Illness duration and treatment outcome of intensive cognitive-behavioral therapy in adolescents with anorexia nervosa.

OBJECTIVE: This study aimed to compare the effectiveness of an intensive treatment based on enhanced cognitive-behavioral therapy (CBT-E) in patients aged between 12 and 18 years with anorexia nervosa with a duration of illness <3 versus ≥3 years. METHODS: One hundred and fifty-nine consecutively treated patients (n = 122 with illness duration <3 years and n = 37 ≥ 3 years) were enrolled in a 20-week intensive CBT-E program. All patients underwent assessment at admission, end of treatment (EOT), and 20-week follow-up. The following measures were used: body mass index (BMI)-for-age percentile and percentage of expected body weight (EBW), Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment. RESULTS: Approximately 81% of eligible patients began the program, with over 80% successfully completing it. Patients with a longer or shorter duration of illness did not show significantly different treatment outcomes. In detail, BMI-for-age percentile and percentage of EBW outcomes were significantly improved from baseline to EOT, remaining stable until 20-week follow-up in both groups. Similarly, in both groups, scores for eating disorder psychopathology, general psychopathology, and clinical impairment decreased significantly at EOT and remained stable from EOT to follow-up. Furthermore, a substantial percentage of adolescents in both groups achieved a good BMI outcome at EOT and 20-week follow-up, with approximately 60% maintaining a full response at the latter time point. DISCUSSION: These findings suggest that intensive CBT-E appears to be an effective treatment for severely ill adolescent patients with anorexia nervosa, regardless of whether the duration of illness is shorter or longer than 3 years. PUBLIC SIGNIFICANCE: Existing treatment outcome studies in adolescents, whether randomized controlled trials or longitudinal investigations, typically involve patients with less than 3 years of illness, while data on the treatment outcomes for adolescents with anorexia nervosa with an illness duration of 3 years or over is very limited. Our findings suggest that adolescents with anorexia nervosa, irrespective of the duration of their illness, can derive similar benefits from intensively CBT-E.

The impact of the COVID-19 pandemic on intensive cognitive behavioral therapy outcomes in patients with anorexia nervosa-A cohort study.

OBJECTIVE: This study aimed to assess the impact of the COVID-19 pandemic on the efficacy of an intensive treatment based on enhanced cognitive behavioral therapy (CBT-E) in patients with anorexia nervosa. METHODS: This cohort study analyzed 57 patients with anorexia nervosa who experienced the COVID-19 pandemic during intensive CBT-E, comparing their outcomes (body mass index [BMI], eating-disorder and general psychopathology, and clinical impairment) with those of patients with anorexia nervosa matched by gender, age, and BMI given the same treatment before the COVID-19 outbreak as controls. Patients were assessed at baseline, at the end of treatment and after 20 weeks of follow-up. RESULTS: More than 75% of patients during the pandemic versus 85% of controls completed the treatment, a difference that was not significant. BMI, eating disorder and general psychopathology and clinical impairment scores improved significantly from baseline to 20-week follow-up in both groups. However, the improvement was more marked in controls than in those treated during the COVID-19 pandemic. CONCLUSION: Patients with anorexia nervosa given intensive CBT-E during the COVID-19 pandemic had significantly improved psychopathology, albeit to a lesser extent than patients given the same treatment before the COVID-19 pandemic. PUBLIC SIGNIFICANCE STATEMENT: In this study, the outcome of 57 patients with anorexia treated with intensive enhanced cognitive behavior therapy during the COVID-19 pandemic was compared with a matched group treated before the pandemic hit. The rate of remission from anorexia nervosa was similar between the two groups. However, patients exposed to the COVID-19 pandemic showed lesser improvement than those not exposed.

Effectiveness of enhanced cognitive behaviour therapy for patients aged 14 to 25: A promising treatment for anorexia nervosa in transition-age youth.

OBJECTIVE: The study aimed to evaluate the effectiveness of enhanced cognitive behaviour therapy (CBT-E) on patients with anorexia nervosa (AN) aged 14 to 25 treated in a real-world setting. METHOD: One hundred and fifteen patients with AN (n = 61, age <18 years) were recruited from consecutive referrals to a clinical eating disorder service offering outpatient CBT-E. Body Mass Index (BMI), BMI centiles, Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment scores were recorded at admission, at the end of treatment, and at 20-week follow-up. RESULTS: The seventy-two patients (62.6%) who finished the programme showed considerable weight gain and reduced scores for clinical impairment and eating-disorder and general psychopathology. Changes remained stable at 20 weeks. A comparison between adolescent and adult patients indicates similar improvements in eating-disorder psychopathology. CONCLUSIONS: The benchmark data yielded by this study suggest that CBT-E is a well-accepted and promising treatment that could be adopted to ensure continuity of care across the transitional age.

Metabolomics signatures of acutely ill and short-term weight recovered women with anorexia nervosa.

Although metabolomics studies are recently spreading and have allowed the characterization of putative biomarkers in many diseases, they are relatively scanty in anorexia nervosa (AN). In this explorative study we analyzed the fecal metabolomics profiles of women with AN in the underweight phase (n = 24) and after short-term weight restoration (n = 16) and compared them with 20 healthy women. An untargeted metabolomic procedure allowed the characterization of 224 metabolites involved in energy, lipid, and amino acid metabolism. A partial least square discriminant analysis identified 14 metabolites with a variable importance in projection score >1.5 that clearly differentiated underweight from weight-restored patients from healthy women. Compared with healthy women, fecal concentrations of valeric acid and 3-methyl,2-ketobutyric acid were increased in both underweight and weight-restored patients; fecal concentrations of propionic acid, stearic acid, linolenic acid, methyl-galactoside, coprosterol, cycloserine, and lauric acid were increased while fecal levels of xylose, fucose, and rhamnose were decreased in underweight patients and normalized after weight-restoration; fecal concentrations of piperine, phenylalanine, butyric acid, and meso-erythritol-1 were decreased while fecal levels of hydroxystearic acid were increased in weight-restored but normal in underweight AN patients. All these changes point to peculiar fecal metabolomics profiles of acute and short-term weight restored AN patients. The value of these changes to improve our understanding of the pathophysiology of AN and to characterize potential biomarker targets for developing new treatment strategies needs further studies to be clarified.

Changes in specific and nonspecific psychopathology network structure after intensive cognitive behavior therapy in patients with anorexia nervosa.

OBJECTIVE: This study aimed to compare eating disorder-specific and nonspecific clinical features in patients with anorexia nervosa before and after intensive enhanced cognitive behavior therapy (CBT-E) via network analysis. METHODS: All consecutive patients admitted to intensive CBT-E were eligible, and the sample comprised patients aged ≥16 years who completed a 20-week intensive CBT-E program. Body mass index (BMI), Eating Disorder Examination Questionnaire and Brief Symptoms Inventory responses were gathered at baseline and end of treatment, and used to generate statistical networks of the connections between symptoms (nodes) and the strength and centrality thereof. RESULTS: A total of 214 patients were included. Most nodes had relatively similar centrality compared to other nodes in the networks. "Eating concern" and "phobic anxiety" showed the greatest bridge centrality at both time points. No differences were found between baseline and the end of treatment in either global network or individual connection strengths. CONCLUSION: These findings suggest that some clinical expressions not specific to eating-disorder psychopathology remain strongly connected in the generalized network of patients with anorexia nervosa after CBT-E. Future research should examine whether additional procedures specifically designed to target these symptoms should be integrated into this and other treatments.

Day-hospital enhanced cognitive behavior therapy for adults with eating disorders: Immediate and follow-up effects.

OBJECTIVE: To assess outcomes in adult patients with eating disorders administered enhanced cognitive behavioral therapy (CBT-E) in a day-hospital setting. METHOD: Forty-three consecutive patients with eating disorders (86% females; mean age 28.8 [SD = 11.8]) were admitted to a 13-week day-hospital CBT-E program. Twenty-five (58.1%) patients were underweight (i.e., body mass index [BMI] <18.5 kg/m2 ; BMI 15.4 [SD = 2.2]) and 18 not (mean BMI 23.1 [SD = 6.3]) at baseline. All patients responded poorly to prior outpatient treatment. Body mass index and Eating Disorder Examination Questionnaire (EDE-Q), Brief Symptom Inventory (BSI), and Clinical Impairment Assessment (CIA) scores were recorded at baseline, end of treatment, and 20-week follow-up. RESULTS: In 37 patients (86.0%) who completed the treatment, there were substantial improvements in eating-disorder features, general psychopathology, clinical impairment, and body weight (only in underweight patients), which were well maintained at follow-up. DISCUSSION: Day-hospital CBT-E is a promising treatment for adults with eating disorders.

The clinical perfectionism questionnaire: psychometric properties of the Italian version in patients with eating disorders.

BACKGROUND: Problematic perfectionism has been traditionally conceptualized as a multidimensional construct, and specific instruments have been developed to capture its various dimensions. However, the Clinical Perfectionism Questionnaire (CPQ) was recently designed to measure a unidimensional construct called "clinical perfectionism", but the questionnaire has not yet been validated in Italian. AIM: This study aimed to propose the Italian version of the CPQ and examine its psychometric properties. METHODS: The CPQ was translated into Italian using translation and back-translation procedures. Then, it was administered to 188 Italian-speaking patients with eating disorders and 126 non-eating disorder group (excluded if the Italian version of the Eating Attitudes Test-26 was ≥ 20). The clinical group also completed the Italian versions of the Frost Multidimensional Perfectionism Scale (FMPS), the Eating Disorder Examination Questionnaire (EDE-Q), and the Brief Symptom Inventory (BSI). RESULTS: Confirmatory factor analysis revealed a good fit for the bifactor structure of the 10-item version. Internal consistency was high for the general clinical perfectionism factor, and test-retest reliability was good. Convergent validity was acceptable for the general clinical perfectionism and 'overvaluation of striving' group factors. The CPQ showed significantly higher scores in patients with eating disorders than in the non-eating disorder group. CONCLUSIONS: Overall, the study demonstrated the good psychometric properties of the Italian version of the CPQ, and validated its use in Italian-speaking patients with eating disorders. Although further research is required, the CPQ has promising evidence as a reliable and valid measure of clinical perfectionism in its Italian version. LEVEL OF EVIDENCE: Level V, Descriptive study.

McArdle disease in a patient with anorexia nervosa: a case report.

BACKGROUND: McArdle disease is an autosomal recessive genetic disorder caused by a deficiency of the glycogen phosphorylase (myophosphorylase) enzyme, which muscles need to break down glycogen into glucose for energy. Symptoms include exercise intolerance, with fatigue, muscle pain, and cramps being manifested during the first few minutes of exercise, which may be accompanied by rhabdomyolysis. CASE PRESENTATION: This case report describes for the first time the clinical features, diagnosis and management of a 20 year-old patient with anorexia nervosa and McArdle disease, documented by means of muscle biopsy. CONCLUSION: Anorexia nervosa and McArdle disease interact in a detrimental bidirectional way. In addition, some laboratory parameter alterations (e.g., elevated values of creatine kinase) commonly attributed to the specific features of eating disorders (e.g., excessive exercising) may delay the diagnosis of metabolic muscle diseases. On the other hand, the coexistence of a chronic disease, such as McArdle disease, whose management requires the adoption of a healthy lifestyle, can help to engage patients in actively addressing their eating disorder.

Validity and reliability of the Dietary Rules Inventory (DRI).

BACKGROUND: Dietary rules are common in patients with eating disorders, and according to transdiagnostic cognitive behavioural theory for eating disorders, represent a key behaviour maintaining eating-disorder psychopathology. The aim of this study was to describe the design and validation of the Dietary Rules Inventory (DRI), a new self-report questionnaire that assesses dietary rules in patients with eating disorders. METHODS: A transdiagnostic sample of 320 patients with eating disorders, as well as 95 patients with obesity and 122 healthy controls were recruited. Patients with eating disorders also completed the Dutch Eating Behaviour Questionnaire (DEBQ), the Eating Disorder Examination Questionnaire, the Brief Symptoms Inventory and the Clinical Impairment Assessment. Dietary rules were rated on a continuous Likert-type scale (0-4), rating how often (from never to always) they had been applied over the previous 28 days. RESULTS: DRI scores were significantly higher in patients with eating disorders than in patients with obesity and healthy controls. Principal factor analysis identified that 55.8% of the variance was accounted for by four factors, namely 'what to eat', 'social eating', 'when and how much to eat' and 'caloric level'. Both global score and subscales demonstrated high internal and test-retest reliability. The DRI global score was significantly correlated with the DEBQ 'restrained eating' subscale, as well as eating-disorder and general psychopathology and clinical impairment scores, demonstrating good convergent validity. CONCLUSIONS: These findings suggest that the DRI is a valid self-report questionnaire that may provide important clinical information regarding the dietary rules underlying dietary restraint in patients with eating disorders. LEVEL OF EVIDENCE: V, descriptive study.

Change in eating-disorder psychopathology network structure in patients with anorexia nervosa treated with intensive cognitive behavior therapy.

OBJECTIVE: This study was designed to compare the change in eating-disorder feature networks in patients with anorexia nervosa after treatment with intensive enhanced cognitive behavior therapy (CBT-E). METHODS: Patients seeking treatment for anorexia nervosa were consecutively recruited from January 2016 to September 2020. All patients aged ≥16 years who completed a 20-week intensive CBT-E program (13 weeks of inpatient followed by 7 weeks of day-hospital treatment) were included in the study. Body mass index (BMI) was measured, and the Eating Disorder Examination Questionnaire completed for each patient, both at baseline and the end of treatment. RESULTS: The sample comprised 214 patients with anorexia nervosa. Treated patients showed significant improvements in BMI and eating-disorder psychopathology. Network analysis revealed a significant reduction in the network global and connection strengths at the end of treatment. The most central and highly interconnected nodes in the network at baseline were related to the drive for thinness, but at the end of treatment to body image concerns. Some edge connections were significantly stronger at baseline than at the end of treatment, while others were significantly stronger at the end of treatment than at baseline. DISCUSSION: CBT-E reduces the psychopathology network connectivity over time in patients with anorexia nervosa. The differences in central nodes and edge connections between baseline and end of treatment, not detected by classical inferential analysis, may be informative for understanding the centrality of symptoms in the psychopathology network, and how a specific treatment may act to reduce symptoms and change their connections over time.

Enhanced cognitive behavior therapy for severe and extreme anorexia nervosa: An outpatient case series.

OBJECTIVE: The study aimed to assess outcomes in patients with severe and extreme anorexia nervosa managed with enhanced cognitive behavior therapy (CBT-E) in a real-world outpatient setting. METHOD: Thirty patients with anorexia nervosa and body mass index (BMI) <16 aged ≥17 years were recruited from consecutive referrals to an eating disorder service clinic offering outpatient CBT-E. BMI and Eating Disorder Examination Questionnaire (EDE-Q), Brief Symptom Inventory (BSI), and Clinical Impairment Assessment (CIA) scores were recorded at admission, end of treatment, and 20- and 60-week follow-ups for treatment completers. RESULTS: Twenty patients (66.7%) completed the treatment and showed both considerable weight gain (Cohen's f = 1.43), and significantly reduced scores for clinical impairment (f = 1.26) and eating-disorder (f = 1.03) and general psychopathology (f = 0.99). Changes remained stable at both follow-ups. About half of the patients who completed treatment had a BMI ≥18.5 at the end of treatment and follow-ups. DISCUSSION: CBT-E seems suitable and promising for patients with severe and extreme anorexia nervosa seeking treatment in a real-world clinical setting, provided that their medical conditions are stable, and they have no current major depressive episodes or substance abuse; it may represent a valid alternative to inpatient treatment for those who are able to sustain engagement in a full course of outpatient treatment.

Attachment representations and alexithymia in community adolescents with binge-eating attitudes.

PURPOSE: The aims of the current study were: (a) to compare community adolescent groups with and without binge eating (BE) on attachment representations and alexithymia, using an age-adapted interview to assess attachment; and (b) to explore the independent role of attachment and alexithymia as potentially related to BE in community adolescents. METHODS: Three hundred eighty-two community adolescents were screened with respect to BE symptoms through the Binge Eating Scale (BES). The 22 girls identified with BE (BE group) and 22 age- and gender-matched peers without BE (NBE group) were assessed with the Friends and Family Interview (FFI) and the Toronto Alexithymia Scale (TAS-20). RESULTS: Binge eating group reported greater attachment preoccupation in comparison to NBE, while no difference emerged in alexithymia. More insecure attachment patterns, both preoccupied and dismissing, were significantly and independently associated with BES score in community girls. CONCLUSIONS: Insecure attachment, assessed with semi-structured interview, is associated with BE among adolescents' community girls, while apparently alexithymia is not. Future prospective studies should assess the role of attachment in the development of BE in adolescents. LEVEL OF EVIDENCE: III, case-control analytic study.

Enhanced cognitive-behavior therapy and family-based treatment for adolescents with an eating disorder: a non-randomized effectiveness trial.

BACKGROUND: Family-based treatment (FBT) is an efficacious intervention for adolescents with an eating disorder. Evaluated to a lesser degree among adolescents, enhanced cognitive-behavior therapy (CBT-E) has shown promising results. This study compared the relative effectiveness of FBT and CBT-E, and as per manualized CBT-E, the sample was divided into a lower weight [<90% median body mass index (mBMI)], and higher weight cohort (⩾90%mBMI). METHOD: Participants (N = 97) aged 12-18 years, with a DSM-5 eating disorder diagnosis (largely restrictive, excluding Avoidant Restrictive Food Intake Disorder), and their parents, chose between FBT and CBT-E. Assessments were administered at baseline, end-of-treatment (EOT), and follow-up (6 and 12 months). Treatment comprised of 20 sessions over 6 months, except for the lower weight cohort where CBT-E comprised 40 sessions over 9-12 months. Primary outcomes were slope of weight gain and change in Eating Disorder Examination (EDE) Global Score at EOT. RESULTS: Slope of weight gain at EOT was significantly higher for FBT than for CBT-E (lower weight, est. = 0.597, s.e. = 0.096, p < 0.001; higher weight, est. = 0.495, s.e. = 0.83, p < 0.001), but not at follow-up. There were no differences in the EDE Global Score or most secondary outcome measures at any time-point. Several baseline variables emerged as potential treatment effect moderators at EOT. Choosing between FBT and CBT-E resulted in older and less well participants opting for CBT-E. CONCLUSIONS: Results underscore the efficiency of FBT to facilitate weight gain among underweight adolescents. FBT and CBT-E achieved similar outcomes in other domains assessed, making CBT-E a viable treatment for adolescents with an eating disorder. CLINICAL TRIAL REGISTRATION INFORMATION: Treatment Outcome in Eating Disorders; https://clinicaltrials.gov/; NCT03599921.

Severe and enduring anorexia nervosa: No easy solutions.

There is currently no evidence-based definition of severe and enduring anorexia nervosa (SE-AN) with which to reliably inform clinical practice and research. Indeed, data on the effect of AN severity and duration on treatment outcome are inconsistent. A large group of patients with SE-AN are repeatedly unsuccessfully managed with the available eating disorders treatments and have no access to adequate treatment for their illness. Cognitive behavioral therapy (CBT) adapted for SE-AN has been designed to enhance quality of life and reduce harm rather than promoting weight gain in such patients, and has had some success. However, a percentage of patients with SE-AN achieves remission, or at least returns to a normal weight range, with available evidence-based treatments for eating disorders, such as enhanced CBT (CBT-E). It would therefore be worth conducting a large-scale randomized controlled trial comparing CBT adapted for SE-AN with CBT-E to assess their relative acceptability; efficacy, including their effect on quality of life and medical stability; cost-effectiveness; and the treatment response moderators that might allow better matching of patients with SE-AN to a treatment oriented either to harm reduction or to change.

Psychological features in obesity: A network analysis.

OBJECTIVE: Enhanced understanding of psychosocial factors associated with obesity may improve knowledge of their interplay mechanisms. The aim of this study was to assess the relationship between psychosocial variables in individuals with obesity using a network analysis. METHODS: Patients seeking treatment for obesity were consecutively recruited from a rehabilitative residential treatment program for severe obesity between January 2016 and March 2019. Each patient completed the following questionnaires: Eating Disorder Examination Questionnaire, Symptom Checklist-90, Obesity Related Well-Being, and Weight Bias Internalization Scale. In addition, current body mass index (BMI) was measured, and maximum acceptable and dream BMI were assessed. RESULTS: The sample comprised 996 patients with obesity (age 52.3 [SD = 16.0] years; BMI 41.8 [SD = 7.8] kg/m2 ; 65.7% women; 52.2% married or living with a partner). Network analysis showed that interpersonal sensitivity and shape-weight concern, but also internalized weight stigma, were the most central and highly interconnected nodes in the network. In contrast, objective binge-eating episodes and dietary restraint were the most peripheral and least connected nodes. Eating disorder features and psychological distress formed two clearly separate clusters. No difference in network structure was found between men and women. CONCLUSIONS: The pattern of network node connections supports the importance of assessing psychological distress, interpersonal sensitivity, shape-weight concern, and internalized weight stigma in patients seeking treatment for obesity.

Effectiveness of intensive cognitive behavioral therapy in adolescents and adults with anorexia nervosa.

OBJECTIVE: This study aimed to compare the effectiveness of an intensive treatment based on enhanced cognitive behavioral therapy (CBT-E) in adolescent and adult patients with anorexia nervosa. METHODS: A total of 150 consecutive patients (74 adolescents and 81 adults) were admitted to a 20-week intensive CBT-E program (13 weeks of inpatient followed by 7 weeks of day-hospital treatment). All patients had responded poorly to previous outpatient treatments and were assessed at admission, end of treatment (EOT), and 20- and 60-week follow-ups. RESULTS: About 70% of eligible patients began the program, and more than 85% completed it. Body mass index (BMI) in adults and BMI-for-age percentile in adolescents improved significantly from baseline to EOT, remained stable until 20-week follow-up, and slightly decreased from 20-week follow-up to 60-week follow-up, while remaining in the lower normal range. Eating disorder psychopathology, general psychopathology, and clinical impairment scores decreased significantly at EOT and showed only a slight increase from EOT to follow-ups. No difference was found between adolescent and adult patients in treatment acceptance, dropout, or any outcome measure. DISCUSSION: These findings indicate that intensive CBT-E seems to be an effective treatment for severely ill adolescent and adult patients with anorexia nervosa.

Eating disorder psychopathology in adults and adolescents with anorexia nervosa: A network approach.

OBJECTIVE: The aim of this study was to assess and compare eating disorder feature networks in adult and adolescent patients with anorexia nervosa. METHODS: Patients seeking treatment for anorexia nervosa in inpatient and outpatient settings were consecutively recruited from January 2008 to September 2019. Body mass index was measured, and each patient completed the Eating Disorder Examination Questionnaire. RESULTS: The sample comprised 547 adolescent and 724 adult patients with anorexia nervosa. Network analysis showed that in both adults and adolescents, the most central and highly interconnected nodes in the network were related to shape overvaluation and desiring weight loss. The network comparison test identified similar global strength and network invariance, confirming the similarity of the two network structures. DISCUSSION: The network structures in adult and adolescent patients with anorexia nervosa are similar, and lend weight to the cognitive behavioral theory that overvaluation of shape and weight is the core feature of anorexia nervosa psychopathology.

Controlling binge eating and weight: a treatment for binge eating disorder worth researching?

PURPOSE: The majority of those who seek treatment for binge eating disorder also have accompanying obesity or overweight. The best available psychological treatments for binge eating disorder produce good and lasting outcomes with regard to control over eating but virtually no weight loss, yet control over eating and weight loss are both important and valued goals of those who seek treatment. METHODS: We have devised a model of the processes maintaining both the binge eating and the overweight or obesity that occurs in many patients with binge eating disorder who seek treatment. The model draws on previous research findings to highlight and integrate the factors maintaining both the disordered eating and the accompanying overweight or obesity. RESULTS: We outline a new treatment based on the proposed model that explicitly addresses the twin goals of cessation of binge eating and weight loss in an integrated fashion. The proposed treatment incorporates and integrates elements from two previously tested evidence-based interventions, enhanced cognitive behavioural therapy for eating disorders shown to reduce binge eating and cognitive behaviour therapy of obesity, which produces weight loss. CONCLUSION: To meet a major challenge for the treatment of binge eating disorder (BED), we have proposed that an integrated treatment with the goals of addressing both binge eating and overweight or obesity is worth researching further. Should this treatment be successful, the goals of many patients who seek treatment for BED are more likely to be met. LEVEL OF EVIDENCE: This brief report proposes a new approach to clinical practice to be researched further. The evidence on the basis of which the case is made is derived from Level 1: evidence obtained from at least one properly designed randomized controlled trial; systematic reviews and meta-analyses; and experimental studies.

The association between weight maintenance and session-by-session diet adherence, weight loss and weight-loss satisfaction.

OBJECTIVE: The aim of this study was to assess the association between weight-loss maintenance and weight-loss satisfaction, adherence to diet and weight loss, all measured session-by-session during the weight-loss phase of cognitive behavioral therapy. METHODS: The present exploratory study examined a subgroup of fifty-eight patients who participated in a randomized controlled trial and who lost at least the 10% of their baseline weight. Patients were grouped into weight-loss 'Maintainers' (i.e., those who maintained a weight loss of ≥ 10% of baseline body weight at 6 months after the weight-loss phase) and 'Regainers' (i.e., those who did not maintain > 10% weight loss at 6 months after the weight-loss phase). Body weight, adherence to diet and weight-loss satisfaction were measured session-by-session during the weight-loss phase. RESULTS: Thirteen patients (22.4%) were classified as 'Regainers', and 45 (77.6%) as 'Maintainers'. Compared to 'Maintainers', 'Regainers' had a lower adherence to diet after the initial 11 weeks, and a progressively declining weight loss and weight-loss satisfaction from week 15 or 19 of the weight-loss phase. 11-week dietary adherence and 15-week weight loss were significantly associated with weight maintenance. Similar results were obtained using the amount of weight change as dependent variable. CONCLUSIONS: Adherence to diet, weight loss and weight-loss satisfaction, measured during the late weight-loss phase, are associated with weight-loss maintenance. LEVEL OF EVIDENCE: Level III, evidence obtained from well-designed cohort or case-control analytical studies.

Personalized group cognitive behavioural therapy for obesity: a longitudinal study in a real-world clinical setting.

PURPOSE: Severe obesity is difficult to treat, and non-surgical treatment is not supported by robust evidence. The aim of the present study was to establish the immediate and longer-term outcomes following "personalized" form of group cognitive behavioural therapy for obesity (CBT-OB)-a new treatment designed to address specific cognitive processes that have been associated with attrition, weight loss, and weight maintenance in previous studies. METHODS: Sixty-seven adult patients with obesity (body mass index (BMI) ≥ 30 kg/m2) were recruited from consecutive referrals to an Italian National Health Service obesity clinic. Each patient was offered 22 group sessions of CBT-OB (14 in the 6-month weight-loss phase and 8 in the subsequent 12-month weight-maintenance phase). RESULTS: 76.2% patients completed the treatment, with an average weight loss of 11.5% after 6 months (10% in the intention-to-treat analysis) and 9.9% (7.5% in the intention-to-treat analysis) after 18 months. Weight loss was associated with a significant reduction in cardiovascular risk factors, anxiety, depression, and eating disorder psychopathology, and an improvement in obesity-related quality of life. CONCLUSIONS: These findings provide strong preliminary support for the use of CBT-OB for obesity in standard clinical settings, and justify its further evaluation in randomized controlled trials. LEVEL OF EVIDENCE: Level III, longitudinal cohort study.