagrammatic concept of the 'vicious cycle' (Figure 1) in overweight/obesity, which was based upon the 'symptom cycle' described in the Stanford chronic disease SMP. This was intended to illustrate both the negative and positive impact that people can have on their own health behaviour and weight (body fat) management. In the chronic disease context, the cycle is used to highlight that symptoms experienced are not due to only one cause (the disease) but interactions of various other symptoms (for example; stress can cause tense muscles which may cause pain). For our purpose, factors that can contribute to weight (body fat) gain were included, and self-management strategies to address these issues were highlighted. For example; it was suggested that fatigue/tiredness can reduce motivation for exercise, which can lead to loss of fitness and de-conditioning, potentially increasing risk of pain and injury when exercising, and negatively self-perpetuating the 'cycle'. It was also posed that secondary behaviours may arise from an existing issue or problem; for example fatigue/tiredness/stress may lead to non-hungry eating or poor food choices (e.g. energy-dense snacks or fast food). The alternative focus of the cycle we proposed was that healthy behaviours can have a positive impact on other lifestyle factors, for example; managing sore joints through appropriate exercise can increase flexibility and improve ability, which can boost motivation for PA and in turn impact positively upon other issues through positive feedback. Further description on the adaptation of self-management activities from the Stanford course may be found elsewhere [ 42].

Diagrammatic representation of the 'vicious cycle' used throughout the Shape up for Life program.

Food labels, shopping and cooking

To demonstrate 'real-life' dietary and activity changes, practical activities were conducted. These practical activities included food-label reading education using real product labels, and referring participants to Nutrition Australia recommendations for understanding food labels [ 34, 43]. Participants were encouraged to bring in labels from their own shopping to discuss. A visit to a local supermarket provided participants with another opportunity to review nutrient information labels, nutrient claims, and to physically compare different food products to determine which were better quality. In these interactive tours, participants were directed towards buying seasonal produce and alternatives such as frozen vegetables, dried beans, and tinned fruit. Participants were directed to judge for themselves the nutritional value of commonly-used products such as bakery and delicatessen items, savoury crackers, margarines and spreads, yoghurts and dairy desserts. Two interactive cooking sessions were conducted to demonstrate meal ideas consistent with education topics, and to encourage variation in the intake of foods, condiments and cooking methods. During these sessions participants were provided with recipes and ingredients to prepare various meals, snacks and desserts. A cookbook was later compiled and provided to participants, including the recipes individuals contributed during sessions.

Exercise sessions

Participants were asked to attend at least one supervised exercise session each week during the intervention period. Group exercise was conducted for 45-60 minutes, usually directly after the information session. Additional sessions were held at different times to accommodate participants' work/family commitments. Study leaders demonstrated techniques such as heart-rate monitoring for aerobic activity, safe and effective use of gym equipment, core strengthening, and stretches. Examples of other types of exercises included in the sessions were walk-aerobics [ 44], weight-room circuits, aerobics, step/dance-aerobics, hand-weights and resistance bands, mixed circuits, and Tai Chi. Gymnasium facilities were established at the commencement of the study, shared with University staff and students, equipped with resistance and cardio machines, dumbbells, fitballs, boxing bags, mats and space for aerobics (with a TV and CD/DVD players). These facilities were made freely available to participants after they had been instructed in their correct use by study staff. Rubber resistance bands and handouts on exercise examples were offered for home use. Pedometers (step-counters) were also provided to encourage participants to monitor their movement through daily incidental activity. Participants were informed that a recommended level to work towards achieving was 10,000 steps per day, which appears to be in line with national recommendations [ 45- 47]. Heart rate monitors were available during exercise sessions to encourage participants to monitor their cardiovascular exercise intensity.

Peer-group setting

Information sessions were presented by two leaders, and groups consisted of up to fifteen individuals per session. Several repeat sessions were held throughout the week to accommodate all participants. The intervention was conducted by a study coordinator with health science/nutrition background together with a leader with expertise and experience in chronic disease SMP facilitation and training. Both leaders assumed a 'peer' role in conducting sessions, in that they provided information for participants to consider incorporating into their existing lifestyles. Leaders encouraged all participants to modify their own dietary and PA behaviours. Participants were also encouraged to share their experiences and ideas, to listen to and be respectful of others in the group, and to interact with each other both during and outside of sessions.

Additional program materials

The lifestyle program was compiled as a "leader's manual" which included written narratives, brainstorming activities, and prompts for leaders to 'model' lifestyle behaviours. PowerPoint™ slides were designed and used to guide session conduct. The manual ensured session consistency for the different intakes of study participants, and also served as a 'script', so that with training, individuals other than study coordinators would be able to lead future education sessions. Other supporting materials for the program included action-plan templates, a weekly food and PA record, information hand-outs, study newsletters, recipes and fact-sheets.

Compliance assessments

Weekly attendance was recorded for each individual, for attendance at both information and PA sessions. If absent from information sessions, participants were followed up by phone to ascertain a reason and to schedule a 'catch up' prior to the next week's session, and were encouraged to do their own exercise if they were unable to attend group exercise (or did not wish to take part in group exercise). Sample foods were provided by sponsor companies to offer to participants as examples of healthy products (wholegrain breads, breakfast cereal, tinned fish and unsalted nuts). A template log was provided to participants to complete during the week to record their PA together with the number of serves of food products consumed.

Participant feedback

Individuals' motivations for wanting to achieve lifestyle changes, and their perceptions of how much their lifestyle had changed were discussed during the information session at week 12. Questions were intended to prompt reflection on healthy habits adopted as a result of the program (being 3 months into the intervention), and also to focus on maintaining these changes (having only 1 month until the end of the intervention when physical assessments would be performed). Participants were asked why they were taking part in the study; and what changes they had made as a result. Participants' personal goals were collected at the end of the intervention at session week 16. Long-term goal-setting was conducted to encourage behaviour maintenance over the remaining 8 months of the study. Participant responses were transcribed verbatim and later categorised into common themes. Finally, feedback was invited from study participants after the 16-week program. Focus groups were conducted by researchers who were independent from the delivery of the study, with the aim of evaluating participants' satisfaction with the program. Examples of information gathered included (1) participants' opinions on the diet and PA components of the program, (2) how the program impacted on the participants/their families, (3) whether participation enabled sustainable lifestyle changes, and (4) suggestions for improvement of the program.

Data analysis

Data were collated and analysed using MS Excel (Microsoft corporation, US) and SPSS 15.0 for Windows (SPSS Inc, Chicago, Illinois). Session attendance counts and weekly report completion scores were entered into spreadsheets and chi-square analyses were performed. Correlations (Spearman) were performed using SPSS. Data from weekly records (i.e. number of food serves; duration of PA) were not directly used, due to overall poor completion. However, the records received were assessed for completeness, and these scores were incorporated into the overall compliance assessment. Qualitative data (participant quotes) were transcribed verbatim and entered into spreadsheets, and subjective responses were reduced and grouped thematically to reveal predominant themes. Focus group data were recorded on audiotape, transcribed, and compiled thematically using evaluative codes.

Results

Clinical outcomes

The success of the clinical study has been described elsewhere [ 1]. The study demonstrated that the intervention was effective in improving body composition (4% reduction in body fat mass and abdominal body fat mass, 3 cm waist reduction), blood pressure (>5% reduction), total cholesterol and LDL (8 - 10% reduction), and physical fitness (12% improvement). There were also statistically significant correlations within-individuals between attendance at program sessions and clinical changes from baseline. For example, greater attendance at information and exercise sessions was associated with greater reductions in body fat (Figure 2), blood pressure (DBP r = -0.31, p < 0.001; and SBP r = -0.28, p = 0.01), total cholesterol ( r = -0.35, p < 0.001) and plasma glucose ( r = -0.35, p < 0.001). Dietary intake and PA outcomes were limited by the methods of data collection; however both groups (intervention and control) significantly reduced overall energy intake and increased levels of PA (data not shown).

Correlations between rate of attendance at intervention program sessions and reduction in body fat mass. Note: Attendance at exercise exceeded 100% in some cases as participants chose to attend more sessions than required.

Program compliance

Information session attendance was 77%, with an average of 12 sessions attended out of a total of 15 or 16 scheduled (one program intake was condensed into 15 sessions due to the course overlapping Christmas). Exercise sessions were less attended at 66% overall, with an average of 9 sessions attended out of a possible 14 conducted (two sessions were not followed by exercise due to time constraints (cooking)). In most cases, the reasons for non-attendance to information/exercise sessions were related to work or family commitments (data not shown). Attendance declined gradually approximately half-way through the program (Figure 3). Based upon data from other interventions [ 15, 48- 50] and testing with chi-square; attendance to information sessions did not differ from an expected 75% ( p = NS) but exercise sessions were in fact attended more than an expected 50% ( p < 0.001).

Attendance at intervention sessions (all participants, n= 103).

Weekly participant diet and physical activity records were poorly maintained, with approximately one-third of the group not completing or not returning weekly records, and another third did not complete fully or accurately. Ultimately a subjective assessment was made by two research staff (one of whom was actively engaged in the program with the participants, and another who had no direct contact with participants) to judge the accuracy of returned records. A score was allocated by mutual agreement between the two research staff, of 0 = effectively non-compliant; 0.5 = uncertain or partly-compliant (eg. not attending exercise sessions, but reported doing additional PA outside of sessions); or 1.0 = appears compliant. The average of all scores was 0.51 (part-compliant). Attendance at exercise sessions were significantly correlated with attendance at information sessions. Weekly report completion scores also correlated significantly with information session attendance (Table 3).

Table 3 Correlation coefficients for attendance at sessions and compliance outcomes (Spearman) all participants (n = 103)

Participant perceptions

A total of n = 124 responses were obtained from the group sessions (week 12 and week 16) where questions were posed (Figure 4). Reasons for taking part in the program ( n = 33) were predominantly to reduce risk for diabetes, metabolic or cardiovascular disease (25%); to change lifestyle or habits (18%); and to lose weight or look better (15%). Other categories that emerged included improve quality of life; improve mindset/thinking; improve general health; eat healthier; and get fitter. Discussion of lifestyle habits changed elicited themes such as eating breakfast; healthier/less snacks or better food choices overall; drinking more water and/or less alcohol and caffeine; improved cooking and less takeaway purchase; inclusion of more fish, nuts, fruit, veg and wholegrains; more self-discipline, self control, motivation and better habits; making informed choices and reading food labels; more exercise and/or resistance exercise; and reduced fat/saturated fat, sugar and salt. The categories with the greatest responses were reduced fat/saturated fat, sugar and salt (22%) and more exercise and/or resistance exercise (17%). Personal goals made ( n = 32) when prompted to consider making a goal at the end of the program included firstly to lose 2 dress/trouser sizes or 5 kg (24%); to maintain lifestyle changes (18%) and to lose 10-15 kg (18%).

Participant responses during facilitated discussion.

Program acceptability

Finally, feedback from study participants during focus groups was used evaluate overall satisfaction with the program. A total of 33 participants volunteered to take part in these focus groups. Questions and guided discussion revealed information on 3 common areas; food/dietary factors, exercise issues, and support. Participants reported that food-label reading and information on takeaway food were useful, together with cooking sessions. Participants were pleased that the program leaders took a peer role in all sessions, and had realistic expectations of them, particularly in exercise sessions. Home-based exercise options were viewed favourably; however participants reported needing follow-up instructions, such as use of resistance bands. Provision of the gym was appreciated (due to cost saved), but for many it was not utilised with the main reason reported for this lack of use being embarrassment.

Regarding overall program structure, participants felt that the leaders' encouraging attitudes assisted with compliance, and found goal-setting and problem solving skills useful. Home-based exercise options, monthly study newsletters, and importantly the commonalities amongst the peer group were also appreciated and considered to be useful. The group setting was found to be of a supportive nature, and new social supports were formed as a result.

A common suggestion made was to schedule more frequent clinical assessments, to maintain motivation and be aware of personal progress. It was suggested that this take place half-way through the intervention (week 8). Participants reported having experienced a feeling of loss at the end of the intervention. Some participants suggested that future programs include a referral pathway (e.g. to counsellor or psychologist) to deal with underlying issues causing barriers to behaviour change.

Discussion

The intervention program evaluated in the current analysis was effective in improving a range of health outcomes in INT compared to CON and that are described elsewhere [ 1]. Despite an average of approximately two thirds of sessions attended overall, this was sufficient to improve diet, increase PA and produce clinically relevant outcomes in free-living individuals with MetS. This suggests that the methods and delivery of this program were acceptable. Also, the content and structure of the program has to some extent been reported as acceptable by participants.

Program content

The content of the education program was based upon Australian national guidelines. There is recent evidence to suggest that lifestyle intervention in accordance with general lifestyle recommendations can be beneficial to health in at-risk individuals [ 15, 18, 20] when delivered by health professionals/lifestyle counsellors. In order to achieve clinically significant outcomes through our group-based approach, we hypothesised that promoting dietary quality would result in a more balanced, nutrient-dense diet, with increased complex carbohydrate, bioactive nutrient and fibre intake, together with reduced total energy intake. Additionally we hypothesised that benefit may be gained by introducing participants to the 'functional' aspects of recommended foods (low GI, omega-3), for which the evidence-base relating to health benefits is increasing [ 51- 54]. Our intervention program provided a simple, group-based approach to improving diet and PA, and essentially provided a strategy for encouraging adoption of the national recommendations. Consequently this intervention may be more easily transferred into communities than complicated or restrictive diets and personalised or prescribed exercise, which are generally unsustainable.

The overall aim of the PA component of the intervention was to increase energy expenditure and promote overall fitness by increasing moderate/vigorous exercise and incidental/low intensity (long-duration) leisure activity in accordance with national guidelines. We encouraged engagement in regular PA in order to achieve not only body fat reduction, but also to improve risk factors which constitute the metabolic syndrome. [ 55, 56]

We also proposed that self-management techniques, that have proven successful in the management of chronic disease, might also be applicable in managing overweight [ 26, 57]. Lifestyle topics and strategies were incorporated to address some of the external and personal issues that are often barriers to healthy lifestyle choices. The activities incorporated were adapted from other successful SMP's described previously. The effectiveness of the Stanford techniques for chronic disease have been demonstrated internationally [ 21, 58] and locally [ 59].

The literature suggests that programs combining diet, exercise, and behaviour modification are the most effective for improving health outcomes in the short term [ 60] (as cited in [ 61]). Self-managed strategies are also useful in the management of weight [ 26] and are considered to apply especially well to preventive interventions involving lifestyle modification [ 57]. In our program, practical sessions and supervised exercise were included to address 'real-life' aspects of dietary choice and PA, and to introduce participants to different options to consider. Self-efficacy is also recognised as associated with health behaviour change [ 62] and current evidence continues to confirm it's importance to diet and activity [ 63]. Therefore action planning and problem solving were integral to the program to promote self-efficacy; through accomplishing small, weekly behavioural goals which would lead to achieving a larger health-related goal.

Program format and conduct

Recent data has indicated that group-based lifestyle intervention with monthly follow-up can improve body weight, PA, health and wellbeing to a similar extent as individualised dietetic treatment. [ 64] In our program, group meetings were conducted for all sessions. A group setting was used to more effectively manage a number of individuals over time, compared one-on-one individual interventions [ 64]. A similar strategy has also been recently described for engaging larger groups of individuals; through adaptation of the DPP intervention for delivery in the community [ 17]. Additionally there is evidence to show that the social support network may assist individuals in maintaining weight loss through continued follow-up [ 28], shared short-term goal setting and problem solving [ 26], which is also why we considered the peer-group setting to be a useful strategy. The presence of a peer leader endeavouring to achieve the same lifestyle goals as the other participants also provided a source of collegial support.

Program duration and follow-up

Based upon published outcomes of the American and Finnish Diabetes prevention studies [ 7, 65], and other trials conducted in our research clinic [ 66] we considered that a 4 month period was sufficient to demonstrate the effect of the intervention on study outcome measures. In order to maximise the potential benefit of the intervention, but without over-burdening participants, education meetings were scheduled weekly for 1 hour with 45-60 min exercise following. Frequency of contact was adapted from the 'Lifestyle balance' program by the Diabetes Prevention Program Research Group (DPPRG)[ 40], the aims of which were weight loss and increased PA. Weekly contact in initial stages is accepted as standard for weight loss interventions [ 67]. These and other reports suggest that individuals are more likely to maintain lifestyle changes if they have regular follow-up [ 28]. [ 67- 70]

Program compliance

Assessments of compliance revealed that the program was well tolerated. The gradual decline in attendance appearing approximately half-way through may suggest 'program fatigue', but no further data is available to support this. Interventions of longer duration tend to have greater attrition [ 48] and more than 50% dropout might be expected in community-based interventions [ 19]. Although commitment to weekly sessions may have been at times difficult to manage for participants, it appears that these compliance rates are acceptable. To compare with other lifestyle interventions [ 15, 48- 50], we might expect average attendance of 75% to information, and 50% to exercise sessions, so attendance to our information sessions was consistent with other studies, and exercise adherence slightly better. Attendance to information tended to predict attendance to group exercise, which may indicate that the format of the program was useful in encouraging participation in exercise, as participants may have been more likely to join in group exercise or use the gym (directly after the information session). Some have suggested the use of home-based exercise equipment as a means to improving adherence in overweight adults, especially women [ 71] which appears to be consistent with the feedback reported by participants during focus groups. Some research indicates that although home-based training is not as effective at improving factors such as glycemic control, it is effective for maintaining improvements in muscle strength and lean body mass following gymnasium-based training [ 72].

Compliance with self-reports were poorly completed, with only one-third of participants returning a reasonable record of weekly PA and food serves consumed. Adherence to self-monitoring during lifestyle intervention is a complex issue and is notoriously sub-optimal [ 73], which is consistent with other weight-management studies [ 12, 74].

Program uptake/acceptability

Our understanding of participants' perceived lifestyle changes and reasons for being involved is limited to a small sample of responses. Despite this, some common themes were identified that appear to support the major aims of the program but this may be biased due to the most motivated individuals attending focus groups, and also because responses were collected during the intervention. For perceived lifestyle changes, most frequent responses were around specific dietary changes, and engagement in formal exercise (including resistance exercise and trying new activities) and incidental PA. Other interesting comments included feelings of self-discipline, self control, motivation and the formation of better habits. Although it is difficult to extrapolate from this small sample of responses, it appeared that the main motivations given for participating were not simply to 'lose weight', but to modify size, health risk factors and lifestyle habits. This may be suggesting that individuals taking on lifestyle changes were seeing a bigger picture than actually making dietary and activity adjustments.

Mechanisms

Results from the focus-group indicated that there was significant value in certain aspects of the dietary education provided, including food-label reading, cooking, and nutritional composition of packaged foods. There was also interest in specific information on serving sizes and daily allowances, which may have benefitted the more motivated individuals to better understand their required energy intake. Participants also suggested more instruction for home-based exercises. Participants considered peer-leadership to be important and interactive sessions more valuable than a didactic format, and the peer-group setting was important for collegial support. Learning and applying self-management skills was also found to be useful. Clinical monitoring, progress checks and continued support were also identified as vital for continued motivation. The acknowledgement of psychological counselling is not a surprising finding owing to the complex nature of obesity and the underlying issues that present barriers to healthy lifestyle.

Participants commented that the session content was appropriate to the level of understanding of the participants, and participants consequently were empowered to make behavioural changes. Increased feelings of wellbeing and achievement were noted as a result. It was identified that there is a need to focus on maintenance and support of these behaviours after the cessation of the intervention, including clinical assessment and social support networks.

A simpler strategy for lifestyle modification?

Community or population level interventions need to be simple and inexpensive to be cost effective. The Ottawa charter for health promotion (WHO) states that healthy choices should be the easy choices [ 75] and there is further evidence emerging that this may empower individuals to continue making the healthy choices [ 76]. This is an important consideration in this context, where the ultimate goal is to avoid preventable lifestyle disease. This study was predicated on the assumption that the usual dietary restriction and high levels of PA to counter overweight are difficult for the general population to sustain [ 77]. Our approach was to implement a program based on dietary and PA guidelines that were already in place, and to assess its effect on clinical outcomes in comparison to a control group who were simply provided with the guideline documents.

This study also confirms that simply providing written guidelines to CON was not sufficient to effect significant change in dietary and physical activity behaviour. The implication of this is that the current practice of government and other organisations to develop and disseminate written guidelines will not of itself address the needs of overweight individuals. Rather these guidelines are best accompanied by additional support strategies including active behavioural intervention and practical examples that translate guidelines into everyday strategies that assist individuals from different backgrounds in achieving lifestyle recommendations

To our knowledge, this is the first demonstration of a targeted self-management program for individuals who are overweight/obese with MetS, in a randomised controlled trial. Longer-term research is warranted to understand whether a peer-led model would translate into improvements in body composition, cardiovascular risk factors and quality of life, and whether it would be readily accepted in the community. The current intervention has achieved success in the short-term, and analysis of long term clinical and compliance data will contribute to current understandings of the effectiveness of 'modest' lifestyle intervention on body composition and metabolic fitness. The importance of active or follow-up in maintaining improvements will be of particular interest in this assessment. Further research may then be warranted to investigate the sustainability of a similar program in a peer led, community-based setting.

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Acknowledgements

We thank Debra Misan for assistance in study coordination and program delivery, and all the study participants in Whyalla - without their commitment this work would not have been possible. Project funding was received from the ATN Centre for Metabolic Fitness and Spencer Gulf Rural Health School (SGRHS), with additional support from the University of South Australia Whyalla campus (Centre for Regional Engagement) and SGRHS.

Author information

Affiliations

1. Australian Technology Network (ATN) Centre for Metabolic Fitness and Nutritional Physiology Research Centre, School of Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia

Tahna L Pettman

, Gary MH Misan

, Katherine Owen

, Alison M Coates

, Jonathan D Buckley

& Peter RC Howe

2. Spencer Gulf Rural Health School, c/o University of South Australia, Nicolson Avenue, Whyalla, 5608, South Australia, Australia

Tahna L Pettman

, Gary MH Misan

& Kate Warren

3. Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Broadway, 2007, UK

Corresponding author

Correspondence to Tahna L Pettman.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

All authors read, assisted in editing and approved the final manuscript. TLP drafted the manuscript, coordinated the design and conduct of the clinical study, co-created the intervention program, and conducted the intervention. GMHM was project manager, was involved conducting the intervention, and contributed to drafting and revising the manuscript. KO assisted in drafting and revision of the manuscript. KW assisted in coordination and conduct of the clinical study, co-created the intervention program, and conducted the intervention. AMC contributed to the clinical study design and drafting of the manuscript. JDB contributed to the clinical study design and revision of the manuscript. PRCH contributed to the clinical study design and revision of the manuscript

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Self-management for obesity and cardio-metabolic fitness: Description and evaluation of the lifestyle modification program of a randomised controlled trial

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Sustainable lifestyle modification strategies are needed to address obesity and cardiovascular risk factors. Intensive, individualised programs have been successful, but are limited by time and resources. We have formulated a group-based lifestyle education program based upon national diet and physical activity (PA) recommendations to manage obesity and cardio-metabolic risk factors.

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Obesity/Weight Management

First published:

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Summary

Obesity in pregnancy is rising and is associated with severe health consequences for both the mother and the child. There is an increasing international focus on guidelines to manage the clinical risks of maternal obesity, and for pregnancy weight management. However, passive dissemination of guidelines is not effective and more active strategies are required for effective guideline implementation into practice. Implementation of guidelines is a form of healthcare professional behaviour change, and therefore implementation strategies should be based on appropriate behaviour change theory. This systematic review aimed to identify the determinants of healthcare professionals' behaviours in relation to maternal obesity and weight management. Twenty‐five studies were included. Data synthesis of the existing international qualitative and quantitative evidence base used the Theoretical Domains Framework to identify the barriers and facilitators to healthcare professionals' maternal obesity and weight management practice. The domains most frequently identified included 'knowledge', 'beliefs about consequences' and 'environmental context and resources'. Healthcare professionals' weight management practice had the most barriers compared with any other area of maternal obesity practice. The results of this review will be used to inform the development of an intervention to support healthcare professional behaviour change.

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Implementation of pregnancy weight management and obesity guidelines: a meta‐synthesis of healthcare professionals' barriers and facilitators using the Theoretical Domains Framework

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Obesity/Weight Management First published: Get access to the full version of this article. View access options below. If you have previously obtained access with your personal account, Please log in. Obesity in pregnancy is rising and is associated with severe health consequences for both the mother and the child.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836178/

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Approach inspired by high relapse rate of calorie restrictive 'diets'.

Move from a weight-centred approach to a health-centred one

Improving health behaviours irrespective of weight outcome as it has been suggested you can still be healthy and overweight

Idea that targeting weight as the issue does not target comorbidities directly like targeting health behaviour does

Weight-loss dieting failure can be damaging to self-esteem so this approach would try to avoid that

Energy expenditure increased in long term measures

Improves body dissatisfaction long term

Improvement in body image avoidance behaviours

This non-diet approach minimised attrition rate and attribution of blame to self as a 'failure'

non-diet approach saw metabolic fitness improvements however saw no weight loss. This was not a goal of the programme however would have been good to see as well... however if neither diet or non-diet approaches produce long term weight loss achievements then the improved metabolic health in the non-diet approach is a suitable alternative.

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1. Treat as a lifestyle change, not a diet. More sustainable approach hopefully encouraging long term weight loss and improved health goals.

2. Mindfulness participation to decrease stigma and negative feelings associated with physical appearance and high weight which may prevent physical activity participation due to anticipated judgement.

3. Education, possible CBT to debunk existing food beliefs.

4. Introduction of intuitive eating to improve attitude towards the body and food.

5. Social support through family and friends, if not available: turn to online platforms such as the creation of an Instagram wellness blog to record progress and seek support from others in the community.

My own powerpoint brainstorm on lifestyle changes:

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Abstract

Existing research suggests that there is an overlap between binge eating disorder (BED) and the construct of 'food addiction' (FA). The objective of this study was to determine the overlapping features of BED and FA through a comparison of the individual scales of commonly used tools including the Binge Eating Scale (BES) and the Yale Food Addiction Scale (YFAS) in a sample of Australian adults. Adults (>18 years of age) were invited to complete an anonymous online survey on FA. Binge eating was assessed through the BES and addictive eating behaviours were assessed through the YFAS ( n = 1344). The prevalence and severity of both FA and binge eating increased across weight categories. The overall correlation between the total score from the BES and FA symptoms was r = 0.76, p < 0.001; for females it was r = 0.77, p < 0.001, and for males it was r = 0.65, p < 0.001. Total BES score and the BES emotion factor were most often associated with FA symptoms, as was demonstrated to produce stronger correlations with FA symptoms. In contrast, the BES behaviour factor was less strongly associated to FA with the majority of correlations <0.6. This study demonstrates the overlap between BED and FA, and highlights the possible unique differences between the forms of disordered eating.

Keywords: binge eating, food addiction

1. Introduction

'Food addiction' (FA) presents as a contentious construct, which has yet to gain scientific acceptance due to an overall lack of high quality research [ 1]. There is scientific debate about the appropriateness of terminology, with 'eating addiction' previously proposed to be more reflective rather than 'food addiction', given the uncertainty of whether addictive eating behaviours more closely align to substance-based addictions, like drug and alcohol addictions, or with behavioural addictions, such as gambling addiction [ 2]. Addictions to drugs, alcohol, and gambling are formally recognised in the Diagnostic Statistics Manual, version 5 (DSM-5) [ 2]. However, FA is currently not a recognised condition in DSM and instead is characterised through the assessment and endorsement of addiction-like symptoms through self-report tools or surveys. The most commonly used tool is the Yale Food Addiction Scale (YFAS). Originally developed in 2009 and revised in 2016, the YFAS 2.0 maps to the criteria used to classify substance dependence [ 3]. The YFAS tool assesses 11 symptoms of addiction, as well the level of distress associated with them, which parallel other addiction symptoms in DSM such as tolerance and craving. In addition, the tool can determine the level of severity of addiction ranging from mild to severe [ 4].

There has been previous suggestion that FA may be a sub-type of disordered eating, and that the FA construct is an indicator of higher eating disorder severity [ 5]. Research suggests that FA does show overlap with several disordered eating phenotypes, with the majority of existing research investigating binge eating disorder (BED) and bulimia nervosa rather than other disordered eating categories such as anorexia nervosa [ 6, 7].

BED is classified by the DSM-5 as the recurrent, periodic, and uncontrolled consumption of large quantities of food without compensatory behaviours (e.g., purging, laxative use) to control weight [ 8]. It has been estimated that BED affects approximately 2% of the global population [ 9], while FA affects approximately 20%, with both conditions found to be more common in females [ 1, 10]. The prevalence of FA in two existing studies of individuals with diagnosed BED was 41.5% and 56.8% [ 11, 12]. The prevalence of FA in individuals with a current diagnosis of bulimia nervosa was 83.6% and 100%, and 30% of individuals with a history of bulimia nervosa met the diagnostic criteria for FA [ 13, 14]. In a more recent study of individuals with clinical BED assessed through an objective clinical interview rather than self-report, those with BED were also identified with FA (33.8%). Existing research suggests an overlap between these conditions, often through cross-sectional studies, which show that the overlap between BED and FA varies between 0.59 and 0.78) [ 1]. The overlap between BED and FA however is not 100%, and while binge eating is a key eating disorder feature, the association between FA and disordered eating behaviour is unclear. It is acknowledged that the symptoms of general psychological distress found to be associated with FA are strongly associated with binge eating and other eating disorder symptoms [ 15, 16].

Similarities in symptomology that exist between FA and BED include the consumption of larger amounts of food than intended, reduced control over eating and continued use despite negative consequences [ 13, 17], intense cravings [ 18], emotional dysregulation, and increased impulsivity [ 5, 6, 19]. Due to these similarities, it is not unusual that BED and FA are often highly correlated. A meta-analysis also reported that YFAS symptom scores were positively associated with binge eating behaviours [ 1].

Existing research has investigated FA specifically in binge eating populations and individuals seeking bariatric surgery, and identified similarities in the specific characteristics of both conditions when assessed by validated surveys [ 20, 21]. In addition, recent research highlights the associations between patterns of compulsive overeating, including binge eating with 'food addiction' [ 22]. However, these conditions have not been investigated at the scale, factor, or item level of common assessment scales. Instead previous research has explored associations in absolute scores that indicate the overall severity of FA or BED. Investigating factor levels for these constructs may provide important information about where the overlapping features exist and whether there are factors which separate these conditions. Strong correlations would be expected between subscales that may map to the same attribute, and lower correlations between subscales from different attributes. Therefore, the current study aims to determine the overlapping features of BED and FA through a comparison of the individual constructs of the Binge Eating Scale (BES) and YFAS in a sample of Australian adults.

2. Materials and Methods

Participants aged 18 years or above and living in Australia were invited to complete an anonymous online survey on FA. The survey took approximately 20 min to complete. Exclusion criteria included being pregnant/currently lactating and being unable to comprehend English. Recruitment was undertaken over a three month period in 2016. The study was advertised through University of Newcastle media releases and promoted via a variety of social media platforms (i.e., Facebook, Twitter). The advertisements contained a link to the survey, and participants provided informed consent before completing the survey. Survey completers were invited to enter a prize draw to win 1 of 10 shopping vouchers ($50 value). This study was approved by The University of Newcastle Ethics Committee.

The survey comprehensively assessed a range of measures relating to diet and mental health which has been previously reported [ 15]. The current study is a secondary analysis relating specifically to FA and BED status. Demographic information was assessed through 10 items and included information on gender, age, ethnicity, marital status, postcode, highest level of education, height, and weight, which was converted into body mass index (BMI) using standardised equations. Participants' BMI was then classified according to World Health Organisation classifications [ 23]. Postcode was used to determine the Index of Relative Socioeconomic Advantage and Disadvantage (ISRAD), where postcode is rated from one (most disadvantage/least advantage) to 10 (least disadvantaged/most advantaged).

FA was assessed using the 35-item YFAS 2.0 [ 4]. Each question offers a participant an option of eight responses ranging from 'never' to 'every day'. Each symptom is considered met when one or more of the relevant questions for each criteria meet a predefined threshold. It provides a 'diagnosis' of FA which, depending on the number of symptoms endorsed, can be classified as 'mild', 'moderate' or 'severe'. A mild diagnosis score is given when 2-3 symptoms are reported, moderate when 4-5 symptoms are present, and severe when 6 or more symptoms. Symptoms include tolerance, withdrawal, and loss of control with respect to eating behaviour. The YFAS 2.0 asks participants to think of specific foods such as highly processed foods; however, participants in this study were asked to consider all food. In the current study, the Cronbach alpha for this tool was 0.95, indicating acceptable internal consistency.

Binge eating was assessed through the standardised BES, which comprises 16 questions. Each question requires a response consisting of three to four possible responses, reflecting a range of severity. The total score is tallied to give a score out of 46, with higher scores representing increased binge status. Based on the total score, individuals can be classified as 'no binge eating' if the score is ≤17, 'mild to moderate binge eating' if the score is 18-26, and 'severe binge eating' if the score is >27. The BES has been previously shown to have a two-factor structure, which was originally demonstrated by Gormally et al. [ 24] and confirmed more recently by Kelly et al. [ 25]. These factors relate to (1) behavioural manifestations (eight items) including factors such as eating large amounts of food, and (2) feelings and cognitions (eight items) surrounding a binge eating episode including guilt, fear of not being able to stop eating, and preoccupation with eating. For the current study, in addition to the total score, the two-factor scores were also determined according to author instructions. The BES is not designed as a direct measure of BED [ 26]. In the current, study the Cronbach alpha for this tool was 0.92, indicating acceptable internal consistency.

Statistics: Descriptive statistics were undertaken, t-tests were used to examine differences between groups (food addicted vs. non-food addicted or females vs. males). ANOVA were used to determine differences in addiction severity (mild, moderate, severe). Correlation matrices for the scales for both YFAS and BES were undertaken. Also, Spearman and Pearson correlations were determined in the cases where data distribution was not normal. Both correlations produced similar results; associations between factors of the BES and between symptoms of the YFAS are presented using Pearson correlations. Correlations were determined as small (0.1-0.2), medium (0.3-0.5), or large (>0.6). The correlation analysis between scales used for this study has been undertaken in previous health research [ 27]. The results presented are for complete cases, with 869 of the 1344 respondents who started the survey having answered all questions. A missing value analysis was undertaken, and the demographics of those with missing values were compared, with no patterns identified. Therefore, there was no imputation of data for missing values. Due to the multiple statistical tests completed as part of this analysis, data were adjusted using a Bonferroni correction with a lower statistical threshold, and a statistical significance of p < 0.01. Data was analysed using SPSS version 22.0 (SPSS Inc., Chicago, IL, USA).

3. Results

3.1. Participants

The survey recruited n = 1344 individual; 80.7% were female and 19.3% were male. The demographic details can be found in . The mean ISRAD score was 6.2 ± 2.9, reflecting a moderate socioeconomic status; however, this value varied from 1-10, reflecting a moderately diverse population group. A total of 44.3% of the sample were married, 27% were never married, and 14.5% had been married but were without a current partner. The population comprised 1.6% with a trade/apprenticeship, 20% with a certificate/diploma, 36% with a university degree, and 31% with a higher education including masters, Ph.D.

3.2. Food Addiction and Binge Eating

Across the whole sample, the prevalence of FA was found to be 22.2% ( n = 228). This differed significantly by gender, with females (24.4%) having a higher prevalence than males (13.3%; p < 0.001). According to the YFAS 2.0 categorisations of severity, the majority of individuals classified as severely food addicted 18.9% ( n = 194), while 2.6% ( n = 27) were moderately addicted, and <1% were classified as mild. The prevalence and severity of both FA and binge eating increased across weight categories ().

For those who had completed the BES, the mean BES score was 11.9 ± 9.3 (range 0-42). For males the mean BES scores was 9.2 ± 7.4 (range 0-36), and for females the mean score was 12.6 ± 9.6 (range 0-42). The mean values for each sex were significantly different ( p < 0.01). For the BES, severity for the total group was determined, with 74% of individuals classified as non-binge eaters ( n = 660), 17.4% ( n = 155) moderate binge eaters, and 8.7% ( n = 78) severe binge eaters. Differences in BES severity were determined by sex, and significant differences were found between males and females. Among non-binge eaters, males accounted for 86.2% vs. females 70.9%, among moderate binge eaters it was males 12.1% vs. females 18.6%, and among severe binge eaters it was males 1.7% vs. females 10.4%, all p < 0.01. Individuals with FA reported significantly higher on the BES total, emotions, and behavioural scales than those who were non-food addicted (). Of those with FA, 72.7% reported scores of either moderate (41%) or severe (31.7%) bingeing compared with only 9.9% in the non-food addicted group. A significant correlation was found between the two-factor scores of behaviours and emotions of the BES: r = 0.82, p < 0.001 ().

3.3. Relationships between Food Addiction and Binge Eating

The overall correlation between the total score from the BES and FA symptoms was r = 0.76, p < 0.001; for females it was r = 0.77, p < 0.001, and for males it was r = 0.65, p < 0.001 (). Total BES score and BES emotion factor were more strongly associated with FA symptoms, as evidenced by the majority of correlations ( n = 7) with values >0.6. In contrast, the BES behaviour factor was less strongly associated to FA, as evidenced by smaller correlation values, with only three correlations classified as large ( r > 0.6, p < 0.001). Of the 11 individual FA symptoms and clinical impairments, correlations with BES factors and the FA symptoms 'consumed more than planned' were small, with the majority being <0.3, while 'use in physically hazardous situations' produced significant negative correlations.

4. Discussion

This study investigated the overlap in symptoms of FA and BED as measured by the YFAS 2.0 and the BES's emotional and behavioural factors. It was found that substantial overlap ( r = 0.76) exists between the commonly used assessment tools in a sample of Australian adults from a wide age range, which concurs with existing research [ 28, 29]. However, this is the first study to demonstrate that the strongest overlap occurred with the BES emotion factor, while less overlap was observed with the BES behaviour factor. This was evidenced by larger correlation values with the BES emotion factor, compared with very few strong correlations (greater than 0.6) with the BES behaviour factor. The behaviour factor relates to behavioural expressions surrounding a binge eating episode which showed small to moderate correlations with the majority of the 11 symptoms assessed by the YFAS 2.0 tool. These correlations are not unexpected, as previous findings indicate that individuals with co-existing FA and BED experience significantly higher levels of depression, negative affect, poorer emotion dysregulation, and lower self-esteem [ 11]. This would seem to indicate that high levels of emotional and psychosocial distress accompany both eating pathologies. Research has demonstrated that, in the context of binge eating, emotions and behaviour rarely occur exclusively [ 30] and are correlated as shown in this study. For this reason, it would be expected that both features be present and it is unsurprising that these symptoms would co-occur in FA. However, strong evidence for the cognitive and behavioural aspects of BED is lacking, and further investigations into BED and behaviour are warranted.

It is important to attempt to articulate the unique features that may set the construct of FA apart from BED, given that previous overlaps have been shown, although these are not in entirety or not 100% overlapping. In this study, it appears that several symptoms are unique to FA, as evidenced by lower correlation valueswith BES. Specifically, small associations were found with FA symptoms of 'consumed more than planned' or 'use in physically hazardous situations'; the latter symptom in this study actually showed significant negative relationships. The symptom of 'use in physically hazardous situations' has previously been debated as a difficult factor to interpret in relation to food, given that food in its true sense is needed for survival. Recent studies assessing FA using the YFAS 2.0 tool have found the endorsement of 'use in physically hazardous situations' symptom in three non-clinical samples ( n = 1900) to have low endorsement rates ranging from 9.1% to 24.8%; with two of the studies reporting the endorsement rate in FA individuals ( n = 109) as 37.0% and 68.3%, respectively [ 4, 28, 31]. However, in the context of FA, this symptom can be described as causing impairment to performance, such as eating while driving, or impairment to health that is hazardous. In the context of obesity and related metabolic syndrome risk factors, this could include the consequences of individuals with diabetes, dyslipidaemia, or hypertension overconsuming foods containing excessive amounts of sugar, fat, or sodium [ 32]. However, this symptom may not have been well-reported by participants with this rationale in mind nor understood in terms of addiction by the participants completing the surveys, thus influencing the results because the questions did not ask participants to consider this aspect of the symptom. Existing public views suggest that individuals believe some foods are addictive and that addiction can cause obesity [ 33]. Future qualitative work on FA is warranted to better understand how the symptoms are experienced and if they differ for each individual, particularly as this field is still emerging.

The FA symptom of "loss of control with respect to eating behaviour" overlaps with that of "loss of control over eating", the latter being a core eating disorder behaviour and a diagnostic criterion for the eating disorders bulimia nervosa and binge eating disorder [ 32]. The symptoms of FA as assessed by the YFAS were determined with mapping to the DSM-5. However, it is noted that when considering some of these symptoms at a broader population level, with increasing prevalence rates of overweight and obesity, some symptoms or traits presently being assessed overlap with general dieting practices undertaken by many individuals. FA symptoms measured by the YFAS, specifically 'repeated attempts to cut down food', may not be unique to FA, but apply to the population in general.

In the current analysis of those individuals with FA, 72.7% also had reported BES scores which related to either moderate or severe bingeing. While not directly comparable due to the use of different tools and methods to assess the disordered eating status, the value in the current study is higher than that previously reported by Gearhardt et al., who found in a sample of overweight individuals with BED, determined by clinical interview, that 57% met the classification for FA [ 11]. In a more racially diverse sample of obese, treatment-seeking adults with BED ( n = 96) as assessed by an alternate tool, The Eating Disorder Examination Questionnaire (EDEQ), the findings were similar, with 42% of participants meeting the classification for FA [ 12]. In both studies, YFAS scores were also significant predictors of binge eating frequency. In an additional study, Ivezaj et al. [ 34] examined the eating and health-related behaviours of overweight/obese adults ( n = 502), and found that 61.7% of adults meeting BED criteria as assessed by the EDEQ also met FA criteria. Adults with co-occurring BED and FA had significantly higher BMI and depression scores, combined with greater disturbances on most impulsivity and self-control measures relative to the control group [ 35]. A strong association between FA and BE severity ( r = 0.78, p = 0.0045) as well as a moderate association between FA and measures of general psychopathology were reported. A similar relationship between FA and BE has also been shown to exist in younger adolescent populations [ 35].

Rates of FA among those with BED is higher in individuals with obesity than in those who are not obese [ 36]; this was also shown in the current study across increasing weight status of healthy, overweight, and obese participants. Individuals who meet the criteria for both BED and FA tend to exhibit more frequent binge eating episodes, experience stronger cravings for food, and elevated levels of impulsivity and depressive symptoms than those with only BED [ 5, 12, 13]. It has been suggested the co-occurrence of BED and FA may represent a more severe BED subgroup characterised by greater eating disorder psychopathology and associated pathology [ 11].

Recent evidence suggests altered reward sensitivity may contribute to the pathophysiology of disordered eating behaviours. A review of neuroimaging studies ( n = 15) in BED found that the alterations in corticostriatal circuitry were similar to those observed in substance abuse, including altered function of prefrontal, insular, and orbitofrontal cortices and the striatum [ 37]. Preliminary evidence by Gearhardt et al. suggests that reward dysfunction may also be a relevant mechanism in the FA construct [ 38]. Human genetics and animal studies suggest that changes in neurotransmitter networks, including dopaminergic and opioidergic systems, are associated with compulsive-eating behaviours [ 37, 39].

This study has several limitations which should be considered when interpreting the findings: the survey was collected online and is based on self-report measures and was analysed using correlation analysis only. However, it is noted that for food addiction and binge eating, the majority of measures used for these eating behaviours are based on self-report, and self-reported height and weight have been shown previously to be a valid measure of weight status [ 40]. It could be likely that individuals who are motivated by food may have been more likely to complete the survey. The study sample had a majority of participants who were female, so results may not be generalisable to the broader population or to other ethnicities. The findings of this study have some clinical implications, as they provide a further understanding of the underlying aetiology of co-occurring FA and BED, to progress and tailor treatment options as FA appears to be more physiological than behavioural in nature.

5. Conclusions

This is one of the first studies to investigate the potential overlap between the common tools used to assess BED and FA and their individual constructs, particularly with reference to the YFAS 2.0 tool which maps to current DSM criteria. This study demonstrates the overlap between BED and FA, and highlights the possible unique differences between the forms of disordered eating.

Acknowledgments

T.B. is supported by a UON Brawn research fellowship.

Author Contributions

T.B. conceived, designed and conducted the study; T.B. analysed the data; T.B. developed initial draft of paper, and J.S., R.M. and M.R. contributed to and approved the final version of the manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

References

# data[].attributes.attachment_link.title
Food Addiction, Binge Eating Disorder, and Obesity: Is There a Relationship?

# data[].attributes.attachment_link.description
Existing research suggests that there is an overlap between binge eating disorder (BED) and the construct of 'food addiction' (FA). The objective of this study was to determine the overlapping features of BED and FA through a comparison of the individual scales of commonly used tools including the Binge Eating Scale (BES) and the Yale Food Addiction Scale (YFAS) in a sample of Australian adults.

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Case report

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Binge Eating Disorder and Obesity

1

Selçuk University, Selçuklu Medical Faculty Department of Psychiatry, Konya, Turkey

Binge eating disorder (BED) is included into eating disorders that are not otherwise specified in DSM-IV. It is more common among overweight women applied to treatment. In the conducted researches it was found that there was high level psychiatric comorbidity in patients with BED. In addition, it has been emphasized that depression caused relapses after BED treatment. In this article, a case of a young woman that failed obesity treatment and therefore referred to psychiatry clinic has been presented. In her treatment fluoxetine and BDT were used and effective results have been obtained. The patient at the same time followed the diet program given by dietician and was controlled by internal medicine department. Multidisciplinary approach is important in the treatment of obesity. Successful results have been obtained with psychiatric evaluation and with the treatment of psychopathologies.

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Binge eating disorder (BED) is included into eating disorders that are not otherwise specified in DSM-IV. It is more common among overweight women applied to treatment. In the conducted researches it was found that there was high level psychiatric comorbidity in patients with BED. In addition, it...

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Conceptualizing Obesity as a Chronic Disease: An Interview With Dr. Arya Sharma

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Conceptualizing Obesity as a Chronic Disease: An Interview With Dr. Arya Sharma

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Dr. Arya M. Sharma challenges the conventional wisdom of relying simply on "lifestyle" approaches involving exercise, diet, and behavioral interventions for managing obesity, suggesting that people living with obesity should receive comprehensive medical interventions similar to the approach taken for other chronic diseases such as Type 2 diabetes or hypertension. He purports that the stigma-inducing focus on self-failing (e.g., coping through food, laziness, lack of self-regulation) does not address biological processes that make obesity a lifelong problem for which there is no easy solution. Interdisciplinary approaches to obesity are advocated, including that of adapted physical activity. Physical activity has multifaceted impacts beyond increasing caloric expenditure, including improved sleep, better mood, increased energy levels, enhanced self-esteem, reduced stress, and an enhanced sense of well-being. The interview with Dr. Sharma, transcribed from a keynote address delivered at the North American Adapted Physical Activity Symposium on September 22, 2016, in Edmonton, AB, Canada, outlines his rationale for approaching obesity as a chronic disease.

# data[].attributes.attachment_link.title
Conceptualizing Obesity as a Chronic Disease: An Interview With Dr. Arya Sharma.

# data[].attributes.attachment_link.description
Dr. Arya M. Sharma challenges the conventional wisdom of relying simply on "lifestyle" approaches involving exercise, diet, and behavioral interventions for managing obesity, suggesting that people living with obesity should receive comprehensive medical interventions similar to the approach taken for other chronic diseases such as Type 2 diabetes or hypertension.

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Obesity should be recognised  as a disease 

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Obesity should be recognised  as a disease 

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Is Obesity A Disease or A Behavior Abnormality? Did the AMA Get It Right?

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Is Obesity A Disease or A Behavior Abnormality? Did the AMA Get It Right?

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In June 2013, the American Medical Association (AMA) House of Delegates voted to recognize obesity as a disease state requiring treatment and prevention efforts. A number of other medical societies had sponsored a resolution to support this idea, including the American Association of Clinical Endocrinologists, the Endocrine Society, the American College of Cardiology, the American College of Surgeons, and the American Heart Association. The National Institutes of Health had declared obesity a disease in 1998 and the American Obesity Society did so in 2008. Because the AMA is thought of as the most influential medical association in the country, their statement is expected to have a significant influence on health care policy, through effects on insurers, industry, and lawmakers. The stated purpose for this decision is to improve research into the causes of obesity, leading to improvement in methods to prevent and treat it, ultimately improving patient health and outcomes. This decision would be expected to improve insurance coverage and reimbursement to providers for treating individuals with obesity. In addition, this change in public policy by the AMA supports the concept that obesity is a serious disease that requires treatment and also removes the stigma currently associated with obesity (i.e., it is not just a poor lifestyle choice).

The AMA decision is controversial, since the AMA's own Council on Science and Public Health in 2012 said that there was not sufficient data to support calling obesity a disease. In this article I will discuss some of the issues associated with this controversy, as well as what we know regarding the etiology of obesity. I will then return to the discussion of whether designating obesity as a disease is an appropriate decision.

Obesity as a Leading Heath Problem

According to the American Heart Association, obesity is found in almost one-third of U.S. adults and 17% of U.S. children ages 2 to 19. Worldwide it was estimated in 2010 that there are approximately 500 million obese people and another 1.4 billion who are overweight. The number of obese individuals is estimated to rise to 700 million by 2015.1 Obesity is estimated to cause approximately 112,000 to 365,000 deaths per year. Its prevalence has increased since the 1970s in the U.S. (data from NHANES II and III) and in Europe.2 This increase has occurred across every age group, sex, race, and smoking status.3

Obesity is recognized as a significant public health hazard, as it increases the risks for multiple diseases, such as type II diabetes, cardiovascular disease, hyperlipidemia, hypertension, stroke, breast and colon cancer, and degenerative arthritis.4 The cost of treating obesity related conditions are estimated to range from 147 to 210 billion dollars per year. It decreases quality of life, functional capacity, and increases morbidity and mortality. Treatment has been shown to reduce morbidity and mortality.5 Therefore, preventing or treating obesity would be very beneficial on both an individual and societal basis.

One of the controversies regarding whether to define obesity as a disease is the fact that there is not agreement as to the definition of obesity. Obesity can be defined as an excess of body fat that leads to increased morbidity and mortality. From an epidemiological standpoint, it may be defined as a BMI of greater than or equal to 30 kg of body weight per meter squared.2 This is a simple and easy to use calculation, as the data are readily available. The BMI is considered a marker for adiposity and is widely used to predict and evaluate disease risk. It is not an ideal measure, as it does not account for variations in body composition. Other methods to measure body fat and composition include waist circumference, skin fold thickness, waist to hip ratio, waist to height ratio, bioelectrical impedance, and dual energy X-ray absorptiometry. These metrics or techniques are not consistently available in all settings. In 2012 the AMA Council argued that the lack of a universally agreed upon metric limits the ability to define obesity as a disease and therefore, calling it a disease would not improve health outcomes.

Can Obesity Ever Be 'Healthy?'

It is known that some people with a BMI in the obese range are putatively 'healthy,' and some with a normal BMI have an excess of visceral body fat and are not healthy. There is also the "obesity paradox." It appears that some people with a BMI in the obese or overweight range have better short- and long-term health outcomes than those with a normal BMI. Research suggests that the "obesity paradox" may have been due, in part, to the level of physical fitness of the individual. Those persons with a higher fitness level have the more favorable prognosis.6 A more recently study7 provides evidence that the "obesity paradox" is not true. This meta-analysis investigated the association of BMI, metabolic status, and cardiovascular events and total mortality. The result of this study was that obese individuals, regardless of their metabolic status (healthy or unhealthy) were at increased risk for adverse health outcomes, when compared to individuals of normal weight. This risk was seen only in the studies with more than 10 years of follow-up.

This study, and the accompanying editorial,8 support the concept that obesity increases risks for adverse health outcomes, and should be considered a disease. AACE5 and others9 argue that the epidemiologic evidence supports the association of excess body fat with risks for other primary diseases, such as diabetes, hypertension, hyperlipidemia, and coronary artery disease. The lack of a universal metric should not preclude calling obesity a disease.

Is Obesity a Disease?

A related and more challenging controversy is whether obesity meets the definition of a disease. To discuss this, we need to agree on the definition of a disease, which is not as obvious as it would seem. Historically, it has long been recognized that people who are overweight or obese were at higher risk of sudden death; this dates back to Hippocrates over 2500 years ago. More recent historical comments, from 1600 through 1934, demonstrate that many observers thought that "corpulency" was a disease in some but not all cases, which could lead to increased morbidity and mortality in some cases.9

There is not one agreed upon definition of a disease. I have chosen several as representative examples. Kincaid9 states that disease is deviation from species-typical functioning; disease is deviation from the average. In the evolutionary function view, disease occurs when an organ is not performing the job that allowed it to evolve by natural selection.

A more widely held definition is that of Heshka and Allison;10 theirs is an extraction of four points common to definitions from multiple general language and medical dictionaries:

1. Disease is a condition of the body, its parts, organs, or systems or an alteration thereof.

2. It results from infection, parasites, nutritional, dietary, environmental, genetic, or other causes.

3. It has a characteristic, identifiable, marked group of signs or symptoms.

4. It deviates from normal structure or function (variously described as abnormal structure or function; incorrect function; impairment of normal state; interruption, disturbance, cessation, disorder, derangement of bodily or organ functions).

Definitions from the FDA in 1993, Downey and Conway (2001), and Rene (2004)9 share some but not all of these criteria. In 2007, the AMA stated that criteria 1, 2, and 4 were necessary for a condition to be called a disease. At that time, it stated that obesity did not meet the criteria to be considered a disease.9 Several of these authors, as well as the AMA Council in 2012, did not think obesity met the definition of a disease. Conversely, AACE, in a 2012 position statement, stated that obesity met these three conditions.5 The AACE position probably stems from differences of opinion in the definition of a disease, how to apply those definitions, and which facts regarding obesity fit which definition. As there is no universally accepted definition of a disease, it is possible that one cannot have a scientific, definitive answer regarding obesity. The American Obesity Society9 suggested that since there is no clear definition of a disease, it does not make sense to ask if obesity is a disease. They do support calling obesity a disease based on a utilitarian approach to public health.

The epidemic of obesity and its associated complications are challenging the world's health care system and might slow or even reverse the life expectancy gains of the last 50 years. Understanding its multiple causes would help in the development of effective preventions and treatments. Obesity is a complex condition with many causes. In general, obesity results from an imbalance between energy consumption (dietary intake) relative to energy expenditure (energy used in metabolic and physical activity). People gain weight because energy intake exceeds expenditure, i.e., positive energy balance. There are multiple potential contributing factors to this imbalance including genetic, environmental, behavioral, physiologic, psychological, social, and economic.3

Twin and adoption studies show that variations in BMI have a significant genetic component, and it has been estimated that these genetic effects contribute as much as 70% of the variation in obesity. These effects may contribute to obesity via effects on energy intake, expenditure, and abnormal regulation of satiety signals.1 Rare, simple genetic defects such as leptin deficiency or MC4R abnormalities have clearly been shown to cause obesity. More common gene variations seem to have a small effect size on weight, and no single widespread gene has been found that can explain obesity. It is likely that multiple genes are involved in the heritability and susceptibility for obesity.1, 11, 12

Why is Obesity More Prevalent?

Environmental influences are another major contributor to obesity.3,11,12,13 The so-called "obesogenic" environment with its reduced food costs, the especially plentiful high calorie dense foods, larger ser ving portions, reduced physical activity, and the influential food industry, are likely contributors. U.S. government food policies in the 1970s are also thought to be a contributor to obesity. Other environmental contributors include endocrine disrupters (industrially produced chemicals such as plastics) that can disturb endocrine function. The most widely studied of these is bisphenol A. Sleep deprivation, medications, social networks, stress, and changes in bacteria in the GI tract (microbiome) are thought to be contributing factors. It has been suggested that obesity is a biologic adaptation to this obesogenic environment,14 or that it is a chronic relapsing neurochemical disease.15 Epigenetics has been proposed as a possible link between the complex interplay of both genetic and environmental factors in regulation of energy intake, expenditure, and energy balance. 16

There are multiple contributing factors for obesity, as well as many unanswered questions. If the environment promotes obesity, why is everyone not obese? Why do some people eat more than others? It is known that simply trying to increase calorie expenditure as a method of weight reduction does not consistently work. Studies have shown that losing fat mass can have adverse effects on appetite control and even reduce energy expenditures, making further weight loss even more difficult.14 The contrarian food writer, G. Taubes,17 as well as Hebert,6 think that the energy balance hypothesis is incorrect, and that this has adversely influenced research and policy decisions on prevention, treatment, and public health. Both suggest further research into the causes of obesity.

What Good or Bad Effects Might Come From Calling Obesity a Disease?

So is it a good idea to label obesity a disease? Overall, I think yes it is despite the many controversies associated with the disease designation. These include the controversy regarding the lack of a universal definition for obesity, and whether it fits the scientific definition of a disease. There are also concerns that the definition of obesity as a disease will shift the emphasis towards treatment with surgery/medications, and away from prevention efforts via lifestyle changes, including behavior modification, diet, and exercise. There are concerns that obese people will be labeled as having a disease, even if they are not sick. This could have effects on obese individuals' efforts to manage their weight and make lifestyle changes.

The position of the AMA, AACE, Obesity Society, and other medical organizations is that obesity and its related diseases have a significant adverse effect on public health. This designation will focus society on the importance of preventing and treating it. A designation of obesity as a disease that results from a complex interplay of behavioral, environmental, and genetic factors should shift the stigma and discrimination from considering it as simply a lifestyle issue of poor eating habits and sedentary lifestyle.

In our society, labeling it as a disease would be expected to improve attitudes and financial support for obesity treatment. This would include more resources for health promotion, research into the behavioral, environmental, and genetic causes, as well as prevention and treatment (medical and surgical). This would improve insurance coverage and reimbursement for screening, health promotion, prevention, and treatment.

Obviously obesity is a complex topic. Despite extensive research, the causes for this disease are not well understood and good treatment options remain elusive. As Dr. George Bray, a distinguished obesity researcher, once said, "Obesity isn't rocket science, it's much more complicated."13

Biography

Howard Rosen, MD, MSMA member since 1990 and Missouri Medicine Editorial Board Member for Endocrinolgoy, practices in North Kansas city and specializes in Endocrinology, Diabetes & Metabolism.

Contact: moc.odneckn@yraterces

Articles from Missouri Medicine are provided here courtesy of Missouri State Medical Association

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Is Obesity A Disease or A Behavior Abnormality? Did the AMA Get It Right?

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In June 2013, the American Medical Association (AMA) House of Delegates voted to recognize obesity as a disease state requiring treatment and prevention efforts. A number of other medical societies had sponsored a resolution to support this idea, including the American Association of Clinical Endocrinologists, the Endocrine Society, the American College of Cardiology, the American College of Surgeons, and the American Heart Association.

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Not very NICE: deviance, stigma and nutritional guidelines related to healthy weight and obesity.

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Not very NICE: deviance, stigma and nutritional guidelines related to healthy weight and obesity.

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Why NHS guidelines are likely to fail.

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Not very NICE: deviance, stigma and nutritional guidelines related to healthy weight and obesity.

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Weight stigma predicts inhibitory control and food selection in response to the salience of weight discrimination

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Weight stigma predicts inhibitory control and food selection in response to the salience of weight discrimination

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The higher participants were in perceived weight stigma, the more poorly they performed on the inhibitory control task and the more calories they ordered when they read about discrimination against individuals with higher body weight.

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The relationship between weight stigma and eating behavior is explained by weight bias internalization and psychological distress.

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The relationship between weight stigma and eating behavior is explained by weight bias internalization and psychological distress.

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The relationship between weight stigma and eating behavior is explained by weight bias internalization and psychological distress.

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Weight stigma and eating behaviors on a college campus: Are students immune to stigma's effects?

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Weight stigma and eating behaviors on a college campus: Are students immune to stigma's effects?

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Weight stigma and eating behaviors on a college campus: Are students immune to stigma's effects?

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Patronised for eating 'healthy'?

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Socioeconomic status and obesity: A review of the literature

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Socioeconomic status and obesity: A review of the literature

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Outdated lit review on socioeconomic influences on obesity (Sobal & Stunkard, 1989).

This research highlights an inverse relationship between socioeconomic status and obesity for women in developed countries, as women of a higher socioeconomic strata have a higher likelihood of obesity.

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Are certain populations more vulnerable?

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Are certain populations more vulnerable?

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What specific self-management challenges do low SES obese people face?

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What specific self-management challenges do low SES obese people face?