Maintenance of weight loss after obesity treatment: is continuous support necessary?

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Abstract

Objective: This study examined outcome differences of 109 obese subjects, who participated in a 10-week cognitive-behavioral inpatient treatment followed by either a weight maintenance program or a follow-up period without professional support.

Methods: Self-rated weight loss, eating behaviors, and general psychopathology were assessed several months before treatment, when subjects were admitted, at discharge, and at the 6-, 12-, and 18-month follow-ups. Structured interviews for mental disorders and eating pathology were conducted additionally.

Results: The mean weight of the sample at baseline was 127 kg. Weight loss of the total sample amounted to 8.0 kg (6.3%) and was completely maintained during the follow-up period. Significant reductions of eating and general psychopathology were observed at the 18-month follow-up. The outcome in the maintenance condition did not significantly differ from the outcome in the control condition.

Conclusions: Weight regain after obesity treatment is not inevitable, but continuous patient–therapist contacts do not distinctly improve treatment effects.

Introduction

Obesity is very common in the western industrialized countries. About 25% of the US population is obese (Kuczmarski, 1992). Obesity is associated with increased risk for hypertension, diabetes, cardiovascular and other diseases (Pi-Sunyer, 1991), and prevalence is increasing (Flegal, Harlan, & Landis, 1988). On the other hand, even small weight losses of 5–10% already reduce health risks substantially (Blackburn & Kanders, 1987). This proportion is also recommended by the US Department of Agriculture Dietary Guidelines for overweight persons (Agricultural Research Service, 1995).

Various interventions, such as very low calorie diets (VLCD), physical exercise programs, pharmacological treatments and cognitive-behavioral therapies (CBT) induce effective weight loss averaging 10–20 kg. However, most obese subjects are unable to maintain these effects and regain a large part of the weight lost after treatment (Wadden, Stunkard, & Liebschutz, 1988; Wadden, 1993a; Wadden, Foster, & Letizia, 1994; Wilson, 1994). Especially rapid and large weight losses, as achieved by VLCD, are often followed by rapid and large weight gains in the follow-up period or even during treatment, and sometimes result in worse cumulative weight reductions than less restrictive treatments (Perri et al., 1988, Wadden et al., 1988, Wadden et al., 1994). As a consequence, small changes in weight and eating behavior, as achieved by CBT programs without dieting, have been recommended by various investigators (Brownell & Wadden, 1991; Foster & Kendall, 1994; Foster, Wadden, Vogt & Brewer, 1997).

Binge eating disorder might be a negative predictor of weight loss. Agras, Telch, Arnow, Eldredge, and Marnell (1997) reported a weight gain of 3.6 kg in subjects who continued binging at 1-year follow-up, while those who stopped binging were 4 kg below their baseline weight. Fichter, Quadflieg, and Brandl (1993) found that obese binge eaters regained a large portion of their initial weight loss within the first 3 years after discharge. Other predictors of weight loss might be: low frequency of previous dieting (Pasman, Saris, & Westerterp-Plantenga, 1999), no history of repeated weight loss and better satisfaction with body (Kiernan, King, Kraemer, Stefanick, & Killen, 1998), baseline body mass index, minutes of exercise per week, and age (Stevens et al., 1989). In summary, however, convergent evidence about predictors of weight loss so far does not exist.

As a consequence of rapid weight regain after treatment, strategies to improve long-term outcome were investigated. Therapeutic support was extended by either prolonged treatment durations up to 1 year or the application of maintenance programs (consisting of bi-weekly or monthly therapist contacts) to foster behavior changes achieved during treatment. In several studies Perri and associates found that maintenance programs consisting of professional contacts, skills training, peer support, and physical exercise can improve maintenance for up to an 18-month period (Perri, Sears, & Clark, 1993). However, some other studies showed that weight regain already occurred in the treatment period (Perri et al., 1987, Wadden et al., 1994; Wing, Blair, Marcus, Epstein, & Harvey, 1994), while, on the other hand, studies demonstrating satisfactory long-term outcome (Karvetti & Hakala, 1992; Pekkarinen & Mustajoki, 1997) did not necessarily include maintenance programs. On a retrospective basis Fichter et al. (1993) found that weight even declined in the first quarter after treatment without professional support, while weight regain mainly occurred between the first and the third year after discharge. Mustajoki and Pekkarinen (1999) point out that that the ability of subjects to take responsibility for their lives might be a better predictor for successful maintenance than continuous therapeutic support or prescribing exercise and diets. However, reinforcing patients' responsibility for their life-style and supporting continuous behavior modifications by maintenance programs need not be contrary but can be complementary strategies as well.

The present study investigated the effects of a 10-week cognitive-behavioral inpatient treatment without dietary restriction followed by either an 18-month maintenance program or an 18-month follow-up period without professional support. It was hypothesized that all subjects would significantly benefit from the treatment program, regarding weight loss. Since one principal intention of the treatment program was to use cognitive-behavioral interventions instead of direct weight reduction measures (like diets), we expected a significant improvement of dysfunctional eating behavior and general psychopathology as an essential requirement for weight reduction. Subjects supported by a maintenance program were expected to achieve a significantly better therapy outcome than those obtaining only inpatient treatment. Another intention of the study was to identify variables predicting overall weight loss at the 18-month follow-up.

Section snippets

Sample

For two years all patients referred to the eating disorder department of a Center for Behavioral Medicine were consecutively screened regarding fulfillment of the study criteria for the obesity treatment program. Weight and DSM-IV-criteria for bulimia nervosa and binge eating disorder were investigated. Inclusion criteria were: severe obesity as defined by a BMI >30; referral to the Center due to ineffective former treatment trials, very severe obesity, concomitant characteristics of eating

General characteristics of the sample and baseline differences between the experimental group and the control group

The final sample consisted of 109 participants of the inpatient treatment program. Ninety-one (83.5%) subjects were female, mean age was 37.1 years (SD=10.8). The mean weight of the sample at baseline was 127 kg (SD=26.4), which corresponds to a Body Mass Index of 44.8 (SD=8.7) indicating a very severe degree of obesity. Weight ranged from 85 to 223 kg. The following frequencies of comorbid mental disorder diagnoses (present/lifetime) were determined: binge eating disorder (DSM-IV research

Discussion

Initial weight loss of the total sample during inpatient treatment was within the range of studies using CBT or CBT in combination with mild caloric restriction (Wadden, 1993a, Wadden, 1993b, Wadden et al., 1994). The weight reduction of 8.0 kg (6.3%) is satisfactory considering that it was achieved in 10 weeks and without any diet. Weight loss is within the range of 5–10% reduction, which was found to improve obesity-related physical conditions distinctly (Blackburn, 1995). However, a reduction

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