Standard Behavioral Weight Loss Treatment Research Articles

Dietary adaptation for weight loss maintenance at Yale (DAWLY): Protocol and predictions for a randomized controlled trial.

BackgroundCurrent therapies for obesity treatment are effective at producing short-term weight loss, but weight loss maintenance remains a significant challenge. Here we investigate the impact of pre-intervention dietary fat intake on the efficacy of a dietary supplement to support weight loss maintenance. Preclinical work demonstrates that a vagal afferent pathway critical for sensing dietary lipids is blunted by a high-fat diet (HFD), resulting in a reduced preference for a low-fat emulsion and severe blunting of the dopamine (DA) response to the gastric infusion of lipids. Infusion of the gut lipid messenger oleoylethanolamide (OEA), which is also depleted by HFD, immediately reverses this DA blunting and restores preference for the low-fat emulsion. Studies of OEA supplementation for weight loss in humans have had limited success. Given the strong effect of HFD on this pathway, we designed a study to test whether the efficacy of OEA as a weight loss treatment is related to pre-intervention habitual intake of dietary fat.Methods/DesignWe employed a randomized, double-blind, placebo-controlled trial in which 100 adults with overweight/obesity (OW/OB) were randomized to receive either OEA or placebo daily for 16 months. Following a baseline evaluation of diet, metabolic health, adiposity, and brain response to a palatable an energy dense food, participants in both groups underwent a 4-month behavioral weight loss intervention (LEARN®) followed by a 1-year maintenance period. The study aims are to (1) determine if pre-intervention dietary fat intake moderates the ability of OEA to improve weight loss and weight loss maintenance after a gold standard behavioral weight loss treatment; (2) identify biomarkers that predict outcome and optimize a stratification strategy; and (3) test a model underlying OEA’s effectiveness.DiscussionFocusing on interventions that target the gut-brain axis is supported by mounting evidence for the role of gut-brain signaling in food choice and the modulation of this circuit by diet. If successful, this work will provide support for targeting the gut-brain pathway for weight loss maintenance using a precision medicine approach that is easy and inexpensive to implement.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [NCT04614233].

Nightly Variation in Sleep Influences Self-efficacy for Adhering to a Healthy Lifestyle: A Prospective Study.

Self-efficacy, or the perceived capability to engage in a behavior, has been shown to play an important role in adhering to weight loss treatment. Given that adherence is extremely important for successful weight loss outcomes and that sleep and self-efficacy are modifiable factors in this relationship, we examined the association between sleep and self-efficacy for adhering to the daily plan. Investigators examined whether various dimensions of sleep were associated with self-efficacy for adhering to the daily recommended lifestyle plan among participants (N = 150) in a 12-month weight loss study. This study was a secondary analysis of data from a 12-month prospective observational study that included a standard behavioral weight loss intervention. Daily assessments at the beginning of day (BOD) of self-efficacy and the previous night's sleep were collected in real-time using ecological momentary assessment. The analysis included 44,613 BOD assessments. On average, participants reported sleeping for 6.93 ± 1.28h, reported 1.56 ± 3.54 awakenings, and gave low ratings for trouble sleeping (3.11 ± 2.58; 0: no trouble; 10: a lot of trouble) and mid-high ratings for sleep quality (6.45 ± 2.09; 0: poor; 10: excellent). Participants woke up feeling tired 41.7% of the time. Using linear mixed effects modeling, a better rating in each sleep dimension was associated with higher self-efficacy the following day (all p values < .001). Ourfindings supported the hypothesis that better sleep would be associated with higher levels of reported self-efficacy for adhering to the healthy lifestyle plan.

Feasibility of Integration of Yoga in a Behavioral Weight-Loss Intervention: A Randomized Trial.

This study examined the feasibility and comparison of two styles of yoga within the context of a standard behavioral weight-loss intervention (SBWI). Fifty adults with obesity (BMI: 31.3 ± 3.8 kg/m2 ) participated in this 6-month study that included a SBWI and a calorie- and fat-reduced diet. Randomization was to restorative Hatha (SBWI+RES) or Vinyasa (SBWI+VIN) yoga. Yoga was prescribed to increase from 20 to 40 to 60 minutes per session across the intervention. Weight was assessed at baseline and 6 months. Perceptions of yoga were assessed at the completion of the intervention. Adjusted weight loss was -3.4 kg (95% CI: -6.4 to -0.5) in SBWI+RES and -3.8 kg (95% CI: -6.8 to -0.9) in SBWI+VIN (P < 0.001), with no difference between groups. Of all participants, 74.4% reported that they would continue participation in yoga after the SBWI. Session duration was a barrier as yoga increased from 20 to 40 to 60 minutes per day, with 0%, 7.5%, and 48.8% reporting this barrier, respectively. Among adults with obesity, yoga participation, within the context of a SBWI, appears to be feasible, with weight loss not differing by style of yoga. Progressing to 60 minutes per session appears to be a barrier to engagement in yoga in this population.

Comparative effectiveness of a standard behavioral and physical activity enhanced behavioral weight loss intervention in Black women

ABSTRACT Black women typically lose small amounts of weight in behavioral weight loss interventions, partially due to low engagement in physical activity. Culturally relevant enhancement of the physical activity component may improve weight loss. This study compared the effectiveness of a culturally-relevant, physical activity-enhanced behavioral weight loss intervention to a standard behavioral weight loss intervention in Black women (n = 85) over 6 months. The study was conducted in two cohorts from March 2016 to February 2017 at the University of North Carolina at Chapel Hill. Participants had an average age of 48.30 ± 11.02 years with an average body mass index of 36.46 ± 4.50 kg/m2. Standard and enhanced groups’ weight change (−2.83 kg and −2.08 kg, respectively) and change in physical activity (43.93 min/ week and 15.29 min/week, respectively) did not differ between groups. Significantly more standard group participants lost 5% of baseline weight compared to enhanced group participants. This study produced typical weight loss results in Black women. Behavioral weight loss treatment remains moderately effective for Black women. Strategies to increase attendance and self-monitoring, and the inclusion of cultural contexts to weight-related behaviors are needed to improve outcomes.

Associations between change in sedentary behavior and outcome in standard behavioral weight loss treatment.

Sedentary behavior, particularly in prolonged periods, is an important determinant of health. Little research exploring changes in sedentary behavior during behavioral weight loss programs exists. This study evaluated the magnitude of changes in total and prolonged sedentary behavior and how these changes related to changes in weight and cardiovascular outcomes during a behavioral weight loss program. Participants (n = 450) in two lifestyle modification programs underwent assessments of sedentary behavior (by accelerometry), weight, waist circumference, blood pressure, and resting heart rate at baseline and after 6 months of treatment. Sedentary behavior was defined as both total and prolonged (≥30 continuous minutes) sedentary minutes/day. Reductions in total and prolonged sedentary time were significant and were accounted for by increases in moderate-to-vigorous physical activity (MVPA). Only changes in MVPA significantly predicted change in weight when entered into a model simultaneously with changes in sedentary behavior. Changes in total and prolonged sedentary time were not associated with changes in waist circumference, heart rate, or blood pressure. Change in sedentary time was not independently associated with change in health outcomes during a behavioral weight loss treatment. High variability in changes in sedentary time indicate that individual differences may be important to examine. Reducing sedentary time may not be powerful enough to impact these health outcomes above the effects of other changes made during these programs; alternatively, it may be that increasing focus in treatment on reducing sedentary time may engender greater decreases in sedentariness, which could lead to better health outcomes.

Project TEAMS (Talking about Eating, Activity, and Mutual Support): a randomized controlled trial of a theory-based weight loss program for couples

BackgroundObesity risk is shared between spouses, yet existing weight loss programs focus on individuals and not the marital dyad. Given the interdependence of weight in couples, weight management outcomes might be improved by targeting joint weight loss and the creation of an interpersonal milieu that supports long-term behavior change. According to Self-Determination Theory (SDT), greater autonomous self-regulation of behaviors, and subsequently better treatment outcomes, are observed in needs supportive environments in which personally meaningful choice is supported and criticism and control are minimized. Correlational analyses confirm these pathways in weight management, with needs support from one’s spouse or partner emerging as a distinct predictor of weight loss success. Research is now needed to establish causal links and to develop and test weight loss interventions designed to facilitate the needs supportive behavior of spouses.MethodsProject TEAMS (Talking about Eating, Activity, and Mutual Support) is a randomized controlled trial testing a couples-based intervention, grounded in SDT, designed to change the social context of weight loss by training spouses to provide needs support for each other’s eating and physical activity behavior. Sixty-four couples will be randomized to either 6 months of behavioral weight loss treatment informed by SDT (SDT-WL) or to 6 months of standard behavioral weight loss treatment (BWL). Couples will attend weekly sessions for 6 months and will be assessed at 0, 3, 6, and 12 months. By bolstering needs support, SDT-WL is predicted to increase autonomous self-regulation and perceived competence and produce greater weight loss and maintenance than standard behavioral treatment. Exploratory analyses will examine the SDT process model prediction that the influence of needs support on treatment outcomes will be mediated by autonomous self-regulation and perceived competence.DiscussionThis study addresses the fundamental importance of interpersonal support in weight management by focusing on couples rather than individuals and using a rich theoretical framework to train spouses in supportive behaviors.Trial registrationClinicaltrials.gov; NCT02570009.

Abstract MP075: Profiles of Obese Depressed Adults in a Randomized Controlled Trial of Integrated Behavior Therapy

Objective: To identify distinct profiles of obese depressed patients in an ongoing trial that tests the effectiveness and implementation potential of an integrated care model in primary care combining standard behavioral weight loss treatment and problem solving therapy plus as-needed antidepressant(s). Design and Methods: Analysis of variance for continuous and Chi-square tests for categorical variables compared 4 domains (sociodemographic, behavioral, clinical and psychosocial characteristics) among 4 severity categories of obese depressed participants (i.e., body mass index [BMI]&lt;35 kg/m 2 and Depression Symptom Checklist 20 [SCL20]&lt;1.5; BMI&lt;35 and SCL20≥1.5; BMI≥35 and SCL20&lt;1.5; and BMI≥35 and SCL20≥1.5). Discriminant analysis identified combinations of characteristics that best differentiated these categories. Results: Participants (n=322) had baseline mean (SD) age of 50.4 (12.2) years, BMI of 36.7 (6.4) kg/m 2 , and SCL20 of 1.5 (0.5). Pairwise comparisons showed participants in the 4 categories had similar sociodemographic characteristics, but they differed significantly in the other 3 domains (Table). Discriminant analysis showed the combination of higher abdominal obesity, problems with usual activities (eg, work and family or leisure activities), higher anxiety, poorer self-reported mental health, and more obesity-related problems differentiated the highest from lowest severity category. The combination of lower abdominal obesity, more obese-related problems, and higher anxiety differentiated the 2 intermediate (lower obesity/high depression vs. high obesity/lower depression) categories. Conclusions: Discernable behavioral, clinical and psychosocial profiles reveal important variability according to comorbidity severity within a largely sociodemographically similar group of obese depressed adults. This insight may inform future analysis of heterogeneity of treatment effects and targeting of strategies to baseline participant profiles in a multicomponent intervention.

Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss

Effective long-term treatments are needed to address the obesity epidemic. Numerous wearable technologies specific to physical activity and diet are available, but it is unclear if these are effective at improving weight loss. To test the hypothesis that, compared with a standard behavioral weight loss intervention (standard intervention), a technology-enhanced weight loss intervention (enhanced intervention) would result in greater weight loss. Randomized clinical trial conducted at the University of Pittsburgh and enrolling 471 adult participants between October 2010 and October 2012, with data collection completed by December 2014. Participants were placed on a low-calorie diet, prescribed increases in physical activity, and had group counseling sessions. At 6 months, the interventions added telephone counseling sessions, text message prompts, and access to study materials on a website. At 6 months, participants randomized to the standard intervention group initiated self-monitoring of diet and physical activity using a website, and those randomized to the enhanced intervention group were provided with a wearable device and accompanying web interface to monitor diet and physical activity. The primary outcome of weight was measured over 24 months at 6-month intervals, and the primary hypothesis tested the change in weight between 2 groups at 24 months. Secondary outcomes included body composition, fitness, physical activity, and dietary intake. Among the 471 participants randomized (body mass index [BMI], 25 to <40; age range, 18-35 years; 28.9% nonwhite, 77.2% women), 470 (233 in the standard intervention group, 237 in the enhanced intervention group) initiated the interventions as randomized, and 74.5% completed the study. For the enhanced intervention group, mean base line weight was 96.3 kg (95% CI, 94.2-98.5) and 24-month weight 92.8 kg (95% CI, 90.6- 95.0) [corrected]. For the standard intervention group, mean baseline weight was 95.2kg (95%CI,93.0-97.3)and24-month weight was 89.3 kg (95%CI, 87.1-91.5) [corrected]. Weight change at 24 months differed significantly by intervention group (estimated mean weight loss, 3.5 kg [95% CI, 2.6-4.5} in the enhanced intervention group and 5.9 kg [95% CI, 5.0-6.8] in the standard intervention group; difference, 2.4 kg [95% CI, 1.0-3.7]; P = .002). Both groups had significant improvements in body composition, fitness, physical activity, and diet, with no significant difference between groups. Among young adults with a BMI between 25 and less than 40, the addition of a wearable technology device to a standard behavioral intervention resulted in less weight loss over 24 months. Devices that monitor and provide feedback on physical activity may not offer an advantage over standard behavioral weight loss approaches. clinicaltrials.gov Identifier: NCT01131871.

Response to a standard behavioral weight loss intervention by age of onset of obesity.

SummaryBackgroundThe purpose of this study was to examine weight loss, physical activity, fitness and diet changes in response to a standard behavioral weight loss intervention in adults with self‐reported juvenile onset (n = 61) or adult onset (n = 116) obesity.MethodsParticipants (n = 177; 43.0 ± 8.6 years; body mass index [BMI] = 33.0 ± 3.4 kg m−2) engaged in an 18‐month standard behavioral weight loss intervention. Participants were randomized into three different intervention groups as part of the larger parent trial. BMI, physical activity, fitness and diet were assessed at baseline, 6, 12 and 18 months. Separate adjusted mixed models were constructed using SAS version 9.4 (SAS Institute, Cary, NC).ResultsThere was significant weight loss, increased physical activity, improved fitness and reduced caloric intake over time (p < 0.001). There were no significant differences in these outcome variables by obesity onset group. However, there was a significant group by time interaction for fitness (p = 0.001), with the adult onset making significantly greater gains in fitness from baseline to 6 months (p < 0.001); however, this difference was no longer present at 12 or 18 months.ConclusionsWith the exception of fitness at 6 months, weight loss, physical activity and diet did not differ between juvenile onset and adult onset participants, suggesting that those with juvenile onset obesity are equally responsive to a standard behavioral weight loss intervention in adulthood.

Abstract P251: Triggers of Temptations and Urges Do Not Change During a 12-Month Behavioral Intervention for Weight Loss

Introduction: Ecological momentary assessment (EMA) assesses individuals’ behaviors and moods as they occur in their natural environment. We examined self-reported triggers of temptations/urges to eat and compared percent of times each trigger was reported as the top trigger in the 1st 6 mos. vs. the 2nd 6 mos. of a standard behavioral weight loss intervention. Hypothesis: The distribution of self-reported triggers of urges/temptations changes over time. Methods: We provided participants a smartphone app programmed to permit them to self-initiate completing EMA and report temptations/urges in real time. Questions included: What were the triggers for the temptation/urge? What was the top trigger? Only data from subjects reporting ≥ one urge/temptation were included in the analysis. For each trigger, generalized estimating equations were used to fit logistic regression models to test the hypothesis that proportion of urges/temptations including that trigger did not change between the 1st and 2 nd 6 mos. of EMA surveillance. Results: The sample ( N = 139) was 90.6% female, 82.7% White, 50.9±10.10 years of age with a BMI of 34.2±4.6 kg/m2. There were 3175 reported episodes of temptation/urges. During both 6-mo.periods, sight/smell of food was the most frequently reported trigger occurring in 34.8% of temptations/urges in the first 6 mos., increasing to 35.52% in the second 6-mos. This was followed by stress, hunger/thirst, and habit during both 6-mo. periods. There were no significant differences in the frequency or type of triggers over time, except for “out of nowhere”, which occurred less often in the second period (6.98% vs. 5.42%, p = .02). The triggers are plotted in order of most to least frequent for both periods in the figure below. Conclusions: Fewer temptations/urges were reported in the second 6 mos., which likely is attributed to a decrease in compliance by participants to EMA protocols. The sight/smell of food remained the most frequently reported trigger, which is a concern in an environment that is very food centric.

Abstract MP92: Changes in Objective and Subjective Sleep Parameters Following a 12-month Behavioral Weight Loss Intervention and Their Relationship to Weight Change

Introduction: Despite increased recognition of the influence of sleep on weight loss, lifestyle interventions have paid little attention to sleep and its change with intervention. Moreover, available evidence on the relevance of sleep in weight loss interventions has been limited to self-reported sleep data. The purpose of these analyses was to examine the influence of a 12-mo behavioral weight loss intervention on objective and subjective sleep parameters and to evaluate whether changes in sleep were related to weight loss. Hypothesis: We hypothesized that objective and subjective sleep measures would improve following the intervention and that improved sleep would be associated with greater weight loss. Methods: A sample of 127 adults (89% female, 84% Caucasian, 51.8±9.7 y, 34.0±4.5 kg/m2) participated in a 12-mo standard behavioral weight loss intervention that included 24 group sessions. Sleep was assessed objectively at baseline and 12 mo with 5-7 days of actigraphy (Philips Actiwatch 2). Measures included total sleep time (total time spent asleep), sleep efficiency (percentage of time asleep while in bed), and the Fragmentation Index (restlessness during sleep). Subjective sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), yielding a global PSQI score (overall sleep quality) and individual PSQI factors (perceived sleep quality, sleep efficiency, daytime disturbance) were evaluated. Weight outcomes included the percentage of baseline weight lost at 12 mo and whether clinically significant weight loss (≥10%) was achieved. Analyses (repeated measures ANOVA, multiple linear regression, and binary logistic regression) were adjusted for age, sex, and race. Results: The mean 12-mo weight loss was 9.1±8.1%, with 43% achieving at least 10% weight loss. No actigraphic sleep measures significantly changed from baseline to 12 mo. Overall sleep quality significantly improved over the 12 mo (6.4±3.6 to 5.9±3.1 [P=.02]), as did the PSQI factors of perceived sleep quality (P=.05) and sleep efficiency (P=.03). Baseline to 12-mo improvements in the Fragmentation Index and PSQI perceived sleep quality were associated with greater weight loss (β=.22 [P=.03] and β=.29 [P&lt;.01]). Blunted improvements in the Fragmentation Index and the PSQI perceived sleep quality factor were associated with reduced odds of achieving at least 10% weight loss (OR=0.89 [P=.02] and OR=0.20 [P&lt;.01]). No other sleep measures were associated with weight loss outcomes. Conclusions: Following a behavioral intervention that resulted in clinically significant weight loss, only subjective sleep quality was improved. However, weight loss was optimized among adults whose sleep fragmentation decreased and sleep quality improved. Whether augmenting behavioral weight loss interventions with sleep-focused content would lead to greater weight loss remains to be determined.

The SELF trial: A self-efficacy-based behavioral intervention trial for weight loss maintenance.

ObjectiveThe SELF Trial examined the effect of adding individual, self-efficacy (SE) enhancement sessions to standard behavioral weight loss treatment (SBT).MethodsParticipants were randomly assigned to SBT or SBT plus SE sessions (SBT+SE). Outcome measures were weight loss maintenance, quality of life, intervention adherence and self-efficacy at 12 and 18 months.ResultsThe sample (N=130) was female (83.08%) with a mean (SD) body mass index of 33.15 (4.11) kg/m2. There was a significant time effect for percent weight change (p=.002), yet no significant group or group-by-time effects. The weight loss for the SBT+SE group was 8.38% (7.48) at 12 months and 8.00% (7.87) at 18 months, with no significant difference between the two time points (p=.06). However, weight loss for the SBT group was 6.95% (6.67) at 12 months and 5.96% (7.35) at 18 months, which was significantly different between the two time points (p=.005) indicating that the SBT group had significant weight regain.ConclusionsBoth groups achieved clinically significant weight loss. The group receiving an intervention targeting enhanced self-efficacy had greater weight loss maintenance whereas the SBT group demonstrated significant weight regain possibly related to the greater attention provided to the SBT+SE group.

An initial evaluation of a weight loss intervention for individuals who engage in emotional eating.

Emotional eating may contribute to variability in weight loss and may warrant specialized treatment, although no randomized studies of specialized treatments exist for individuals who engage in emotional eating. This pilot study tested a new weight loss intervention for individuals who emotionally eat and compared it to the standard behavioral weight loss treatment (SBT). 79 predominantly female (95 %), predominantly African American (79.7 %) individuals who emotionally eat (BMI = 36.2 ± 4.1 kg/m(2)) were randomized to (1) a new enhanced behavioral treatment (EBT), incorporating skills for managing emotions and emotional eating or (2) a SBT. Primary outcomes were weight and emotional eating at 20 weeks. Weight decreased significantly in both groups (SBT: -5.77 kg (-7.49, -4.04); EBT: -5.83 kg (-7.57, -4.09)), with no significant between-group differences. Similar results were produced for emotional eating. Results suggest that SBT may be effective for reducing weight and emotional eating in individuals who emotionally eat, and that adding emotional-eating specific strategies may not provide additional benefits beyond those produced by SBT interventions in the short-term.Registration site: www.clinicaltrials.gov . NCT02055391.

Effects Of Changes In Obesity, Fitness, And Physical Activity On Aortic Stiffness In Obese Adults

Aortic stiffness, a precursor to adverse cardiovascular outcomes, is worsened in conditions of general and abdominal obesity, low cardiorespiratory fitness (CRF), and physical inactivity. Elevated carotid-femoral pulse wave velocity (cfPWV) is an indicator of aortic stiffness. Behavioral weight loss interventions promote decreased caloric intake and increased moderate-vigorous physical activity (MVPA), but whether increases in MVPA and CRF have independent or additive effects with weight loss on aortic stiffness remains unclear. PURPOSE: To determine the overall and independent effects of changes in general and abdominal obesity, CRF, and MVPA on cfPWV in overweight and obese adults. METHODS: Eighty three (N=83) sedentary, overweight and obese adults (age 44.5 ± 8.1 years; BMI 32.4 ± 4.0 kg/m2) completed 6 months of a standard behavioral weight loss intervention. Assessments included cfPWV (m/s) by applanation tonometry, abdominal obesity by dual X-ray absorptiometry (DXA), MVPA (min/wk, MET-min/wk) by objective activity monitoring and CRF by graded exercise testing. Changes in systolic and diastolic blood pressure (SBP, DBP) were also evaluated. Multiple linear regression was performed to determine the effect of changes in CRF and MVPA on cfPWV with changes in body weight and abdominal fat as covariates. RESULTS: After 6 months, body weight, BMI, waist circumference, and abdominal fat significantly decreased, while CRF and MVPA significantly increased (all p0.1). Reductions in body weight, BMI, waist circumference, and abdominal fat were not associated with the decrease in cfPWV (all p>0.1). The decrease in cfPWV was moderately correlated with decreases in SBP (r=0.379, p<0.001) and DBP (r=0.317, p=0.004). CONCLUSION: These data did not support that changes in fatness were associated with improved aortic stiffness, however, the significant improvements in CRF and cfPWV suggest that targeting fitness in lifestyle interventions for a sedentary, obese population maybe be important for better vascular health. Supported by NIH (HL103646)

Abstract P117: Day to Day Variation in Self-Efficacy Associated with Weight Loss and Risk of Dietary Lapses

Introduction: Ecological momentary assessment (EMA) assesses individuals' experiences, behaviors, and moods as they occur in real time and in their own environment, making it useful to understand the processes of behavior change. We report the use of EMA to study the triggers of lapses after intentional weight loss in a 12-mo. study that includes a standard behavioral weight loss intervention. Purpose: We examined daily self-reports of self-efficacy and how they were related to unplanned eating episodes (‘lapses’) and weight change over the first 6 mos. of the study. Hypothesis: Higher self-efficacy is related to fewer “lapses” and better weight loss over time. Methods: Participants were provided a smartphone app programmed to administer EMA assessments up to 5 randomly-selected times/day. Each assessment included the self-efficacy query, How confident are you that if you have an urge to go off your healthy lifestyle plan, you can resist the urge? measured on a scale of 1-10. Participants were weighed at weekly, and after 3 months bi-weekly, group sessions. To account for replicate observations among subjects, generalized estimating equations were used to fit logistic regression models predicting lapses as a function of self-efficacy, adjusting for location (e.g., home, work, restaurant) and social setting (e.g., with others, alone). Results: The sample (N = 151) was 90.7% female and 79.5% White, and on average, 51.18 (10.22) years of age with a mean BMI of 34.0 (4.6) kg/m2. Of the 59,913 random assessments conducted over 6 mos., eating episodes were recorded in 7,991 (13.34%) of those assessments, of which 881 (11.03%) were not planned. Most of the 7,991 planned and unplanned eating episodes were captured when individuals were with others who were eating (49%), or when completely alone (24%). After adjusting for location and social setting, self-efficacy remained a significant predictor of a lapse (p &lt; 0.001). The odds of a lapse decreased by 70% (95% CI, 64%, 76%) for every unit increase in self efficacy. After controlling for social setting, participants were estimated to lose 0.35 more lbs/mo. (SE = 0.14; p = 0.02) for each unit increase in self efficacy. Self-efficacy maintained a stable level between 7.3 and 7.4 for the first 4 mos., before decreasing at a rate of 0.11 points/month (SE = 0.04; p = 0.002) in the last 2 mos. This temporal trend in self-efficacy was paralleled by a similar trend in participants’ weights; they lost an average of 3.26 lbs/mo. (SE = 0.18) in the first 4 mos. compared to only 0.59 lbs/mo. (SE = 0.29) in the last 2 mos. Conclusions: The data suggest that as self-efficacy decreased to near 7.0, individuals were at greater risk to experience a lapse in their diet, an integral part of the healthy lifestyle plan. Targeting enhanced and sustained levels of self-efficacy above 7 may enable a person to resist lapses and prevent weight regain.

Effects of the Addition of Yoga to a Standard Behavioral Weight Loss Treatment Program

Yoga has become a popular form of physical activity. However, there is little research examining if the addition of yoga to a standard behavioral weight loss program enhances treatment outcomes.PURPOSE: To examine the effect of yoga plus aerobic exercise (YOGA) versus aerobic exercise only (AR) on e

Achieving Weight Loss Goals at Lower Cost

Jakicic JM, Tate DF, Lang W, Davis KK, Polzien K, Rickman AD, Erickson K, Neiberg RH, Finkelstein EA: Effect of a stepped-care intervention approach on weight loss in adults: a randomized clinical trial. JAMA 307:2617–2626, 2012 Objective. To determine whether a stepped-care weight loss intervention would result in greater weight loss than a standard behavioral weight loss intervention. Design. A total of 363 overweight and obese adults were randomized to either a standard- or stepped-care weight loss intervention. During the 18-month trial period, all participants were placed on low-calorie diets, were prescribed increases in physical activity, kept self-monitoring diaries, and attended group counseling sessions. The standard-care group was assigned to a fixed counseling program consisting entirely of group sessions: weekly for months 1–6, twice per month for months 7–12, and once per month for months 13–18. For the stepped-care group, counseling frequency, type, and weight loss strategies could be modified every 3 months in response to observed weight loss. Six steps of increasingly intensive contact were used, ranging from monthly group counseling alone to a multifaceted program that included group counseling, individual counseling, telephone contacts, and meal replacements (Table 1). The primary endpoint was mean change in weight at the 18-month time point. Secondary endpoints included resting heart rate and blood pressure, waist circumference, body composition, fitness, physical activity, dietary intake, and cost of the program. The authors also reported the results of a regression analysis taking into account the changes in weight at all six of the 3-month time points. Subjects. Most (82.6%) of the participants were female, with an average age of ~ 42 years. About 88% had at least some college education. About 28% were African American, and 67% were white. The average BMI was 32.95 kg/m2. View this table: Table 1. Stages of Stepped-Care Intervention* Results. The study …

Abstract P029: Associations between Weight Loss and Regain and Metabolic Measures in Obese Adults: Results from a 24-Month Behavioral Weight Loss Trial

Introduction: Obesity is linked to the development of insulin resistance (IR) and type 2 diabetes. Weight loss achieved by lifestyle modification could improve insulin sensitivity (IS). However, weight loss is difficult to maintain, and individuals often weight cycle, potentially placing them at greater risk for adverse health outcomes. Objective: The purpose of this secondary analysis was to examine how long-term changes in weight are associated with changes in factors related to the development of diabetes (IR and IS) among obese adults enrolled in a 24-month behavioral weight loss trial. Methods: The sample (N=66) included non-diabetic adults who lost and regained at least 10 lbs during the 24-month trial. All participants received standard behavioral weight loss treatment during the first 18 months. Assessments were conducted at baseline, 6, 12, 18, and 24 months. IR was assessed using the homeostatic model assessment (HOMA), and IS was assessed using the quantitative insulin sensitivity check for insulin sensitivity (QUICKI). Linear mixed modeling was used to examine the association between % changes in weight and % changes in fasting insulin, HOMA, and QUICKI. All models were adjusted for time, age, gender, race, % change in energy intake, and % change in physical activity. Results: The sample was 80% female and 86% White. At baseline, the mean (±SD) values were: age, 48.4±7.4 years; BMI, 34.5±4.4 kg/m 2 ; energy intake, 2176.8±603.8 kcal/day; physical activity, 11.4±13.6 MET- hr/week; plasma insulin, 16.9±6.0 μU/mL; HOMA, 4.1±1.7; and QUICKI, 0.3±.02. On average, compared to baseline, participants experienced an 11% decrease in weight (p&lt;.0001), a 9% decrease in insulin (p=.004), a 10% decrease in HOMA (p=.01), and a 2% increase in QUICKI (p=.0003) at 6 months. Following 6-month weight loss, an average of 8.4% weight was regained by 24 months (p&lt;.0001), and the positive changes observed in the other measures were partially reversed, e.g., a 19% increase in insulin (p=.001), a 26% increase in HOMA (p=.001), and a 2% decrease in QUICKI (p=.0002). Overall, weight change was positively associated with changes in insulin [b(se)=0.5(0.1), p≤.0001] and HOMA [b(se)=0.8(0.2), p≤.0001], and negatively associated with a change in QUICKI [b(se)= -0.2(0.1), p≤.0001]. Conclusion: In this unique sample of participants who weight cycled during a 24-month trial, weight loss improved metabolic outcomes; however, this was partially attenuated when weight was regained. These results reveal the effects of changes in weight on metabolic outcomes and highlight the importance of sustaining healthy lifestyle changes that support weight loss maintenance and improved metabolic outcomes.

Effect of a Stepped-Care Intervention Approach on Weight Loss in Adults

Given the obesity epidemic, effective but resource-efficient weight loss treatments are needed. Stepped-treatment approaches customize interventions based on milestone completion and can be more effective while costing less to administer than conventional treatment approaches. To determine whether a stepped-care weight loss intervention (STEP) compared with a standard behavioral weight loss intervention (SBWI) would result in greater weight loss. A randomized clinical trial of 363 overweight and obese adults (body mass index: 25-<40; age: 18-55 years, 33% nonwhite, and 83% female) who were randomized to SBWI (n = 165) or STEP (n = 198) at 2 universities affiliated with academic medical centers in the United States (Step-Up Study). Participants were enrolled between May 2008 and February 2010 and data collection was completed by September 2011. All participants were placed on a low-calorie diet, prescribed increases in physical activity, and attended group counseling sessions ranging from weekly to monthly during an 18-month period. The SBWI group was assigned to a fixed program. Counseling frequency, type, and weight loss strategies could be modified every 3 months for the STEP group in response to observed weight loss as it related to weight loss goals. Mean change in weight over 18 months. Additional outcomes included resting heart rate and blood pressure, waist circumference, body composition, fitness, physical activity, dietary intake, and cost of the program. Of the 363 participants randomized, 260 (71.6%) provided a measure of mean change in weight over 18 months. The 18-month intervention resulted in weight decreasing from 93.1 kg (95% CI, 91.0 to 95.2 kg) to 85.6 kg (95% CI, 83.4 to 87.7 kg) (P < .001) in the SBWI group and from 92.7 kg (95% CI, 90.8 to 94.6 kg) to 86.4 kg (95% CI, 84.5 to 88.4 kg) in the STEP group (P < .001). The percentage change in weight from baseline to 18 months was -8.1% (95% CI, -9.4% to -6.9%) in the SBWI group (P < .001) compared with -6.9% (95% CI, -8.0% to -5.8%) in the STEP group (P < .001). Although the between-group difference in 18-month weight loss was not statistically different (-1.3 kg [95% CI, -2.8 to 0.2 kg]; P = .09), there was a significant group × time interaction effect (P = .03). The cost per participant was $1357 (95% CI, $1272 to $1442) for the SBWI group vs $785 (95% CI, $739 to $830) for the STEP group (P < .001). Both groups had significant and comparable improvements in resting heart rate, blood pressure level, and fitness. Among overweight and obese adults, the use of SBWI resulted in a greater mean weight loss than STEP over 18 months. Compared with SBWI, STEP resulted in clinically meaningful weight loss that cost less to implement. clinicaltrials.gov Identifier: NCT00714168.

Abstract 026: Adherence to Weight Loss Treatment Across Three Self-Monitoring Approaches and the Association with Weight Change

Background: Adherence to the multiple components of a weight loss intervention is critical for successful short- and long-term outcomes. The purpose of this analysis was to determine if there was a difference in adherence to the five components of a standard behavioral weight loss intervention across three methods of self-monitoring diet and exercise in the 24-month SMART trial. Methods: In the SMART trial, 210 adults were randomized with equal allocation to one of three self-monitoring methods: 1) paper diary, 2) personal digital assistant (PDA) and 3) PDA + daily tailored feedback message (PDA+FB). The five treatment components included: attending group sessions; meeting the daily energy and fat goals and the weekly exercise goal; and self-monitoring eating and exercise behaviors. The cognitive-behavioral intervention was delivered in 39 group sessions over 18 months plus a maintenance session in the 21 st month. Attendance was measured objectively, whereas adherence to the other four components was based on self-report. Generalized mixed modeling was used to examine adherence over time and among the three groups as well as the association of adherence with weight loss. Results: The sample was predominantly female (84.8%), White (78.6%) and well educated (Mean±SD: 15.7±3.0 years). Mean BMI was 34.01±4.48 kg/m 2 . Initially, adherence was 100% for attendance, nearly 100% for self-monitoring, 60-80% for exercise, and less than 60% for the dietary goals. On average, participants in the PDA+FB and the PDA groups were more adherent to the treatment protocol than participants in the paper diary group for attendance (p&lt;.05), self-monitoring (p&lt;.05), energy goals (p&lt;.05), fat goals (p=.07), and exercise goals (p&lt;.05). Over time, there was a non-linear decline in adherence to all five components in all three groups. We also found a significant group by time interaction for adherence to each of the five components and a significant association between adherence to each component and weight change (ps&lt;.0001). Conclusion: Compared to the paper diary group, adherence was usually higher in the groups using a PDA to self-monitor. Better weight loss was associated with better adherence to the five treatment components. These results suggest that using an electronic diary such as the PDA improves treatment adherence. The increasing availability of additional mobile devices for self-monitoring lifestyle and receiving real time feedback offers potential opportunity to build on these findings and possibly improve adherence and weight loss outcomes.