Is it possible to assess when patients will lose and not regain the weight with various interventions to improve longterm outcomes?
A panel of experts explored the clinical potential for determining patients’ responsiveness to a variety of weight loss interventions, including lifestyle,1 gastric procedures2 and bariatric surgery,3 in order to assure patients can realize a more predictable and sustainable weight loss, during a symposium presented by the World Obesity Federation during ObesityWeek on November 3, 2016.
Obesity, as a chronic disease, will require a mixing and matching of treatments to find the right fit for each individual, was the takeaway from the session. In fact, physicians, patients, even society as a whole, will need to shift away from a perspective of compliance and expectations of sheer will-power as essential factors for successful weight loss. Rather, clinicians are now being advised to adopt a new paradigm with regard to weight management, namely—adherence.
Lifestyle intervention is considered the foundation or core to weight management approaches, with specific attention to 2 primary components: diet and physical activity, and remains first line treatment, and is often a prerequisite to initiation of pharmacotherapy and/or surgery. However, the rising rates of obesity and comorbidities including cardiovascular disease and diabetes have caused researchers to reflect on the professions’ collective failure to prompt successful weight management.
In the Look AHEAD study (Action for Health in Diabetes), weight loss data fell on bell-shaped curve with the intensity of adherence to treatment as the overriding factor for sustained weight loss,1,4 according to Donna Ryan, MD, a professor and associate executive director of clinical research at the Pennington Biomedical Research Center in Baton Rouge, Louisiana, in her presentation at ObesityWeek.
Clinicians have had a tendency to focus on behavior, or more aptly a failure to change behaviors as a way of explaining weight regain; however, our evolving understanding of the mechanics of obesity and peoples’ response to treatment has researchers reframing the process away from behavior and toward adherence, which is more reflective of our biology, said Dr. Ryan.
In 2001, the Look AHEAD study was initiated to test the efficacy of intensive lifestyle intervention (ILI) to promote weight loss in order to improve cardiovascular morbidity and mortality when compared against diabetes support and education in individuals with type 2 diabetes.5 This ongoing randomized trial focused on the effectiveness of ILI-- healthy eating and increased physical activity--on weight loss. The Look AHEAD Extension (LA-E) study is continuing to examine the impact of ILI over 10 years to provide data on longterm outcomes.6
In evaluating individuals from the Look AHEAD trial, those who lost the most weight during the first month were consistently more likely to maintain their weight loss at least 4 years,4 according to Dr. Ryan.
“A 10% weight loss initially was predictive of better weight control going out one year, and these individuals maintained better through 8 years,”6 said Dr. Ryan. “Another factor was the consistent use of 1-2 meal replacements daily.”6
In the Look Ahead trial, “the intensity of the intervention: number of sessions attended, minutes of activity weekly, number of words written in food diary entries, and consistent use of meal replacements” led to the greatest success., according to Dr. Ryan. However, men lost more weight than women, individuals with better glucose control and lower A1C did better, and older individuals (> 65 years old) achieved the best results as compared to individuals age 45-54, people on insulin lost less.6
Older patients showed the greatest adherence to the lifestyle protocol: attending sessions, minutes of physical activity, completing a food diary.4 In effect, older people typically have less demands for their time, and are better able to focus on their own needs,” said Dr. Ryan. So they could consistently keep regular appointments, keep comprehensive food records, and walk for hours, and “success breeds success”.1
Men had better adherence then women not because of a difference in lean to fat mass, but because women have many more responsibilities, and tend to put their needs last, said Dr. Ryan.
Similar to the older individuals, most women’s time is limited; mothers, for example, typically are pulled in many directions, trying to meet their family’s needs and work, so their poor adherence–and the fact that the outcomes for women were below that of men--can be easily explained, Dr. Ryan told EndocrineWeb.
Other barriers to a successful outcome included depression, being single, and never weighing oneself. Conversely, the influence of social support showed a mediating effect particularly for exercise, which has been repeatedly demonstrated. However, there was a secondary effect on family, who tended to participate with evident weight loss.1
The findings from Look AHEAD,4-6 suggest that by accounting for known barriers that patients bring into a weight management program, clinicians will be better able to tailor recommendations and individualize a plan that can improve adherence, and ultimately successful weight loss and avoidance of weight regain,7 according to Dr. Ryan.
“As we develop a better understanding of the underlying mechanisms (of successful weight control), we will be able to create effective step care approaches,” said. Dr. Ryan
In concluding her presentation, Dr. Ryan said, "the guidelines8 have not taken hold, structured skills training is needed, and must be consistently and uniformly employed by every clinician who is working with patients to address their obesity.”
1. Ryan DH. Predicting weight loss after lifestyle changes: Lessons for the Look AHEAD Study. November 2, 2016. Presented at ObesityWeek, New Orleans, Louisiana.
2. Finer, N. Predicting weight loss after gastric bypass and sleeve gastrectomy. November 2, 2016. Presented at ObesityWeek, New Orleans, Louisiana.
3. Dixon JB. Predicting weight loss after bariatric surgery. November 2, 2016. Presented at ObesityWeek, New Orleans, Louisiana.
4. Wadden TA, Neiberg RH, Wing RR, et al. Four-Year Weight Losses in the Look AHEAD Study: Factors Associated with Long-Term Success. Obesity 2011;19(10):1987-1998.
5. Wadden TA, West DS, Neibert RH et al for the Look AHEAD Research Group. One-year weight losses in the Look AHEAD Study: factors associated with success. Obesity. 17:713-722.
6. Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: the Look AHEAD study. Obesity. 2014;22(1):5-13.
7. Apovian CM, Garvey WT, Ryan DH. Challenging Obesity: Patient, Provider, and Expert Perspectives on the Roles of Available and Emerging Nonsurgical Therapies. Obesity. 2015;23(0 2):S1-S26.
8. Pi-Sunyer FX for the NHLBI Obesity Education Initiative Expert Panel. The Practice Guide: The Identification, Evaluation, and Treatment of Overweight and Obese Adults. NIH/NHLBI and North American Association for the Study of Obesity. October 2000. NIH Publication 00-4084.