Elsevier

Behaviour Research and Therapy

Volume 63, December 2014, Pages 157-161
Behaviour Research and Therapy

The influence of cognitive factors in the treatment of obesity: Lessons from the QUOVADIS study

https://doi.org/10.1016/j.brat.2014.10.004Get rights and content

Highlights

  • We analyzed cognitive factors influencing obesity treatment, based on QUOVADIS study.

  • Dropout is associated with higher weight loss expectations and unsatisfactory results.

  • Weight loss is associated with increased dietary restraint and reduced disinhibition.

  • Weight maintenance is associated with satisfaction with results and self confidence.

Abstract

Weight-loss maintenance remains a problematic issue in lifestyle modification programmes, but a small percentage of individuals are able to maintain a significant long-term weight loss. This means cognitive mechanisms may effectively contrast the biological pressures to regain weight arising from an obesiogenic environment. Aims of this review were to summarizes and synthesizes the data on the cognitive factors associated with program attrition, weight loss and weight maintenance derived from the QUOVADIS (QUality of life in Obesity: eVAluation and DIsease Surveillance), an observational study on quality of life in 1944 obese patients seeking treatment in 25 medical centres in Italy, and discuss its results in light of other literature. The data obtained suggest that some cognitive factors are associated with treatment discontinuation (namely higher weight-loss expectations, appearance-based primary motivation for weight loss, and unsatisfactory progress), while others with the amount of weight lost (i.e., increased dietary restraint and reduced disinhibition) or with long-term weight loss maintenance in patients who interrupted the treatment (i.e., satisfaction with results achieved, confidence in being able to lose weight without professional help). All these findings have important clinical implications.

Introduction

The short-term outcomes of weight-loss lifestyle modification programmes are generally satisfactory. Indeed, data from randomized controlled trials of structured group weight-loss interventions indicate that, on average, 80% of patients who enrol in such programmes go on to complete the treatment (Wadden & Butryn, 2003), with completers achieving a mean weight loss of 8–10% of their initial body weight within roughly 30 weeks (Wadden & Butryn, 2003). According to the 2013 Guidelines for the Management of Overweight and Obesity in Adults (Jensen et al., 2014), this amount of weight loss can be considered successful (i.e., in line with a 5–10% reduction of initial weight), being associated with a significant reduction in the incidence of type-2 diabetes (Knowler et al., 2002), and clinical improvements in weight-related medical comorbidities (e.g., sleep apnoea, diabetes, hypertension, hyperlipidaemia) (Jensen et al., 2014), and psychosocial outcomes (e.g., mood, quality of life, and body image) (Dalle Grave et al., 2007, Faulconbridge et al., 2012, Fontaine et al., 2004).

However, in the year following treatment, obese participants in standard lifestyle-modification programs typically regain about 30–35% of the weight lost during treatment (Wadden, Butryn, & Byrne, 2004). Although weight regain tends to slow down after the first year, by 5 years post-treatment, 50% or more patients are likely to have returned to their baseline weight (Wadden, Sternberg, Letizia, Stunkard, & Foster, 1989). This indicates that a greater focus on long-term maintenance of weight loss is required for such programmes to be considered successful in real terms.

Thankfully, better long-term weight-loss outcomes have been demonstrated in trials of the latest generation of lifestyle modification programmes that include the most innovative and powerful procedures that the state of the art can offer. The most striking example is the Look AHEAD study, a long-term randomized trial of 5100 overweight participants with type-2 diabetes randomly assigned to either intensive lifestyle intervention (ILI) or diabetes support and education (DSE) (Ryan et al., 2003). At year 1, more ILI than DSE participants had lost ≥5% of their initial weight (68.0% vs. 13.3%), with the ILI group showing an average weight loss of 8.5%, significantly greater than the 0.6% seen in DSE participants. After 8 years, the weight-loss gap between the two groups had narrowed somewhat, with ILI and DSE participants having lost means of 4.7% and 2.1% of their starting weight, respectively, but about half of the ILI participants (50.3%) had maintained a loss of ≥5% of their initial body weight, as compared to only 35.7% in DSE participants (Look AHEAD Research Group, 2014). Despite these promising results in terms of long-term weight-loss outcome with respect to previously studied lifestyle modification programmes, it is clear that Look AHEAD was not able to definitively resolve the problem of weight regain in a large percentage of its participants.

In order to elucidate the factors implicated in the long-term maintenance of intentional weight loss, in-depth study of the characteristics of individuals who successfully achieve this goal is indispensible. To this end, the National Weight Control Registry (NWCR) compared the behavioural strategies adopted by successful individuals in this regard (i.e., an average weight loss of 37 pounds maintained for over 7 years) with those of regainers and weight-stable controls. This report revealed that, in addition to reporting higher levels of strenuous physical activity and a greater frequency of self-weighing, long-term maintainers continued to use many more behavioural strategies to control their dietary fat intake. (McGuire, Wing, Klem, & Hill, 1999). This report was not, unfortunately, set up to answer the central question, namely why some individuals do manage to continue to practice weight-control behaviours, and therefore maintain weight-loss long term, while others do not.

It has been suggested that the driving force behind weight regain is the biological pressure on individuals to overeat in order to restore their original weight (the set-point theory) (Keesey & Hirvonen, 1997). However, both the Look AHEAD and the NWCR studies clearly show that many individuals are able to overcome these pressures in the long-term and to maintain a significant weight loss through lifestyle modification. If biological pressures are not entirely to blame, it is conceivable that cognitive mechanisms interacting with specific changes in diet and physical activity may play a pivotal role in long-term weight maintenance. Indeed, the “complex behaviours” involved in lifestyle modification, in this case adopting and persisting with the strategies required to lose and maintain weight, are in part influenced by conscious cognitive processes. Nevertheless, cognitive factors have largely been overlooked in traditional weight-loss lifestyle modification programmes, which could be one of the main reasons for their limited effectiveness in promoting long-term weight loss (Cooper & Fairburn, 2001).

However, intriguing clues as to the cognitive factors associated with attrition, weight loss and weight maintenance are coming to light, in particular from the QUOVADIS study (QUality of life in Obesity: eVAluation and DIsease Surveillance). QUOVADIS was set out to investigate the quality of life of 1944 treatment-seeking obese patients in a “real-world” setting, represented by 25 medical centres authorized to treat obesity by the Italian National Health Service (Melchionda et al., 2003). The study was purely observational; all subjects received an anthropometric and clinical evaluation and were asked to complete a large number of self-administered questionnaires, to explore the psychological status, quality of life, body image and psychiatric distress. Patients were evaluated at baseline, approximately 1 week before beginning the treatment in question, and again 6 and 12 months after treatment. In 18 of the participating centres, an additional telephone interview follow-up was scheduled, on average 36 months after enrolment. All centres were expected to treat patients according to their own specific programmes, which included dieting and/or cognitive behavioural therapy, drugs and/or bariatric surgery (<2% of patients). The protocol was approved by the ethical committees of different centres, as well as by the co-ordinating centre (Azienda Ospedaliera di Bologna, Policlinico S. Orsola – Malpighi), and informed written consent was obtained from all patients.

This review summarizes the QUOVADIS data on cognitive factors associated with attrition, weight loss and maintenance, and discusses the results with reference to the literature.

Section snippets

Cognitive factors and attrition

The association of some cognitive factors with attrition was tested in the large group of Italian obesity patients, 51.7% of whom interrupted their treatment programme after 12 months. The strongest predictors of attrition were lower age and higher expected one-year BMI loss, and attrition was also high in subjects with a primary motivation for weight loss based on their appearance. As regards the initial weight loss expectations, at baseline the group as a whole reported a mean dream body mass

Cognitive factors and weight loss

The QUOVADIS study also analysed some psychosocial factors associated with weight loss at 12-month follow-up in 500 participants (Dalle Grave, Calugi, Corica, Di Domizio, & Marchesini, 2009). This group was not different from the total entry population in terms of sex distribution or BMI, and displayed only minor differences in age. In the absence of a robust theory supported by empirical findings on the psychological factors associated with weight loss, the study looked at several

Cognitive factors and weight-loss maintenance

Finally, the QUOVADIS study did analyse the effect of weight-loss maintenance at 36 months in the 15 medical centres offering patients a continuous care program (Dalle Grave, Melchionda, et al., 2005). Whilst the theory on which treatment was based varied between centres, all adopted a low-intensity approach with periodic check-ups over an indefinite period of time. In general, these check-ups occurred every 2–4 months, after an initial period of more intensive treatment (3–6 months). The very

Discussion

The QUOVADIS data, derived from a variety of authentic care settings, indicate that some cognitive factors are associated with attrition, while others with the amount of weight lost or the long-term weight loss maintenance in patients who interrupted treatment. Future studies should evaluate the mechanisms by which cognitive factors, interacting with behavioural factors (i.e., diet and physical activity), may influence the success or the failure of obesity management.

The naturalistic

Conflict of Interest

None declared.

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    http://www.dallegrave.it.

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    N.B. Dalle Grave is the family name.

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