Leslie G. Womble

PSYCHOSOCIAL ASPECTS OF OBESITY AND OBESITY SURGERY

There is a growing consensus that bariatric surgery is the treatment of choice for extremely obese individuals who have failed to reduce their weight satisfactorily using behavioral or pharmacologic interventions. The gastric bypass in particular is associated with excellent long-term weight loss. Although most extremely obese individuals will have essentially normal psychological functioning, a significant minority suffer from depression, binge eating, trauma, or other emotional complications that may require treatment before or after bariatric surgery. A structured behavioral assessment, conducted by a mental-health professional and a registered dietitian, can readily identify those who are most likely to require adjunct counseling.

Body image assessment for obesity (BIA-O): development of a new procedure

OBJECTIVE: A new measure of body image, named the body image assessment for obesity (BIA-O) was developed and tested for reliability and validity in a sample of 1209 adult men and women. Separate BIA-O procedures were developed for men and women. Current, ideal and reasonable body image estimates of Caucasian and African-American men and women were compared.METHOD: Figural stimuli of males and females were developed for body sizes ranging from very thin to very obese in 18 increments. Participants selected figures that represented estimates of current, ideal and reasonable (a body size that could be maintained over time) body size. Some participants (n=641) also completed two measures of body dissatisfaction in a test of the validity of the BIA-O as a measure of body dissatisfaction. A sample of 77 participants was administered the BIA-O on two occasions to test the test–retest reliability of the BIA-O.RESULTS: The reliability of the BIA-O was supported by test–retest reliability coefficients which ranged from 0.65 to 0.93. Concurrent validity of the discrepancy between current and ideal and current and reasonable body size estimates was supported by positive correlations with two measures of body dissatisfaction. The BIA-O body size estimates of Caucasians and African-Americans, controlled for age and BMI, were compared. As BMI increased, Caucasian men and women were found to select larger current body size estimates in comparison to African-Americans.DISCUSSION: The reliability and validity of the BIA-O were supported. Greater body size dissatisfaction in obese Caucasians, relative to African-Americans of the same size, may be a function of biased estimates of current body size.

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/m2, 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 (⩽44 years) participants (47.5 vs 20.8%; P<0.0001). After 1 year of treatment, a moderate decrease in weight (8.0±8.7 kg) resulted in significant reductions in the prevalence of metabolic syndrome from 34.8 to 27.2% of all participants (P<0.02). Logistic regression analyses indicated that for each 1 kg of weight lost, the odds of metabolic syndrome were reduced by 8% (CI=0.89–0.97; P<0.003). Lifestyle modification either alone (P<0.04), or in combination with sibutramine (P<0.05), significantly reduced the prevalence of metabolic syndrome compared with sibutramine alone. The group effect was removed after controlling for weight loss.Conclusions:The metabolic syndrome was prevalent in over one-third of obese individuals who sought weight loss treatment, and the prevalence differed by age, sex and ethnicity. Moderate weight loss markedly reduced the odds of metabolic syndrome in this sample.

Changes in Symptoms of Depression with Weight Loss: Results of a Randomized Trial

Recent studies of rimonabant have re‐awakened interest in the possible adverse psychiatric effects of weight loss, as well as of weight loss medications. This study examined changes in symptoms of depression in 194 obese participants (age = 43.7 ± 10.2 years; BMI = 37.6 ± 4.1 kg/m2) in a 1‐year randomized trial of lifestyle modification and medication. Participants were assigned to (i) sibutramine alone; (ii) lifestyle modification alone; (iii) sibutramine plus lifestyle modification (i.e., combined therapy); or (iv) sibutramine plus brief therapy. Participants completed the Beck Depression Inventory‐II (BDI‐II) at baseline and weeks 6, 10, 18, 26, 40, and 52. At 1 year, participants in combined therapy lost the most weight and those in sibutramine alone the least (12.1 ± 8.8% vs. 5.5 ± 6.5%; P < 0.01). Mean BDI‐II scores across all participants declined from 8.1 ± 6.9 to 6.2 ± 7.7 at 1 year (P < 0.001), with no significant differences among groups. Despite this favorable change, 13.9% of participants (across the four groups) reported potentially discernible increases (≥ 5 points on the BDI‐II) in symptoms of depression at week 52. They lost significantly less weight than participants in the rest of the sample (5.4 ± 7.8% vs. 9.0 ± 7.8%, respectively; P < 0.03). The baseline prevalence of suicidal ideation was 3.6%. Seven new cases of suicidal ideation were observed during the year, with three in lifestyle modification alone. Further research is needed to identify characteristics of obese patients at risk of negative mood changes (and suicidal ideation) in response to behavioral and pharmacologic therapies.

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/m2) 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.

Psychological and behavioral predictors of weight loss during drug treatment for obesity

OBJECTIVE: This study investigated whether baseline eating behavior, emotions, and body image were significant predictors of change in body mass index (BMI) over 6 month and 12 month time intervals for individuals enrolled in a weight loss program that combined appetite suppressant medications and behavior therapy for obesity.METHOD: Participants were asked to complete self-report questionnaires at baseline, 6 months, and 12 months. In addition, their height and weight were measured and they were administered a body image assessment procedure at each time interval.RESULTS: At baseline, perceived hunger, dietary restraint, current body size, and trait anxiety were important components in a model for prediction of weight loss at 6 months. Perceived hunger, dietary restraint, and current body size as measured at baseline were important components in the prediction of weight loss at 12 months. These predictive variables, together with gender and initial BMI, accounted for 48.6% of the variance in weight loss at 6 months and 51.7% of the variance in weight loss at 12 months.DISCUSSION: These findings suggest that scores on certain paper and pencil tests may be useful as predictors of success or failure for individuals entering a weight loss program using pharmacological and behavioral interventions.

Meal replacements in the treatment of adolescent obesity: a randomized controlled trial.

Use of meal replacements (MRs) in lifestyle modification programs (LMPs) for obese adults significantly increases weight loss, compared with prescription of an isocaloric conventional diet (CD). This 12‐month randomized trial examined 113 obese adolescents (mean ± s.d. age of 15.0 ± 1.3 years and BMI of 37.1 ± 5.1 kg/m2) who were assigned to a LMP, combined with meal plans of 1,300–1,500 kcal/day of CD (self‐selected foods) or MR (three SlimFast shakes, one prepackaged meal, five vegetable/fruit servings). After month 4 (phase 1), participants originally treated with MR were unmasked to their phase 2 (months 5–12) random assignment: continued use of MR (i.e., MR+MR) or transitioned to CD (i.e., MR+CD). Participants initially treated with CD in phase 1, continued with CD (i.e., CD). All three groups were treated for an additional 8 months (phase 2). Regression models were used to evaluate percentage change in BMI from baseline to month 4 (phase 1), months 5–12 (phase 2), and baseline to month 12. At month 4, participants assigned to MR (N = 65) achieved a mean (±s.e.) 6.3 ± 0.6% reduction in BMI, compared to a significantly (P = 0.01) smaller 3.8 ± 0.8% for CD participants (N = 37). In phase 2, BMI increased significantly (P < 0.001) in all three conditions, resulting in no significant (P = 0.39) differences between groups in percentage change in BMI at month 12. Across groups, mean reduction in BMI from baseline to month 12 was 3.4 ± 0.7% (P < 0.01). Use of MR significantly improved short‐term weight loss, compared with CD, but its continued use did not improve maintenance of lost weight.

Protective Factors for Eating Disorders in Female College Athletes

Abstract Sundgot-Borgen (1993) hypothesized that participants in refereed sports, e.g., basketball, may be at lower risk for the development of eating disorders in comparison to those participating in judged sports, e.g., gymnastics. This study tested this hypothesis. Structured interviews and self-report questionnaires were employed to assess the presence of eating disorder diagnoses, the presence of body weight and shape concerns, psychopathology, and body mass index among female collegiate athletes. The sample included three groups of participants: nonathletic students (n = 62), student athletes participating in refereed sports (n = 33), and student athletes participating in judged sports (n = 37). Comparison of eating disorder diagnoses between groups found a trend toward a higher rate of diagnoses among members of judged sports as compared to both refereed sports and nonathletic students, approximately (13%, 3%, and 3%, respectively). Participants in judged sports did not differ from nonathletic stud...

Cognitive Behavior Therapy for Eating Disorders

The criteria for a diagnosis of anorexia nervosa are summarized in Table 1. It is generally believed that fear of weight gain and body image disturbances are central features of anorexia nervosa that motivate extreme weight control methods such as fasting or purging (Williamson, 1990). The Diagnostic and Statistical Manual for Mental Disorders, 4th ed. (DSM-IV; American Psychiatric Association, 1994) designates two subtypes of anorexia nervosa. The restricting subtype describes anorexic patients who lose weight by restrictive eating and do not binge eat or purge. The binge eating/purging subtype describes anorexic patients who binge eat and/or purge. The DSM-IV criteria for a diagnosis of bulimia nervosa are summarized in Table 2. A central feature of bulimia nervosa is binge eating in which the individual uncontrollably eats a large amount of food in a short period of time. Compensatory behaviors such as self-induced vomiting, laxative and/or diuretic abuse, compulsive exercising, or fasting are presumed to be motivated by fear of weight gain and body image disturbances (Williamson, 1990). Two subtypes of bulimia nervosa are designated in DSM-IV. The purging subtype describes persons who binge eat, but use self-induced vomiting, laxative abuse, or diuretic abuse to prevent weight gain. The nonpurging subtype describes persons who binge eat, but use other forms of compensatory behavior such as dieting or excessive exercise to prevent weight gain. It is our experience that these patients are usually 10 to 15 pounds overweight. In addition to anorexia nervosa and bulimia nervosa, DSM-IV designates a subclinical eating disorder category, eating disorder not otherwise specified (American Psychiatric Association, 1994). Examples of this diagnosis include subthreshold anorexics who are not emaciated and obese binge eaters who binge eat but do not use vomiting or exercise to prevent weight gain (Williamson, Gleaves, & Savin, 1992).

Metabolic Syndrome and Health-related Quality of Life in Obese Individuals Seeking Weight Reduction

Background: No previous research has examined the association between metabolic syndrome (MetSyn) and health‐related quality of life (HRQoL) using standard criteria for defining MetSyn. We hypothesized that MetSyn would be associated with lower HRQoL on measures of physical and mental health.