Furthering Scientific Inquiry for Weight Loss Maintenance: Assessing the Psychological Processes Impacted by a Low intensity Technology-Assisted Intervention (NULevel Trial).

BACKGROUND: NULevel was a randomized control trial to evaluate a technology-assisted weight loss maintenance (WLM) program in the UK. The program included: (a) a face-to-face goal-setting session; (b) an internet platform, a pedometer, and wirelessly connected scales to monitor and report diet, physical activity, and weight, and; (c) regular automated feedback delivered by mobile phone, tailored to participants' progress. Components were designed to target psychological processes linked to weight-related behavior. Though intervention participants showed increased physical activity, there was no difference in WLM between the intervention and control groups after 12 months (Sniehotta FF, Evans EH, Sainsbury K, et al. Behavioural intervention for weight loss maintenance versus standard weight advice in adults with obesity: A randomized controlled trial in the UK (NULevel Trial). PLoS Med. 2019; 16(5):e1002793. doi:10.1371/journal.pmed.1002793). It is unclear whether the program failed to alter targeted psychological processes, or whether changes in these processes failed to influence WLM. PURPOSE: We evaluate whether the program influenced 16 prespecified psychological processes (e.g., self-efficacy and automaticity toward diet and physical activity), and whether these processes (at 6 months) were associated with successful WLM (at 12 months). METHODS: 288 adults who had previously lost weight were randomized to the intervention or control groups. The control group received wireless scales and standard advice via newsletters. Assessments occurred in person at 0, 6, and 12 months. RESULTS: The intervention significantly altered 10 of the 16 psychological processes, compared with the control group. However, few processes were associated with WLM, leading to no significant indirect effects of the intervention via the processes on WLM. CONCLUSIONS: Changes in targeted processes were insufficient to support WLM. Future efforts may more closely examine the sequence of effects between processes, behavior, and WLM.

Many tools exist to help people lose weight, but it is common for people to regain that weight over time. Thus, understanding how to support the maintenance of weight loss remains a priority. The NULevel program was a 12-month weight loss maintenance (WLM) intervention for individuals who had recently lost weight. It promoted psychological factors, shown to be tied to weight-related behaviors, using face-to-face and technology-based (e.g., mobile phone feedback) elements. For example, the program encouraged making plans to improve lifestyles (e.g., exercise, better diet) and promoted people's confidence in these behaviors. However, the program was not more successful than a control condition in maintaining weight loss. We sought to understand why this occurred. We found that the program was indeed successful in influencing most of the psychological factors it targeted. Instead, it was the psychological factors that failed to predict WLM. Were the psychological factors insufficient to impact behavior? Or did the promoted behaviors fail to aid WLM? Future research should focus on answering such questions. Doing so would inform whether interventions should target different psychological factors to change behaviors, or choose different sets of behaviors to support WLM.

Validation of a Latin-American Spanish version of the Body Esteem Scale for Adolescents and Adults (BESAA-LA) in Colombian and Nicaraguan adults.

BACKGROUND: Body dissatisfaction (BD) is a growing concern in Latin America; reliable and culturally appropriate scales are necessary to support body image research in Spanish speaking Latin American countries. We sought to validate a Latin-American Spanish version of the Body Esteem Scale for Adolescents and Adults (BESAA; Mendelson et al. 2001). METHODS: The BESAA was translated, culturally adapted, and validated in a sample of adults in Colombia (N = 525, 65% women, Mage 24.4, SD = 9.28). We assessed factor structure (using confirmatory factor analysis (CFA), exploratory factor analysis (EFA) and exploratory structural equation model (ESEM)), internal reliability (using Cronbach's alpha and omega), validity (using the Body Appreciation Scale BAS and Sociocultural Attitudes Towards Appearance Questionnaire SATAQ), test-retest stability in a small subsample (N = 84, using Intraclass correlations ICC) and measurement invariance across gender. To evaluate the generalizability of the scale, we assessed reliability, validity, and factor structure in a second sample from rural Nicaragua (N = 102, 73% women, Mage 22.2, SD = 4.72), and assessed measurement invariance across Nicaraguan and Colombian participants. RESULTS: The scale showed good internal reliability and validity in both samples, and there was evidence of adequate test-retest stability in the Colombian sample. EFA showed a three-factor structure with subscales we labelled 'appearance-positive', 'appearance-negative' and 'weight', that was confirmed using CFA and ESEM in the Colombian sample. Measurement invariance was confirmed across the Colombian and Nicaraguan samples, and across gender within the Colombian sample. CONCLUSION: The Latin-American Spanish version of the BESAA (BESAA-LA) appears to be a psychometrically sound measure with good reliability, validity and invariance across gender and countries. These results support the use of this scale to measure body satisfaction/dissatisfaction in Latin American adult populations.

The developmental theory of embodiment: Quantitative measurement of facilitative and adverse experiences in the social environment.

The present program of research involved developing and evaluating three fully structured measures of facilitative and adverse social experiences during adulthood described by the developmental theory of embodiment (DTE) as shaping the quality of the experiences of living in the body. The Physical Freedom Scale - adulthood (PFSa) addresses physical experiences, the Mental Freedom Scale - adulthood (MFSa) assesses exposure to social environments that either facilitate or constrict freedom from constraining social discourses, and the Social Power and Relational Connections Scale - adulthood (SPRCSa) covers experiences of accessing, or being barred from, social power and empowering relational connections. The pilot study ( N = 92) involved item revision and deletion. Study 1 (N = 412) involved factor analyses of the three scales, leading to the emergence of six, three, and four factors in the PFSa, MFSa, and SPRCSa, respectively. The study also provided initial support for the internal consistency of the scales and subscales, as well as their convergent validity. Study 2 (N = 373) confirmed the factor structure of the scales from study 2. Study 3 (N = 64) demonstrated that the scales and their factors were stable over a 3-week period. The scales can be used to study integrated sociocultural models of embodiment.

Not a happy story. A love story: Professional perceptions of love in families with child sexual abuse in two US mid-Atlantic Child Advocacy Centers.

BACKGROUND: Although research on child sexual abuse (CSA) has greatly evolved, studies revealing survivors' conflicting feelings towards their perpetrators and family members are scarce. Professionals' perceptions of love in intrafamilial CSA are often overlooked. OBJECTIVE: The current study examined the perceptions of professionals working on CSA multidisciplinary teams (MDT). The research questions were: (1) How do professionals define love in families with CSA? (2) What are professionals' perceptions of parental love in families with CSA? (3) What are professionals' perceptions of love from the abused child towards their parents and siblings? (4) What are the differences between professionals' perceptions of love and those of the families they serve, and how do professionals deal with these different perceptions during interventions? METHOD: Five focus groups with a total of 34 child advocacy center (CAC) and MDT professionals from two CACs in the US mid-Atlantic region were conducted virtually and analyzed using a thematic approach. RESULTS: The findings indicated that professionals recognized parental love at the center of familial child sexual abuse (FCSA) cases and its range from benevolent and healthy to maladaptive, offensive love. Professionals also recognized the mechanisms enabling children's love for both offending and non-offending parents and complex expressions of love between siblings, even when one sibling sexually abused another. CONCLUSIONS: This study highlights the importance of promoting discourse on love in cases of intrafamilial CSA. Recognizing and embracing the complexity of love bonds may empower the abused child and support their need to believe in their parents' love.

How do looking patterns, anti-fat bias, and causal weight attributions relate to adults' judgements of child weight?

Prevailing weight-normative approaches to health pressure adults to visually categorise children's weight, despite little understanding of how such judgements are made. There is no evidence this strategy improves child health, and it may harm children with higher weights. To understand decision-making processes and identify potential mechanisms of harm we examined perceptual and attitudinal factors involved in adults' child weight category judgements. Eye movements of 42 adults were tracked while categorizing the weight of 40 computer-generated images of children (aged 4-5 & 10-11 years) varying in size. Questionnaires assessed child-focused weight bias and causal attributions for child weight. Participants' eye movement patterns resembled those previously reported for adult bodies. Categorisation data showed a perceptual bias towards the 'mid-range' category. For higher weight stimuli, participants whose category judgements most closely matched the stimulus's objective weight had higher child-focused anti-fat bias and weaker genetic attributions for child weight - i.e,. adults who 'label' higher weight in children in line with BMI categories report more stigmatising beliefs about such children, suggesting a possible mechanism of harm. Overall, adults' judgements reflect both unalterable perceptual biases and potentially harmful attitudinal factors, calling into question the feasibility and appropriateness of public health efforts to promote visual child weight categorisation.

The associations between autistic traits and disordered eating/drive for muscularity are independent of anxiety and depression in females but not males.

Previous research has shown a positive correlation between autistic traits and eating disorder symptoms, and this relationship appears to be independent of co-occurring mental health status. The current study followed a pre-registered analysis plan with the aim to investigate a previously unconsidered factor in the relationship between autistic traits and disorders of eating and body image: the drive for muscularity. Participants (N = 1068) completed the Autism Spectrum Quotient (AQ), Hospital Anxiety and Depression Scale (HADS), Eating Attitudes Test-26 (EAT-26) and Drive for Muscularity Scale (DMS). Positive correlations between AQ and EAT-26 and AQ and DMS were observed. In females, AQ remained significantly correlated with EAT-26 and DMS when controlling for co-occurring anxiety and depression symptoms, but this was not the case in males. These findings demonstrate the moderating role of sex, and the need to consider autistic traits in individuals diagnosed with, or at a heightened risk for, disorders of eating and body image.

Newspaper media framing of obesity during pregnancy in the UK: A review and framework synthesis.

Two thirds of women report experiencing weight stigma during pregnancy. Newspaper media is powerful in framing health issues. This review synthesized UK newspaper media portrayal of maternal obesity. NexisUni was searched to identify newspaper articles, published January 2010 to May 2021, reporting content on obesity during pregnancy. Framework synthesis integrated quantitative and qualitative analysis of the content of articles. There were 442 articles included (59% tabloids and 41% broadsheets). Three overarching themes with interacting sub-themes were as follows: (1) Women were blamed for their weight, risks, and NHS impact. (2) Women were solely responsible for solving obesity, gendered from school age. (3) Women with obesity were a burden on individuals (e.g., themselves, their children, and health professionals), to society, and the NHS. Catastrophizing language framed the "problem," "scale," and "public health concern" of maternal obesity, emphasizing risk, and danger and was alarmist, aggressive, and violent as to elicit fear or devalue women. Articles platformed 'expert' voices rather than women's lived experiences. This review identified that UK newspaper media negatively frames and oversimplifies the topic of maternal obesity. Exposure to blaming and alarmist messaging could increase women's guilt, stigma, and internalized weight bias. The newspaper media should be harnessed to de-stigmatize maternal obesity and promote maternal well-being.

A Theory- and Evidence-Based Digital Intervention Tool for Weight Loss Maintenance (NoHoW Toolkit): Systematic Development and Refinement Study.

BACKGROUND: Many weight loss programs show short-term effectiveness, but subsequent weight loss maintenance is difficult to achieve. Digital technologies offer a promising means of delivering behavior change approaches at low costs and on a wide scale. The Navigating to a Healthy Weight (NoHoW) project, which was funded by the European Union's Horizon 2020 research and innovation program, aimed to develop, test, and evaluate a digital toolkit designed to promote successful long-term weight management. The toolkit was tested in an 18-month, large-scale, international, 2×2 factorial (motivation and self-regulation vs emotion regulation) randomized controlled trial that was conducted on adults with overweight or obesity who lost ≥5% of their body weight in the preceding 12 months before enrollment into the intervention. OBJECTIVE: This paper aims to describe the development of the NoHoW Toolkit, focusing on the logic models, content, and specifications, as well as the results from user testing. METHODS: The toolkit was developed by using a systematic approach, which included the development of the theory-based logic models, the selection of behavior change techniques, the translation of these techniques into a web-based app (NoHoW Toolkit components), technical development, and the user evaluation and refinement of the toolkit. RESULTS: The toolkit included a set of web-based tools and inputs from digital tracking devices (smart scales and activity trackers) and modules that targeted weight, physical activity, and dietary behaviors. The final toolkit comprised 34 sessions that were distributed through 15 modules and provided active content over a 4-month period. The motivation and self-regulation arm consisted of 8 modules (17 sessions), the emotion regulation arm was presented with 7 modules (17 sessions), and the combined arm received the full toolkit (15 modules; 34 sessions). The sessions included a range of implementations, such as videos, testimonies, and questionnaires. Furthermore, the toolkit contained 5 specific data tiles for monitoring weight, steps, healthy eating, mood, and sleep. CONCLUSIONS: A systematic approach to the development of digital solutions based on theory, evidence, and user testing may significantly contribute to the advancement of the science of behavior change and improve current solutions for sustained weight management. Testing the toolkit by using a 2×2 design provided a unique opportunity to examine the effect of motivation and self-regulation and emotion regulation separately, as well as the effect of their interaction in weight loss maintenance.

Evidence-Based Digital Tools for Weight Loss Maintenance: The NoHoW Project.

BACKGROUND: Effective interventions and commercial programmes for weight loss (WL) are widely available, but most people regain weight. Few effective WL maintenance (WLM) solutions exist. The most promising evidence-based behaviour change techniques for WLM are self-monitoring, goal setting, action planning and control, building self-efficacy, and techniques that promote autonomous motivation (e.g., provide choice). Stress management and emotion regulation techniques show potential for prevention of relapse and weight regain. Digital technologies (including networked-wireless tracking technologies, online tools and smartphone apps, multimedia resources, and internet-based support) offer attractive tools for teaching and supporting long-term behaviour change techniques. However, many digital offerings for weight management tend not to include evidence-based content and the evidence base is still limited. The Project: First, the project examined why, when, and how many European citizens make WL and WLM attempts and how successful they are. Second, the project employed the most up-to-date behavioural science research to develop a digital toolkit for WLM based on 2 key conditions, i.e., self-management (self-regulation and motivation) of behaviour and self-management of emotional responses for WLM. Then, the NoHoW trial tested the efficacy of this digital toolkit in adults who achieved clinically significant (≥5%) WL in the previous 12 months (initial BMI ≥25). The primary outcome was change in weight (kg) at 12 months from baseline. Secondary outcomes included biological, psychological, and behavioural moderators and mediators of long-term energy balance (EB) behaviours, and user experience, acceptability, and cost-effectiveness. IMPACT: The project will directly feed results from studies on European consumer behaviour, design and evaluation of digital toolkits self-management of EB behaviours into development of new products and services for WLM and digital health. The project has developed a framework and digital architecture for interventions in the context of EB tracking and will generate results that will help inform the next generation of personalised interventions for effective self-management of weight and health.

Can realistic dolls protect body satisfaction in young girls?

Ultra-thin fashion dolls may represent a risk factor for thin-ideal internalisation and body dissatisfaction amongst young girls. We asked thirty one 5- to 9-year-old girls to engage in interactive play with commercially available dolls which were either ultra-thin (Barbie and Monster High) or represented a putative realistic childlike shape (Lottie and Dora) and to indicate their perceived own-body size and ideal body size on an interactive computer task both before and after play. There was a significant interaction between testing phase and doll group such that playing with the ultra-thin dolls led to the girls' 'ideal self' becoming thinner. A further 46 girls played with the ultra-thin dolls and then played with either the same dolls again, the realistic childlike dolls, or with cars. Initial play with the ultra-thin dolls again produced a drop in perceived ideal own body size; however, no group showed any significant change in their body ideals during the additional play phase. These data indicate the potential benefit of dolls representing a realistic child body mass to young girls' body satisfaction and do not support the hypothesis that the negative impacts of ultra-thin dolls can be directly countered by other toys.

The acceptability and feasibility of using a 3D body size scale to initiate conversations about weight in toddlerhood: a mixed-methods study.

BACKGROUND: Health Care Professionals struggle to initiate conversations about overweight in toddlerhood. A novel 3D body size scale (3D BSS) may facilitate engagement with this topic during pediatric appointments. OBJECTIVES: To explore barriers and facilitators to using the 3D BSS through a mixed-methods design. METHODS: For the qualitative phase, parents of toddlers (n = 38) participated in semi-structured interviews introducing the 3D BSS of 4-5-year-old children. For the quantitative phase, pre- and post-interview questionnaires were administered to ascertain the acceptability of the 3D BSS. RESULTS: Parents rated the 3D BSS as "very" (n = 20, 52.6%) to "moderately" (n = 12, 31.6%) acceptable. Thematic analysis revealed four barriers to acceptability: i) the sensitive nature of child weight, ii) the belief that weight does not determine health, iii) the visual normalisation of overweight and iv) the need to account for individual variation in growth patterns. However, these barriers could be overcome through three facilitators: i) the provision of expert guidance ii) the value of simple tools, and iii) tailoring conversations to familial needs. CONCLUSIONS: Parents considered the 3D BSS an acceptable visual resource to discuss child weight during routine appointments. However, the acceptability of the tool was conditional on a sensitive, collaborative, and tailored delivery approach.

Corrigendum: The Impact of a Dissonance-Based Eating Disorders Intervention on Implicit Attitudes to Thinness in Women of Diverse Sexual Orientations.

[This corrects the article DOI: 10.3389/fpsyg.2019.02611.].

Television consumption drives perceptions of female body attractiveness in a population undergoing technological transition.

Perceptions of physical attractiveness vary across cultural groups, particularly for female body size and shape. It has been hypothesized that visual media propagates Western "thin ideals." However, because cross-cultural studies typically consider groups highly differentiated on a number of factors, identifying the causal factors has thus far been impossible. In the present research, we conducted "naturalistic" and controlled experiments to test the influence of media access on female body ideals in a remote region of Nicaragua by sampling from villages with and without regular TV access. We found that greater TV consumption remained a significant predictor of preferences for slimmer, curvier female figures after controlling for a range of other factors in an ethnically balanced sample of 299 individuals (150 female, aged 15-79) across 7 villages. Within-individual analyses in 1 village over 3 years also showed an association between increased TV consumption and preferences for slimmer figures among some participants. Finally, an experimental study in 2 low-media locations demonstrates that exposure to media images of fashion models can directly impact participants' body size ideals. We provide the first converging cross-sectional, longitudinal, and experimental evidence from field-based research, that media exposure can drive changes in perceptions of female attractiveness. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Impact of a Dissonance-Based Eating Disorders Intervention on Implicit Attitudes to Thinness in Women of Diverse Sexual Orientations.

Dissonance-based body image programs have shown long-term effectiveness in preventing eating disorders and reducing risk factors for eating disorders in women. Here we report on the potential for one such intervention to impact on implicit attitudes toward thinness as well as an explicit measure of eating attitudes, across a sexually diverse group of young women. The Succeed Body Image Programme was adapted to remove heteronormative assumptions and was delivered to a final sample of 56 undergraduate women who reported their sexual orientation as either "predominantly heterosexual" (our term; 1 or 2 on a 7-point Kinsey scale, n = 38) or non-heterosexual (3-7 on the Kinsey scale, n = 18). Before and after the intervention, they completed the Eating Attitudes Test-26, and an associative reaction time task based on the Implicit Association Test, in which bodies of low and higher weight were paired with socially desirable or undesirable traits. A total of 37 predominantly heterosexual women completed a control intervention in which they read NHS leaflets on eating disorders and healthy weight. Results showed that the intervention made predominantly heterosexual participants less prone, versus control, to associating thinness with positive traits on the IAT and all women completing the intervention reported a lower level of disordered eating attitudes at post- than pre-test. Non-heterosexual women, however, showed a non-significant increase in thin-bias on the IAT, perhaps due to their low baseline. These results imply that intensive dissonance-based programs can change attitudes at the automatic, implicit level as well as merely giving women tools to overcome those implicit attitudes.

The NoHoW protocol: a multicentre 2×2 factorial randomised controlled trial investigating an evidence-based digital toolkit for weight loss maintenance in European adults.

INTRODUCTION: Obesity and associated diseases place a severe burden on healthcare systems. Behavioural interventions for weight loss (WL) are successful in the short term but often result in weight regain over time. Self-regulation of eating and activity behaviours may significantly enhance weight loss maintenance (WLM) and may be effectively augmented by contextual behavioural approaches to emotion regulation. The NoHoW trial tests the efficacy of a theoretically informed, evidence-based digital toolkit using a mobile-enabled website, activity trackers and Wi-Fi scales for WLM aiming to target (1) self-regulation and motivation, and (2) emotion regulation in adults who achieved clinically significant (≥5%) WL in the previous 12 months (initial body mass index (BMI) ≥25 kg/m2). METHODS AND ANALYSIS: The study is an 18-month, 3-centre, 2×2 factorial single-blind, randomised controlled trial, which recruited 1627 participants achieving ≥5% WL between March 2017 and March 2018. Participants are randomly allocated to one of four arms: (1) self-monitoring only (self-weighing and activity tracker), (2) self-regulation and motivation, (3) emotion regulation or (4) combined self-regulation, motivation and emotion regulation. Participants attend four clinical investigation days at 0, 6, 12 and 18 months and are instructed to use the digital toolkit for 18 weeks during the first 6 months and at their discretion for the remaining 12 months. The primary outcome is change in weight (kg) at 12 months from baseline. Secondary outcomes are body composition (eg, bioimpedance analysis), health biomarkers (glycated haemoglobin, lipids, blood pressure, hair cortisol), dietary intake, physical activity, sleep, motivational, self-regulatory, emotion regulatory moderators/mediators of WLM, engagement, user experience, acceptability and cost-effectiveness of the interventions. ETHICS AND DISSEMINATION: Ethical approval was granted by Institutional Ethics Committees at the Universities of Leeds (17-0082; 27 February 2017), Lisbon (17/2016; 20 February 2017) and Capital Region of Denmark (H-16030495, 8 March 2017). Results will be published in scientific journals. TRIAL REGISTRATION NUMBER: ISRCTN88405328.

Obesity Stigma: Is the 'Food Addiction' Label Feeding the Problem?

Obesity is often attributed to an addiction to high-calorie foods. However, the effect of "food addiction" explanations on weight-related stigma remains unclear. In two online studies, participants (n = 439, n = 523, respectively, recruited from separate samples) read a vignette about a target female who was described as 'very overweight'. Participants were randomly allocated to one of three conditions which differed in the information provided in the vignette: (1) in the "medical condition", the target had been diagnosed with food addiction by her doctor; (2) in the "self-diagnosed condition", the target believed herself to be a food addict; (3) in the control condition, there was no reference to food addiction. Participants then completed questionnaires measuring target-specific stigma (i.e., stigma towards the female described in the vignette), general stigma towards obesity (both studies), addiction-like eating behavior and causal beliefs about addiction (Study 2 only). In Study 1, participants in the medical and self-diagnosed food addiction conditions demonstrated greater target-specific stigma relative to the control condition. In Study 2, participants in the medical condition had greater target-specific stigma than the control condition but only those with low levels of addiction-like eating behavior. There was no effect of condition on general weight-based stigma in either study. These findings suggest that the food addiction label may increase stigmatizing attitudes towards a person with obesity, particularly within individuals with low levels of addiction-like eating behavior.

Behavioural intervention for weight loss maintenance versus standard weight advice in adults with obesity: A randomised controlled trial in the UK (NULevel Trial).

BACKGROUND: Scalable weight loss maintenance (WLM) interventions for adults with obesity are lacking but vital for the health and economic benefits of weight loss to be fully realised. We examined the effectiveness and cost-effectiveness of a low-intensity technology-mediated behavioural intervention to support WLM in adults with obesity after clinically significant weight loss (≥5%) compared to standard lifestyle advice. METHODS AND FINDINGS: The NULevel trial was an open-label randomised controlled superiority trial in 288 adults recruited April 2014 to May 2015 with weight loss of ≥5% within the previous 12 months, from a pre-weight loss BMI of ≥30 kg/m2. Participants were self-selected, and the majority self-certified previous weight loss. We used a web-based randomisation system to assign participants to either standard lifestyle advice via newsletter (control arm) or a technology-mediated low-intensity behavioural WLM programme (intervention arm). The intervention comprised a single face-to-face goal-setting meeting, self-monitoring, and remote feedback on weight, diet, and physical activity via links embedded in short message service (SMS). All participants were provided with wirelessly connected weighing scales, but only participants in the intervention arm were instructed to weigh themselves daily and told that they would receive feedback on their weight. After 12 months, we measured the primary outcome, weight (kilograms), as well as frequency of self-weighing, objective physical activity (via accelerometry), psychological variables, and cost-effectiveness. The study was powered to detect a between-group weight difference of ±2.5 kg at follow-up. Overall, 264 participants (92%) completed the trial. Mean weight gain from baseline to 12 months was 1.8 kg (95% CI 0.5-3.1) in the intervention group (n = 131) and 1.8 kg (95% CI 0.6-3.0) in the control group (n = 133). There was no evidence of an effect on weight at 12 months (difference in adjusted mean weight change from baseline: -0.07 [95% CI 1.7 to -1.9], p = 0.9). Intervention participants weighed themselves more frequently than control participants and were more physically active. Intervention participants reported greater satisfaction with weight outcomes, more planning for dietary and physical activity goals and for managing lapses, and greater confidence for healthy eating, weight loss, and WLM. Potential limitations, such as the use of connected weighing study in both trial arms, the absence of a measurement of energy intake, and the recruitment from one region of the United Kingdom, are discussed. CONCLUSIONS: There was no difference in the WLM of participants who received the NULevel intervention compared to participants who received standard lifestyle advice via newsletter. The intervention affected some, but not all, process-related secondary outcomes of the trial. TRIAL REGISTRATION: This trial is registered with the ISRCTN registry (ISRCTN 14657176; registration date 20 March 2014).

Attribution of weight regain to emotional reasons amongst European adults with overweight and obesity who regained weight following a weight loss attempt.

PURPOSE: Despite the wide availability of effective weight loss programmes, maintenance of weight loss remains challenging. Difficulties in emotion regulation are associated with binge eating and may represent one barrier to long-term intervention effectiveness in obesity. The purpose of this study was to determine the relationship between emotion regulation difficulties and the extent of weight regain in a sample of adults who had lost, and then regained, weight, and to examine the characteristics associated with emotional difficulties. METHODS: 2000 adults from three European countries (UK, Portugal, and Denmark) completed an online survey assessing self-reported weight loss and regain following their most recent weight loss attempt. They also completed a binge eating disorder screening questionnaire and, if they had regained weight, were asked if they attributed it to any emotional factors (a proxy for emotion regulation difficulties). Spearman's correlations and logistic regression were used to assess the associations between emotion regulation, weight regain, and strategy use. RESULTS: Emotion regulation difficulties were associated with greater weight regain (N = 1594 who lost and regained weight). Attribution to emotional reasons was associated with younger age, female gender, loss of control and binge eating, lower perceptions of success at maintenance, using more dietary and self-regulatory strategies in weight loss, and fewer dietary strategies in maintenance. CONCLUSIONS: Weight-related emotion regulation difficulties are common amongst regainers and are associated with regaining more weight. Affected individuals are already making frequent use of behavioural strategies during weight loss, but do not apply these consistently beyond active attempts. Simply encouraging the use of more numerous strategies, without concurrently teaching emotion regulation skills, may not be an effective means to improving weight outcomes in this group. LEVEL OF EVIDENCE: Level V, descriptive (cross-sectional) study.

The complexity of self-regulating food intake in weight loss maintenance. A qualitative study among short- and long-term weight loss maintainers.

RATIONALE: Whether self-regulation of food intake in weight loss maintenance (WLM) differs between being a short-term maintainer (having maintained without regaining less than 12 months) and a long-term maintainer (having maintained without regaining at least 12 months) is under-researched. OBJECTIVE: The aim of this study was to explore the self-regulatory strategies and self-efficacy beliefs applied by short- and long-term maintainers to the complex set of behaviours comprising food intake in WLM, and to obtain a better understanding of their challenges in the various food-intake processes in WLM. METHOD: Individual interviews (14 female/4 male) were conducted with nine Danish short- and nine long-term weight loss maintainers. The Health Action Process Approach (HAPA) was applied post-hoc to organise data and support analyses, since the approach focuses on both the cognitions (e.g., self-efficacy, the nature of which differs depending on the phase of behaviour change) and self-regulatory strategies (e.g., action planning and coping planning) involved in behaviour change. RESULTS: Self-regulatory strategies and self-efficacy beliefs varied between the food-related behaviours and between short- and long-term maintainers. Consistent with the progression suggested by HAPA, with repeated use of action and coping planning, long-term maintainers had formed habitual routines, not only allowing them more flexibility, but also providing them stronger self-control in the behaviours related to WLM such as buying and storing food, and eating at social gatherings. The short-term maintainers often displayed a 'weight loss mind-set.' The short-term maintainers focused on the avoidance of certain behaviours, showed less self-regulatory flexibility, and exhibited more detailed action planning, but their interviews also inferred that they had ambitions to build strong WLM-habits, maintenance, and recovery self-efficacy. CONCLUSION: The contribution of this study is a more comprehensive view on food intake as an outcome of a set of complex behaviours, revealing insights into the differences in cognitions and strategies applied to the task of WLM, between short- and long-term maintainers.