The impact of a primary care-based weight loss intervention on the quality of life.

OBJECTIVE: This study investigated changes in the quality of life of men and women who participated in a primary care-based weight loss intervention program. METHODS: Participants were enrolled in a 2-year randomized clinical trial (POWER-UP) conducted at the University of Pennsylvania and in six affiliated primary care practices. Inclusion criteria included the presence of obesity (body mass index of 30-50 kg m(-2)) and at least two components of the metabolic syndrome. MAIN OUTCOME MEASURES: Quality of life was assessed by three measures: the Short Form Health Survey (SF-12); the Impact of Weight on Quality of Life-Lite; and the EuroQol-5D. RESULTS: Six months after the onset of treatment, and with a mean weight loss of 3.9 ± 0.3 kg, participants reported significant improvements on all measures of interest with the exception of the Mental Component Score of the SF-12. These changes remained significantly improved from baseline to month 24, with the exception of the EuroQol-5D. Many of these improvements were correlated with the magnitude of weight loss and, for the most part, were consistent across gender and ethnic group. CONCLUSIONS: Individuals with obesity and components of the metabolic syndrome reported significant improvements in most domains of the quality of life with a modest weight loss of 3.7% of initial weight, which was achieved within the first 6 months of treatment. The majority of these improvements were maintained at month 24, when participants had lost 3.0% of their weight.

Managing obesity in primary care practice: an overview with perspective from the POWER-UP study.

Primary care practitioners (PCPs) have been encouraged to screen all adults for obesity and to offer behavioral weight loss counseling to the affected individuals. However, there is limited research and guidance on how to provide such intervention in primary care settings. This led the National Heart, Lung and Blood Institute in 2005 to issue a request for applications to investigate the management of obesity in routine clinical care. Three institutions were funded under a cooperative agreement to undertake the practice-based opportunities for weight reduction (POWER) trials. The present article reviews selected randomized controlled trials, published before the initiation of POWER, and then provides a detailed overview of the rationale, methods and results of the POWER trial conducted at the University of Pennsylvania (POWER-UP). POWER-UP's findings are briefly compared with those from the two other POWER trials, conducted at Johns Hopkins University and Harvard University/Washington University. The methods of delivering behavioral weight loss counseling differed markedly across the three trials, as captured by an algorithm presented in the article. Delivery methods ranged from having medical assistants and PCPs from the practices provide counseling to using a commercially available call center, coordinated with an interactive website. Evaluation of the efficacy of primary care-based weight loss interventions must be considered in light of costs, as discussed in relation to the recent treatment model proposed by the Centers for Medicare and Medicaid Services.

Changes in eating, physical activity and related behaviors in a primary care-based weight loss intervention.

OBJECTIVE: To examine changes in eating behaviors and physical activity, as well as predictors of weight loss success, in obese adults who participated in a 2-year behavioral weight loss intervention conducted in a primary care setting. DESIGN: A longitudinal, randomized controlled, multisite trial. SUBJECTS: Three hundred ninety obese (body mass index, 30-50 kg m(-2)) adults, ≥ 21 years, in the Philadelphia region. METHODS: Participants were assigned to one of three interventions: (1) Usual Care (quarterly primary care provider (PCP) visits that included education on diet and exercise); (2) Brief Lifestyle Counseling (quarterly PCP visits plus monthly lifestyle counseling (LC) sessions about behavioral weight control); or (3) Enhanced Brief LC (the previous intervention with a choice of meal replacements or weight loss medication). RESULTS: At month 24, participants in both Brief LC and Enhanced Brief LC reported significantly greater improvements in mean (± s.e.) dietary restraint than those in Usual Care (4.4 ± 0.5, 4.8 ± 0.5 and 2.8 ± 0.5, respectively; both P-values ≤ 0.016). The percentage of calories from fat, along with fruit and vegetable consumption, did not differ significantly among the three groups. At month 24, both the Brief LC and Enhanced Brief LC groups reported significantly greater increases than usual care in energy expenditure (kcal per week) from moderately vigorous activity (+593.4 ± 175.9, +415.4 ± 179.6 and -70.4 ± 185.5 kcal per week, respectively; both P-values ≤ 0.037). The strongest predictor of weight loss at month 6 (partial R(2)=33.4%, P<0.0001) and at month 24 (partial R(2)=19.3%, P<0.001) was food records completed during the first 6 months. Participants who achieved a 5% weight loss at month 6 had 4.7 times greater odds of maintaining a ≥ 5% weight loss at month 24. CONCLUSIONS: A behavioral weight loss intervention delivered in a primary care setting can result in significant weight loss, with corresponding improvements in eating restraint and energy expenditure. Moreover, completion of food records, along with weight loss at month 6, is a strong predictor of long-term weight loss.

Cost-effectiveness of a primary care intervention to treat obesity.

BACKGROUND: Data on the cost-effectiveness of the behavioral treatment of obesity are not conclusive. The cost-effectiveness of treatment in primary care settings is particularly relevant. METHODS: We conducted a within-trial cost-effectiveness analysis of a primary care-based obesity intervention. Study participants were randomized to: Usual Care (UC; quarterly visits with their primary care provider); Brief Lifestyle Counseling (BLC; quarterly provider visits plus monthly weight loss counseling visits) or Enhanced Brief Lifestyle Counseling (EBLC; all above interventions, plus choice of meal replacements or weight loss medication). A health-care payer perspective was used. Intervention costs were estimated from tracking data obtained prospectively. Quality-adjusted life years (QALYs) were estimated with the EuroQol-5D. We estimated cost per kilogram-year of weight loss and cost per QALY. RESULTS: Weight losses after 2 years were 1.7, 2.9 and 4.6 kg for UC, BLC and EBLC, respectively (P=0.003 for comparison of EBLC vs UC). The incremental cost per kilogram-year lost was $292 for EBLC compared with UC (95% confidence interval (CI): $219-$437). The short-term incremental cost per QALY was $115,397, but the 95% CI were undefined. Comparison of short-term cost per kg with published estimates of longer-term cost per QALY suggested that the intervention could be cost-effective over the long term (≥ 10 years). CONCLUSIONS: A primary care intervention that includes monthly counseling visits and a choice of meal replacements or weight loss medication could be a cost-effective treatment for obesity over the long term. However, additional studies are needed on the cost-effectiveness of behavioral treatment of obesity.

Lack of relationship between mitochondrial heteroplasmy or variation and childhood obesity.

Mitochondrial electron transport has a central role in regulating energy supply within a cell. We hypothesized that mitochondrial variants or increased levels of mitochondrial heteroplasmy could be associated with common childhood obesity through their effects on mitochondrial function. To investigate this question, we queried two genome-wide genotyped childhood obesity datasets, consisting of 1080 European-American (EA) obese children (defined as BMI ≥ 95th percentile) together with 2500 EA lean controls (defined as BMI<50th percentile) and 1479 African-American (AA) obese children and 1575 AA lean controls. Association was not observed between childhood obesity and any of the assayed mitochondrial polymorphisms in either ethnicity. We also found no observable differences in heteroplasmy between each obese and non-obese group. Finally, we analyzed the quantitative mitochondrial genotype cells generated, whether they exceeded the heteroplasmy threshold or not. With this more lenient test, we found six positions with a significant difference between EA cases and controls (P<1 × 10(-4)). However, when evaluating the AA data set, no differences were noted at these sites, suggesting that our initial observations were because of chance rather than a meaningful relationship to childhood obesity. As such, it is unlikely that common mitochondrial polymorphisms or heteroplasmy have a role in childhood obesity.

Everyday discrimination in a racially diverse sample of patients with obesity.

Weight discrimination affects a significant proportion of individuals with obesity and contributes to poor mental and physical health. Prior research on weight discrimination has been limited by a lack of racial diversity in samples and has not considered other potential forms of discrimination that individuals with obesity may experience. The current study assessed different reasons for discrimination in a racially diverse sample of treatment-seeking individuals with obesity (N = 122, 66.4% black, mean body mass index = 38.5 ± 6.2 kg/m2 ). Results showed that over half of participants reported experiencing at least one form of repeated discrimination, and 30% reported two or more reasons for discrimination. Race and weight were the most commonly reported reasons for repeated, everyday instances of discrimination. Among participants who reported experiencing weight discrimination (28.7%), over 80% reported experiencing at least one other form of discrimination, with 60% reporting discrimination due to race. These findings indicate that individuals with obesity may face multiple forms of discrimination in their daily lives. Further research is needed to understand how all forms of discrimination contribute to obesity-related health problems.

Observed parent-child feeding dynamics in relation to child body mass index and adiposity.

BACKGROUND: Restrictive feeding is associated with child overweight; however, the majority of studies used parent-report questionnaires. OBJECTIVES: The relationship between child adiposity measures and directly observed parent and child behaviours were tested using a novel behavioural coding system (BCS). METHODS: Data from 109 children, participants in a twin study and their mothers, were analyzed. Parent-child dyads were video-recorded twice in the laboratory, while children ate ad libitum from a buffet lunch. Mother and child behaviours were assessed using the BCS. Height, body weight and body fat were directly measured for each child. Associations between child adiposity measures and average BCS behaviour (i.e. pooled across visits) were tested using partial correlations adjusting for child age. RESULTS: Regarding discouragement prompts, child body mass index (BMI) z-score was significantly associated with a greater rate of total discouragements (per minute, min-1 ), nonverbal discouragements (min-1 ) and temporary (delay) discouragements (min-1 ) (p < 0.05). Child percent body fat was associated with greater nonverbal discouragements (min-1 ). Regarding encouragement prompts, child BMI z-score was significantly associated with a greater rate of total encouragements (min-1 ), nonverbal encouragements (min-1 ) and reward encouragements (min-1 ). Child BMI z-score and percent body fat were both positively associated with greater maternal health encouragements (min-1 ). Associations with encouragement to eat prompts were no longer significant when accounting for the dependence among twins (being part of the same family). CONCLUSIONS: Heavier children received greater maternal discouragements to eat and, with qualifications, encouragements to eat. The role of nonverbal parenting cues warrants further research regarding child eating regulation and obesity.

A randomized controlled trial of lorcaserin and lifestyle counselling for weight loss maintenance: changes in emotion- and stress-related eating, food cravings and appetite.

Anti-obesity medication may help people maintain diet-induced reductions in appetite. The present exploratory analysis assessed the effects of lorcaserin on changes at 24 weeks post-randomization in emotion- and stress-related eating, food cravings and other measures of appetite (i.e. binge eating, cognitive restraint, disinhibition, hunger, preoccupation with eating and fullness). The parent study investigated the efficacy of combined lorcaserin and behavioural treatment in facilitating weight loss maintenance (WLM) in 137 adults (mean age = 46.1 years, 86.1% female, 68.6% black) who had lost ≥5% of initial weight during a 14-week, low-calorie diet (LCD) run-in. Participants were randomly assigned to lorcaserin or placebo and were provided with group WLM counselling sessions. Emotion- and stress-related eating, food cravings and appetite were measured at the start of the LCD (week -14), randomization (0) and week 24. From randomization, lorcaserin-treated participants had significantly greater improvements in emotion- and stress-related eating compared to placebo-treated participants (P = 0.04). However, groups did not differ significantly after randomization in changes in the frequency of food cravings, binge eating or other measures of appetite (Ps > 0.05). Compared to placebo, lorcaserin may improve emotion- and stress-related eating.

High energy expenditure is not protective against increased adiposity in children.

BACKGROUND: Low levels of energy expenditure (TEE) may contribute to excess weight during childhood, but limited longitudinal data exist. OBJECTIVES: This is to test whether low TEE during the first 6 years of life could predict excess weight status at 8 years. METHODS: Total energy expenditure from doubly labelled water, weight, stature, waist circumference and fat mass and fat-free mass (FFM) in children at 0.25, 2, 4 and 6 years of age. This cohort includes individuals at high (n = 27) and low risk (n = 26) for childhood obesity, based upon whether pre-pregnant maternal obesity. A linear mixed effects model was fit to TEE. Individual variation was accounted for as a random effect. Residual TEE was calculated for age and individually averaged across time. RESULTS: Fat-free mass (kg) was highly correlated (R2 = 0.91) with TEE (kcal/day), and waist circumference and sex were also significant predictors of TEE. TEE residual tracked within individuals. TEE residuals did not correlate with either BMI or %fat at age 8 years. CONCLUSION: Using the residual TEE approach to identify high and low TEE during the first 6 years of life did not explain excess weight at 8 years of life in this cohort of children at high and low risk of obesity based upon maternal obesity status.

Benefits of lifestyle modification in the pharmacologic treatment of obesity: a randomized trial.

BACKGROUND: Weight loss medications are recommended as an adjunct to diet and exercise modification but seem to be prescribed as a monotherapy by many physicians. This practice is likely to be associated with suboptimal weight loss. METHODS: This 1-year, randomized trial compared the effects of sibutramine hydrochloride used alone (ie, the drug-alone group) to sibutramine plus group lifestyle modification, prescribed with either a 5021- to 6276-kJ/d diet (1200-1500-kcal/d diet) (ie, the drug-plus-lifestyle group) or, for the first 4 months, a 4184-kJ/d diet (1000-kcal/d diet (ie, drug-plus-lifestyle with a portion-controlled diet [the combined treatment] group). Participants were 53 women with a mean (+/-SD) age of 47.2 +/- 9.8 years and weight of 101.3 +/- 9.7 kg. At baseline, they reported the number of pounds they expected to lose at the end of treatment. RESULTS: At month 12, patients treated with the drug alone lost (mean +/- SD) 4.1% +/- 6.3% of their initial body weight compared with significantly (P<.05) larger losses in the drug-plus-lifestyle group of 10.8% +/- 10.3% and the combined treatment group of 16.5% +/- 8.0%. Women in the 2 lifestyle groups achieved a significantly (P<.05) greater percentage of their expected weight loss than those in the drug-alone group and were significantly more satisfied with the medication and with changes in weight, health, appearance, and self-esteem (P<.05 for all). Significant reductions were observed at 12 months in triglyceride and low-density lipoprotein cholesterol levels but systolic and diastolic blood pressure both increased significantly (P<.05 for all). CONCLUSION: The addition of group lifestyle modification to the pharmacologic management of obesity significantly improved weight loss and patients' satisfaction with treatment outcome.

Prevention of excess weight gain in paediatric primary care: beverages only or multiple lifestyle factors. The Smart Step Study, a cluster-randomized clinical trial.

BACKGROUND: Insufficient evidence exists to support obesity prevention in paediatric primary care. OBJECTIVES: To test a theory-based behaviour modification intervention delivered by trained paediatric primary care providers for obesity prevention. METHODS: Efficacy trial with cluster randomization (practice level) and a 12-session 12-month sweetened beverages decrease intervention or a comprehensive dietary and physical activity intervention, compared with a control intervention among children ages 8-12 years. RESULTS: A low recruitment rate was observed. The increase in body mass index z-score (BMIz) for the 139 subjects (11 practices) randomized to any of the two obesity interventions (combined group) was less than that of the 33 subjects (five practices) randomized to the control intervention (-0.089, 95% confidence interval [CI]: -0.170 to -0.008, P = 0.03) with a -1.44 kg weight difference (95% CI: -2.98 to +0.10 kg, P = 0.095). The incidences of obesity and excess weight gain were lower in the obesity interventions, but the number of subjects was small. Post hoc analyses comparing the beverage only to the control intervention also showed an intervention benefit on BMIz (-0.083, 95% CI: -0.165 to -0.001, P = 0.048). CONCLUSIONS: For participating families, an obesity prevention intervention delivered by paediatric primary care clinicians, who are compensated, trained and continuously supported by behavioural specialists, can impact children's BMIz.

Energy intake, not energy output, is a determinant of body size in infants.

BACKGROUND: It has been proposed that the primary determinants of body weight at 1 y of age are genetic background, as represented by parental obesity, and low total energy expenditure. OBJECTIVE: The objective was to determine the relative contributions of genetic background and energy intake and expenditure as determinants of body weight at 1 y of age. DESIGN: Forty infants of obese and 38 infants of lean mothers, half boys and half girls, were assessed at 3 mo of age for 10 risk factors for obesity: sex, risk group (obese or nonobese mothers), maternal and paternal body mass index, body weight, feeding mode (breast, bottle, or both), 3-d energy intake, nutritive sucking behavior during a test meal, total energy expenditure, sleeping energy expenditure, and interactions among them. RESULTS: The only difference between risk groups at baseline was that the high-risk group sucked more vigorously during the test meal. Four measures accounted for 62% of the variability in weight at 12 mo: 3-mo weight (41%, P = 0.0001), nutritive sucking behavior (9%, P = 0.0002), 3-d food intake (8%, P = 0.0002), and male sex (3%, P = 0.05). Food intake and sucking behavior at 3 mo accounted for similar amounts of variability in weight-for-length, body fat, fat-free mass, and skinfold thickness at 12 mo. Contrary to expectations, neither total nor sleeping energy expenditure at 3 mo nor maternal obesity contributed to measures of body size at 12 mo. CONCLUSIONS: Energy intake contributes significantly to measures of body weight and composition at 1 y of age; parental obesity and energy expenditure do not.

Maintenance following a very-low-calorie diet.

The authors posed 2 questions in this randomized study of maintenance procedures in which participants were followed for 15 months after completion of a very-low-calorie diet: Would stimulus narrowing during the reintroduction of solid food, achieved by the use of prepackaged foods, improve weight losses and the maintenance of those losses as compared with the use of regular food? Would reintroduction of foods dependent on progress in losing or maintaining weight be superior to reintroduction on a time-dependent basis? Neither the stimulus narrowing condition nor the reintroduction procedure enhanced either maximum weight loss or maintenance of those losses. The stimulus narrowing condition appeared to be poorly tolerated; compliance and attendance were poorer in this condition than in the regular food condition.

Exercise in the treatment of obesity: effects of four interventions on body composition, resting energy expenditure, appetite, and mood.

This study investigated changes in body composition, resting energy expenditure (REE), appetite, and mood in 128 obese women who were randomly assigned to 1 of 4 treatment conditions: diet alone, diet plus aerobic training, diet plus strength training, or diet combined with aerobic and strength training (i.e., combined training). All women received the same 48-week group behavioral program and were prescribed the same diet. Exercising participants were provided 3 supervised exercise sessions per week for the first 28 weeks and 2 sessions weekly thereafter. Participants across the 4 conditions achieved a mean weight loss of 16.5 +/- 6.8 kg at Week 24, which decreased to 15.1 +/- 8.4 kg at Week 48. There were no significant differences among conditions at any time in changes in weight or body composition. Women who received aerobic training displayed significantly smaller reductions in REE at Week 24 than did those who received strength training. There were no other significant differences among conditions at any time on this variable or in changes in appetite and mood.

A summer day camp approach to adolescent weight loss.

Twenty-five overweight adolescents completed a summer weight loss day camp program on the Stanford University campus. All participants attended camp four days per week for four hours to learn and practice eating and exercise skills conducive to weight loss. Parents met weekly to discuss the program content and to explore their role in their adolescent's weight management. At posttreatment, reductions were achieved in weight, percent overweight, and skinfold, with greater changes observed for the eight-week group than for the four-week group. Improvements were also evident in participants' self-reported habits and knowledge of weight management concepts. Parent and participant assessment of the camp experience was very positive. The results of the summer weight loss day camp suggest that an intensive program of eating and exercise habit instruction, practice, and monitoring, which allows the participants to remain in the home setting, may provide benefits not found in other more traditional approaches to adolescent weight loss.

Change in body composition during a weight loss trial in obese adolescents.

UNLABELLED: What is already known about this subject Adolescence is an important period of physiological growth. Loss of central adiposity with preservation of lean mass during weight loss is optimal. There are discrepancies in the literature concerning changes in lean mass during weight loss in adolescents. What this study adds This study provides information of regional and total body composition change in adolescents during weight loss. This study controls for important factors that impact body composition in growing adolescents such as age, sex, height, baseline weight and race. This study provides correlations of changes in waist circumference and body mass index (BMI) with total and trunk fat mass during weight loss in adolescents. SUMMARY: Background Changes in body composition during weight loss among obese adolescents are poorly understood. This study characterized the composition of weight loss and its association with changes in waist circumference (WC) in obese adolescents. Methods Total (Tot), trunk (Tr) and appendicular (Ap) fat mass (FM) and lean mass (LM) were measured by dual-energy X-ray absorptiometry in 61 obese adolescents (40 girls) who participated in a randomized controlled weight loss trial. Changes in body composition were assessed at 0, 6 and 12 months using mixed-effects regression models. Correlation analysis of change in WC and total and regional compartments of FM and LM were assessed. Results Weight loss for adolescents was 90.3% FM and 15.9% LM at 0-6 months, and 98.2% FM and 7% LM at 0-12 months. At 12 months, girls lost 2.67 kg more TotFM than boys in models adjusted for height, age, race and baseline weight. Boys gained LM in all compartments in all models. At 12 months, girls lost TotLM (2.23 ± 0.74, P < 0.004) and ApLM (0.69 ± 0.31, P = 0.03) and gained TrLM (0.37 ± 0.35, P = 0.29). The percentage LM, increased for boys and girls in all models. TotFM was correlated with body mass index (BMI) change with TotFM (R = 0.70-0.91, P = 0.001) and WC change (R = 0.53-0.55, P < 0.001). Conclusions Weight loss in obese adolescents during a weight loss trial using lifestyle management and sibutramine was primarily from trunk FM. Although absolute LM increased in boys and decreased in girls, the percentage of weight that is LM increased for both boys and girls. Changes in BMI were more reflective of changes in FM than changes in WC.

The role of patients' expectations and goals in the behavioral and pharmacological treatment of obesity.

OBJECTIVE: To investigate weight loss expectations and goals among obese treatment seekers and to examine the relationships of these expectations and goals to treatment outcomes. METHOD: Participants were 180 obese men and women (age 43.8+/-10.1 years; body mass index 37.6+/-4.2 kg/m(2)) who received one of four-year-long treatments that combined behavioral and pharmacological methods. Before treatment, they reported the amount of weight they realistically expected to lose after 4, 12, 26 and 52 weeks of treatment, as well as their ultimate weight loss goals. Expectations and goals were compared across treatment groups and examined in relation to previous weight loss efforts, weight loss and regain in treatment, attrition, satisfaction with treatment and mood. RESULTS: Participants in all treatment groups expected reductions at week 52 that were significantly greater than the 5-15% of initial weight they were told was realistic and significantly more than they had ever lost before. Weight loss expectations were unrelated to achieved weight loss in all groups but one, in which greater expectations were associated with greater losses. Failure to meet weight loss expectations for the first 26 weeks of treatment was related to lower satisfaction ratings, but was not related to weight regain or attrition over the next 26 weeks. Symptoms of depression were reduced from baseline, regardless of whether participants achieved or failed to achieve their expected weight losses. CONCLUSION: Across groups, we observed no negative consequences of having (and failing to meet) unrealistic expectations for weight loss.

Impact of weight loss on the metabolic syndrome.

OBJECTIVE: To evaluate the effects of weight loss on the risk of having metabolic syndrome after 1 year of treatment with lifestyle modification alone, pharmacotherapy alone (sibutramine) or the combination of the two. DESIGN: Randomized, controlled, 1-year clinical trial. PATIENTS: One hundred and eighty women and 44 men, 18-65 years of age, with a body mass index of 30-45 kg/m(2), free of uncontrolled hypertension or type 1 or 2 diabetes. INTERVENTION: Fifteen milligrams of sibutramine per day alone, lifestyle modification counseling alone, sibutramine plus lifestyle modification counseling or sibutramine plus brief lifestyle modification counseling. MEASUREMENTS: The metabolic syndrome, as defined by the Adult Treatment Panel III. RESULTS: Before treatment, 34.8% of the participants had the metabolic syndrome. Metabolic syndrome was more prevalent in Caucasians than African Americans (42.5 vs 20.3%; P<0.03), in males than females (65.1 vs 34.9%; P<0.002) and in older (>44 years) than younger (

Dietary energy density increases during early childhood irrespective of familial predisposition to obesity: results from a prospective cohort study.

OBJECTIVE: This study compared 4-year changes in daily energy density (ED; kcal/g) in children born at different risk for obesity, characterized the stability of ED and examined associations between ED and child body composition. DESIGN: Prospective cohort study to measure habitual dietary ED of children who are born at different risk for obesity. SUBJECTS: Children who were born at high risk (n=22) or low risk (n=27) for obesity based on maternal pre-pregnancy weight. MEASUREMENTS: Three-day food records were collected from children's mothers at child ages 3, 4, 5 and 6 years. Three categories of ED were computed (food only, food and milk, and food and all beverages) and body composition assessed at each year. RESULTS: The mean (+/-s.e.m.) ED increased over time across all children (linear trend: P<0.003): 2.18+/-0.07 to 2.32+/-0.06 kcal/g (food only); 1.66+/-0.07 to 1.82+/-0.06 kcal/g (food and milk); and 1.24+/-0.04 to 1.37+/-0.05 kcal/g (food and all beverages). Intraindividual coefficients of variation were smaller than those previously reported for adults. Weight indices were not correlated with dietary ED (P>0.05). CONCLUSION: Dietary ED increased in young children, irrespective of their predisposition to obesity, between the ages of 3 and 6 years. The genes that promote childhood obesity may not exert their influence through dietary ED, which may be more strongly influenced by environmental factors.

Behavioural treatment of the overweight patient.

The goal of obesity treatment has changed significantly in the past decade. Where once the goal was a reduction to ideal weight, the current objective is the achievement of a healthier weight. For many obese individuals, this means losing as little as 5-15% of their initial weight. This article briefly describes behavioural methods to help obese individuals modify their eating and activity habits in order to achieve these new goals. A review of recent studies shows that patients treated by a comprehensive group behavioural programme lose approximately 9% of their initial weight in 20 weeks and, without further treatment, maintain a loss of 5% 1 year later. Methods of improving the maintenance of weight loss include increasing physical activity, extending the length of behavioural treatment and, with appropriately selected individuals, combining behavioural and pharmacological interventions. The importance of helping obese individuals adopt realistic treatment expectations is also discussed.