Effects of Diet versus Gastric Bypass on Metabolic Function in Diabetes.

BACKGROUND: Some studies have suggested that in people with type 2 diabetes, Roux-en-Y gastric bypass has therapeutic effects on metabolic function that are independent of weight loss. METHODS: We evaluated metabolic regulators of glucose homeostasis before and after matched (approximately 18%) weight loss induced by gastric bypass (surgery group) or diet alone (diet group) in 22 patients with obesity and diabetes. The primary outcome was the change in hepatic insulin sensitivity, assessed by infusion of insulin at low rates (stages 1 and 2 of a 3-stage hyperinsulinemic euglycemic pancreatic clamp). Secondary outcomes were changes in muscle insulin sensitivity, beta-cell function, and 24-hour plasma glucose and insulin profiles. RESULTS: Weight loss was associated with increases in mean suppression of glucose production from baseline, by 7.04 µmol per kilogram of fat-free mass per minute (95% confidence interval [CI], 4.74 to 9.33) in the diet group and by 7.02 µmol per kilogram of fat-free mass per minute (95% CI, 3.21 to 10.84) in the surgery group during clamp stage 1, and by 5.39 (95% CI, 2.44 to 8.34) and 5.37 (95% CI, 2.41 to 8.33) µmol per kilogram of fat-free mass per minute in the two groups, respectively, during clamp stage 2; there were no significant differences between the groups. Weight loss was associated with increased insulin-stimulated glucose disposal, from 30.5±15.9 to 61.6±13.0 µmol per kilogram of fat-free mass per minute in the diet group and from 29.4±12.6 to 54.5±10.4 µmol per kilogram of fat-free mass per minute in the surgery group; there was no significant difference between the groups. Weight loss increased beta-cell function (insulin secretion relative to insulin sensitivity) by 1.83 units (95% CI, 1.22 to 2.44) in the diet group and by 1.11 units (95% CI, 0.08 to 2.15) in the surgery group, with no significant difference between the groups, and it decreased the areas under the curve for 24-hour plasma glucose and insulin levels in both groups, with no significant difference between the groups. No major complications occurred in either group. CONCLUSIONS: In this study involving patients with obesity and type 2 diabetes, the metabolic benefits of gastric bypass surgery and diet were similar and were apparently related to weight loss itself, with no evident clinically important effects independent of weight loss. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT02207777.).

Pilot test of an interactive obesity treatment approach among employed adults in a university medical billing office.

BACKGROUND: There is a need for workplace programs promoting healthy eating and activity that reach low-wage employees and are scalable beyond the study site. Interventions designed with dissemination in mind aim to utilize minimal resources and to fit within existing systems. Technology-based interventions have the potential to promote healthy behaviors and to be sustainable as well as scalable. We developed an interactive obesity treatment approach (iOTA), to be delivered by SMS text messaging, and therefore accessible to a broad population. The aim of this pilot study was to evaluate participant engagement with, and acceptability of, this iOTA to promote healthy eating and activity behaviors among low-wage workers with obesity. METHODS: Twenty participants (self-reporting body mass index ≥ 30 kg/m2) of a single workgroup employed by a university medical practice billing office had access to the full intervention and study measures and provided feedback on the experience. Height and weight were measured by trained research staff at baseline. Each participant was offered a quarterly session with a health coach. Measured weight and a self-administered survey, including dietary and activity behaviors, were also collected at baseline, 3, 6, 12, 18, and 24 months. Participant engagement was assessed through responsiveness to iOTA SMS text messages throughout the 24-month pilot. A survey measure was used to assess satisfaction with iOTA at 3 months. Due to the small sample size and pilot nature of the current study, we conducted descriptive analyses. Engagement, weight change, and duration remaining in coaching are presented individually for each study participant. RESULTS: The pilot was originally intended to last 3 months, but nearly all participants requested to continue; we thus continued for 24 months. Most (14/20) participants remained in coaching for 24 months. At the 3-month follow-up, eight (47%) of the remaining 17 participants had lost weight; by 24 months, five (36%) of the remaining 14 participants had lost weight (one had bariatric surgery). Participants reported very high satisfaction. CONCLUSIONS: This pilot provides important preliminary results on acceptability and participant engagement with iOTA, which has significant potential for dissemination and sustainability.

Effect of a Home-Based Lifestyle Intervention on Breastfeeding Initiation Among Socioeconomically Disadvantaged African American Women with Overweight or Obesity.

BACKGROUND: Socioeconomically disadvantaged (SED) African American women with overweight or obesity are less likely to breastfeed. OBJECTIVE: To test whether a home-based lifestyle intervention impacts breastfeeding initiation rates in SED African American women with overweight or obesity. STUDY DESIGN: This was a secondary analysis of a randomized controlled trial from October 2012 to March 2016 at a university-based hospital within the LIFE-Moms consortium. SED African American women with overweight or obesity and singleton gestations were randomized by 16 weeks to Parents as Teachers (PAT)-a home-based parenting support and child development educational intervention-or PAT+, PAT with additional content on breastfeeding. Participants completed a breastfeeding survey. Outcomes included breastfeeding initiation and reasons for not initiating or not continuing breastfeeding. RESULTS: One hundred eighteen women were included: 59 in PAT+; 59 in PAT. Breastfeeding initiation rates were similar in each group (78.00% in PAT+; 74.58% in PAT). On a one to four scale, with four denoting "very important," women in PAT+ and PAT were equally likely to rate their beliefs that formula was better than breast milk or breastfeeding would be too inconvenient as the most important reasons to not initiate breastfeeding. On the same scale, women similarly rated their difficulty latching or concern for low milk supply as the most important reasons for breastfeeding cessation. CONCLUSION: SED African American women with overweight or obesity who received a home-based educational intervention had higher breastfeeding rates than is reported nationally for black women (59%). However, the intervention with more breastfeeding content did not further increase breastfeeding rates or impact reasons for breastfeeding cessation. TRIAL REGISTRATION: ClinicalTrials.gov : NCT01768793.

A 2-Year Randomized Controlled Trial of Human Caloric Restriction: Feasibility and Effects on Predictors of Health Span and Longevity.

BACKGROUND: Caloric restriction (CR), energy intake reduced below ad libitum (AL) intake, increases life span in many species. The implications for humans can be clarified by randomized controlled trials of CR. METHODS: To determine CR's feasibility, safety, and effects on predictors of longevity, disease risk factors, and quality of life in nonobese humans aged 21-51 years, 218 persons were randomized to a 2-year intervention designed to achieve 25% CR or to AL diet. Outcomes were change from baseline resting metabolic rate adjusted for weight change ("RMR residual") and core temperature (primary); plasma triiodothyronine (T3) and tumor necrosis factor-α (secondary); and exploratory physiological and psychological measures. RESULTS: Body mass index averaged 25.1 (range: 21.9-28.0 kg/m(2)). Eighty-two percent of CR and 95% of AL participants completed the protocol. The CR group achieved 11.7±0.7 %CR (mean ± standard error) and maintained 10.4±0.4% weight loss. Weight change in AL was negligible. RMR residual decreased significantly more in CR than AL at 12 months (p = .04) but not 24 months (M24). Core temperature change differed little between groups. T3 decreased more in CR at M12 and M24 (p < .001), while tumor necrosis factor-α decreased significantly more only at M24 (p = .02). CR had larger decreases in cardiometabolic risk factors and in daily energy expenditure adjusted for weight change, without adverse effects on quality of life. CONCLUSIONS: Sustained CR is feasible in nonobese humans. The effects of the achieved CR on correlates of human survival and disease risk factors suggest potential benefits for aging-related outcomes that could be elucidated by further human studies.

Reduction in food away from home is associated with improved child relative weight and body composition outcomes and this relation is mediated by changes in diet quality.

BACKGROUND: Reducing consumption of food away from home is often targeted during pediatric obesity treatment, given the associations with weight status and gain. However, the effects of this dietary change on weight loss are unknown. OBJECTIVE: Our aim was to evaluate associations between changes in dietary factors and child anthropometric outcomes after treatment. It is hypothesized that reduced consumption of food away from home will be associated with improved dietary intake and greater reductions in anthropometric outcomes (standardized body mass index [BMI] and percent body fat), and the relationship between food away from home and anthropometric outcomes will be mediated by improved child dietary intake. DESIGN: We conducted a longitudinal evaluation of associations between dietary changes and child anthropometric outcomes. Child diet (three 24-hour recalls) and anthropometric data were collected at baseline and 16 weeks. PARTICIPANTS/SETTING: Participants were 170 overweight and obese children ages 7 to 11 years who completed a 16-week family-based behavioral weight-loss treatment as part of a larger multi-site randomized controlled trial conducted in two cohorts between 2010 and 2011 (clinical research trial). INTERVENTION: Dietary treatment targets during family-based behavioral weight-loss treatment included improving diet quality and reducing food away from home. MAIN OUTCOME MEASURES: The main outcome measures in this study were child relative weight (standardized BMI) and body composition (percent body fat). STATISTICAL ANALYSES: We performed t tests and bootstrapped single-mediation analyses adjusting for relevant covariates. RESULTS: As hypothesized, decreased food away from home was associated with improved diet quality and greater reductions in standardized BMI (P<0.05) and percent body fat (P<0.01). Associations between food away from home and anthropometric outcomes were mediated by changes in diet quality. Specifically, change in total energy intake and added sugars mediated the association between change in food away from home and standardized BMI, and change in overall diet quality, fiber, added sugars, and added fats mediated the association between change in food away from home and percent body fat. Including physical activity as a covariate did not significantly impact these findings. CONCLUSIONS: These results suggest that reducing food away from home can be an important behavioral target for affecting positive changes in both diet quality and anthropometric outcomes during treatment.

Bariatric surgery-induced weight loss causes remission of food addiction in extreme obesity.

OBJECTIVE: To test the hypotheses that bariatric surgery-induced weight loss: induces remission of food addiction (FA), and normalizes other eating behaviors associated with FA. METHODS: Forty-four obese subjects (BMI= 48 ± 8 kg/m(2) ) were studied before and after ∼20% weight loss induced by bariatric surgery (25 Roux-en-Y gastric bypass, 11 laparoscopic adjustable gastric banding, and eight sleeve gastrectomy). We assessed: FA (Yale Food Addiction Scale), food cravings (Food Craving Inventory), and restrictive, emotional and external eating behaviors (Dutch Eating Behavior Questionnaire). RESULTS: FA was identified in 32% of subjects before surgery. Compared with non-FA subjects, those with FA craved foods more frequently, and had higher scores for emotional and external eating behaviors (all P-values <0.01; all Cohen's d >0.8). Surgery-induced weight loss resulted in remission of FA in 93% of FA subjects; no new cases of FA developed after surgery. Surgery-induced weight loss decreased food cravings, and emotional and external eating behaviors in both groups (all P-values < 0.001; all Cohen's d ≥ 0.8). Restrictive eating behavior did not change in non-FA subjects but increased in FA subjects (P < 0.01; Cohen's d>1.1). CONCLUSION: Bariatric surgery-induced weight loss induces remission of FA and improves several eating behaviors that are associated with FA.

Modifications in parent feeding practices and child diet during family-based behavioral treatment improve child zBMI.

OBJECTIVE: To examine associations between modifications in parent feeding practices, child diet, and child weight status after treatment and to evaluate dietary mediators. METHODS: Children classified as overweight or obese and 7-11 years old (N = 170) completed a 16-session family-based behavioral weight loss treatment (FBT) program. Anthropometrics (standardized body mass index (zBMI)), Child Feeding Questionnaire, and 24-hr dietary recalls were collected at baseline and post-FBT. Linear regression predicted child zBMI change. Single and multiple mediation tested child dietary modifications as mediators between change in parent feeding practices and child zBMI. RESULTS: Restrictive parent feeding practices significantly decreased during FBT. Reductions in parent restriction, child weight concern, child's total energy intake, and percent energy from fat, and increases in parent perceived responsibility, and child percent energy from protein, predicted reductions in child zBMI. Change in child total energy intake mediated the relation between parent restriction and child zBMI change after accounting for covariates and additional dietary mediators. CONCLUSIONS: FBT is associated with a decrease in parental restriction, which is associated with reductions in child relative weight, which was mediated by a decrease in child energy intake. Teaching parents to reduce children's energy intake without being overly restrictive may improve child weight.

Adherence to behavioral targets and treatment attendance during a pediatric weight control trial.

OBJECTIVE: Better weight loss outcomes are achieved in adults and youth who adhere to obesity treatment regimens (i.e., session attendance and prescribed changes in weight control behaviors). However, more research is needed regarding children's adherence to a range of behaviors relevant for weight maintenance over long-term follow-up. DESIGN AND METHODS: Overweight children (N = 101, aged 7-12 years), along with an overweight parent, participated in a 20-week family-based behavioral weight loss treatment (FBT) and were then assigned to either a behaviorally focused or socially focused 16-week weight maintenance treatment (MT). Treatment attendance and child and parent adherence (i.e., reported use of skills targeted within treatment) were examined in relation to child percent overweight change from baseline to post-FBT, post-MT, and 2-year follow-up. RESULTS: Higher attendance predicted better child weight outcomes at post-MT, but not at 2-year follow-up. Adherence to self-regulatory skills/goal-setting skills predicted child weight outcomes at 2-year follow-up among the behaviorally focused MT group. CONCLUSIONS: Future research is needed to examine mediators of change within family-based weight control interventions, including behavioral and socially based targets. Incorporating self-regulatory weight maintenance skills into a comprehensive MT may maximize children's sustained weight control.

Preadolescents' and parents' dietary coping efficacy during behavioral family-based weight control treatment.

Developmentally relevant high-risk dietary situations (e.g., parties where tempting foods are available) may influence overweight youth's weight control, as they increase risk for overeating. Better self-efficacy for coping with these situations-which preadolescents may learn from their parents-could foster successful weight control. Overweight preadolescents (N = 204) ages 7-12 years (67% female), each with one parent, separately completed the Hypothetical High-Risk Situation Inventory (HHRSI) pre- and post-weight loss treatment. The HHRSI assesses temptation to overeat and confidence in refraining from overeating in response to four high-risk dietary scenarios. Participants generated coping strategies for each scenario. Coping strategies and confidence increased and temptation decreased from pre- to post-weight loss treatment. Parents' increase in confidence from pre- to post-treatment was associated with preadolescents' and parents' weight loss. Tailoring treatments to enhance parents' coping skills (e.g., building strategies, targeting high temptation/low confidence scenarios) may maximize preadolescents' weight control.

Myocardial oxygen consumption change predicts left ventricular relaxation improvement in obese humans after weight loss.

Obesity adversely affects myocardial metabolism, efficiency, and diastolic function. Our objective was to determine whether weight loss can ameliorate obesity-related myocardial metabolism and efficiency derangements and that these improvements directly relate to improved diastolic function in humans. We studied 30 obese (BMI >30 kg/m2) subjects with positron emission tomography (PET) (myocardial metabolism, blood flow) and echocardiography (structure, function) before and after marked weight loss from gastric bypass surgery (N = 10) or moderate weight loss from diet (N = 20). Baseline BMI, insulin resistance, hemodynamics, left ventricular (LV) mass, systolic function, myocardial oxygen consumption (MVO2), and fatty acid (FA) metabolism were similar between the groups. MVO2/g decreased after diet-induced weight loss (P = 0.009). Total MVO2 decreased after dietary (P = 0.02) and surgical weight loss (P = 0.0006) and was related to decreased BMI (P = 0.006). Total myocardial FA utilization decreased (P = 0.03), and FA oxidation trended lower (P = 0.06) only after surgery. FA esterification and LV efficiency were unchanged. After surgical weight loss, LV mass decreased by 23% (Doppler-derived) E/E' by 33%, and relaxation increased (improved) by 28%. Improved LV relaxation related significantly to decreased BMI, insulin resistance, total MVO2, and LV mass but not FA utilization. Decreased total MVO(2) predicted LV relaxation improvement independent of BMI change (P = 0.02). Weight loss can ameliorate the obesity-related derangements in myocardial metabolism and LV structure and diastolic function. Decreased total MVO2 independently predicted improved LV relaxation, suggesting that myocardial oxygen metabolism may be mechanistically important in determining cardiac relaxation.

The challenge of identifying behavioral alternatives to food: clinic and field studies.

BACKGROUND: One of the basic principles of behavioral economics interventions is identification of alternative behaviors to compete with the reinforcing value of a highly rewarding commodity. PURPOSE: Two experiments that attempt to increase alternatives to eating in obese youth are presented. METHODS: A randomized, controlled trial was used in Study 1 to compare a comprehensive family-based behavioral treatment program or an experimental treatment that incorporated reinforcing children for engaging in alternative behaviors to eating for 41 overweight 8- to 12-year-old children. Study 2 used a within-subject design with baseline, enriched environment and a second baseline phase to determine the influence of providing activities that compete with eating for 13 overweight 8- to 12-year-old children. Measurements included body mass index (BMI) change, alternatives to eating, eating, and physical activity. RESULTS: In Study 1 both treatments were associated with significant (p < .05) and maintained reductions in z-BMI over the 24 months of observation. The experimental group showed a significantly (p < .05) greater increase in alternatives to eating, and both groups showed significant (p < .05) increases in physical activity. In Study 2 alternative behaviors to eating were increased by almost 1 hr/day (p < .001) but were not associated with significant changes in energy intake or physical activity. CONCLUSION: These results suggest that using the methods studied, increasing behaviors that could compete with eating did not influence relative weight in a clinical outcome study or energy intake in a controlled field study.