Qualitative inquiry with persons with obesity about weight management in primary care and referrals.

Introduction: Referrals to evidence-based weight management in the community-commercial sector are aligned with clinical recommendations but underutilized. Methods: This qualitative study explored patients' perceptions and expectations about obesity treatment in primary care and referral to community-commercial sector programs. Individual semi-structured interviews were conducted with a sample of US persons with obesity via telephone. Audiotape transcripts, interviewer notes, and independent review of data by two investigators allowed for data and investigator triangulation. Transcripts were analyzed using thematic analysis. Results: Data saturation was reached with 30 participants who had a mean age of 41.6 years (SD 9.4), 37% male, 20% Black/African American and 17% Hispanic, 57% college educated, and 50% were employed full-time. Three primary themes emerged: (1) frustration with weight management in primary care; (2) patients expect providers to be better informed of and offer treatment options; and (3) opportunities and challenges with referrals to community-commercial programs. Discussion: Patients expect that providers offer personalized treatment options and referrals to effective community-commercial programs are an acceptable option. If patient-level data are shared between clinical and community entities to facilitate referrals, then privacy and security issues need attention. Future research is needed to determine feasibility of implementing clinical to community-commercial referrals for obesity treatment in the United States.

The effect of weight loss on changes in health-related quality of life among overweight and obese women with urinary incontinence.

OBJECTIVE: To estimate the effect of change in weight and change in urinary incontinence (UI) frequency on changes in preference-based measures of health-related quality of life (HRQL) among overweight and obese women with UI participating in a weight loss trial. METHODS: We conducted a longitudinal cohort analysis of 338 overweight and obese women with UI enrolled in a randomized clinical trial comparing a behavioral weight loss intervention to an educational control condition. At baseline, 6, and 18 months, health utilities were estimated using the Health Utilities Index Mark 3 (HUI3), a transformation of the SF-36 to the preference-based SF-6D, and the estimated Quality of Well-Being (eQWB) score (a summary calculated from the SF-36 physical functioning, mental health, bodily pain, general health perceptions, and role limitations-physical subscale scores). Potential predictors of changes in these outcomes were examined using generalized estimating equations. RESULTS: In adjusted multivariable models, weight loss was associated with improvement in HUI3, SF-6D, and eQWB at 6 and 18 months (P < 0.05). Increases in physical activity also were independently associated with improvement in HUI3 (P = 0.01) and SF-6D (P = 0.006) scores at 18 months. In contrast, reduction in UI frequency did not predict improvements in HRQL at 6 or 18 months. CONCLUSION: Weight loss and increased physical activity, but not reduction in UI frequency, were strongly associated with improvements in health utilities measured by the HUI3, SF-6D, and eQWB. These findings provide important information that can be used to inform cost-utility analyses of weight loss interventions.

Qualitative inquiry with primary care providers and specialists about adult weight management care and referrals.

Obesity is a highly prevalent disease and providers are expected to offer or refer patients for weight management yet increasingly fewer clinical visits address obesity. Challenges to offering care are known but less is known about referrals and how specialists who treat obesity-related comorbidities address care and referrals. This study explored perceptions of primary care providers (PCPs) and specialty providers regarding care and referrals for weight management, specifically referrals to programs in the community setting. A qualitative design was used to interview 33 PCPs (mean age 54 years) and 31 specialists (cardiology, gynecology, endocrinology, and orthopedics [mean age 62 years]) in the USA during 2019. Each interview was conducted by telephone, audio-recorded, and transcribed verbatim. Inductive analysis was used and followed the constant comparative method. Four themes emerged from the data including (a) Clinical guidelines and provider discretion influence obesity care; (b) Facilitators and barriers to discussing weight and small step strategies; (c) Informal referrals are made for weight management in community settings; and (d) Opportunities and challenges for integrating clinical and community services for weight management. Facilitating referrals to effective programs, ideally with a feedback loop could coordinate care and enhance accountability, but education, compliance, and cost issues need addressed. Care may be offered but not be well-aligned with clinical guidelines. Knowledge gaps regarding community programs' offerings and efficacy were evident. Referrals could be systematically promoted, facilitated, and tracked to advance weight management objectives.

Comparison and correlates of three preference-based health-related quality-of-life measures among overweight and obese women with urinary incontinence.

PURPOSE: To compare three preference-based health-related quality-of-life (HRQL) measures and examine independent correlates of HRQL among overweight and obese women with urinary incontinence (UI) enrolled in a weight loss intervention trial. METHODS: Participants completed baseline questionnaires, which included the Health Utilities Index 3 (HUI3) and Medical Outcomes Study Short Form-36 (SF-36). The SF-36 was used to derive SF-6D and estimated Quality of Well-Being (eQWB) scores. Height, weight, medical history, incontinence measures, and level of physical activity also were assessed. The intraclass correlation coefficient (ICC) was computed, and differences in mean scores across HRQL measures were examined. Potential correlates of HUI3, SF-6D, and eQWB scores were evaluated using multivariable generalized linear models. RESULTS: Mean ± SD scores for the HUI3, SF-6D, and eQWB were 0.81 ± 0.18, 0.75 ± 0.10, and 0.71 ± 0.06, respectively. Significant differences were observed across measures (P < 0.0001), and the overall ICC was 0.36. In multivariable analyses, BMI was negatively associated with HUI3 (P = 0.003) and eQWB (P < 0.001), and UI episode frequency was negatively associated with eQWB (P = 0.015) and SF-6D (P < 0.001). CONCLUSIONS: Significant differences in mean utilities across the HUI3, SF-6D, and eQWB indicate that these measures do not assess identical dimensions of HRQL. Both BMI and UI episode frequency were related to HRQL in this cohort; however, the magnitude of the relationship depended on the preference-based measure used. These findings highlight the need to consider the method used to generate HRQL values for calculating quality-adjusted life-years in cost-utility analyses, since choice of method may have a substantial impact on the outcome of the analysis.

Effect of teammates on changes in physical activity in a statewide campaign.

OBJECTIVE: Most Americans do not meet physical activity recommendations. Statewide campaigns can effectively increase activity levels. Reported herein are physical activity outcomes from Shape Up Rhode Island (SURI) 2007, a statewide campaign to increase steps through team-based competition. Given the importance of social networks in behavior change, this paper focused on the effects of team and team characteristics on activity outcomes. METHOD: For 16weeks, 5333 adults comprising 652 teams wore pedometers and reported their steps online. RESULTS: Participants' daily steps increased from 7029(3915) at baseline to 9393(5976) at SURI end (p<0.001). There was a significant intraclass correlation for step change among team members (ICC=0.09); thus, an individual's change in steps was influenced by what team they were on. Moreover, baseline team characteristics predicted individual step change; being on a more active team was associated with greater increases in activity for individual members (p<0.001), whereas being on a team with a broad range of steps was associated with smaller changes in activity for individual members (p=0.02). CONCLUSION: These findings are the first to suggest that team members influence individual activity outcomes in team-based statewide campaigns. Future research should explore ways to use social network factors to enhance team-based physical activity programs.

Behavioral and Psychological Strategies of Long-Term Weight Loss Maintainers in a Widely Available Weight Management Program.

OBJECTIVE: The study's purpose was to use validated questionnaires to identify novel behavioral and psychological strategies among weight loss maintainers (WLMs) in a commercial weight management program. METHODS: Participants were 4,786 WLMs in WW (formerly Weight Watchers, New York, New York) who had maintained weight loss ≥ 9.1 kg (24.7 kg/23.8% weight loss on average) for 3.3 years and had a current mean BMI of 27.6 kg/m2 . A control group of 528 weight-stable individuals with obesity had a mean BMI of 38.9 kg/m2 and weight change < 2.3 kg over the previous 5 years. RESULTS: WLMs versus Controls practiced more frequent healthy dietary choices (3.3 vs. 1.9; η p 2 = 0.37), self-monitoring (2.6 vs. 0.7; η p 2 = 0.30), and psychological coping (2.5 vs. 1.1; η p 2 = 0.25) strategies. WLMs also reported more willingness to ignore food cravings (4.4 vs. 3.5; η p 2 = 0.16) and had greater habit strength for healthy eating (5.3 vs. 3.2;  η p 2 = 0.21). Standard canonical coefficients indicated that dietary (0.52), self-monitoring (0.40), and psychological (0.14) strategies as well as habit strength for healthy eating (0.15) contributed independently and most (49.5% of variance) to discriminating groups. CONCLUSIONS: In a widely available weight management program, more frequent practice of healthy dietary, self-monitoring, and psychological coping strategies as well as development of greater habit strength for healthy eating differentiated long-term WLMs from weight-stable individuals with obesity.

The Eating Disorder Recovery Self-Efficacy Questionnaire (EDRSQ): change with treatment and prediction of outcome.

The purpose of this study was to examine the predictive validity of the Eating Disorder Recovery Self-Efficacy Questionnaire (EDRSQ), an empirically-derived self-report instrument that assesses confidence to eat without engaging in eating disordered behavior or experiencing undue emotional distress (Normative Eating Self-Efficacy) and confidence to maintain a realistic body image that is not dominated by pursuit of thinness (Body Image Self-Efficacy). Participants were 104 female inpatients with anorexia nervosa (AN), subthreshold AN, or underweight bulimia nervosa who were treated at a specialized eating disorder clinic and completed the EDRSQ and Eating Disorder Inventory-2 (EDI-2) Drive for Thinness (DT) and Body Dissatisfaction (BD) subscales upon admission. A subset of patients completed the EDRSQ (n=81) and EDI-2 subscales (n=70) following inpatient treatment. Self-efficacy increased significantly during treatment. EDRSQ scores at admission were inversely related to length of hospital stay and posttreatment DT and BD subscales and positively related to partial hospital weight gain rate. The EDRSQ significantly predicted length of hospital stay and posttreatment BD above and beyond clinical indicators and eating disorder psychopathology at inpatient admission. Findings support the validity of the EDRSQ and suggest it is a useful predictor of short-term hospital treatment outcome in underweight eating disorder patients.

Perceived coercion and change in perceived need for admission in patients hospitalized for eating disorders.

OBJECTIVE: Ambivalence toward treatment is characteristic of eating disorders, and patients are often admitted to inpatient programs under pressure from clinicians, family, friends, educators, or employers. This study evaluated patient perceptions of the admissions process and perceived need for hospitalization and assessed whether these perceptions remain stable in the short term. METHOD: A total of 139 patients with eating disorders completed a 13-item self-report scale on the admission experience when they were admitted to a behavioral inpatient specialty program and again 2 weeks into their hospitalization. RESULTS: Patients with anorexia nervosa reported higher levels of perceived coercion and pressure and a lower sense of procedural justice than did those with bulimia. Patients under 18 (N=35) reported more perceived coercion than did adult patients (N=104), and a trend was noted for them to disagree that they needed hospitalization. Perceptions of coercion, of pressure by others toward hospitalization, and of procedural justice were stable in the short term. However, of the 46 patients (30 of them adults) who initially did not endorse needing admission, 20 patients (17 of them adults) changed their minds by 2 weeks into hospitalization and agreed that they needed hospital admission. CONCLUSIONS: Nearly half of patients with eating disorders who denied a need for treatment on admission converted to acknowledging that they needed to be admitted within 2 weeks of hospitalization. Since treatment avoidance is associated with poor outcome, these findings suggest a need for studies assessing the long-term outcome and ethics of pressuring patients with eating disorders into treatment.

The Value of Removing Daily Obstacles via Everyday Problem-Solving Theory: Developing an Applied Novel Procedure to Increase Self-Efficacy for Exercise.

The objective of the study was to develop a novel procedure to increase self-efficacy for exercise. Gains in one's ability to resolve day-to-day obstacles for entering an exercise routine were expected to cause an increase in self-efficacy for exercise. Fifty-five sedentary participants (did not exercise regularly for at least 4 months prior to the study) who expressed an intention to exercise in the near future were selected for the study. Participants were randomly assigned to one of three conditions: (1) an Experimental Group in which they received a problem-solving training session to learn new strategies for solving day-to-day obstacles that interfere with exercise, (2) a Control Group with Problem-Solving Training which received a problem-solving training session focused on a typical day-to-day problem unrelated to exercise, or (3) a Control Group which did not receive any problem-solving training. Assessment of obstacles to exercise and perceived self-efficacy for exercise were conducted at baseline; perceived self-efficacy for exercise was reassessed post-intervention (1 week later). No differences in perceived challenges posed by obstacles to exercise or self-efficacy for exercise were observed across groups at baseline. The Experimental Group reported greater improvement in self-efficacy for exercise compared to the Control Group with Training and the Control Group. Results of this study suggest that a novel procedure that focuses on removing obstacles to intended planned fitness activities is effective in increasing self-efficacy to engage in exercise among sedentary adults. Implications of these findings for use in applied settings and treatment studies are discussed.

Development and validation of the weight control strategies scale.

OBJECTIVE: To develop and validate the Weight Control Strategies Scale (WCSS), a self-report instrument to assess the use of specific behaviors thought to facilitate weight loss. DESIGN AND METHODS: Factor analysis was conducted on 323 overweight and obese adults (mean age = 48.7 ± 10.9 years, mean body mass index = 35.4 ± 4.9 kg/m(2) , 74% female) enrolled in three different behavioral weight loss trials who completed the WCSS prior to starting treatment. To evaluate construct validity, additional data on dietary intake, physical activity, treatment session attendance, and weight change were obtained from a subsample of participants before and after participation in a 48-week weight loss program. RESULTS: Principal components analysis with varimax rotation revealed a four-component solution for the WCSS, representing the following subscales: Dietary Choices, Self-monitoring Strategies, Physical Activity, and Psychological Coping (α from 0.79 to 0.89). Longitudinal analyses showed that WCSS subscale scores increased during treatment (P < 0.01). In adjusted models, changes in WCSS total and subscale scores were associated with post-treatment weight loss (P < 0.01). Additionally, changes in WCSS Dietary Choices and Physical Activity subscales were related to post-treatment changes in total daily kilocalorie consumption (P = 0.019) and weekly kilocalorie expenditure through physical activity (P < 0.001), respectively. CONCLUSIONS: Findings support the validity and reliability of the WCSS in a weight loss treatment-seeking sample.

Combining behavioral weight loss treatment and a commercial program: a randomized clinical trial.

OBJECTIVE: To test the hypothesis that a novel weight loss approach that combined the fundamental components of professionally delivered behavioral weight loss (BWL) treatment with the existing Weight Watchers (WW) program would produce better weight losses than WW alone no differences were expected between the novel treatment and BWL alone. DESIGN AND METHODS: Participants were 141 overweight and obese adults (90% women, 67% non-White, mean age = 49.7 ± 9.2 years, mean body mass index = 36.2 ± 5.5 kg/m(2) ) randomly assigned to 48 weeks of BWL, 48 weeks of WW, or 12 weeks of BWL followed by 36 weeks of WW [combined treatment (CT)]. Assessments were conducted at baseline and weeks 12, 24, and 48, with weight change as the primary outcome. RESULTS: Linear mixed model analysis showed that 24-week weight losses did not differ significantly between treatment groups; however, weight losses at 48 weeks were greater in the WW group (M = -6.0 kg, standard error (SE) = 0.8) compared with the CT group (M = -3.6 kg, SE = 0.8; P = 0.032), with BWL not significantly different from either (M = -5.4 kg, SE = 0.8). Further, a greater proportion of WW participants lost 10% of baseline weight by 48 weeks compared with BWL or CT (36.7%, 13.0%, and 15.2%, respectively, P < 0.05). CONCLUSION: This study shows that the WW program can produce clinically meaningful weight losses and provides no evidence that adding brief BWL to the WW program improves outcome.

Validation and predictive utility of the Sociocultural Attitudes Toward Appearance Questionnaire for Eating Disorders (SATAQ-ED): internalization of sociocultural ideals predicts weight gain.

A widely used measure of societal influences on body image and eating disturbances--the Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ) was validated in women with eating disorders. The original SATAQ and measures of convergence and divergence were administered to 165 eating disordered inpatients. Factor analyses were conducted to determine the underlying structure of the SATAQ. Convergent validity, diagnostic category norms and the predictive utility of the revised SATAQ were examined. Factor analyses indicated three factors: Internalization, Awareness, and Success. Internalization significantly predicted treatment success after controlling for admission BMI and drive for thinness. The revised SATAQ-ED measures multiple aspects of societal influence, predicts short-term outcome, and can be a useful tool for evaluating potential outcome and treatment efficacy.

Behavioral approaches to weight control: a review of current research.

Weight management is a salient issue for women. Studies of behavioral, pharmacological and surgical interventions indicate that women comprise the majority of patients presenting for weight-loss treatment. In this review we discuss the health impact of obesity for women, review behavioral treatments for adult overweight and obesity, and address topics of particular relevance for women, including concerns that weight-loss treatment may precipitate the development of eating pathology, as well as time periods of high risk for weight gain such as pregnancy and menopause.

Motivation to change as a predictor of treatment response in obsessive compulsive disorder.

BACKGROUND: Motivation to change has been shown to predict treatment outcome in various areas of mental health but has never been examined in obsessive compulsive disorder (OCD). The purpose of this report is to present the first use of the University of Rhode Island Change Assessment (URICA) in an OCD pharmacotherapy sample and to determine whether motivation to change predicts degree of treatment response in this group. METHODS: The sample consisted of 32 outpatients diagnosed with OCD who completed an open-label 10-week trial of fluvoxamine. Participants completed the URICA at baseline. OCD symptom severity was rated at baseline and end of treatment. RESULTS: While overall readiness was not related to change in severity, high scores on the Precontemplation subscale (indicating greater resistance to changing OC behaviors) were associated with less change pre- to post-treatment. CONCLUSIONS: Preliminary findings indicate that greater resistance to change is associated with less improvement in OCD symptom severity following pharmacotherapy. As this is the first use of the URICA as a predictor of OCD response, future research should further examine the role of motivation to change in treatment outcome in a larger OCD sample.