Refining the conceptualization and assessment of internalized weight stigma: A mixed methods approach.

Internalized weight stigma has gained increasing attention in empirical studies, though questions remain about the adequacy of existing measures. The current study utilized a mixed methods approach, including a novel semi-structured interview, to revisit the conceptualization of internalized weight stigma and explore in more depth the stereotypes and impacts of weight reported by individuals with high scores on the widely-used Weight Bias Internalization Scale. All participants were interviewed as part of the screening procedures for two clinical trials (Study 1 n = 84, mean age=47.8 years, 83.3% women, 67.9% Black, mean BMI=39.2 kg/m2; Study 2 n = 129, mean age=50.0 years, 88.4% women, 65.1% white, mean BMI=37.8 kg/m2). The most common weight stereotypes identified were being lazy, lacking willpower or self-control, and having poor eating habits. Up to 66% of participants reported that they did not endorse negative weight stereotypes or apply them to themselves. The most highly identified impacts of weight were on self-image (>70%) and emotions (68-83%), followed by social (37-62%) and health concerns (20-25%). Approximately 60% of participants indicated that weight affected their self-directed thoughts and feelings "very much" to "extremely." Findings have implications for understanding and assessing internalized weight stigma in research and in clinical settings where interventions are needed.

Within-Trial Cost-Effectiveness of a Structured Lifestyle Intervention in Adults With Overweight/Obesity and Type 2 Diabetes: Results From the Action for Health in Diabetes (Look AHEAD) Study.

OBJECTIVE: To assess the cost-effectiveness (CE) of an intensive lifestyle intervention (ILI) compared with standard diabetes support and education (DSE) in adults with overweight/obesity and type 2 diabetes, as implemented in the Action for Health in Diabetes study. RESEARCH DESIGN AND METHODS: Data were from 4,827 participants during their first 9 years of study participation from 2001 to 2012. Information on Health Utilities Index Mark 2 (HUI-2) and HUI-3, Short-Form 6D (SF-6D), and Feeling Thermometer (FT), cost of delivering the interventions, and health expenditures was collected during the study. CE was measured by incremental CE ratios (ICERs) in costs per quality-adjusted life year (QALY). Future costs and QALYs were discounted at 3% annually. Costs were in 2012 U.S. dollars. RESULTS: Over the 9 years studied, the mean cumulative intervention costs and mean cumulative health care expenditures were $11,275 and $64,453 per person for ILI and $887 and $68,174 for DSE. Thus, ILI cost $6,666 more per person than DSE. Additional QALYs gained by ILI were not statistically significant measured by the HUIs and were 0.07 and 0.15, respectively, measured by SF-6D and FT. The ICERs ranged from no health benefit with a higher cost based on HUIs to $96,458/QALY and $43,169/QALY, respectively, based on SF-6D and FT. CONCLUSIONS: Whether ILI was cost-effective over the 9-year period is unclear because different health utility measures led to different conclusions.

Impact of an intensive lifestyle intervention on use and cost of medical services among overweight and obese adults with type 2 diabetes: the action for health in diabetes.

OBJECTIVE: To assess the relative impact of an intensive lifestyle intervention (ILI) on use and costs of health care within the Look AHEAD trial. RESEARCH DESIGN AND METHODS: A total of 5,121 overweight or obese adults with type 2 diabetes were randomly assigned to an ILI that promoted weight loss or to a comparison condition of diabetes support and education (DSE). Use and costs of health-care services were recorded across an average of 10 years. RESULTS: ILI led to reductions in annual hospitalizations (11%, P = 0.004), hospital days (15%, P = 0.01), and number of medications (6%, P < 0.001), resulting in cost savings for hospitalization (10%, P = 0.04) and medication (7%, P < 0.001). ILI produced a mean relative per-person 10-year cost savings of $5,280 (95% CI 3,385-7,175); however, these were not evident among individuals with a history of cardiovascular disease. CONCLUSIONS: Compared with DSE over 10 years, ILI participants had fewer hospitalizations, fewer medications, and lower health-care costs.

Deep brain stimulation compared with bariatric surgery for the treatment of morbid obesity: a decision analysis study.

OBJECT: Roux-en-Y gastric bypass is the gold standard treatment for morbid obesity, although failure rates may be high, particularly in patients with a BMI > 50 kg/m(2). With improved understanding of the neuropsychiatric basis of obesity, deep brain stimulation (DBS) offers a less invasive and reversible alternative to available surgical treatments. In this decision analysis, the authors determined the success rate at which DBS would be equivalent to the two most common bariatric surgeries. METHODS: Medline searches were performed for studies of laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB), and DBS for movement disorders. Bariatric surgery was considered successful if postoperative excess weight loss exceeded 45% at 1-year follow-up. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment by LAGB, LRYGB, DBS, or no surgical treatment. A sensitivity analysis in which major parameters were systematically varied within their 95% CIs was used. RESULTS: Fifteen studies involving 3489 and 3306 cases of LAGB and LRYGB, respectively, and 45 studies involving 2937 cases treated with DBS were included. The operative successes were 0.30 (95% CI 0.247-0.358) for LAGB and 0.968 (95% CI 0.967-0.969) for LRYGB. Sensitivity analysis revealed utility of surgical complications in LRYGB, probability of surgical complications in DBS, and success rate of DBS as having the greatest influence on outcomes. At no values did LAGB result in superior outcomes compared with other treatments. CONCLUSIONS: Deep brain stimulation must achieve a success rate of 83% to be equivalent to bariatric surgery. This high-threshold success rate is probably due to the reported success rate of LRYGB, despite its higher complication rate (33.4%) compared with DBS (19.4%). The results support further research into the role of DBS for the treatment of obesity.

Insurance coverage for obesity treatment.

Recent work demonstrates the benefits of weight loss from intensive lifestyle modification. One barrier to counseling may be lack of reimbursement. We sought to quantify the obesity coverage policies of insurers in Pennsylvania. A three-page questionnaire was sent to eligible Pennsylvania health plans. Respondents included company medical directors and administrators from other departments, including public relations, provider relations, disease management, and utilization review. The questionnaire inquired about major treatment modalities for obesity, including details of coverage. Sixteen of 19 eligible plans (84%) responded. All plans provided some coverage for bariatric surgery. Nine out of 16 companies (56%) stated that they covered individual dietary counseling, but only five paid for intensive counseling. Less than 50% of plans reimbursed other forms of lifestyle modification or weight loss medication. Surgery was covered significantly more often than all other treatment modalities (P<0.02 for all comparisons). No differences in reimbursement were found by plan type or by number of enrollees. Insurance reimbursement for obesity in Pennsylvania does not consistently reflect recent evidence for the benefits of lifestyle modification. Given the increasing evidence for the clinical and cost-effectiveness of nonsurgical weight loss therapy, coverage policies may begin to change.

Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach.

This paper discusses the behavioral evaluation of patients who seek bariatric surgery and the psychosocial complications most frequently observed in these individuals. The effects of such complications on surgical outcome are briefly examined, as is the challenge of predicting therapeutic response on the basis of preoperative variables. The paper concludes with a description of the goals and methods of a behavioral assessment used at the University of Pennsylvania. This evaluation includes the use of the Weight and Lifestyle Inventory, a questionnaire that guides our interview with patients.

Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach.

This paper discusses the behavioral evaluation of patients who seek bariatric surgery and the psychosocial complications most frequently observed in these individuals. The effects of such complications on surgical outcome are briefly examined, as is the challenge of predicting therapeutic response on the basis of preoperative variables. The paper concludes with a description of the goals and methods of a behavioral assessment used at the University of Pennsylvania. This evaluation includes the use of the Weight and Lifestyle Inventory, a questionnaire that guides our interview with patients.

Systematic review: an evaluation of major commercial weight loss programs in the United States.

BACKGROUND: Each year millions of Americans enroll in commercial and self-help weight loss programs. Health care providers and their obese patients know little about these programs because of the absence of systematic reviews. PURPOSE: To describe the components, costs, and efficacy of the major commercial and organized self-help weight loss programs in the United States that provide structured in-person or online counseling. DATA SOURCES: Review of company Web sites, telephone discussion with company representatives, and search of the MEDLINE database. STUDY SELECTION: Randomized trials at least 12 weeks in duration that enrolled only adults and assessed interventions as they are usually provided to the public, or case series that met these criteria, stated the number of enrollees, and included a follow-up evaluation that lasted 1 year or longer. DATA EXTRACTION: Data were extracted on study design, attrition, weight loss, duration of follow-up, and maintenance of weight loss. DATA SYNTHESIS: We found studies of eDiets.com, Health Management Resources, Take Off Pounds Sensibly, OPTIFAST, and Weight Watchers. Of 3 randomized, controlled trials of Weight Watchers, the largest reported a loss of 3.2% of initial weight at 2 years. One randomized trial and several case series of medically supervised very-low-calorie diet programs found that patients who completed treatment lost approximately 15% to 25% of initial weight. These programs were associated with high costs, high attrition rates, and a high probability of regaining 50% or more of lost weight in 1 to 2 years. Commercial interventions available over the Internet and organized self-help programs produced minimal weight loss. LIMITATIONS: Because many studies did not control for high attrition rates, the reported results are probably a best-case scenario. CONCLUSIONS: With the exception of 1 trial of Weight Watchers, the evidence to support the use of the major commercial and self-help weight loss programs is suboptimal. Controlled trials are needed to assess the efficacy and cost-effectiveness of these interventions.

Bariatric surgery patients' views of their physicians' weight-related attitudes and practices.

OBJECTIVE: A prior study found that nearly 80% of bariatric surgery patients felt that they were treated disrespectfully by members of the medical profession. This study assessed patient-physician interactions in a group of bariatric surgery patients and in a group of less obese patients who sought weight loss by other means. RESEARCH METHODS AND PROCEDURES: A total of 105 bariatric surgery candidates (mean BMI, 54.8 kg/m(2)) and 214 applicants to a randomized controlled trial of the effects of behavior modification and sibutramine (mean BMI, 37.8 kg/m(2)) completed a questionnaire that assessed patient-physician interactions concerning weight. RESULTS: Only 13% of bariatric surgery patients reported that they were usually or always treated disrespectfully by members of the medical profession, a percentage substantially lower than that found in the previous study. Surprisingly, surgery patients were significantly more satisfied than nonsurgery patients with the care they received for their obesity. Surgery patients also reported significantly more interactions with physicians concerning obesity and weight loss compared with nonsurgery patients. A substantial percentage of both groups, however, reported that their physician did not discuss weight control with them. DISCUSSION: These and other findings suggest that doctor-patient interactions concerning weight may have improved in the past decade; however, there is still much room for improvement. Increased efforts are needed to help physicians discuss, assess, and potentially treat obesity in primary care practice.

Agreement between weekly vs. daily assessment of appetite.

Hunger, satiation, and other aspects of appetite are frequently measured using end-anchored line ratings. This study investigated whether a single assessment of appetite, which covered the prior week, would yield the same results obtained by assessing appetite 3 days during the week. Participants were 51 women and 9 men (age mean 44.1, SD 9.8 years; BMI mean 38.0, SD 5.2 kg/m(2)) in a study evaluating the effectiveness of four weight control programs, three of which used sibutramine (15 mg/d). On three separate days of one week, participants rated appetite for that day. During a subsequent clinic visit, participants completed the same ratings in reference to the past week. The three daily values were averaged. All correlations between weekly and averaged daily values were strongly positive (r=0.63-0.80) and statistically significant (all p<0.001). All mean daily and weekly ratings fell within 3.3-7.2 mm of each other. Thus, good agreement was observed between the average daily assessments and one weekly assessment. The weekly assessment of appetite in the clinic appears to have several benefits, including uniformity of test administration and decreased burden on participants.

What consumers want to know about commercial weight-loss programs: a pilot investigation.

OBJECTIVE: In 1999, the Partnership for Healthy Weight Management recommended that providers of commercial weight-loss programs (and products) voluntarily disclose information concerning the safety, costs, and central components of their programs, as well as the credentials of program staff. These guidelines were drafted without the benefit of data from consumers concerning the specific information they desired. The present study provides such data. RESEARCH METHODS AND PROCEDURES: Participants were 90 women with a mean age of 44.02 +/- 9.17 years and body mass index of 36.11 +/- 4.82 kg/m(2) who were participants in one of two randomized weight-control trials. Before treatment, respondents were asked to imagine that they were "looking for a weight-loss plan" and to rate how important each of 16 factors would be in helping them select a plan. Ratings were made using 5-point scales, anchored by "not at all important" and "extremely important," (scored 1 and 5, respectively). Participants also identified the five factors that they thought were the most important, as well as the single most important. RESULTS: The mean rating for the importance of safety (4.57 +/- 0.60) was significantly greater than that for each of the 15 other variables (all p values < 0.05). In addition, significantly more respondents (27.8%) selected safety as the single most important factor than any other variable (all p values < 0.05). Other factors that were consistently judged as very important included information about diet (4.38 +/- 0.68), behavior modification (4.32 +/- 0.76), cost (4.19 +/- 0.92), and maintenance of weight loss (4.15 +/- 0.91). Staff credentials (3.88 +/- 0.83) were among the lowest rated items. DISCUSSION: The results generally support the disclosure guidelines proposed by the Partnership for Health Weight Management. Consumers, however, seem to desire information about weight loss, in addition to that concerning safety, cost, and central program components.