"There Are Healthier Ways": Perspectives of Emerging Adults on Weight Loss Medications.

Weight stigma is prevalent among adolescents and can negatively impact physical and mental health. This study examined the effects of a combined physical activity and attitude education intervention on weight stigma and related outcomes among high school students. A randomized controlled trial was conducted with 524 high school students. The intervention group received a 3-month program combining physical activity education and anti-stigma attitude training. Outcomes measured included the use of weight loss medication, physical activity levels, weight loss, and depressive symptoms. The intervention group showed significant decreases in weight loss medication use and depressive symptoms, and increases in physical activity levels compared to the control group. No significant differences were observed in weight loss between groups. Gender differences were noted, with girls showing greater improvements in physical activity. Findings support integrating weight stigma reduction strategies into school health programs. Schools should adopt attitude modification approaches, promote inclusive physical activities, and foster social support to address weight stigma and associated depression symptoms. Combining physical activity and attitude education can effectively reduce weight stigma and improve health behaviors among high school students. Future research should explore long-term effects and tailored approaches for different student populations.

I understand that the Endocrine Society has new clinical guidelines on medicating patients with obesity. What exactly do these guidelines cover? Daniel Bessesen, MD: About a year ago, the American Heart Association, in conjunction with the Obesity Society and the American College of Cardiology, published updated guidelines on obesity care. Unfortunately, that document left out information or guidance on medications, in particular, the use of medications to help patients lose weight, and also the role that medications we prescribe for other health conditions play in producing weight gain in some patients. The Endocrine Society's clinical guidelines really focus on these aspects of medication use in patients who are obese. How were these guidelines developed? Bessesen: The Endocrine Society has a guideline committee that selects areas where there might be a need for a new direction for care providers. They decided that the area of medication use in obesity was an important area, so they convened a task force to draft the new guidelines. Caroline Apovian, MD, was the chair of that task force, and it had members from a variety of backgrounds. They conducted an extensive review of the evidence available on the topic in the literature and used the ‘Grade System,' which is an international system for deciding about the level of evidence available, to come up with their recommendations around the use of medications in patients who are obese. How can these guidelines be accessed?Bessesen: The guidelines were published in The Journal of Clinical Endocrinology and Metabolism in February 2015 and are available on the Endocrine Society website. Can you tell us something about the content?Bessesen: The original guidelines from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) gave some guidance about the use of weight loss medications, but these new guidelines provide critical updates, and the focus is really on 3 areas. First is the medications that doctors use for other health care problems and the guidelines provide guidance about which of those medicines are most likely to cause weight gain. Second, they provide guidance about alternative medications for those problems that might cause less weight gain with a special focus on the use of medications in the treatment of diabetes that are least likely to promote weight gain. And finally, they provide guidance about the use of weight loss medications specifically and in clinical conditions where obesity is a problem. What is new in these guidelines, and what will they tell us?Bessesen: For many years there were not many options when a patient came to the office and told us that they were concerned about their weight and asked if there is a medication that might be helpful. We now have a total of 5 FDA-approved medications, with another one currently under review at the FDA, so it may well be that by the middle of next year we will have 6 medications available to help people who are obese. The guidelines suggest that it is appropriate to have a conversation with patients about a weight-loss medication if their body mass index (BMI) is greater than 30 kg/m2, or if their BMI is greater than 27 kg/m2, and they have a weight-related health problem such as diabetes, lipid problems, or sleep apnea. The guidelines really give specific advice about the use of these medications, in particular, giving a trial of medications and seeing if the patient actually loses weight. If a patient does not lose 5% of his or her weight after several months on the medications, then it would seem inappropriate to continue the medications. But, if at 3 months the patient loses 5% of their baseline weight, the medication should probably be continued indefinitely. The guidelines give some suggestions about which medications might be most appropriate for which patient, in particular if a person has a problem with blood pressure or coronary heart disease, then the medications that could raise blood pressure or pulse should be avoided in favor of those that have less risk of this effect. The guidelines strongly emphasize that diet, exercise, and behavior modification are a foundation for all obesity care, and that pharmacotherapy should be used only in conjunction with a good diet and exercise program. I think the other suggestion, or point of view, that the guidelines offer is, in the past, physicians have tended to treat the complications of obesity, such as diabetes, high blood pressure, hypertension, and left the problem of weight off to the side, providing some diet and exercise guidance, or perhaps not even mentioning it at all. I think the guidelines suggest a shift in paradigm. We know that weight and obesity are integral and central to the development of these metabolic problems, and so the guidelines really suggest that clinicians focus on weight as a central factor in the treatment of these other metabolic problems, and treat the weight first or at least in conjunction with the treatment of these other metabolic disorders. What was your role in developing these new clinical guidelines?Bessesen: I am a clinician and researcher, and I have been involved with the Endocrine Society for a long time. I think our committee gave a variety of perspectives on the care of the patient who is obese, and so my role was to participate in the group to try to provide a sense of what the working clinician sees in the office when faced with a patient who struggles with weight gain. One of the things I think the guidelines address are a reluctance on the part of many clinicians to prescribe or to even discuss weight-loss medications with their patients. Even though we have 5 FDA-approved medications, the reality is, very few patients who are obese ever get a prescription for a weight-loss medicine. There was a recent study in the journal Obesity (1) that looked at Veterans hospitals and how many patients who are obese and would qualify for consideration of a weight loss medication actually ever got a prescription for one. Out of 2 million eligible veterans, only 0.2% ever received a prescription for a weight-loss medicine. In fact, national data collected from the United States shows that the number of prescriptions written for weight loss medications has gradually fallen over the last 15 years (2). This has occurred despite the evidence from research studies that weight loss medications can help people lose weight, and even epidemiologic data that suggest that weight loss medications, short of surgery, are one of the most effective ways for people to lose weight (3). Part of my role on the committee was to be a voice of the working clinician who feels that it is important to provide general clinicians with some guidelines about a reasonable approach to discussing weight-loss medicines with their patients. Weight-loss medicines are really not a panacea, they do not fix the problem of obesity on their own. But on the other hand, how many health problems do we wait for the patient to ask us for a medication, and then tell the patient if they have diabetes, "No, no, you cannot use a medication for your diabetes because you are not sticking to your diet well enough yet?" In the area of weight-loss medicines, there has been a bit of a reluctance for clinicians to prescribe. Some of this comes from a history of adverse effects of weight-loss medicines, so I think the reluctance is understandable. On the other hand, obesity is incredibly common, and many of our patients want information about their options. More than anything, my role on the committee was to try to be a voice for providing clinicians with some information on which they could provide a useful conversation with their patients about weight-loss medicines. Overall, the Endocrine Society has done a great service to practitioners by providing these clinical guidelines. How active is the society in managing obesity?Bessesen: Obesity is a huge public health problem, and I think all clinicians, whether they be surgeons, gastroenterologists, nurse practitioners, or family doctors see the health toll that obesity is putting on their patients. A lot of organizations are trying to address the problem of obesity within their specific areas of expertise. Endocrinologists are uniquely positioned to provide information or guidance in this area. The Endocrine Society has a long history of being a source of reputable scientific information that can be trusted. In addition, endocrinologists take care of some of the most common complications of obesity, including diabetes and hyperlipidemia. The Endocrine Society has made a decision within the last year to take a bigger role in the area of obesity. Over the coming years, this may involve activities both in training to try to develop a good curriculum of what clinicians should know about the care of the patient who is obese, to information for patients with diabetes who have obesity, and even perhaps efforts at the government level to help improve the insurance coverage for the care of people with obesity. Is there anything else about the guidelines that we should know to keep primary care physicians up-to-date?Bessesen: I did not touch on the other big area, which is the use of medications in patients who have other health problems. Clinicians will find some useful information in these guidelines about the care of patients with high blood pressure, arthritis, women who need birth control medications, patients who have depression or other psychiatric diseases, and which medications might be the most weight-friendly in these other health care conditions. A lot of primary care physicians see patients who get put on a psychiatric medication and then gain a lot of weight, and may have health complications from that weight gain. This new guideline provides authoritative evidence on the selection of medications that are the least likely to produce unwanted weight gain in those conditions. In summary, there are a lot of guideline documents out there, and sometimes clinicians might think that some of them do not give them clear guidance or may even provide conflicting guidance. I think clinicians should find these new guidelines from the Endocrine Society useful in that they address situations that are seen every day in their practice. The purpose of the ENDO guidelines is not to insist on prescribing weight-loss medicines, but rather to provide information on which general clinicians can base their conversations with their patients around medications and their effects on weight.

Patient-Centered Care for Obesity: How Health Care Providers Can Treat Obesity While Actively Addressing Weight Stigma and Eating Disorder Risk

BackgroundWhilst the consequences of weight bias and weight bias internalisation (WBI) have been explored, less is known about the factors contributing to their development. Some research has explored the role of social exposure in weight bias and WBI but has been limited in its definition of exposure and focused solely on western countries. The present study therefore aimed to assess the role of social exposure defined in terms of both population and personal exposure in predicting weight bias and WBI, in an international sample.MethodsParticipants (N = 1041) from 33 countries, aged 18–85 years completed online measures of demographics, weight bias, WBI, and population and personal social exposure. Population exposure was defined using national obesity prevalence data from the World Health Organisation to classify countries as low (obesity rates ≤19.9%; n = 162), medium (20.0–29.9%; n = 672) or high prevalence (≥30%; n = 192). Personal exposure was defined in terms of personal contact and health and attractiveness normalisation.ResultsUsing regression analysis, greater weight bias was significantly predicted by being younger, male, less educated, and personal exposure in terms of normalisation beliefs that thinner body types are healthier and more attractive, greater daily exposure and overall exposure to thinner friends. The strongest predictors of weight bias (adj R2 = 13%) were gender (β = −0.24, p < .001), and personal exposure in terms of normalisation beliefs that thinner body types are more attractive (β = −0.13, p = .001). The strongest predictors of WBI (adj R2 = 6%) were attractiveness normalisation (β = −0.23, p < 0.001) and participants’ perceived body shape (β = −0.27, p < 0.001). Population exposure did not predict either weight bias or WBI.ConclusionsPersonal exposure is more important than population exposure in predicting both weight bias and WBI. Findings hold implications for improving the wellbeing and lived experiences of those living with overweight and obesity.

Controversial issues: A practical guide to the use of weight loss medications after bariatric surgery for weight regain or inadequate weight loss

This study examined whether eating disorder (ED) psychopathology related to weight loss medication and over-the-counter weight loss supplement use over time in women. It was hypothesized that ED psychopathology at baseline would relate to the following 6-months later: (1) use of any weight loss medications or supplements; and specific use of: (2) over-the-counter weight loss supplements, (3) prescription weight loss medications, (4) glucagon-like peptide 1 (GLP-1) agonist medications used for weight loss. Women in the United States were recruited for a 6-month long online study. Questionnaire data were provided, including the 7-item version of the Eating Disorder Examination Questionnaire. Baseline ED psychopathology was related to use of weight loss medications and supplements 6-months later, controlling for baseline use and body mass index (BMI). Analyses found greater odds of using over-the-counter weight loss supplements, prescription weight loss medications, and GLP-1 medications, at 6months associated with higher baseline ED psychopathology, controlling for baseline weight loss medication/supplement use and BMI. Medications such as GLP-1s can benefit chronic disease management when used appropriately but these, and other weight loss medications and supplements, may also be appealing to those with ED psychopathology to promote restriction and weight loss. ED symptom screening is important prior to, and during, medication use. These data are relevant for prescribers and suggest that evaluation of ED symptoms, especially "atypical" anorexia nervosa presentations, may be warranted among those seeking weight loss medications. Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

Background: People living with obesity frequently experience weight bias, stigma and discrimination, from childhood through all their lives. Wight bias are negative weight-related attitudes, beliefs, assumptions and judgments in society, that are held about people with obesity. Weight stigma is characterized by prejudiced, stereotyped, and discriminatory views and actions towards people with obesity, often fuelled by inaccurate ideas about the causes of obesity. Weight bias, stigma and discrimination usually lead to several physical, psychological and psychosocial consequences. Some of the consequences of weigh bias and stigmatization include increased chronic stress, cortisol levels, oxidative stress, and increased risk for obesity, diabetes, avoidance of healthcare, greater cardiovascular risks, psychological distress, anxiety, body image disturbance and depression. Weight bias can also have social and economic consequences, such as fewer opportunities for education and employment for people living with obesity. A fundamental driver of weight bias is a lack of public understanding of the complex and multifactorial nature of obesity. Public health strategies that focus on obesity as an issue of unhealthy eating and physical inactivity, and ignore biological, genetic, environmental and social contributors of obesity, can contribute to the lack of public understanding of the disease and can lead to people experiencing weight bias and stigma. Public health campaigns that promote negative attitudes and stereotypes toward people with obesity, are not only ineffective in motivating behaviour change but also end up labelling and stigmatizing individuals further. Conclusions: In order to reduce weight bias and stigmatization, public health professionals should be aware of and concerned about weight stigma and its consequences, while all health workers need to be educated and trained in reducing weight stigmatization and discrimination. Instead of using stigmatizing language and images, public health policy makers should develop people-centred policies that move beyond personal responsibility, recognize the complexity of obesity and promote health, dignity and respect, regardless of body weight or shape.

Weight stigma is a painful and distressing phenomenon experienced by many individuals with overweight and obesity around the world. Weight stigma, whether experienced from others, or internalised by individuals with overweight, is associated with a myriad of detrimental physical and mental health outcomes (Latner, Durso, & Mond, 2013; Papadopoulos & Brennan, 2015; Pearl, Puhl, & Dovidio, 2015; Puhl & Brownell, 2001). Given the widespread and negative impact of weight stigma, there is a need for strategies to alleviate the effects of weight stigma and assist individuals to better cope with stigmatising situations (Flint, Raisborough, & Hudson, 2020). Concurrently, there has been an increased interest in the field of self-compassion research, for which there is now compelling evidence highlighting that self-compassion is beneficial for mental health and well-being. Evidence shows that self-compassion is particularly important during times of suffering and distress, and can serve to buffer the effects of stigma for various populations, including marginalised groups (Fredrick, Williams, & LaDuke, 2019). Evidence demonstrating the advantages of self-compassion provides a persuasive rationale to argue that self-compassion has the potential to attenuate the negative effects of weight stigma. However, studies merging the fields of weight stigma and self-compassion research are limited, and the role of self-compassion within the context of weight stigma is an understudied area of investigation. Based on empirical evidence available from both fields, it is argued that self-compassion can serve as a protective factor in the lives of weight stigmatised individuals with overweight. It is further argued that a compassion focused method to alleviate the effects of weight stigma and develop the capacity for self-compassion offers an important empirical contribution to the field of weight stigma research, which has not been offered by the approaches currently available. This dissertation aimed to firstly present a review of empirical evidence across the fields of weight stigma and self-compassion. Following this, a series of studies aimed to identify and address gaps in the literature. Specifically, the research presented in this dissertation was designed to address three primary aims: 1) to investigate the role of internalised weight stigma and self-compassion in the relationship between weight stigma and outcomes of psychological distress, body shame, loneliness and life satisfaction; 2) develop a compassion-focused group intervention specifically designed to reduce the adverse effects of weight stigma; and 3) conduct a pilot study to examine the acceptability and feasibility of a compassion-focused group intervention for weight stigmatised women with overweight and obesity. This dissertation presents a compendium of three studies conducted to achieve these aims. Study 1 involved an empirical study that tested the relative contribution of both internalised weight stigma and self-compassion on weight stigma, as mediators in the relationship between weight stigma and outcomes of psychological distress, loneliness, body shame and life satisfaction. Results revealed that internalised weight stigma mediated the relationship between external weight stigma and body shame, while self-compassion mediated the relationship between external weight stigma and psychological distress, loneliness and satisfaction with life. Study 2 provided a detailed account of the development of a 2-day Compassion-Focused Therapy (CFT) intervention, designed to increase self-compassion, and reduce internalised weight stigma for women with overweight and obesity. Two case studies demonstrated improvements in the expected direction for self-compassion, internalised weight stigma, depression, body shame, loneliness, weight self-efficacy, body dissatisfaction, life satisfaction, as well as weight loss. Study 3 tested the feasibility/acceptability of the 2-day, Compassion-Focused Therapy (CFT) program for a group of weight stigmatised females with overweight and obesity in Australia. Significant group improvements were found from pre-treatment to post-treatment for self-compassion and internalised weight stigma, with gains maintained at 3-month follow-up. Significant improvements were also found for psychological distress, life satisfaction, eating self-efficacy, body dissatisfaction and loneliness at the post-treatment assessment. A non-significant trend of mean group weight loss from pre-treatment to three-month follow-up was also observed. Credibility ratings of the program were high. This compendium of research has advanced research knowledge in two main ways. Firstly, the research reported herein is the first to have demonstrated the unique roles of both self-compassion and internalised weight stigma as mechanisms through which experienced weight stigma can affect a range of adverse psychological consequences. Secondly, this dissertation has demonstrated the feasibility and acceptability of a 2-day CFT-based group program specifically designed to increase self-compassion and reduce internalised weight stigma for women with overweight and obesity. The current program has merged two important fields of self-compassion and weight stigma research, thus providing evidence for self-compassion as a promising strategy through which to assist individuals to better cope with the painful effects of weight stigma.

The purpose of this research was to develop a baseline understanding of the knowledge and perceptions that certified personal trainers have of both prescription and nonprescription weight loss drugs. A 16-item qualitative survey instrument was used to interview certified personal trainers. Interviews were conducted via telephone to assess trainers' current level of knowledge and perceptions of weight loss drugs. Questions about both prescription medications and over-the-counter (OTC) medications were included in the survey instrument. All trainers (n = 43) held current National Association of Personal Trainers (NAPT) certifications or certification from the American College of Sports Medicine (ACSM). Criteria for inclusion were dependent on having knowledge about prescription weight loss medications (n = 24). Almost half of the sample had no knowledge of weight loss medications. Of the 43 trainers surveyed, 58% were able to list one currently or previously available medication, 42% were able to list two medications, and no certified personal trainer was able to provide names of more than two medications. Personal trainers did not support the use of either prescription or OTC weight loss medications. In fact, these interventions were rated the lowest on a 7-point scale among options assessed concerning their importance to a weight loss program: diet (6.67), exercise (7.00), and medication use (1.96). The results suggest a lack of awareness of weight loss medications and a potential bias against prescription weight loss medication use. This finding illustrates the need for further studies of fitness professionals' perceptions of and attitudes toward antiobesity medications as a form of weight loss intervention.

“Shape Carries Story”: Navigating the World as Fat

Patterns of Weight Loss Medication Utilization and Outcomes Following Bariatric Surgery

Fat Studies 101: Learning to Have Your Cake and Eat It Too

Background Obesity is increasingly prevalent in patients with IBD and has been linked to non-response to medical therapies and disease progression. In the last decade the management of obesity in the general population has undergone a paradigm shift following the widespread use of medical therapies and bariatric surgery. Few studies have assessed weight loss strategies used by obese patients with IBD. Methods We designed a Patient and Public Involvement and Engagement survey to assess past use and future interest in interventions for obesity. We also sought interest in a trial of a licensed weight loss medication as an adjunct to conventional IBD therapy. We used the MyChart application in our electronic patient record (EPIC) to distribute our questionnaire between 6th and 18th November 2024. The response rate was 31% (828/2700): 40.0% [322/828], 52.9% [426/828], 7.1% [57/828] patients were diagnosed with Crohn’s disease, UC and IBDU, respectively. Body mass indices were available in 97% (807/828) patients. Results The median [IQR] age was 54.0 (41.0 - 65.0) years, 58.5% (484/828) were female and 92.8% [768/828] were of white European ancestry. Overall, 29.0% (234/807) were overweight and 25.0% (202/807) were obese. 30.7% (254/828) were eligible for a medication for weight management, by having a BMI ≥30 kg/m2 or a BMI ≥27 kg/m2 in addition to one or more weight-related comorbidity. Amongst these patients prior experience with weight loss strategies included: 51.6% (131/254) self-directed dieting; 33.9% (86/254) calorie counting using a smartphone app; 38.2% (97/254) had attended a weight-loss group; 16.1% (41/254) had had advice from a dietician; 2.8% (7/254) had taken part in a formal exercise program; 5.9% (15/254) had used weight loss medications [6 orlistat, 14 GLP-1 agonist] and 1.6% (4/254) had had bariatric surgery. Of 14 patients treated with a GLP-1 agonist, 5 and 9 were prescribed by public and private healthcare professionals respectively. Amongst patients eligible for pharmacological treatment: 11.4% (29/254) expressed interest in future group-based support; 30.8% (78/254) in a formal exercise program; 37.4% (95/254) advice from a dietitian; 43.3% (110/254) drug treatment and 11.4% (29/254) endoscopic or surgical weight loss procedures. 72.8% (185/254) of patients expressed interest in participating in a trial of a licensed weight loss medication as an adjunct to conventional IBD treatment. Conclusion Obese patients living with IBD want access to weight loss interventions. However, previous use of weight loss medications was uncommon and usually accessed through private healthcare. Three quarters of obese patients expressed an interest in a trial of a licensed weight loss medication as an adjunct to conventional IBD therapy.

BackgroundLimited research has explored the relationship between weight bias and clinical attrition, despite weight bias being associated with negative health outcomes.Participants/methodExperienced weight stigma (EWS), internalized weight bias (IWB), and clinical attrition were studied in a Medical Weight Loss clinic, which combines pharmacological and behavioral weight loss. Patient sociodemographic, medical, and psychological (depression) variables were measured at consultation, and clinic follow-ups were monitored for 6 months. IWB was assessed with the Weight Bias Internalization Scale Modified (WBIS-M).ResultsTwo-thirds (66%) of study participants returned for follow-up appointments during the 6-month period (“continuers”), while 34% did not return after the initial consultation (“dropouts”). Clinic “dropouts” had higher WBIS-M scores at initial consultation than “continuers,” (χ2(1) = 4.56; p < 0.05). No other variables were related to clinical attrition. Average WBIS-M scores (4.57) were similar to other bariatric patient studies, and were associated with younger age (t = −2.27, p < 0.05), higher depression (t = 2.65, p < 0.01), and history of EWS (t = 2.14, p < 0.05).ConclusionStudy findings indicate that IWB has significant associations with clinical attrition. Additional research is warranted to further explore the relationships between EWS, IWB, and medical clinic engagement.

BackgroundDespite rising levels of obesity in England, little is known about slimming club and weight loss drug (medication) use or users. In order to inform future commissioning, we report the prevalence of various weight management strategies and examine the associations between slimming club and medication use and age, gender, deprivation and body mass index.MethodsA population based cross-sectional survey of 26,113 adults was conducted in South Yorkshire using a self-completed health questionnaire. Participants were asked whether they had ever used the following interventions to manage their weight: increasing exercise, healthy eating, controlling portion size, slimming club, over the counter weight loss medication, or meal replacements. Factors associated with slimming club and weight-loss medication use were explored using logistic regression.ResultsOver half of the sample was either overweight (36.6%) or obese (19.6%). Obesity was more common in the most deprived areas compared to the least deprived (26.3% vs. 12.0%). Healthy eating (49.0%), controlling portion size (43.4%), and increasing exercise (43.0%) were the most commonly reported weight management strategies. Less common strategies were attending a slimming club (17.2%), meal replacements (3.4%) and weight-loss medication (3.2%). Adjusting for BMI, age, deprivation and long standing health conditions, women were significantly more likely to report ever using a slimming club (adjusted OR = 18.63, 95% CI = 16.52–21.00) and more likely to report ever using over the counter weight-loss medications (AOR = 3.73, 95% CI = 3.10-4.48), while respondents from the most deprived areas were less likely to report using slimming clubs (AOR = 0.60, 95% CI = 0.53-0.68), and more likely to reporting using weight loss medications (AOR =1.38, 95% CI = 1.05-1.82).ConclusionA large proportion of individuals report having used weight management strategies. Slimming clubs and over-the-counter weight loss medication account for a smaller proportion of the overall uptake. Those from less deprived areas were more likely to use slimming clubs while those from more deprived areas were more likely to use weight-loss medications. Future NHS and Local Authority commissioning of weight management services must be aware of this varying social gradient in weight management strategies.