An Internet-based weight loss programme -- a feasibility study with preliminary results from 4209 completers.

AIMS: 1. To identify characteristics of individuals seeking help for their weight problem via an internet-based programme. 2. To identify indicators of long term success in such a programme. METHODS: An internet-based weight club (www.viktklubb.se) was used consisting of standard algorithms for calculating body mass index (BMI), food energy content and exercise energy cost. All members filled in basic data and could volunteer to fill in additional research related questions. Together with data on treatment success, attrition, and use of the various components of the programme, this information was automatically monitored and downloaded to a database. RESULTS: Eighty-six percent of the members were female, and the age range was wide (range 18-101 years; mean 40.3 +/-11.5 years). At baseline, BMI of the entire group was 29.3 +/-5.1 kg/m(2) with 39% obese and 45% overweight. Among the completers, 16% changed from overweight or obese to normal weight. This corresponded to 29% of the members losing 5-9.9% of their initial body weight and 20% losing > or =10% of their. The strongest predictors of weight loss were activity in the weight club as judged by number of logins and diary entries, and sex. CONCLUSIONS: A sizeable, but seemingly random, dropout rate was observed, together with significant dose-response effects between activity in the internet-based program and weight-loss among completers. Given its low cost and high accessibility at 24 hours a day, this form of programme delivery is interesting to evaluate and develop further, especially regarding attrition.

Diet or exercise, or both, for weight reduction in women after childbirth.

BACKGROUND: Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated. OBJECTIVES: The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2006) and LILACS. We scanned secondary references and contacted experts in the field. SELECTION CRITERIA: All published and unpublished randomised controlled trials (RCT) and quasi-randomised trials of diet or exercise or both, among women during the postpartum period. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trial quality and extracted data. Results are presented using relative risk for categorical data and weighted mean difference (WMD) for continuous data. Data were analysed with a fixed-effect model. A random-effects model was used in the presence of heterogeneity. MAIN RESULTS: Six trials involving 245 women were included. Women who exercised did not lose significantly more weight than women in the usual care group (one trial; n = 33; WMD 0.00 kg; 95% confidence interval (CI) -8.63 to 8.63). Women who took part in a diet (one trial; n = 45; WMD -1.70 kg; 95% CI -2.08 to -1.32), or diet plus exercise programme (four trials; n = 169; WMD -2.89 kg; 95% CI -4.83 to -0.95), lost significantly more weight than women in the usual care. There was no difference in the magnitude of weight loss between diet and diet plus exercise group (one trial; n = 43; WMD 0.30 kg; 95% CI -0.60 to 0.66). The interventions seemed not to affect breastfeeding performance adversely. AUTHORS' CONCLUSIONS: Preliminary evidence from this review suggests that dieting and exercise together appear to be more effective than diet alone at helping women to lose weight after childbirth, because the former improves maternal cardiorespiratory fitness level and preserves fat-free mass, while diet alone reduces fat-free mass. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Due to insufficient available data, additional research, with larger sample size, is needed to confirm the results.

Eating habits in relation to body fatness and gender in adolescents--results from the 'SWEDES' study.

OBJECTIVE: To investigate if eating habits among adolescents are related to body fatness and gender. DESIGN: Cross-sectional study. SETTING: Obesity Unit, Huddinge University Hospital, Sweden, 2001-2002. SUBJECTS: Two hundred and seventy-five girls and 199 boys, aged 16-17 years. METHOD: Questionnaires were used for dietary intake and meal frequency, BodPod for measuring body fatness (BF%). In all, 169 girls and 128 boys were classified as adequate reporters (AR) of energy intake, and were used in the dietary analyses. The whole sample was used in the meal frequency analyses. RESULTS: The correlation between reported energy intake and weight in the AR group was 0.23 (P<0.01) for girls and 0.36 for boys (P<0.001). The correlations were inverse or not significant in the whole sample. The following variables correlated significantly with a high BF% (r (s)=+/-0.2): a low intake of milk in both girls and boys, a high intake of fibre and alcohol and a low intake of sugar in girls and a low intake of breakfast cereals in boys. Those with regular breakfast habits had healthier food choices than others, but this was not related to BF%. Boys had more meals per day (4.9 vs 4.6, P=0.02), especially early in the morning and late at night, whereas girls reported a higher relative intake of light meals and fruit and a lower intake of milk than boys. CONCLUSIONS: A few associations between eating habits and body fatness were found, but without any obvious patterns. The true differences in eating habits between lean and overweight adolescents are probably very small.

Identification of women at risk of adverse weight development following pregnancy.

BACKGROUND: It has been known for long time that pregnancy associated with weight problems women but few important factors have been identified, except for weight gain during pregnancy itself. OBJECTIVE: To identify cutoffs for weight gain during pregnancy for identification of women at risk of high weight retention after pregnancy. METHODS: A longitudinal analysis of 563 women who gave birth in 1984-1985 was used. Weight development during pregnancy was used as diagnostic test for high weight retention at 1 and 15 years follow-up. True positives for high weight retention were defined as > 90th percentile at 1 and 15 years. Receiver Operating Characteristic (ROC) analyses were performed to derive cutoffs minimizing the absolute and relative number of misclassifications. RESULTS: The average weight retention at 1 year (WR1y) and 15 years (WR15y) was 1.1 +/- 3.6 and 7.6 +/- 7.4, respectively. There was a moderately strong correlation between weight gain during pregnancy and weight retention at 1 and 15 years follow-up (r2 = 0.13 and r2 = 0.05, respectively; both P < 0.001) and weight gain during pregnancy as diagnostic test to find high weight retainers performed better than chance both for WR1y (AUC = 0.76 +/- 0.04, P < 0.01) and WR15y (0.63 +/- 0.04, P < 0.05). To minimize the absolute number of misclassifications of high weight retention, a highly specific and insensitive cut-off of around 24 kg weight gain during pregnancy was needed. The best trade-off between sensitivity and specifity, minimizing the relative number of misclassifications, was at a cutoff of around 16 kg, but this resulted in three times as many absolute misclassifications. CONCLUSION: Weight gain during pregnancy was found to be a moderately strong diagnostic test for weight retention after pregnancy. In order to implement weight gain recommendations for clinical practice larger studies need to be conducted and the demands on the reference values specified, since decisions about the trade-offs between types and extent of misclassifications need to be made.

The criterion validity of a last 7-day physical activity questionnaire (SAPAQ) for use in adolescents with a wide variation in body fat: the Stockholm Weight Development Study.

OBJECTIVE: The aim of the present study was to assess the criterion validity of a newly developed self-reported last 7-day physical activity questionnaire (SAPAQ) for use in Swedish adolescents with a wide variation in body fatness. MEASUREMENTS: We compared the self-reported total number of MET-minutes with objectively assessed variables of physical activity obtained by accelerometry in 49 (18 male, 31 female subjects) 17-year-old adolescents. RESULTS: Self-reported physical activity was significantly and inversely related to time spent sedentary (r=-0.45; P<0.001) and significantly and positively associated with time spent in physical activity (r=0.51; P<0.001) and the total amount of physical activity (r=0.49; P<0.001). Gender and body fat did not affect the associations between self-reported and objectively assessed physical activity. CONCLUSION: Our results indicate that the newly developed questionnaire is a valid method for ranking individuals in terms of the total amount of physical activity in Swedish adolescents.

beta1-Adrenoceptor gene polymorphism predicts long-term changes in body weight.

BACKGROUND: The genes controlling long-term weight changes are largely unknown. The beta1 (beta1)-adrenoceptor gene contains two nonsynonomous single nucleotide polymorphisms (SNPs), Ser49Gly and Gly389Arg, that both are functional in human cell lines. DESIGN: We investigated the influence of these two SNPs on short- and long-term changes in body mass index (BMI) in a population-based cohort of 761 women who were examined during pregnancy in 1984-1985 and 15 y thereafter. RESULTS: At entry, no genotype effect on BMI was found. After 15 y, the BMI of women carrying the Gly49-genotype (25.3+/-0.3 kg/m(2)) was higher (P<0.005) than that of Ser49-women (24.4+/-0.2 kg/m(2)). Also, the BMI-increase over 15 y was higher (P=0.018) in Gly49-women (3.3+/-0.2 kg/m(2)) than in Ser49-women (2.8+/-0.1 kg/m(2)). The odds ratio for being overweight after 15 y having the Gly49-genotype was 1.6 (confidence interval 1.1-2.3, P=0.01). No effect of SNP 389 alone on BMI was found but there was a genotype-genotype interaction. Those carrying the Gly49-Gly389 combination increased their BMI about 0.7 kg/m(2) more than other combinations (P=0.025). No genotype effect on BMI changes during pregnancy for either SNP was found. CONCLUSION: Polymorphism of the beta1-adrenoceptor gene influences long-term weight gain and the incidence of adult-onset overweight in women.

BMI, waist-circumference and waist-hip-ratio as diagnostic tests for fatness in adolescents.

OBJECTIVE: To evaluate the diagnostic accuracy of body mass index (BMI, kg/m(2)), waist-circumference (WC) and waist-hip-ratio (WHR) as diagnostic tests for detecting fatness in adolescents. DESIGN: A cross-sectional analysis of 474 healthy adolescents aged 17 y was used. Measurements of height, weight, WC, hip-circumference and body fat percentage (%BF) were obtained. The diagnostic accuracy for detecting excess fatness was evaluated through receiver operating characteristics (ROC) analyses with %BF, measured by densitometry (air-displacement plethysmography), as reference test. RESULTS: BMI and WC showed strong positive correlation (r=0.68-0.73; P<0.0001) with %BF in both sexes, but the correlation was weaker for WHR (r=0.30-0.41; P<0.0001). For overweight and obesity in boys and obesity in girls, the area under the ROC curve was high (0.96-0.99) for BMI and WC. WHR was not significantly better than chance as diagnostic test for obesity in girls. For BMI and WC, highly sensitive and specific cutoffs for obesity could be derived, while larger trade-offs were needed for detecting overweight in girls. The cutoffs producing equal sensitivity and specificity were lower than the ones minimizing the absolute number of misclassifications. The latter approached internationally recommended reference values, but were still several units lower for BMI in girls and several centimeters lower for WC in boys. CONCLUSION: BMI and WC were found to perform well as diagnostic tests for fatness, while WHR was less useful. The discrepancies between cutoffs producing equal sensitivity and specificity, cutoffs minimizing the absolute number of misclassifications and internationally recommended reference values for overweight and obesity highlight the importance of specifying the characteristics of classification systems for different settings.

Effects of obesity on women's reproduction and complications during pregnancy.

Obesity is increasing rapidly among women all over the world, and more women in fertile ages become overweight and obese. Among all other problems, women who are obese have higher rates of amenorrhoea and infertility. Obese women have a higher risk of complications during pregnancy such as hypertensive diagnoses and gestational diabetes, and delivery complications such as higher rates of caesarean sections and prolonged time of delivery. The aim of this article is to review the consequences of being obese during the reproductive life of a woman.

Discrepancies between classification systems of childhood obesity.

Despite growing concern about weight-related problems among children, no universally accepted classification system for childhood obesity exists. There is a number of proposed international body mass index (BMI)-based systems in use and national variants also exist in many countries. The absence of a universally accepted standard and confusion concerning which classification system to use on national levels complicate monitoring of the development of the obesity epidemic, stratification for selective interventions in public health, screening in clinical practice and comparisons between studies. Some proposed international classification systems have not only been recommended for global monitoring and comparisons between studies, but also for clinical and national epidemiological use in some countries. Possible discrepancies may thereby lead to inefficiencies in health care delivery and prevention programmes. The problems associated with misclassification of individuals at risk may lead to overconsumption of health care resources by lower-risk individuals and underconsumption by higher-risk individuals, which is costly both in terms of foregone health improvements and in terms of wasteful monetary usage. The aim of this paper was to review the specific problems associated with BMI as a measure of adiposity in childhood, the most commonly used classification systems for childhood obesity based on BMI, and how their performance can be evaluated.

Weight development over time in parous women--the SPAWN study--15 years follow-up.

BACKGROUND: Weight gain is common after pregnancy. Most studies suggest that weight gain associated with a pregnancy is between 0.5 and 3.8 kg up to 2.5 y of follow-up. However, 73% of the female patients at our obesity clinic identified pregnancy as an important trigger for marked weight retention. The majority retained more than 10 kg after each pregnancy. The aim of this study was to examine long-term weight development after pregnancy in a 15 y follow-up of women who took part in the Stockholm Pregnancy And Women's Nutrition (SPAWN) study. METHOD AND SUBJECTS: The SPAWN study is a long-term follow-up study of women who delivered children in 1984-85 in Stockholm (n=2342). A total of 1423 participants (response rate=61%) completed questionnaires, which covered eating behaviour and exercise, demographic information including social situation and status and details of the pregnancy before, during and up to 1 y after pregnancy. After 15 y, these women were invited to take part in the follow-up study. Anthropometric measurements and the same questionnaire data were collected from the 563 women who participated (response rate=40%). The sample was divided into two main groups: those who were normal weight before pregnancy and remained normal weight, and those who were normal weight before pregnancy and had become overweight at 15 y follow-up. RESULTS: Those women who became overweight had a higher pre-pregnant body mass index (BMI) (22.3+/-1.5 vs 20.5+/-1.6 kg/m(2), P<0.001), gained more weight during pregnancy (16.3+/-4.3 vs 13.6+/-3.7 kg, P<0.001) and had retained more at 1 y follow-up. The women who became overweight had a steeper weight trajectory gaining more from 1 y follow-up to 15 y follow-up (11.1+/-6.5 vs 4.5+/-6.5 kg, P<0.001), with a higher BMI at 15 y follow-up of 27.5+/-2.6 vs 22.5+/-2.3 5 kg/m(2) (P<0.001). However, differences between those who became overweight and those who did not could not be explained by age, number of children and various socioeconomic factors. Features of pregnancy that did differ between the two groups were breastfeeding and smoking cessation. However, women who became overweight had lower lactation scores than women who remained normal weight. Relatively more subjects of the group that became overweight stopped smoking during pregnancy. DISCUSSION: Pregnancy is a vulnerability factor for some women to become overweight. This study attempted to identify those factors that place initially normal weight women on a steeper weight trajectory as a result of pregnancy. Demographic, behavioural, physical and psychological characteristics only partly explain the weight gain observed at 15 y follow-up. Further research is required to investigate the relative role of these characteristics in predicting postpregnancy weight development.

Success rate of Orlistat in primary-care practice is limited by failure to follow prescribing recommendations: the referral letter content vs clinical reality.

Numerous referrals to our Obesity Unit state that 'treatment with Orlistat did not work'. This surprised us, since Orlistat has been well documented to result in long-term sustained moderate weight loss. A simple questionnaire to 70 such patients, however, revealed that in many cases the referral physician had not observed basic rules and regulations, nor given appropriate information on Orlistat use.

Intake of sweet foods and counts of cariogenic microorganisms in relation to body mass index and psychometric variables in women.

OBJECTIVE: As a part of the SPAWN (Stockholm Pregnancy and Women's Nutrition) study, the intake of sweet foods (habitual and pre-menstrual intakes) and the number of cariogenic microorganisms in saliva was analysed in relation to body mass index (BMI) and psychometric variables. DESIGN: A cross-sectional study. SUBJECTS: Three hundred and sixty-two women with a median BMI of 24.2 kg/m(2) (range 17.5-47.8) and 45 y of age (range 34-64). METHODS: A questionnaire of sweet food intake, salivary counts of mutans streptococci and lactobacilli and a self-rating scale on psychometric variables (CPRS-S-A). RESULTS: The number of mutans streptococci correlated with BMI (P<0.05), indirectly indicating a higher intake of sweet foods in obese women. The reported energy intake of sweet foods (more specifically the intake of chocolate), correlated with CPRS scores (P<0.01), indicating that women with more severe psychiatric symptomatology have higher intakes of sweet foods. CONCLUSIONS: This study suggests that women with higher CPRS score have higher energy intakes of sweet foods, indicating a possible link between mood regulation and the intake of sweet food. SPONSORSHIP: Karolinska Institute Research Funds.

Long-term weight development after pregnancy.

For some women pregnancy is a trigger for developing overweight and obesity. Seventy-three per cent of 128 female patients at our Obesity Unit indicated that they had retained more than 10 kg after each of their pregnancies, and for this subgroup weight development after pregnancy was of crucial importance for their future health. Although mean weight increases after pregnancy generally are modest, there are wide individual variations. In studies at the Obesity Unit, weight retention ranging from up to 26.5 kg one year after pregnancy to a loss of 12.3 kg was reported, although the mean weight gained was only 0.5 kg. Numerous studies have analysed factors explaining weight development after pregnancy and delivery, with a range of subjects from several hundred thousand women to fewer than one-hundred, but overall it has been surprisingly difficult to identify strong predictors of weight development. Numerous confounders have been identified; in a review up to 31 such confounders were reported. Methodological problems include weight development over time also in non-pregnant women and problems of identifying the optimal time-point when the overall impact of the pregnancy on weight development should be evaluated. Lactation has consistently been found to play a small role in explaining weight retention up to one year after delivery. Few studies have examined the role of physical activity during pregnancy and after delivery to explain weight development. Our own ongoing follow-up of women who gave birth during 1984-85, the so-called SPAWN (Stockholm Pregnancy and Women's Nutrition) study, illustrates that 15 years after delivery, a significant proportion of the 1423 women initially studied were available for re-examination. Drop-out analyses indicate that for most variables under study, the remaining women were representative for the initial sample. Pregnancy and weight development are intertwined in a complex pattern, which includes a change in lifestyle factors, such as eating behaviour, physical activity, smoking cessation and degree of lactation, but which are still not fully understood.

Patient expectations of obesity treatment-the experience from a day-care unit.

BACKGROUND: Unrealistic patient weight loss expectations in treatment of obesity may hamper the modest success which can actually be achieved. SETTING: Academic Obesity Unit Day Care Centre. OBJECTIVE: Description of weight loss expectations and weight loss concerns by questionnaire analyses. RESULTS: Patients were severely obese, with a median initial body mass index (BMI) of 40.7 kg/m(2). Weight loss expectations were generally unrealistic, with women hoping for a loss up to 42%, and men for 29% of their baseline weight (P<0.001). No effects of age on actual weight loss or weight loss expectations were observed. CONCLUSION: Gender differences in weight loss expectations may be important to acknowledge in future development of obesity treatment programmes. Realistic treatment outcome should be described early in a programme to facilitate compliance.

Referral letters to an obesity unit--relationship between doctor and patient information.

The contents of 200 letters of referrals from physicians to a clinical obesity unit were compared with patient-reported data and analysed for concordant and discordant information. For major comorbidities (diabetes, hypertension, joint problems) concordant information was found in about 80%, whereas discordant information was found in 46% for smoking, and 66% for medication. Forty-five percent of psychological problems, described by patients, were not identified by the referring physician. The role of the referral letter as a tool in medical communication has received little attention and comparative data are generally lacking, but our data suggests that there is room for considerable improvement of the quality of the referral letter.

What is "obesity"--an analysis of referral letters to an obesity unit.

OBJECTIVES: To evaluate the quality of referral letters concerning obese patients from general practice and other specialities to an obesity unit. DESIGN: Retrospective analysis of referral letters in 500 consecutive patient records. SETTING: Academic specialist obesity unit. RESULTS: Most letters came from general practice (70%), followed by internal medicine/endocrinology (12%). Information on body weight was missing in 13% of all referrals and on height in 24%. Waist circumference was mentioned in 1%. Relevant data substantiating possible comorbidities, in particular the metabolic syndrome, was missing in 92-97%. Relevant medication was indicated in 22% of the referrals. On a 3-point, graded global evaluation scale of the referral quality, only 7% of all letters were found to be 'ideal'. CONCLUSION: The low professional quality of these referrals may reflect the fact that physicians find the term 'obesity' enough to warrant the referral without further specifications. An alternative explanation for the inadequate referrals is the well documented negative attitude of physicians, who consider obesity as sloth and as a self-inflicted condition, not necessitating further medical details.