Reductions in Internal Disinhibition During Weight Loss Predict Better Weight Loss Maintenance

The construct of disinhibition, as measured by the Eating Inventory, was recently found to have two factors: internal disinhibition (eating in response to cognitive and emotional cues) and external disinhibition (eating in response to environmental cues). This study examined whether early changes in disinhibition that occurred during a weight loss program predicted later weight loss maintenance. Participants were adults enrolled in a weight loss treatment study (n = 81, 16% men, BMI = 38.4 ± 6.5 kg/m²). Two‐thirds of participants were African Americans. Participants received a uniform, meal‐replacement‐based weight loss program in months 1–3 and one of four nutritionally focused programs for weight loss maintenance in months 4–12. Disinhibition and weight were assessed at clinic visits. Change in internal disinhibition from months 1–3 (i.e., the weight loss period) significantly predicted change in weight from month 4 to 12 (i.e., the weight maintenance period); this remained significant when treatment group, age, gender, ethnicity, baseline weight, baseline depression, baseline internal disinhibition, and initial weight loss were controlled for (P = 0.03). A comparable analysis examining change in external disinhibition found that it was not a significant predictor of weight maintenance (P = 0.43). Participants who experienced the biggest decreases in internal disinhibition during the initial phase of treatment had the most success maintaining their weight loss in the next phase of treatment. Long‐term weight loss outcomes may be improved by spending sufficient treatment time teaching strategies for reducing eating in response to internal cues.     

Mediators of Weight Loss and Weight Loss Maintenance in Middle‐aged Women

Long‐term behavioral self‐regulation is the hallmark of successful weight control. We tested mediators of weight loss and weight loss maintenance in middle‐aged women who participated in a randomized controlled 12‐month weight management intervention. Overweight and obese women (N = 225, BMI = 31.3 ± 4.1 kg/m²) were randomly assigned to a control or a 1‐year group intervention designed to promote autonomous self‐regulation of body weight. Key exercise, eating behavior, and body image variables were assessed before and after the program, and tested as mediators of weight loss (12 months, 86% retention) and weight loss maintenance (24 months, 81% retention). Multiple mediation was employed and an intention‐to‐treat analysis conducted. Treatment effects were observed for all putative mediators (Effect size: 0.32–0.79, P < 0.01 vs. controls). Weight change was ?7.3 ± 5.9% (12‐month) and ?5.5 ± 5.0% (24‐month) in the intervention group and ?1.7 ± 5.0% and ?2.2 ± 7.5% in controls. Change in most psychosocial variables was associated with 12‐month weight change, but only flexible cognitive restraint (P < 0.01), disinhibition (P < 0.05), exercise self‐efficacy (P < 0.001), exercise intrinsic motivation (P < 0.01), and body dissatisfaction (P < 0.05) predicted 24‐month weight change. Lower emotional eating, increased flexible cognitive restraint, and fewer exercise barriers mediated 12‐month weight loss (R² = 0.31, P < 0.001; effect ratio: 0.37), but only flexible restraint and exercise self‐efficacy mediated 24‐month weight loss (R² = 0.17, P < 0.001; effect ratio: 0.89). This is the first study to evaluate self‐regulation mediators of weight loss and 2‐year weight loss maintenance, in a large sample of overweight women. Results show that lowering emotional eating and adopting a flexible dietary restraint pattern are critical for sustained weight loss. For long‐term success, interventions must also be effective in promoting exercise intrinsic motivation and self‐efficacy.     

Gallstone Formation and Weight Loss

Obesity is associated with increased bile stasis and cholesterol saturation, and an increased risk of gallstone development. Conversely, bile composition is normalized following reduction in body weight. It would appear advantageous to promote weight loss in obesity, which would reduce the predisposition to gallstone formation. Despite the potential health benefits of weight reduction, very-low-calorie diets appear to increase the risk for cholesterol crystal and gallstone formation. The incidence of gallstone formation seems to be dependent on the degree of caloric restriction, the rate of weight loss, and the duration of the dietary intervention. Thus, faster rates of weight loss for longer periods of time are associated with increased risk. Available data obtained from prospective studies of subjects during active weight loss suggest that newly formed gallstones occur within 4 weeks and with incidence rates 15 to 25-fold higher than in the general obese population. The stones produce symptoms in approximately one-third of the subjects, of whom approximately one-half will undergo surgery. Proposed mechanisms underlying gallstone formation during weight reduction include bile stasis due to reduced caloric intake, increased biliary cholesterol saturation secondary to increased cholesterol mobilization, and increased nucleation due to changes in bile arachidonate and givcoprotein concentrations. Data are lacking on the effects of gradual rates of weight loss and risk of gallstone formation.     

Sibutramine Produces Dose-Related Weight Loss

BRAY, GEORGE A., GEORGE L. BLACKBURN, JAMES M. FERGUSON, FRANK L. GREENWAY, ADESH K. JAIN, CARL M. MENDEL, JOSEPH MEN-DELS, DONNA H. RYAN, SHERWYN L. SCHWARTZ, MONTE L. SCHEINBAUM, AND TIMOTHY B. SEATON. Sibutramine produces dose-related weight loss. Obes Res. Objective Sibutramine is a weight control drug that inhibits the reuptake of both serotonin and norepinephrine. In animals, it reduces food intake and increases thermogenesis and preliminary data in human beings showed weight loss. This paper reports a 24-week dose-ranging study to determine the effect of sibutramine on body weight of patients with obesity. Research Methods and Procedures Seven clinical centers screened 1463 patients with obesity and randomized 1047 to 24 weeks of treatment with 1 of 6 doses of sibutramine (1, 5, 10, 15, 20, or 30 mg) or placebo once daily. Six hundred eighty-three patients completed the study. A two-week placebo run-in period was used to initiate a standardized program of diet, physical activity, and lifestyle changes. Results Weight loss was dose-related and statistically significant vs. placebo (p <0.05) across all time-points for a 5 mglday to 30 mglday dosage of sibutramine. At week 24, percent weight loss from baseline for completers was: placebo, 1.2%; 1 mg, 2.7%; 5 mg, 3.9%; 10 mg, 6.1%; 15 mg, 7.4%; 20 mg, 8.8%; and 30 mg, 9.4%. Weight loss achieved at week 4 was predictive of weight loss achieved at week 24. Patients losing weight demonstrated an increase in serum high density lipoprotein cholesterol and reductions in serum triglycerides, total cholesterol, low density lipoprotein cholesterol, and uric acid. Small mean increases in blood pressure and pulse rate (with considerable individual variability) were observed in patients treated with sibutramine. The most frequent adverse events were dry mouth, anorexia, and insomnia. Discussion Sibutramine administered once daily for 24 weeks in the weight loss phase of treatment for uncomplicated obesity produced dose-related weight loss and was well tolerated. Improvements in serum lipids and uric acid accompany sibutramine-induced weight loss. Most of the adverse events observed on sibutramine are related to its pharmacology, including small mean increases in blood pressure and heart rate.     

Endoscopic Interventions for Weight Loss Surgery

In this paper we review the state‐of‐the‐art in endoscopic interventions for obesity treatment and make best practice recommendations for weight loss surgery (WLS). We performed a systematic search of English‐language literature published between April 2004 and June 2008 in MEDLINE and the Cochrane Library on WLS and endoscopic interventions, endoscopically placed devices, minimally invasive surgery, image‐guided surgery, endoluminal surgery, endoscopic instrumentation, interventional gastroenterology, transluminal surgery, and natural orifice transluminal surgery. We also searched the literature on endoscopic interventions and WLS and patient safety. We identified 36 pertinent articles, all of which were reviewed in detail; assessed the current science in endoscopic interventions for WLS; and made best practice recommendations based on the latest available evidence. Our findings indicate that endoscopic interventions and endoscopically placed devices may provide valuable approaches to the management of WLS complications and the primary management of obesity. Given the rapid changes in endoscopic technologies and techniques, systematic literature review is required to address issues related to the emerging role of endoluminal surgery in the treatment of obesity. These interventions should be a high priority for development and investigation.     

Pharmaceutical Cost Savings of Treating Obesity with Weight Loss Medications

GREENWAY, FRANK L., DONNA H. RYAN, GEORGE A. BRAY, JENNIFER C. ROOD, ELIZABETH W. TUCKER, AND STEVEN R. SMITH. Pharmaceutical cost savings of treating obesity with weight loss medications. Obes Res. Objective: To evaluate, in compliant patients, the pharmaceutical costs of treating obesity with fenfluraminel/mazindol, fenfluramine/phentermine, caffeine/ephedrine, or mazindol relative to the pharmaceutical costs of treating obesity-related comorbid conditions and reducing cardiovascular risk. Methods and Procedures: Subjects were between 18 and 60 years of age with a BMI of >30 kg/m². Pharmaceutical costs were evaluated in 73 of 220 subjects taking medications for diabetes, hyperlipidemia, or hypertension before and after treatment using fenfluramine with mazindol or phentermine. The pharmaceutical cost of weight loss, cardiac risk reduction, and low-density lipoprotein (LDL) cholesterol reduction was calculated for fenfluramine with mazindol or phentermine, caffeine with ephedrine, or mazindol alone, and compared to approved lipid-lowering medications. Results: Losses of 6% to 10% of initial body weight reduced pharmacy costs $122. 64/month for insulin treated diabetes, $42. 92/month for sulfonylurea-treated diabetes, $61. O7/month for hyperlipidemia treated with medication, and $0. 20/month for hypertension treated with medication. Blood pressure and laboratory evidence of insulin resistance improved in all medication groups. Caffeine/ephedrine was most cost-effective of the three treatments in reducing weight, cardiac risk, and LDL cholesterol. Discussion: Obesity medications produced a substantial weight loss in compliant patients and resulted in a net pharmaceutical cost savings compared to treating obesity related comorbid conditions.     

Effectiveness of a Prebariatric Surgery Insurance‐required Weight Loss Regimen and Relation to Postsurgical Weight Loss

Most US insurance companies require patients to participate in a medically supervised weight loss regimen prior to bariatric surgery. However, the utility of this requirement has not been documented. Data was collected from 94 bariatric surgery patients who were required, and 59 patients who were not required, by their insurance company to participate in a presurgical weight loss regimen. Weight change in the required group, as well as group differences in weight change, was examined from 3 and 6 months presurgery to 1 week presurgery, and from 1 week presurgery to 3 months postsurgery. Weight change presurgery was then used to predict weight loss postsurgery. In the 6 months prior to surgery, required patients gained 3.7 kg ± 5.9 (s.d.) (P < 0.0005), which did not differ from nonrequired patients. From surgery to 3 months postsurgery, required patients lost 23.6 ± 8 kg (P < 0.0005), also without differing from nonrequired patients. Patients who gained more weight prior to surgery, lost more weight postsurgery (P = 0.001), while controlling for initial weight. Findings suggest that the common weight loss regimen requirements of US insurance carriers were ineffective in producing presurgical weight loss in this sample. Most patients (>70%) in this sample gained weight prior to surgery, potentially taking advantage of final opportunities to overindulge in preferred foods. Required patients fared no better in terms of weight change postsurgically and, surprisingly, presurgical weight gain predicted better postsurgical weight loss outcome. Several potential explanations for this finding are offered.     

Weight Loss and Leptin Changes in Individuals with Type 2 Diabetes

WILLIAMS, KATHERINE V., MONICA MULLEN, WE1 LANG, ROBERT V. CONSIDINE, AND RENA R. WING. Weight loss and leptin changes in individuals with type 2 diabetes. Obes Res. Objective To identify variables associated with leptin change in subjects with type 2 diabetes after 3 weeks and 20 weeks of weight loss. Research Methods and Procedures Subjects with type 2 diabetes treated with diet or sulfonylureas (n = 54) were enrolled in a 20-week behavioral weight control program. Sulfonylureas were stopped ≥2 weeks before study entry. Seven subjects who restarted sulfonylureas after week 3 had their data analyzed separately after this point. Results Leptin, fasting plasma glucose, and insulin levels were measured at baseline and at 3, 10, and 20 weeks. After 3 weeks, subjects lost 2.7±2.0 kg (p<0.001), and had significant decreases in leptin (5.2±7.0 ng/mL, p<0.001), fasting plasma glucose (1.8±1.8 mmol/L, p<0.001), and insulin (23±60 pmol/L, p<0.03). Between week 3 and week 20, subjects lost an additional 6.3±4.4 kg (P<0.001), but had no further changes in leptin. The primary determinants of leptin change at all time-points were weight loss and initial leptin level. Changes in insulin were not related to changes in leptin after controlling for the effects of weight loss. At week 20, more recent weight loss (week 10 to week 20) was as strong a predictor of overall change in leptin as overall weight loss (baseline to 20 week). Subjects who restarted sulfonylureas had an increase in both leptin levels (+1.9±9.0 ng/mL, p<0.05) and insulin levels (+23±65 pmol/L, p<0.05), despite significant overall weight loss (-7.4±4.0 kg, p<0.01). Initial changes in leptin (0 weeks to 3 weeks) did not affect subsequent ability to lose weight. Discussion Both short- and long-term changes in weight had an effect on leptin changes in individuals with type 2 diabetes. Although physiological insulin changes did not independently influence changes in leptin concentration with weight loss, increases in insulin levels with sulfonyl-urea therapy were associated with increases in leptin levels despite weight loss.     

Weight Loss Expectations in Patients with Binge‐Eating Disorder

Objective: To study weight loss expectations in patients with binge‐eating disorder and to examine whether expectations differed by sex and motivation for treatment. Research Methods and Procedures: One hundred and thirty patients (104 women and 26 men), aged 23 to 61 (mean age, 43.0 years), with BED completed a measure of desired weights that included their dream weight, happy weight, acceptable weight, and disappointed weight. In a structured interview, participants were asked their primary motivation for seeking treatment (appearance or health) and their lowest adult weight (LAW). Results: The BED participants reported weight loss expectations that far exceeded expert and governmental guidelines. In this sample, desired dream body mass index (BMI), happy BMI, and acceptable BMI averaged reductions in current weight of 36%, 29%, and 23%, respectively. Even the “disappointed” BMI was an average 14% reduction in current weight, and was 1.5 to 3 times greater than the expert recommendation (5% to 10%). Comparisons of desired weights were significantly different for women and men, whereas percent reductions from current weight were not. Although weight goal expectations were significantly lower for those motivated by appearance, compared with those motivated by health, percent reductions for current weight were not. Desired dream weight correlated with reported LAW, and the mean difference between these weights was not significant. Discussion: These findings suggest that patients with BED have weight loss expectations that far exceed expert and governmental guidelines and that these expectations do not differ by sex or motivation for seeking treatment. One possible explanation for these unrealistic desired weights may be the patients’ recollections of their LAWs.     

Adherent Use of Digital Health Trackers Is Associated with Weight Loss

We study the association between weight fluctuation and activity tracking in an on-line population of thousands of individuals using digital health trackers (1,749 ≤ N ≤ 14,411, depending on the activity tracker considered) with millions of recorded activities (119,292 ≤ N ≤ 2,221,382) over the years 2013–2015. In a first between-subject analysis, we found a positive association between activity tracking frequency and weight loss. Users who log food with moderate frequency lost an additional 0.63% (CI [0.55, 0.72]; p < .001) of their body weight per month relative to low frequency loggers. Frequent workout loggers lost an additional 0.38% (CI [0.20, 0.56]; p < .001) and frequent weight loggers lost an additional 0.40% (CI [0.33, 0.47]; p < .001) as compared to infrequent loggers. In a subsequent within-subject analysis on a subset of the population (799 ≤ N ≤ 6,052) with sufficient longitudinal data, we used fixed effect models to explore the temporal relationship between a change in tracking adherence and weight change. We found that for the same individual, weight loss is significantly higher during periods of high adherence to tracking vs. periods of low adherence: +2.74% of body weight lost per month (CI [2.68, 2.81]; p < .001) during adherent weight tracking, +1.35% per month (CI [1.26, 1.43]; p < .001) during adherent food tracking, and +0.60% per month (CI [0.44, 0.76]; p < .001) during adherent workout tracking. The findings suggest that adherence to activity tracking can be utilized as a convenient real-time predictor of weight fluctuations, enabling large-scale, personalized intervention strategies.     

Glucose Tolerance and Weight Loss in Obese Women with Obstructive Sleep Apnea

Background

The association of obstructive sleep apnea (OSA) with glucose intolerance and the beneficial effect of lifestyle intervention have been poorly investigated in women particularly before menopausal status. The study explored 1) whether OSA is associated with impaired glucose homeostasis in obese non diabetic premenopausal and menopausal women and 2) the effects of a 3- month lifestyle intervention on glucose homeostasis in OSA women.

Design and Methods

We consecutively recruited 98 obese women (39 premenopausal) from those referred for a weight loss intervention. Ambulatory nocturnal polysomnography, body composition, oral glucose tolerance test, insulin sensitivity and β cell function were assessed before and after intervention.

Results

41% of premenopausal and 64% of menopausal women had OSA which was associated with worse glucose homeostasis before menopausal status. Mean and minimal nocturnal oxygen saturation (SaO₂) was associated with neck/height ratio (NHR), independently of total and central obesity. Mean and minimal nocturnal SaO₂ and NHR were correlated with insulin sensitivity and fasting glucose. In multivariate analyses, nocturnal mean SaO₂ was negatively and independently correlated with fasting glucose (p<0.0001) and NHR with insulin sensitivity (p<0.0001). In OSA women, the intervention induced a 5% weight reduction and a significant increase in minimal nocturnal SaO₂, insulin sensitivity and β cell function. Changes in fasting glucose and insulin sensitivity were associated with those in minimal nocturnal SaO₂ (p<0.05) and not with weight loss.

Conclusions

In obese women, glucose homeostasis worsens due to nocturnal hypoxia and increased neck circumference through mechanisms partially independent of obesity. OSA is more clearly associated with glucose intolerance in premenopausal than in menopausal women. In OSA women, the improvement of nocturnal hypoxia induced by lifestyle modifications is associated with that of glucose homeostasis.     

Predictors of Weight Loss in Adults with Topiramate‐Treated Epilepsy

Objective: We examined predictors of weight loss with topiramate, an anticonvulsant associated with weight loss in adults. Research Methods and Procedures: In this uncontrolled, prospective clinical trial, topiramate was added to existing anticonvulsants in adults (40 to 110 kg) with partial‐onset seizures. Primary measurements were change from baseline weight after 3 months and 1 year in patients completing 1 year of topiramate treatment (N = 38). Physiological and metabolic measures were analyzed for correlation with weight loss during topiramate treatment. Results: In patients who completed 1 year of topiramate treatment, baseline weight was reduced in 82% at 3 months and in 86% at 1 year. Mean body weight was reduced 3.0 kg (3.9% of baseline) at 3 months and 5.9 kg (7.3%) at 1 year. In obese patients [body mass index (BMI) ≥ 30 kg/m²], mean weight loss was 4.2 kg (4.3%) at 3 months and 10.9 kg (11.0%) at 1 year. Weight loss was primarily caused by reduction in body fat mass. For all patients, weight loss at 3 months correlated most strongly with reduced caloric intake (p = 0.02). At 1 year, caloric intake had returned to baseline levels; weight loss correlated most strongly with higher baseline BMI (p = 0.0007). Discussion: Our results suggest that weight loss occurs in most adults treated with topiramate and is sustained for at least 1 year. Reduced caloric intake may account, in part, for weight loss during early treatment. The pattern of weight loss differs according to baseline BMI, with obese patients experiencing greater weight loss during continued therapy.     

Long-Term Weight Loss and Breakfast in Subjects in the National Weight Control Registry

Objective: To examine breakfast consumption in subjects maintaining a weight loss in the National Weight Control Registry (NWCR). Research Methods and Procedures: A cross-sectional study in which 2959 subjects in the NWCR completed demographic and weight history questionnaires as well as questions about their current breakfast consumption. All subjects had maintained a weight loss of at least 13.6 kg (30 lb) for at least 1 year; on average these subjects had lost 32 kg and kept it off for 6 years. Results: A large proportion of NWCR subjects (2313 or 78%) reported regularly eating breakfast every day of the week. Only 114 subjects (4%) reported never eating breakfast. There was no difference in reported energy intake between breakfast eaters and non-eaters, but breakfast eaters reported slightly more physical activity than non-breakfast eaters (p = 0.05). Discussion: Eating breakfast is a characteristic common to successful weight loss maintainers and may be a factor in their success.