Wanda J. E. Bemelmans

Maintenance of weight loss after lifestyle interventions for overweight and obesity, a systematic review

Lifestyle interventions can reduce body weight, but weight regain is common and may particularly occur with higher initial weight loss. If so, one may argue whether the 10% weight loss in clinical guidelines is preferable above a lower weight loss. This systematic review explores the relation between weight loss during an intervention and weight maintenance after at least 1 year of unsupervised follow‐up. Twenty‐two interventions (during at least 1 month) in healthy overweight Caucasians were selected and the mean percentages of weight loss and maintenance were calculated in a standardized way. In addition, within four intervention groups (n > 80) maintenance was calculated stratified by initial weight loss (0–5%, 5–10%, >10%). Overall, mean percentage maintenance was 54%. Weight loss during the intervention was not significantly associated with percentage maintenance (r = −0.26; P = 0.13). Percentage maintenance also not differed significantly between interventions with a weight loss of 5–10% vs. >10%. Consequently, net weight loss after follow‐up differed between these categories (3.7 vs. 7.0%, respectively; P < 0.01). The analyses within the four interventions confirmed these findings. In conclusion, percentage maintenance does not clearly depend on initial weight loss. From this perspective, 10% or more weight loss can indeed be encouraged and favoured above lower weight loss goals.

Randomized Trial of a Lifestyle Program in Obese Infertile Women

BACKGROUND Small lifestyle-intervention studies suggest that modest weight loss increases the chance of conception and may improve perinatal outcomes, but large randomized, controlled trials are lacking. METHODS We randomly assigned infertile women with a body-mass index (the weight in kilograms divided by the square of the height in meters) of 29 or higher to a 6-month lifestyle intervention preceding treatment for infertility or to prompt treatment for infertility. The primary outcome was the vaginal birth of a healthy singleton at term within 24 months after randomization. RESULTS We assigned women who did not conceive naturally to one of two treatment strategies: 290 women were assigned to a 6-month lifestyle-intervention program preceding 18 months of infertility treatment (intervention group) and 287 were assigned to prompt infertility treatment for 24 months (control group). A total of 3 women withdrew consent, so 289 women in the intervention group and 285 women in the control group were included in the analysis. The discontinuation rate in the intervention group was 21.8%. In intention-to-treat analyses, the mean weight loss was 4.4 kg in the intervention group and 1.1 kg in the control group (P<0.001). The primary outcome occurred in 27.1% of the women in the intervention group and 35.2% of those in the control group (rate ratio in the intervention group, 0.77; 95% confidence interval, 0.60 to 0.99). CONCLUSIONS In obese infertile women, a lifestyle intervention preceding infertility treatment, as compared with prompt infertility treatment, did not result in higher rates of a vaginal birth of a healthy singleton at term within 24 months after randomization. (Funded by the Netherlands Organization for Health Research and Development; Netherlands Trial Register number, NTR1530.).

Preventing Weight Gain : One-Year Results of a Randomized Lifestyle Intervention

BACKGROUND Lifestyle interventions targeting prevention of weight gain may have better long-term success than when aimed at weight loss. Limited evidence exists about such an approach in the primary care setting. DESIGN An RTC was conducted. SETTING/PARTICIPANTS Participants were 457 overweight or obese patients (BMI=25-40 kg/m(2), mean age 56 years, 52% women) with either hypertension or dyslipidemia, or both, from 11 general practice locations in The Netherlands. INTERVENTION In the intervention group, four individual visits to a nurse practitioner (NP) and one feedback session by telephone were scheduled for lifestyle counseling with guidance of the NP using a standardized computerized software program. The control group received usual care from their general practitioner (GP). MAIN OUTCOME MEASURES Changes in body weight, waist circumference, blood pressure, and blood lipids after 1 year (dropout <10%). Data were collected in 2006 and 2007. Statistical analyses were conducted in 2007 and 2008. RESULTS There were more weight losers and stabilizers in the NP group than in the general practitioner usual care (GP-UC) group (77% vs 65%; p<0.05). In men, mean weight losses were 2.3% for the NP group and 0.1% for the GP-UC group (p<0.05). Significant reductions occurred also in waist circumference but not in blood pressure, blood lipids, and fasting glucose. In women, mean weight losses were in both groups 1.6%. In the NP group, obese people lost more weight (-3.0%) than the non-obese (-1.3%; p<0.05). CONCLUSIONS Standardized computer-guided counseling by NPs may be an effective strategy to support weight-gain prevention and weight loss in primary care, in the current trial, particularly among men. TRIAL REGISTRATION The study was registered with the Netherlands Trial Register (NTR), www.trialregister.nl, study no. TC 1365.

Impact of Mediterranean diet education versus posted leaflet on dietary habits and serum cholesterol in a high risk population for cardiovascular disease

OBJECTIVE To investigate the impact of intensive group education on the Mediterranean diet on dietary intake and serum total cholesterol after 16 and 52 weeks, compared to a posted leaflet with the Dutch nutritional guidelines, in the context of primary prevention of cardiovascular disease (CVD). DESIGN Controlled comparison study of an intervention group given intensive group education about the Mediterranean diet and a control group of hypercholesterolaemic persons given usual care by general practitioners (GPs). SETTING A socioeconomically deprived area in the Netherlands with an elevated coronary heart disease (CHD) mortality ratio. SUBJECTS Two hundred and sixty-six hypercholesterolaemic persons with at least two other CVD risk factors. RESULTS After 52 weeks, the intervention group decreased total and saturated fat intake more than the control group (net differences were 1.8 en% (95%CI 0.2-3.4) and 1.1 en% (95%CI 0. 4-1.9), respectively). According to the Mediterranean diet guidelines the intake of fish, fruit, poultry and bread increased in the intervention group, more than in the control group. Within the intervention group, intake of fish (+100%), poultry (+28%) and bread (+6%) was significantly increased after 1 year (P < 0.05). The intensive programme on dietary education did not significantly lower serum cholesterol level more (-3%) than the posted leaflet (-2%) (net difference 0.06 mmol l-1, 95%CI -0.10 to 0.22). Initially, the body mass index (BMI) decreased more in the intervention group, but after 1 year the intervention and control group gained weight equally (+1%). CONCLUSIONS Despite beneficial changes in dietary habits in the intervention group compared with the control group, after 1 year BMI increased and total fat and saturated fat intake were still too high.

Change in saturated fat intake is associated with progression of carotid and femoral intima-media thickness, and with levels of soluble intercellular adhesion molecule-1

BACKGROUND A high saturated fat (SFA) intake may stimulate progression of atherosclerosis, and may be positively associated with expression of adhesion molecules. METHODS In moderately hypercholesterolaemic participants of a dietary intervention study (n=103; 55+/-10 years), we examined associations between reported changes in SFA intake and changes in carotid and femoral intima-media thickness (IMT) and soluble intercellular adhesion molecule-1 (sICAM-1) levels after 2 years. The carotid and femoral IMT was assessed by high-resolution B-mode ultrasound images. RESULTS After 2 years, dietary intake of SFA decreased with 1.8+/-2.6% of energy (P<0.01). In the lowest quintile of change in SFA intake (-5.9+/-1.4% of energy), changes in carotid and femoral IMT were +0.03 mm (SEM 0.03) and -0.09 mm (SEM 0.07), respectively, versus +0.10 mm (SEM 0.03), +0.17 mm (SEM 0.07) in the top quintile (+1.6+/-0.7% of energy) (P linear trend 0.07 (carotis), 0.02 (femoralis)). Changes in sICAM-1 were -19.0 ng/nl (SEM 5.6) in the lowest quintile, versus +8.6 ng/ml (SEM 5.3) in the top quintile (P linear trend <0.001), adjusted for baseline level, SFA intake, body mass index, age, changes in intake of fruit, polyunsaturated fat, and dietary cholesterol. Adjustments for changes in established risk factors did not alter these results. CONCLUSIONS Decreased SFA intake may reduce progression of atherosclerosis, as assessed by IMT, and is associated with reduced levels of sICAM-1 after 2 years. Further research using randomised placebo-controlled trials is necessary to exclude potential confounding variables and to confirm causality.

The LIFESTYLE study: costs and effects of a structured lifestyle program in overweight and obese subfertile women to reduce the need for fertility treatment and improve reproductive outcome. A randomised controlled trial

BackgroundIn the Netherlands, 30% of subfertile women are overweight or obese, and at present there is no agreement on fertility care for them. Data from observational and small intervention studies suggest that reduction of weight will increase the chances of conception, decrease pregnancy complications and improve perinatal outcome, but this has not been confirmed in randomised controlled trials. This study will assess the cost and effects of a six-months structured lifestyle program aiming at weight reduction followed by conventional fertility care (intervention group) as compared to conventional fertility care only (control group) in overweight and obese subfertile women. We hypothesize that the intervention will decrease the need for fertility treatment, diminish overweight-related pregnancy complications, and will improve perinatal outcome.Methods/DesignMulticenter randomised controlled trial in subfertile women (age 18-39 year) with a body mass index between 29 and 40 kg/m2. Exclusion criteria are azoospermia, use of donor semen, severe endometriosis, premature ovarian failure, endocrinopathies or pre-existent hypertensive disorders.In the intervention group the aim is a weight loss of at least 5% to10% in a six-month period, to be achieved by the combination of a diet, increase of physical activity and behavioural modification. After six months, in case no conception has been achieved, these patients will start fertility treatment according to the Dutch fertility guidelines. In the control group treatment will be started according to Dutch fertility guidelines, independently of the patients weight.Outcome measures and analysisThe primary outcome measure is a healthy singleton born after at least 37 weeks of gestation after vaginal delivery. Secondary outcome parameters including pregnancy outcome and complications, percentage of women needing fertility treatment, clinical and ongoing pregnancy rates, body weight, quality of life and costs.Data will be analysed according to the intention to treat principle, and cost-effectiveness analysis will be performed to compare the costs and health effects in the intervention and control group.DiscussionThe trial will provide evidence for costs and effects of a lifestyle intervention aiming at weight reduction in overweight and obese subfertile women and will offer guidance to clinicians for the treatment of these patients.Trial registrationDutch Trial Register NTR1530

Preventing weight gain by lifestyle intervention in a general practice setting - three-year results of a randomized controlled trial

BACKGROUND Weight regain after initial loss of weight is common, which indicates a need for lifestyle counseling aimed at preventing weight gain instead of weight loss. This study was conducted to determine whether structured lifestyle counseling by nurse practitioners (NPs) group compared with usual care by general practitioners (GP-UC) in overweight and obese patients can prevent (further) weight gain. METHODS A randomized controlled trial in 11 general practice locations in the Netherlands of 457 patients (body mass index, 25-40 [calculated as weight in kilograms divided by height in meters squared]; mean age, 56 years; 52% female) with either hypertension or dyslipidemia or both. The NP group received lifestyle counseling with guidance of the NP using a standardized software program. The GP-UC group received usual care from their GP. Main outcome measures were changes in body weight, waist circumference, blood pressure, and fasting glucose and blood lipid levels after 3 years. RESULTS In both groups, approximately 60% of the participants achieved weight maintenance after 3 years. There was no significant difference in mean (SD) weight change and change of waist circumference between the NP and GP-UC groups (weight change: NP group, -1.2% [5.8%], and GP-UC group, -0.6% [5.6%] [P = .37]; and change of waist circumference: NP group, -0.8 [7.1] cm, and GP-UC group, 0.4 [7.2] cm [P = .11]). A significant difference occurred for mean (SD) fasting glucose levels (NP group, -0.02 [0.49] mmol/L, and GP-UC group, 0.10 [0.53] mmol/L [P = .02]) (to convert to milligrams per deciliter, divide by 0.0555) but not for lipid levels and blood pressure. CONCLUSIONS Lifestyle counseling by NPs did not lead to significantly better prevention of weight gain compared with GPs. In the majority in both groups, lifestyle counseling succeeded in preventing (further) weight gain. TRIAL REGISTRATION trialregister.nl Identifier: NTR1365.

Changes in lifestyle habits after counselling by nurse practitioners: 1-year results of the Groningen Overweight and Lifestyle study

OBJECTIVES The Groningen Overweight and Lifestyle (GOAL) study primarily aims at preventing weight gain by nurse practitioners (NP) guided by a standardized computerized software program. Since favourable changes in physical activity (PA) and diet may improve health independently of weight (loss), insight into effects on lifestyle habits is essential. We examined the 1-year effects of lifestyle counselling by NP on PA and diet, compared with usual care from the general practitioner (GP-UC). DESIGN A randomized controlled trial. SETTING Eleven general practice locations in the Netherlands. SUBJECTS A total of 341 GOAL participants with overweight or obesity and either hypertension or dyslipidaemia, or both, who completed an FFQ and Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH) at baseline and after 1 year. RESULTS After 1 year, the NP group spent 33 min/week more on walking compared with the GP-UC group who spent -5 min/week on walking (P = 0.05). No significant differences were found between the NP and GP-UC groups on the percentage of persons complying with the PA guidelines. In both groups, nutrient intake changed in a favourable direction and participants complied more often with dietary guidelines, but without overall difference between the NP and GP-UC groups. CONCLUSIONS With the exception of an increase in walking (based on self-reported data) in the NP group, no intervention effects on PA and diet occurred. Positive changes in nutrient intake were seen in both groups.

Nationwide implementation of Hello World: a Dutch email-based health promotion program for pregnant women.

Background In November 2006, an email-based health promotion program for pregnant women was implemented nationally in the Netherlands. The program consisted of emails containing quizzes with pregnancy-related questions tailored to the number of weeks of pregnancy. Emails were sent out once every 4 weeks, up to a maximum of nine emails. Objectives The aims of the study were (1) to assess the recruitment of participants and their representativeness of the Dutch population and (2) to study differences in recruitment, program use, and program appreciation among women with different levels of education. Methods Data from 13,946 pregnant women who enrolled during the first year of the program were included. Upon registration, participants were asked how they found out about the program and subsequently received an email questionnaire to assess demographic, lifestyle, and Internet characteristics. Program use was tracked, and participants were classified into five user groups (inactive to very active). Program appreciation (low, intermediate, and high) was assessed twice with an email questionnaire that was sent after the woman had received her third and sixth quiz email. Information about pregnant women and their characteristics was obtained from Dutch registries to assess representativeness of the study population. Results About 8% of the pregnant women in the Netherlands enrolled in the program. Immigrants were underrepresented, and women with a low level of education seemed to be slightly underrepresented. Most women knew about the program from a promotional email sent by the organization (32%), followed by the Internet (22%) and midwives (16%). Women with little education were more often inactive users of the program than were highly educated women (15% vs 11%, P < .001), whereas highly educated women were more often very active users compared with women with little education (25% vs 20%, P< .001). However, women with less education were more likely than women with more education to have a high appreciation of the program after receiving three quiz emails (52% vs 44%, P = .001). Conclusions In this real-life setting, pregnant women can be reached through an email-based health promotion program. Selective engagement by education level remains a challenge.

Usage of an online healthy lifestyle program by pregnant women attending midwifery practices in Amsterdam

OBJECTIVE To determine reach, attrition and program engagement and their associations with user characteristics for an online healthy lifestyle program for pregnant women. METHODS From March to August 2006, 1382 pregnant women visiting 20 midwifery practices in Amsterdam were invited to enroll in a healthy lifestyle program through registration on the program website (at home). User characteristics were self-reported upon enrollment, while program use was objectively monitored until January 2007. RESULTS Seventeen percent (n=238) of the women who received information from their midwife enrolled. Most women were highly educated (68%) and already had a healthy lifestyle. About half of them (52%) continued to use the program throughout their pregnancy. Less lower than higher educated women continued using the program (45% vs. 63%, p=0.02). When e-mails were opened almost all lifestyle topics were accessed (85%), but links to related websites were used less often (12%). CONCLUSION The healthy lifestyle program did not reach a substantial proportion of the target population. Only 9% of those invited continued to use the program throughout their pregnancies. In addition to that there was selective enrollment and selective attrition. This research confirms that disadvantaged women, who need the intervention most, are least easily reached.