A systematic review of ecological momentary assessment studies of appetite and affect in the experience of temptations and lapses during weight loss dieting.

Dietary temptations and lapses challenge control over eating and act as barriers toward successful weight loss. These are difficult to assess in laboratory settings or with retrospective measures as they occur momentarily and driven by the current environment. A better understanding of how these experiences unfold within real-world dieting attempts could help inform strategies to increase the capacity to cope with the changes in appetitive and affective factors that surround these experiences. We performed a narrative synthesis on the empirical evidence of appetitive and affective outcomes measured using ecological momentary assessment (EMA) during dieting in individuals with obesity and their association with dietary temptations and lapses. A search of three databases (Scopus, Medline, and PsycInfo) identified 10 studies. Within-person changes in appetite and affect accompany temptations and lapses and are observable in the moments precipitating a lapse. Lapsing in response to these may be mediated through the strength of a temptation. Negative abstinence-violation effects occur following a lapse, which negatively impact self-attitudes. Engagement in coping strategies during temptations is effective for preventing lapses. These findings indicate that monitoring changes in sensations during dieting could help identify the crucial moments when coping strategies are most effective for aiding with dietary adherence.

Association between Indicators of Inequality and Weight Change following a Behavioural Weight Loss Intervention.

INTRODUCTION: Weight loss through behavioural weight management interventions can have important health benefits for people with obesity. However, to maximise the health benefits, weight loss must be maintained. Evidence suggests that behavioural weight loss interventions do not exacerbate inequalities in the short term. However, no study has yet considered whether inequalities exist in long-term weight change following intervention. We aimed to investigate if there are inequalities in weight change following weight loss intervention. METHODS: We conducted a cohort analysis of data from the Weight Loss Referrals for Adults in Primary Care (WRAP) trial (N = 1,267). WRAP randomised participants to receive a brief intervention information booklet or vouchers for 12-weeks or 52-weeks of WW (formerly WeightWatchers) and followed them for 5 years. Multiple linear regression estimated the association between exposures (indicators of inequality) and outcomes (change in weight between 1- and 5-years). Each model was adjusted for the intervention group, baseline weight, weight change between baseline and 1-year, research centre, and source of the 5-year weight data. RESULTS: Of the 1,267 participants in WRAP, 708 had weight change data available. Mean weight change between 1- and 5-years was +3.30 kg (SD 9.10 kg). A 1 year difference in age at baseline was associated with weight change of 0.11 kg ((95% CI 0.06, 0.16), p < 0.001). We did not find evidence of associations between ethnicity, gender, education, indices of multiple deprivation, household income, or other family members participating in a weight loss programme and weight change. CONCLUSION: Except for age, we did not find evidence of inequalities in weight change following a behavioural intervention. Findings further support the use of behavioural weight management interventions as part of a systems-wide approach to improving population health.

Effectiveness and cost-effectiveness of referral to a commercial open group behavioural weight management programme in adults with overweight and obesity: 5-year follow-up of the WRAP randomised controlled trial.

BACKGROUND: There is evidence that commercially available behavioural weight management programmes can lead to short-term weight loss and reductions in glycaemia. Here, we aimed to provide the 5-year impact and cost-effectiveness of these interventions compared with a brief intervention. METHODS: WRAP was a non-blinded, parallel-group randomised controlled trial (RCT). We recruited from primary care practices in England and randomly assigned participants to one of three interventions (brief intervention, 12-week open-group behavioural programme [WW, formerly Weight Watchers], or a 52-week open-group WW behavioural programme) in an uneven (2:5:5) allocation. Participants were followed up 5 years after randomisation using data from measurement visits at primary care practices or a research centre, review of primary care electronic medical notes, and self-report questionnaires. The primary outcome was change in weight at 5 years follow-up, assessed using analysis of covariance. We also estimated cost-effectiveness of the intervention. This study is registered at Current Controlled Trials, ISRCTN64986150. FINDINGS: Between Oct 18, 2012, and Feb 10, 2014, we recruited 1269 eligible participants (two participants were randomly assigned but not eligible and therefore excluded) and 1040 (82%) consented to be approached about additional follow-up and to have their medical notes reviewed at 5 years. The primary outcome (weight) was ascertained for 871 (69%) of 1267 eligible participants. Mean duration of follow-up was 5·1 (SD 0·3) years. Mean weight change from baseline to 5 years was -0·46 (SD 8·31) kg in the brief intervention group, -1·95 (9·55) kg in the 12-week programme group, and -2·67 (9·81) kg in the 52-week programme. The adjusted difference in weight change was -1·76 (95% CI -3·68 to 0·17) kg between the 52-week programme and the brief intervention; -0·80 (-2·13 to 0·54) kg between the 52-week and the 12-week programme; and -0·96 (-2·90 to 0·97) kg between the 12-week programme and the brief intervention. During the trial, the 12-week programme incurred the lowest cost and produced the highest quality-adjusted life-years (QALY). Simulations beyond 5 years suggested that the 52-week programme would deliver the highest QALYs at the lowest cost and would be the most cost-effective. No participants reported adverse events related to the intervention. INTERPRETATION: Although the difference in weight change between groups was not statistically significant, some weight loss was maintained at 5 years after an open-group behavioural weight management programme. Health economic modelling suggests that this could have important implications to reduce the incidence of weight-related disease and these interventions might be cost-saving. FUNDING: The UK National Institute for Health and Care Research Programme Grants for Applied Research and the Medical Research Council.

EAES rapid guideline: systematic review, network meta-analysis, CINeMA and GRADE assessment, and European consensus on bariatric surgery-extension 2022.

BACKGROUND: The European Association for Endoscopic Surgery Bariatric Guidelines Group identified a gap in bariatric surgery recommendations with a structured, contextualized consideration of multiple bariatric interventions. OBJECTIVE: To provide evidence-informed, transparent and trustworthy recommendations on the use of sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, gastric plication, biliopancreatic diversion with duodenal switch, one anastomosis gastric bypass, and single anastomosis duodeno-ileal bypass with sleeve gastrectomy in patients with severe obesity and metabolic diseases. Only laparoscopic procedures in adults were considered. METHODS: A European interdisciplinary panel including general surgeons, obesity physicians, anesthetists, a psychologist and a patient representative informed outcome importance and minimal important differences. We conducted a systematic review and frequentist fixed and random-effects network meta-analysis of randomized-controlled trials (RCTs) using the graph theory approach for each outcome. We calculated the odds ratio or the (standardized) mean differences with 95% confidence intervals for binary and continuous outcomes, respectively. We assessed the certainty of evidence using the CINeMA and GRADE methodologies. We considered the risk/benefit outcomes within a GRADE evidence to decision framework to arrive at recommendations, which were validated through an anonymous Delphi process of the panel. RESULTS: We identified 43 records reporting on 24 RCTs. Most network information surrounded sleeve gastrectomy and Roux-en-Y gastric bypass. Under consideration of the certainty of the evidence and evidence to decision parameters, we suggest sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass over adjustable gastric banding, biliopancreatic diversion with duodenal switch and gastric plication for the management of severe obesity and associated metabolic diseases. One anastomosis gastric bypass and single anastomosis duodeno-ileal bypass with sleeve gastrectomy are suggested as alternatives, although evidence on benefits and harms, and specific selection criteria is limited compared to sleeve gastrectomy and Roux-en-Y gastric bypass. The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp:  https://app.magicapp.org/#/guideline/Lpv2kE CONCLUSIONS: This rapid guideline provides evidence-informed, pertinent recommendations on the use of bariatric and metabolic surgery for the management of severe obesity and metabolic diseases. The guideline replaces relevant recommendations published in the EAES Bariatric Guidelines 2020.

Non-visible disease, the hidden disruptive experiences of chronic illness in adversity.

Objective: This study's principal aim was to describe the lived reality for people with cardiovascular disease (CVD) and other chronic health conditions, who live in economically deprived neighbourhoods in a city in North West England. Methodology: This is a qualitative, exploratory study based on in-depth, semi-structured interviews with participants experiencing compromised cardiovascular health, conducted in August 2017. The study sample comprised 14 adults (3 females) aged 54 to 76. Thematic analysis was used for data analysis, and the biographical disruption concept was used as theoretical reference to explore the results. Wider health inequalities literature supplemented the individual experiences of chronic illness. Results: Four main themes were developed from the data: (1) chronic illness as a disruptive experience; (2) struggling for money; (3) lifestyle and health risks; and (4) reflections on current inequalities. The varied nature of participants' narratives about their chronic illness indicated that the experience of biographical disruption depends on the wider socioeconomic and cultural factors of the individual. Discussion: This study suggests that biographical disruption theory combined with health inequalities contexts highlights the role of hidden suffering and enhances the understanding of chronic illness experiences and thus informs clinical management, service and public health planning.

Greater Attendance at a Community Weight Loss Programme over the First 12 Weeks Predicts Weight Loss at 2 Years.

BACKGROUND: There is considerable heterogeneity in long-term weight loss among people referred to obesity treatment programmes. It is unclear whether attendance at face-to-face sessions in the early weeks of the programme is an independent predictor of long-term success. OBJECTIVE: To investigate whether frequency of attendance at a community weight loss programme over the first 12 weeks is associated with long-term weight change. METHODS: Participants were randomised to receive brief support only (control, n = 211), or a weight loss programme for 12 weeks (n = 530) or 52 weeks (n = 528). This study included participants with data on session attendance over the first 12 weeks (n = 889) compared to the control group. The association between attendance (continuously) and weight loss was explored using a linear model. A multi-level mixed-effects linear model was used to investigate whether attendance (categorised as 0, 1, 2-5, 6-9, and 10-12 sessions) was associated with weight loss at 3, 12, and 24 months compared to the control. RESULTS: For every session attended in the first 12 weeks, the average weight loss was -0.259 kg/session at 24 months (p = 0.005). Analysis by attendance group found only those attending 10-12 sessions had significantly greater weight loss (-7.5 kg [95% CI -8.1 to -6.9] at 12 months; -4.7 kg [95% CI -5.3 to -4.1] at 24 months) compared to the control group (-3.4 [95% CI -4.5 to -2.4] at 12 months, -2.5 [95% CI -3.5 to -1.5] at 24 months). Early attendance was higher for people ≥70 years, but there was no evidence of a difference by gender, ethnicity, education, or income. CONCLUSIONS: Greater attendance at a community weight loss programme in the first 12 weeks is associated with enhanced weight loss up to 24 months. Regular attendance at a programme could be used as a criterion for continued provision of weight loss services to maximise the cost-effectiveness of interventions.

'Eating to survive': A qualitative analysis of factors influencing food choice and eating behaviour in a food-insecure population.

Food insecurity affects approximately 8.4 million people in the UK, one of the worst levels in Europe. Food insecurity is associated with poor diet quality and obesity; however, the drivers of this relationship are unclear. This study used a qualitative approach to explore factors that influence food choice and eating behaviour in a food-insecure population in Liverpool, UK. Face-to-face interviews were conducted with adults (N = 24) who were clients at foodbanks. The interviews were informed by a semi-structured interview schedule, which focussed on access to food, factors influencing food choices, and strategies used to conserve food. Interview transcripts were analysed using inductive thematic analysis. Six themes were developed; 'Income', 'Cost of food', 'Accessibility of shops', 'Health issues', 'Food rationing strategies' and 'Worsened health outcomes'. Income was the most salient factor influencing participants' food choices with all participants reporting a constant struggle to afford food. Food decisions were primarily based on cost; most participants valued eating healthily but could not afford to do so. Strategies to ration food included skipping meals, consuming small portions, cooking in bulk, and prioritising children's food intake. The majority of participants reported pre-existing physical and/or mental health issues, but these were exacerbated by poor access to food leading to a vicious cycle of stress and worsening health issues. In conclusion, participants' food choices and eating behaviour seemed to be most strongly influenced by their level of income. Our findings provide insight into the range of strategies used by participants to conserve food and also highlight the mental health impact of food insecurity. Initiatives addressing income and the cost of healthy food are required.

Plasma metabolites associated with homeostatic model assessment of insulin resistance: metabolite-model design and external validation.

Different plasma metabolites have been related to insulin resistance (IR). However, there is a lack of metabolite models predicting IR with external validation. The aim of this study is to identify a multi-metabolite model associated to the homeostatic model assessment (HOMA)-IR values. We performed a cross-sectional metabolomics analysis of samples collected from overweight and obese subjects from two independent studies. The training step was performed in 236 subjects from the SATIN study and validated in 102 subjects from the GLYNDIET study. Plasma metabolomics profile was analyzed using three different approaches: GC/quadrupole-TOF, LC/quadrupole-TOF, and nuclear magnetic resonance (NMR). Associations between metabolites and HOMA-IR were assessed using elastic net regression analysis with a leave-one-out cross validation (CV) and 100 CV runs. HOMA-IR was analyzed both as linear and categorical (median or lower versus higher than the median). Receiver operating characteristic curves were constructed based on metabolites' weighted models. A set of 30 metabolites discriminating extremes of HOMA-IR were consistently selected. These metabolites comprised some amino acids, lipid species and different organic acids. The area under the curve (AUC) for the discrimination between HOMA-IR extreme categories was 0.82 (95% CI: 0.74-0.90), based on the multi-metabolite model weighted with the regression coefficients of metabolites in the validation dataset. We identified a set of metabolites discriminating between extremes of HOMA-IR and able to predict HOMA-IR with high accuracy.

Extended and standard duration weight-loss programme referrals for adults in primary care (WRAP): a randomised controlled trial.

BACKGROUND: Evidence exist that primary care referral to an open-group behavioural programme is an effective strategy for management of obesity, but little evidence on optimal intervention duration is available. We aimed to establish whether 52-week referral to an open-group weight-management programme would achieve greater weight loss and improvements in a range of health outcomes and be more cost-effective than the current practice of 12-week referrals. METHODS: In this non-blinded, parallel-group, randomised controlled trial, we recruited participants who were aged 18 years or older and had body-mass index (BMI) of 28 kg/m2 or higher from 23 primary care practices in England. Participants were randomly assigned (2:5:5) to brief advice and self-help materials, a weight-management programme (Weight Watchers) for 12 weeks, or the same weight-management programme for 52 weeks. We followed-up participants over 2 years. The primary outcome was weight at 1 year of follow-up, analysed with mixed-effects models according to intention-to-treat principles and adjusted for centre and baseline weight. In a hierarchical closed-testing procedure, we compared combined behavioural programme arms with brief intervention, then compared the 12-week programme and 52-week programme. We did a within-trial cost-effectiveness analysis using person-level data and modelled outcomes over a 25-year time horizon using microsimulation. This study is registered with Current Controlled Trials, number ISRCTN82857232. FINDINGS: Between Oct 18, 2012, and Feb 10, 2014, we enrolled 1269 participants. 1267 eligible participants were randomly assigned to the brief intervention (n=211), the 12-week programme (n=528), and the 52-week programme (n=528). Two participants in the 12-week programme had been found to be ineligible shortly after randomisation and were excluded from the analysis. 823 (65%) of 1267 participants completed an assessment at 1 year and 856 (68%) participants at 2 years. All eligible participants were included in the analyses. At 1 year, mean weight changes in the groups were -3·26 kg (brief intervention), -4·75 kg (12-week programme), and -6·76 kg (52-week programme). Participants in the behavioural programme lost more weight than those in the brief intervention (adjusted difference -2·71 kg, 95% CI -3·86 to -1·55; p<0·0001). The 52-week programme was more effective than the 12-week programme (-2·14 kg, -3·05 to -1·22; p<0·0001). Differences between groups were still significant at 2 years. No adverse events related to the intervention were reported. Over 2 years, the incremental cost-effectiveness ratio (ICER; compared with brief intervention) was £159 per kg lost for the 52-week programme and £91 per kg for the 12-week programme. Modelled over 25 years after baseline, the ICER for the 12-week programme was dominant compared with the brief intervention. The ICER for the 52-week programme was cost-effective compared with the brief intervention (£2394 per quality-adjusted life-year [QALY]) and the 12-week programme (£3804 per QALY). INTERPRETATION: For adults with overweight or obesity, referral to this open-group behavioural weight-loss programme for at least 12 weeks is more effective than brief advice and self-help materials. A 52-week programme produces greater weight loss and other clinical benefits than a 12-week programme and, although it costs more, modelling suggests that the 52-week programme is cost-effective in the longer term. FUNDING: National Prevention Research Initiative, Weight Watchers International (as part of an UK Medical Research Council Industrial Collaboration Award).

The emotional and practical experiences of formula-feeding mothers.

The majority of infant-feeding research is focused on identifying mother's reasons for the cessation of breastfeeding. The experience of mothers who choose to use formula is largely overlooked in quantitative designs. This study aimed to describe the emotional and practical experiences of mothers who formula feed in any quantity, and examine whether these experiences would vary among different cohorts of formula-feeding mothers according to prenatal feeding intention and postnatal feeding method. A total of 890 mothers of infants up to 26 weeks of age, who were currently formula feeding in any quantity, were recruited through relevant international social media sites via advertisements providing a link to an online survey. Predictors of emotional experiences included guilt, stigma, satisfaction, and defense as a result of their infant feeding choices. Practical predictor variables included support received from health professionals, respect displayed by their everyday environment, and main sources of infant feeding information. Descriptive findings from the overall sample highlighted a worryingly high percentage of mother's experienced negative emotions as a result of their decision to use formula. Multinomial logit models revealed that negative emotions such as guilt, dissatisfaction, and stigma were directly associated with feeding intention and method. The evidence suggests that the current approach to infant-feeding promotion and support may be paradoxically related to significant issues with emotional well-being. These findings support criticisms of how infant-feeding recommendations are framed by health care professionals and policy makers, and highlight a need to address formula feeding in a more balanced, woman-centered manner.

Exposure to 'healthy' fast food meal bundles in television advertisements promotes liking for fast food but not healthier choices in children.

Due to regulatory changes, fast food companies often depict healthy foods in their television advertisements to children. The present study examined how exposure to advertising for 'healthy' meal bundles to children influenced the selection of food in children. A total of fifty-nine children (thirty-seven males) aged 7-10 years (8·8 (SD 0·9) years) took part in the present study. The within-participant, counterbalanced design had two conditions: control (exposure to ten toy adverts across two breaks of five adverts each) and experimental (the middle advert in each break replaced with one for a McDonald's Happy Meal® depicting the meal bundle as consisting of fish fingers, a fruit bag and a bottle of mineral water). Following viewing of the adverts embedded in a cartoon, children completed a hypothetical menu task that reported liking for McDonald's food and fast food, in general. Nutritional knowledge, height and weight of the children were measured. There was no significant difference between the two advert conditions for the nutritional content of the meal bundles selected. However, children's liking for fast food, in general, increased after exposure to the food adverts relative to control (P= 0·004). Compared to children with high nutritional knowledge, those with low scores selected meals of greater energy content (305 kJ) after viewing the food adverts (P= 0·016). Exposure to adverts for 'healthy' meal bundles did not drive healthier choices in children, but did promote liking for fast food. These findings contribute to debates about food advertising to children and the effectiveness of related policies.

Willingness to pay for obesity pharmacotherapy.

Several treatments for obesity have received regulatory approval, but health insurers and other payers typically refuse to support access to them. Thus, patients are left to bear significant out-of-pocket costs for obesity pharmacotherapy. This study aimed to assess preferences and willingness to pay (WTP) for obesity medications among people seeking weight loss in the United States and United Kingdom. An online survey was developed based on literature review, clinician interviews, and profiles of available therapies. Participants indicated their preference for hypothetical treatments which varied by seven attributes: percentage of weight loss, long-term health risk reduction, time to noticeable weight loss, delivery mode, side effects, lifestyle modification, and cost; 502 obese participants completed the survey (mean BMI 37.12 kg/m(2) (±4.63); 73.5% female; 47.7 (±12.9) years of age). The participants deemed weight loss of >21 kg (United Kingdom) and >28 kg (United State) as "acceptable". All treatment attributes were important (P < 0.001) except "time to noticeable weight loss." The survey found that percentage weight loss was the most important factor for patients and a reduction in long-term health risk was relatively less important. Patients were willing to pay £6.51/$10.49 per month per percentage point of weight loss that a pharmacotherapy could provide. Participants also highly valued therapies that did not require substantial lifestyle modifications and were willing to pay £17.78/$30.77 more per month for a one-pill-per-day treatment vs. a weekly injectable. Participants placed a high value on weight loss and avoiding changes to their lifestyle, and less value on reducing long-term risks to health.

Pharmacotherapy for obesity.

The current obesity pandemic imposes a major global disease burden. However, sustained weight loss of between 5 and 10% in the obese confers marked health benefits. Currently available pharmacotherapies, orlistat and sibutramine, can induce weight loss of between 5 and 10% over 2 years or more. However, in these trials, drug induced weight loss tends to be only 2-4 kg greater than that produced by placebo control. Despite this, in the XENDOS trial, the modest placebo-subtract weight loss produced by orlistat (2.8 kg) reduced the incidence of diabetes by over a third. Recent data on the potential anti-obesity drug rimonabant are also reviewed.

Adolescence and the diet-dieting disparity: healthy food choice or risky health behaviour?

OBJECTIVES: Food choice in schoolchildren was examined in relation to dieting and measures of eating psychopathology. It was predicted that dieters would make healthier food choices compared to non-dieters and that measures of eating psychopathology would be associated with food choice. DESIGN: A cross-sectional questionnaire design incorporating an established adapted recall method was used to assess patterns of food consumption. METHODS: Questionnaires were administered in 13 state secondary schools. Measures included a food frequency questionnaire, the Children's Eating Attitudes Test (CHEAT), body satisfaction ratings, dietary restraint, and questions about dieting status. The sample consisted of 574 females and 445 males aged 11-16 years. RESULTS: Females made significantly more healthy food choices compared to males. Females reported dieting more than males (35% vs. 18%, respectively), and female dieters made more healthy food choices than female non-dieters. Almost a fifth (19%) of the entire sample reported skipping breakfast, with female dieters being three times more likely to do so than non-dieters. There were small but significant associations between reported food consumption and measures of eating attitudes, body dissatisfaction and restraint. For females who scored in the at-risk range on the CHEAT (8.7%), these associations were more substantial. CONCLUSIONS: Female dieters appear to make more healthy food choices than non-dieters and so may be tuning into healthy eating messages more effectively. Vulnerable females may use 'healthy eating' to hide risky weight reduction behaviours. Further studies are required to examine the nutritional impact of moderate and extreme dieting in this age group.