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Introduction: Individuals who enroll in intensive behavioral therapy (IBT) programs are asked to make several lifestyle changes simultaneously. However, few studies have examined the relative effects of adherence to different treatment components on weight loss. Objective: This secondary analysis of the SCALE IBT trial assessed adherence to the medication regimen, dietary self-monitoring, and physical activity recommendations and their relative contributions to weight change in individuals with obesity who were provided with IBT combined with either liraglutide 3.0 mg or placebo. Methods: SCALE IBT was a double-blinded, multicenter, randomized controlled trial comparing 56-week weight losses in individuals with obesity who received liraglutide 3.0 mg (n = 142) or placebo (n = 140), as an adjunct to IBT. Adherence to dietary self-monitoring, physical activity, and medication usage (liraglutide or placebo) were measured during the 56-week treatment period. A regression model was used to estimate the relative contribution of adherence to each treatment component to weight loss at week 56. Results: The proportion of individuals who adhered to each intervention component decreased over time. Compared with non-adherence, complete adherence to dietary self-monitoring and physical activity recommendations were associated with estimated weight changes of −7.2% (95% CI –10.4 to –4.0; p < 0.0001) and –2.0% (95% CI –3.2 to –0.8; p = 0.0009), respectively. Complete adherence to liraglutide predicted an additional weight loss of –6.5% (95% CI –10.2 to –2.9; p = 0.0005) relative to individuals who did not adhere to the medication regimen, while adherence to placebo did not have a statistically significant effect on weight loss (p = 0.33). Conclusions: High adherence to dietary self-monitoring and use of liraglutide 3.0 mg was associated with clinically relevant weight loss with IBT and adjunctive pharmacotherapy. The effect of adherence to physical activity was significant but smaller.

Objective This prospective, observational fMRI study examined changes over time in blood oxygen level dependent (BOLD) response to high- and low-calorie foods (HCF and LCF) in bariatric surgery candidates and weight-stable controls. Methods Twenty-two Roux-en-Y gastric bypass (RYGB) participants, 18 vertical sleeve gastrectomy (VSG) participants, and 19 weight-stable controls with severe obesity underwent fMRI before and 6 months after surgery/baseline. BOLD signal change in response to images of HCF vs. LCF was examined in a priori regions of interest. Results RYGB and VSG participants lost 23.6% and 21.1% of initial weight, respectively, at 6 months, and controls gained 1.0%. Liking ratings for HCF decreased significantly in the RYGB and VSG groups but remained stable in the control group. BOLD response in the ventral tegmental area (VTA) to HCF (vs. LCF) declined significantly more at 6 months in RYGB compared to control participants but not in VSG participants. Changes in fasting ghrelin correlated positively with changes in VTA BOLD signal in both RYGB and VSG but not in control participants. Conclusions Results implicate the VTA as a critical site for modulating postsurgical changes in liking of highly palatable foods and suggest ghrelin as a potential substrate requiring further investigation.

Currently, 34% of U.S. adults are obese.1 The U.S. Preventive Services Task Force recommends that all adults with a body mass index ≥ 30 kg/m2 be offered intensive counseling for weight loss, or be referred to programs that offer it.2 However, it is not practical to provide intensive counseling to such a large number of individuals. If patient selection could be improved, weight loss programs might achieve lower attrition rates and improved weight losses. The NIH guidelines on evaluation and treatment of obesity state that readiness for weight loss should be assessed in persons presenting for treatment, while noting that such assessment is “easier said than done.”3 However, a recent review challenged the notion that weight loss readiness – a person’s self-reported desire and willingness to make changes to lose weight – is important to assess in clinical settings.4 Self-reported readiness, the review concluded, predicted neither treatment adherence nor the magnitude of weight loss among persons pursuing a variety of weight control methods. The authors suggested that the lack of significant findings may be a function of the limited range of readiness among people who voluntarily engage in weight loss programs. Another explanation may be the limitation of self-report assessments of readiness. Individuals may overestimate their readiness because they do not clearly understand what behaviors are needed to make them successful, or because they greatly desire the outcome of weight loss. We examined the ability of a behavioral task at screening to predict weight loss, session attendance, and physical activity at 1 year among participants who received an intensive lifestyle intervention in the Look AHEAD study.5 Look AHEAD’s careful screening procedures included a 2-week run-in period, in which candidates were required to record (but not required to alter) their food intake for at least 12 of 14 days.6 Look AHEAD investigators believed that participants’ keeping food records during the run-in would predict record keeping during treatment. Keeping food records during treatment, in turn, is positively correlated with weight loss.7–12 Thus, in the current study, we assessed performance of a specific behavior, expected to be related to weight loss, rather than asking about general readiness to lose weight. We specifically sought to determine whether the completeness of record keeping during the screening period would predict weight loss outcomes at 1 year.

Obese individuals with binge eating disorder frequently experience impairments in mood and quality of life, which improve with surgical or behavioral weight loss interventions. It is unclear whether these improvements are due to weight loss itself or to additional aspects of treatment, such as group support, or acquisition of cognitive-behavioral skills provided in behavioral interventions. The objective of the study was to compare changes in weight, symptoms of depression, and quality of life in extremely obese individuals with binge eating disorder undergoing bariatric surgery or a lifestyle modification intervention. The study setting was University Hospital.Symptoms of depression and quality of life were assessed at baseline and 2, 6, and 12 months in participants undergoing bariatric surgery but no lifestyle intervention (n = 36) and in nonsurgery participants receiving a comprehensive program of lifestyle modification (n = 49).Surgery participants lost significantly more weight than lifestyle participants at 2, 6, and 12 months (P.001). Significant improvements in mood (as measured by the Beck Depression Inventory-II [BDI-II]) and quality of life (as measured by the Short Form-36) were observed in both groups across the year, but there were no differences between the groups at month 12 (even when controlling for reductions in binge eating). A positive correlation was observed between the magnitude of weight loss and change in BDI-II score when collapsing across groups. Moreover, weight loss at one time point predicted BDI-II score at the next time point, but BDI-II score did not predict subsequent weight loss.We conclude that similar improvements in mood and quality of life can be expected from either bariatric surgery or lifestyle modification treatments for periods up to 1 year.

OBJECTIVE To examine an intensive lifestyle intervention (ILI) compared with diabetes support and education (DSE) on 4-year change in fitness and physical activity (PA), and to examine the effect of change in fitness and PA, adjusting for potential confounders, on glycemic control in the Look AHEAD Trial. RESEARCH DESIGN AND METHODS Subjects were overweight/obese adults with type 2 diabetes mellitus (T2DM) with available fitness data at 4 years (n = 3,942).This clinical trial randomized subjects to DSE or ILI. DSE subjects received standard care plus information related to diet, PA, and social support three times per year. ILI subjects received weekly intervention contact for 6 months, which was reduced over the 4-year period, and were prescribed diet and PA. Measures included weight, fitness, PA, and HbA1c. RESULTS The difference in percent fitness change between ILI and DSE at 4 years was significant after adjustment for baseline fitness and change in weight (3.70 vs. 0.94%; P < 0.01). At 4 years, PA increased by 348 (1,562) kcal/week in ILI vs. 105 (1,309) kcal/week in DSE (P < 0.01). Fitness change at 4 years was inversely related to change in HbA1c after adjustment for clinical site, treatment, baseline HbA1c, prescribed diabetes medication, baseline fitness, and weight change (P < 0.01). Change in PA was not related to change in HbA1c. CONCLUSIONS A 4-year ILI increased fitness and PA in overweight/obese individuals with T2DM. Change in fitness was associated with improvements in glycemic control, which provides support for interventions to improve fitness in adults with T2DM.

Background Most bariatric surgery programs in the United States require preoperative psychological evaluations for candidates for surgery. Among those who perform these evaluations is concern that many patients engage in "impression management" or minimizing the symptoms of distress to receive a recommendation to proceed with surgery from the mental health professional. We sought to assess the prevalence of socially desirable responding and its associations with measures of psychological functioning among bariatric surgery candidates at 2 academic medical centers in the United States. Methods The participants were male (n = 66) and female (n = 293) bariatric surgery candidates who presented for psychological evaluation. The participants completed 2 measures of socially desirable response styles (Marlowe-Crowne Social Desirability Scale and Personality Assessment Inventory Positive Impression Management scale) and standardized measures of anxiety, depression, and alcohol-related problems. Results The participants exhibited elevated scores on the social desirability indicators, with 33.3–39.8% scoring above the recommended cut-score on the Personality Assessment Inventory Positive Impression Management scale and 62.3–67% scoring 1 standard deviation above the standardization mean on the Marlowe-Crowne Social Desirability Scale. Scores on the Marlowe-Crowne Social Desirability Scale and Personality Assessment Inventory Positive Impression Management scale correlated inversely with the clinical measures of anxiety and depression, and the high/low scorers on the social desirability indices exhibited significant differences in anxiety and depression. Thus, elevated scores on the social desirability indices were associated with underreporting of certain clinical symptoms. Conclusion A substantial proportion of bariatric surgery candidates appear to present themselves in an overly favorable light during the psychological evaluation. This response style is associated with less reporting of psychological problems and might interfere with the accurate assessment of patient functioning.

Depressed individuals are frequently excluded from weight loss trials because of fears that weight reduction may precipitate mood disorders, as well as concerns that depressed participants will not lose weight satisfactorily. The present study examined participants in the Look AHEAD study to determine whether moderate weight loss would be associated with incident symptoms of depression and suicidal ideation, and whether symptoms of depression at baseline would limit weight loss at 1 year. Overweight/obese adults with type 2 diabetes (n = 5,145) were randomly assigned to an Intensive Lifestyle Intervention (ILI) or a usual care group, Diabetes Support and Education (DSE). Of these, 5,129 participants completed the Beck Depression Inventory (BDI) and had their weight measured at baseline and 1 year. Potentially significant symptoms of depression were defined by a BDI score ≥10. Participants in ILI lost 8.6 ± 6.9% of initial weight at 1 year, compared to 0.7 ± 4.8% for DSE (P < 0.001, effect size = 1.33), and had a reduction of 1.4 ± 4.7 points on the BDI, compared to 0.4 ± 4.5 for DSE (P < 0.001, effect size = 0.23). At 1 year, the incidence of potentially significant symptoms of depression was significantly lower in the ILI than DSE group (6.3% vs. 9.6%) (relative risk (RR) = 0.66, 95% confidence interval (CI) = 0.5, 0.8; P < 0.001). In the ILI group, participants with and without symptoms of depression lost 7.8 ± 6.7% and 8.7 ± 6.9%, respectively, a difference not considered clinically meaningful. Intentional weight loss was not associated with the precipitation of symptoms of depression, but instead appeared to protect against this occurrence. Mild (or greater) symptoms of depression at baseline did not prevent overweight/obese individuals with type 2 diabetes from achieving significant weight loss.

Background: The circumstances under which the glycemic index (GI) and glycemic load (GL) are derived do not reflect real-world eating behavior. Thus, the ecologic validity of these constructs is incompletely known. Objective: This study examined the relation of dietary intake to glycemic response when foods are consumed under free-living conditions. Design: Participants were 26 overweight or obese adults with type 2 diabetes who participated in a randomized trial of lifestyle modification. The current study includes baseline data, before initiation of the intervention. Participants wore a continuous glucose monitor and simultaneously kept a food diary for 3 d. The dietary variables included GI, GL, and intakes of energy, fat, protein, carbohydrate, sugars, and fiber. The glycemic response variables included AUC, mean and SD of continuous glucose monitoring (CGM) values, percentage of CGM values in euglycemic and hyperglycemic ranges, and mean amplitude of glycemic excursions. Relations between daily dietary intake and glycemic outcomes were examined. Results: Data were available from 41 d of monitoring. Partial correlations, controlled for energy intake, indicated that GI or GL was significantly associated with each glycemic response outcome. In multivariate analyses, dietary GI accounted for 10% to 18% of the variance in each glycemic variable, independent of energy and carbohydrate intakes (P < 0.01). Conclusions: The data support the ecologic validity of the GI and GL constructs in free-living obese adults with type 2 diabetes. GI was the strongest and most consistent independent predictor of glycemic stability and variability.

Obesity may lead to depression or be one of its consequences. We reviewed population-based studies in order to, first, identify the most commonly used research methods, and, second, to evaluate the strength of evidence for prospective associations among obesity and depression. We examined 25 studies, of which 10 tested 'obesity-to-depression' pathways, and 15 tested 'depression-to-obesity' pathways. Descriptive statistics summarized the frequency with which various measurements, designs and data analytic strategies were used. We tallied the number of studies that reported any vs. no statistically significant associations, and report on effect sizes, identified moderating variables within reports, and sought common findings across studies. Results indicated considerable methodological heterogeneity in the literature. Depression was assessed by clinical interview in 44% of studies, weight and height were directly measured in 32%, and only 12% used both. In total, 80% of the studies reported significant obesity-to-depression associations, with odds ratios generally in the range of 1.0 to 2.0, while only 53% of the studies reported significant depression-to-obesity associations. Sex was a common moderating variable. Thus, there was good evidence that obesity is prospectively associated with increased depression, with less consistent evidence that depression leads to obesity. Recommendations for future research regarding study samples, measurement and data analysis are provided.

Aims To compare the effects of lifestyle modification programs that prescribe low-glycemic load (GL) vs. low-fat diets in a randomized trial. Methods Seventy-nine obese adults with type 2 diabetes received low-fat or low-GL dietary instruction, delivered in 40-week lifestyle modification programs with identical goals for calorie intake and physical activity. Changes in weight, HbA1c, and other metabolic parameters were compared at weeks 20 and 40. Results Weight loss did not differ between groups at week 20 (low-fat: −5.7 ± 3.7%; low-GL: −6.7 ± 4.4%, p = .26) or week 40 (low-fat: −4.5 ± 7.5%; low-GL: −6.4 ± 8.2%, p = .28). Adjusting for changes in antidiabetic medications, subjects on the low-GL diet had larger reductions in HbA1c than those on the low-fat diet at week 20 (low-fat: −0.3 ± 0.6%; low-GL: −0.7 ± 0.6%, p = .01), and week 40 (low-fat: −0.1 ± 1.2%; low-GL: −0.8 ± 1.3%; p = .01). Groups did not differ significantly on any other metabolic outcomes (p ≥ .06). Conclusions Results suggest that targeting GL, rather than dietary fat, in a low-calorie diet can significantly enhance the effect of weight loss on HbA1c in patients with type 2 diabetes.

Background Comparing findings from separate trials is necessary to choose among treatment options, however differences among study cohorts may impede these comparisons. Purpose As a case study, to examine the overlap of study cohorts in two large randomized controlled clinical trials that assess interventions to reduce risk of major cardiovascular disease events in adults with type 2 diabetes in order to explore the feasibility of cross-trial comparisons Methods The Action for Health in Diabetes (Look AHEAD) and The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trials enrolled 5145 and 10,251 adults with type 2 diabetes, respectively. Look AHEAD assesses the efficacy of an intensive lifestyle intervention designed to produce weight loss; ACCORD tests pharmacological therapies for control of glycemia, hyperlipidemia, and hypertension. Incidence of major cardiovascular disease events is the primary outcome for both trials. A sample was constructed to include participants from each trial who appeared to meet eligibility criteria and be appropriate candidates for the other trial’s interventions. Demographic characteristics, health status, and outcomes of members and nonmembers of this constructed sample were compared. Results Nearly 80% of Look AHEAD participants were projected to be ineligible for ACCORD; ineligibility was primarily due to better glycemic control or no early history of cardiovascular disease. Approximately 30% of ACCORD participants were projected to be ineligible for Look AHEAD, often for reasons linked to poorer health. The characteristics of participants projected to be jointly eligible for both trials continued to reflect differences between trials according to factors likely linked to retention, adherence, and study outcomes. Limitations Accurate ascertainment of cross-trial eligibility was hampered by differences between protocols. Conclusions Despite several similarities, the Look AHEAD and ACCORD cohorts represent distinct populations. Even within the subsets of participants who appear to be eligible and appropriate candidates for trials of both modes of intervention, differences remained. Direct comparisons of results from separate trials of lifestyle and pharmacologic interventions are compromised by marked differences in enrolled cohorts. Clinical Trials 2009; 6: 416—429. http://ctj.sagepub.com

The National Institute of Mental Health convened a meeting in October 2005 to review the literature on obesity, nutrition, and physical activity among those with mental disorders. The findings of this meeting and subsequent update of the literature review are summarized here. Levels of obesity are higher in those with schizophrenia and depression, as is mortality from obesity-related conditions such as coronary heart disease. Medication side effects, particularly the metabolic side effects of antipsychotic medications, contribute to the high levels of obesity in those with schizophrenia, but increased obesity and visceral adiposity have been found in some but not all samples of drug-naive patients as well. Many of the weight-management strategies used in the general population may be applicable to those with mental disorders, but little is known about the effects of these strategies on this patient population or how these strategies may need to be adapted for the unique needs of those with mental disorders. The minimal research on weight-management programs for those with mental disorders indicates that meaningful changes in dietary intake and physical activity are possible. Physical activity is an important component of any weight-management program, particularly for those with depression, for which a substantial body of research indicates both mental and physical health benefits. Obesity among those with mental disorders has not received adequate research attention, and empirically-based interventions to address the increasing prevalence of obesity and risk of cardiovascular and metabolic diseases in this population are lacking.

The purposes of this study were to investigate weight loss expectations and goals in a population sample of US adults who planned to make a weight loss attempt, and to examine predictors of those expectations and goals. Participants were 658 overweight and obese adults (55% female, mean age = 47.9 yr, body mass index [BMI] = 31.8 kg/m2) who responded to a telephone survey about weight loss. Respondents reported weight loss expectations (i.e., reductions they realistically expected) and goals (i.e., reductions they ideally desired) for an upcoming “serious and deliberate” weight loss attempt. They also reported the expectations they had, and the reductions they actually achieved, in a previous attempt. Respondents' weight loss expectations for their upcoming attempt (8.0% reduction in initial weight) were significantly more modest than their goals for that attempt (16.8%), and smaller than the losses that they expected (12.0%) and achieved (8.9%) in their most recent past attempt (ps ≤ .003). Women and participants with higher BMI had greater weight loss expectations and goals. After controlling for BMI, age, and gender, previous weight loss was unrelated to expectations, and inversely related to goals, for the upcoming weight loss attempt. Results suggest that overweight and obese individuals can frame realistic weight loss expectations that are more modest than their ideal goals. BMI and gender appear to be more important than previous weight loss experiences in determining expectations among persons planning a weight loss attempt.

Abstract Many protocols have been used in clinical and research settings for collecting systolic blood pressure (SBP) measurements to calculate the ankle–brachial index (ABI); however, it is not known how useful it is to replicate measurements and which measures best reflect cardiovascular risk. Standardized measurements of ankle and arm SBP from 5140 overweight or obese individuals with type 2 diabetes were used to estimate sources of variation. Measurement characteristics of leg-specific ABI, as calculated using a standard algorithm based on the highest SBP of the dorsalis pedis or posterior tibial arteries, were projected using simulations. Coefficients of variability ranged from 2% to 3% when single SBP measurements were used and ABI was overestimated by 2–3%. Taking two SBP measurements at each site reduced standard errors and bias each by 30–40%. The sensitivity of detecting low ABI ranges exceeded 90% for ABI within 0.05 of the 0.90 clinical cut-point. The average and the minimum of the two (i.e. right and left) leg-specific ABI values had similar U-shaped relationships with Framingham risk scores; however, the average leg ABI had slightly greater precision. Replicating SBP measurements reduces the error and bias of ABI. Averaging leg-specific values may increase power for characterizing cardiovascular disease risk.

A panel was convened on February 18, 2008, to discuss the challenges to the diagnosis, evaluation, treatment, and management of clustered cardiometabolic risk factors. Peter W.F. Wilson, MD of Emory University School of Medicine, Atlanta, GA, moderated the panel. Henry R. Black, MD, New York University School of Medicine, New York, NY, Anthony N. Fabricatore, PhD, University of Pennsylvania, Philadelphia, PA, and Ira J. Goldberg, MD, Columbia University, New York, NY, participated in the discussion. This expert panel discussion was supported by and each author received an honorarium from Pfizer Inc for time and effort spent participating in the discussion and reviewing the transcript for important intellectual content before publication. The authors maintained full control of the discussion and the resulting content of this article.

As bariatric surgery for extreme obesity continues to grow in popularity, so does interest in postbariatric surgery body-contouring surgery. There is an extensive literature on the psychological characteristics of persons with extreme obesity who undergo bariatric surgery and the psychological changes that typically occur postoperatively. Far less, however, is known about the psychological aspects of body contouring following massive weight loss. This article reviews the psychosocial characteristics of individuals with extreme obesity who undergo bariatric surgery, as well as the changes in these traits that typically occur postoperatively. Because there have been few studies of the psychological aspects of patients who have lost massive amounts of weight, we use related literatures on the relationship between body image dissatisfaction and other plastic surgical procedures to identify the most relevant research and clinical issues for this unique patient population. Appropriate psychiatric screening and management of these patients is believed to play an important role in successful postoperative outcomes.

Many bariatric surgery programs require that candidates undergo a preoperative mental health evaluation. Candidates may be motivated to suppress or exaggerate psychiatric symptoms (i.e., engage in impression management), if they believe doing so will enhance their chances of receiving a recommendation to proceed with surgery.237 candidates for bariatric surgery completed the Beck Depression Inventory-II (BDI-ll) as part of their preoperative psychological evaluation (Time 1). They also completed the BDI-II approximately 2-4 weeks later, for research purposes, after they had received the mental health professional's unconditional recommendation to proceed with surgery (Time 2).There was a small but statistically significant increase in mean BDI-II scores from Time 1 to Time 2 (11.4 vs 12.7, P.001). Clinically significant changes, defined as a change from one range of symptom severity to another, were observed in 31.2% of participants, with significant increases in symptoms occurring nearly twice as often as reductions (20.7% vs 10.5%, P.008). Demographic variables were largely unrelated to changes in BDI-II scores from Time 1 to Time 2.Approximately one-third of bariatric surgery candidates reported a clinically significant change in depressive symptoms after receiving psychological "clearance" for surgery. Possible explanations for these findings include measurement error, impression management, and true changes in psychiatric status.

Extreme obesity, characterized by a body mass index (BMI) of 40 kg/m(2) or greater, is associated with significantly increased mortality, principally from cardiovascular disease, type 2 diabetes, and several cancers. It also is associated with an increased risk of psychosocial complications, including depression, eating disorders, and impaired quality of life. This article briefly examines the psychosocial status of extremely obese individuals who seek bariatric surgery and describes changes in functioning that can be expected with surgically induced weight loss. The article combines a review of the literature with clinical impressions gained from the more than 2500 candidates for bariatric surgery whom the authors have evaluated at the Hospital of the University of Pennsylvania.

Current practice guidelines for management of overweight and obesity recommend a program of diet, exercise, and behavior therapy for all persons with a body mass index (calculated as kg/m 2 ) of at least 30 (and those with body mass index ≥25 plus two weight-related comorbidities). In this tripartite treatment—often referred to as lifestyle modification—behavior therapy provides a structure that facilitates meeting goals for energy intake and expenditure. Although standard behavior therapy reliably induces mean weight losses of approximately 10% of initial weight, these reductions are difficult to maintain. Some authors argue that a shift in focus from behavior change to cognitive change will improve long-term results of lifestyle modification programs. This review describes, in detail, the standard behavioral treatment of obesity and compares it with an alternative treatment model that is based in a cognitive conceptualization of weight control. A review of the literature suggests that the differences between standard behavior therapy and cognitive-behavioral therapy of obesity lie more in their underlying theories than in their implementation. Empirical comparisons of the long-term effects of these approaches are needed.

The prevalence of obesity is growing at an alarming rate. Thus, investigation into the etiology, comorbidities, and treatment of obesity has burgeoned in recent years. While novel therapies—both behavioral and pharmacological—have been developed and tested, the mean weight losses achieved with nonsurgical approaches have remained virtually unchanged over the past 20 years. Fortunately, the modest weight losses achieved with these methods are associated with significant reductions in obesity-related health problems. With the most intensive available treatment (i.e., bariatric surgery), many patients achieve remission of comorbid conditions. This article defines obesity and provides an overview of the disease conditions associated with excess weight. Treatment options and outcomes are reviewed and future steps—including efforts to prevent obesity—are identified. Finally, the literature on the relationship between obesity and depression is examined.

Objective: To describe the dieting histories of bariatric surgery candidates. Research Methods and Procedures: One hundred seventy-seven individuals with extreme obesity who sought bariatric surgery completed the Weight and Lifestyle Inventory, a self-report instrument that assesses several variables, including weight and dieting history. Patients’ dieting histories were further explored with an aided recall during a preoperative behavioral/psychological evaluation performed by a mental health professional. Results: Participants who completed the Weight and Lifestyle Inventory reported an average of 4.7 ± 2.9 successful dieting attempts, defined as those that resulted in a loss of 10 lbs (4.5 kg) or more. These individuals reported a mean total lifetime weight loss of 61.1 ± 41.3 kg. Despite these efforts, their weight increased from 89.4 ± 27.4 kg at the time of their first diet (age 21.2 ± 10.1 years) to 144.5 ± 30.8 kg at the time they underwent their behavioral/psychological evaluation (age 43.0 ± 11.0 years). Results of the aided recall revealed that participants had made numerous other efforts to lose weight that were unsuccessful. Self-directed diets and commercial programs were used more frequently. Discussion: Individuals who sought bariatric surgery reported an extensive history of dieting, beginning in adolescence, that was not successful in halting progressive weight gain. Thus, the recommendation often made by insurance companies that patients delay surgery to attempt more conservative treatment options may be unwarranted, particularly in the presence of significant obesity-related comorbidities. Weight loss histories should be routinely examined during a behavioral evaluation to determine whether additional attempts at non-surgical weight loss are advisable. Future studies also are needed to explore the potential relationship between dieting history and postoperative outcome.

Objective: To summarize the self-reported eating behaviors of persons seeking bariatric surgery and to provide reliability data for a clinical instrument that assesses those eating behaviors. Research Methods and Procedures: Adults (552) with extreme obesity (mean ± standard deviation BMI = 52.4 ± 10.1 kg/m2) completed the Weight and Lifestyle Inventory (WALI) before undergoing bariatric surgery. The WALI is a self-report instrument that includes 24 items that assess the eating behaviors to which respondents attribute their excess weight. These items were entered into a principal components analysis with promax rotation. Relationships of factor scores to demographic and psychosocial variables were examined. Test-retest reliability data were obtained from a smaller sample (n = 58) of less obese participants (BMI = 34.4 ± 4.0 kg/m2) who completed the WALI twice within 2 weeks, before beginning a non-surgical weight loss program. Results: The principal components analysis yielded five factors with acceptable internal consistency and test-retest reliability. These included: eating in response to negative affect, eating in response to positive affect and social cues, general overeating and impaired appetite regulation, overeating at early meals, and snacking. Each factor was related to symptoms of binge eating disorder, and every factor except the second one was associated with depressive symptoms. Factor scores were unrelated or weakly associated with demographic characteristics. Discussion: The eating behaviors of persons seeking bariatric surgery can be assessed reliably and parsimoniously with the WALI. The predictive utility of the factors obtained in this study remains to be examined.

ALLISON, KELLY C., THOMAS A. WADDEN, DAVID B. SARWER, ANTHONY N. FABRICATORE, CANICE E. CRERAND, LAUREN M. GIBBONS, REBECCA M. STACK, ALBERT J. STUNKARD, AND NOEL N. WILLIAMS. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features. Obesity. 2006;14(Suppl 2):77S–82S. Objective: To assess the prevalence of night eating syndrome (NES) and binge eating disorder (BED) and their related behavioral and psychological correlates in persons who sought bariatric surgery. Research Methods and Procedures: A consecutive series of 215 persons with extreme obesity (82% women, 70% European American) completed the Weight and Lifestyle Inventory and a semistructured interview as part of a presurgery behavioral/psychological assessment. Diagnoses for NES and BED were based on graded diagnostic criteria. Results: Percentages of participants who met diagnostic criteria for NES by interview were 1.9% for the strictest definition and 8.9% across all definitions of NES. After interview, full DSM-TR criteria for BED were met by 4.2%; an additional 1.4% reported binge eating at least once per week. Self-reported prevalence of NES and BED were higher. Those with NES or BED had significantly more symptoms of depression and a greater history of psychological complications than the remaining sample. Discussion: The prevalence rates of NES and BED among this population of bariatric surgery candidates were lower than expected based on previous reports. Findings and hypotheses regarding lowered prevalence rates are discussed.

Bariatric surgery has become an increasingly popular treatment option for individuals with extreme obesity (defined as a BMIor = 40 kg/m2) or those with less severe obesity accompanied by significant comorbidities. Sustained postoperative weight loss and improvements in obesity-related health problems make bariatric surgery the most effective treatment for this population. Nevertheless, most experts agree that psychosocial and behavioral factors contribute to successful postoperative outcomes. This paper reviews the literature on the preoperative psychosocial status, eating behaviors, and quality of life of patients who seek bariatric surgery. In addition, the paper examines studies that investigated changes in these factors postoperatively. The review concludes with an agenda for future research in this area.

Background: Extreme obesity, defined by a body mass index (BMI) ≥40 kg/m2, is associated with increased risk of depression and with impairments in healthrelated quality of life (HRQoL). This study examined the relationships among BMI, HRQoL, and symptoms of depression in persons with extreme obesity. Method: Participants were 306 patients who sought bariatric surgery (mean ± SD age 43.8±9.4 years, BMI 52.8±9.3 kg/m2) and who completed questionnaires to assess symptoms of depression and HRQoL prior to surgery. We defined HRQoL impairment as a score ≥1 SD below national means. Results: Impairments in HRQoL were common: >40% of participants scored in the impaired ranges of physical functioning, physical role limitations, and bodily pain. Results of analyses of variance (ANOVAs) indicated that impairments in HRQoL were significantly related to symptoms of depression. Patients with impaired HRQoL scored above the cut-off point for clinically significant depression, while those without such impairment scored below that cut-off, regardless of BMI. The contribution of BMI to depression was not significant in any ANOVA. Conclusion: HRQoL is more strongly and more directly related to symptoms of depression than is BMI. These findings highlight the need to assess HRQoL in patients with extreme obesity and suggest that interdisciplinary strategies to address HRQoL impairments may be beneficial in this population.

Religious coping has been conceptualized as a mediator, accounting for the relationship between religiousness and mental health in times of stress, and as a moderator, altering the relationship between stressors and mental health (Pargament, 1997). Direct empirical investigations of these conceptual models, however, are few. This study examined 2 forms of religious coping in mediating and moderating roles. Collaborative religious coping, which is active, refers to sharing the responsibility for problem solving with God. The deferring approach is more passive and is characterized by giving the responsibility for problem solving to God. Using structural equation modeling, the authors found that collaborative religious coping mediated the relationships of religiousness to well-being and distress in a sample of undergraduates (N = 175). No mediation effect was found for deferring religious coping. Collaborative religious coping did not moderate the relationship between stressors and mental health variables, b...

In Brief This review found that obese individuals in the general population have essentially normal psychological functioning. Obese women, however, are at greater risk than obese men of depression and related complications. Binge eating and extreme obesity further increase the likelihood of patients reporting emotional complications. Pharmacotherapy and psychotherapy may be of benefit in this subset of individuals.

In Brief Obesity and type 2 diabetes commonly co-occur. Weight loss is associated with significant health benefits, including improved glycemic control and reduced blood pressure. This article reviews approaches to the treatment of obesity, considers special issues relevant to obese patients with type 2 diabetes, and presents suggestions for the prevention of obesity.

Future and current psychologists may find themselves baffled when confronted with the diversity of religious and spiritual backgrounds of their clients. Few psychologists have received professional training with regard toreligion and spirituality, despite the public's overwhelming interest. Currently, the topic of religion/spirituality is being covered to some degree in most accredited clinical programs. However, a distinct minority of these programs approach this education and training in a systematic fashion, whereas other programs report no educational or training opportunities in this area. Several recommendations are made for training programs, which are encouraged to increase their sensitivity to this topic, provide more opportunities for student growth in this area, and incorporate religious and spiritual issues into course work.

Look AHEAD (Action for Health in Diabetes) was a randomized clinical trial designed to examine the long-term health effects of weight loss in overweight and obese individuals with type 2 diabetes. The primary result was that the incidence of cardiovascular events over a median follow-up of 9.6 years was not reduced in the Intensive Lifestyle Group relative to the control group. This finding is discussed, with emphasis on its implications for design of trials and clinical treatment of obese persons with type 2 diabetes.

We investigated the definition, prevalence, perceived prevalence and severity of, as well as justifications for and expected responses to, academic dishonesty at the graduate level in a sample of 246 graduate students, 49 faculty, and 20 administrators. Between 2.5% and 55.1% of students self-reported engaging in academically dishonest behaviors, depending on the nature of the behavior. Students and faculty rated 40 examples of academically dishonest behaviors similarly in terms of severity, but faculty tended to underestimate the prevalence of academic dishonesty. Students and faculty also reported how they would idealistically and realistically expect themselves to respond to cheating situations. Students rated 21 behaviors in terms of their likeliness to increase or decrease academically dishonest behavior. Suggestions are given for developing a climate or culture of academic integrity to address academic dishonesty.

The present study examined the impact that a personal, integrated spirituality has on well-being and its role in moderating the effects of stressors (both significant life events and hassles) on well-being among a sample of 120 undergraduates at a private religiously affiliated college. The hypotheses were as follows: First, stressors would have a negative impact on subjective well-being (SWB), which consists of satisfaction with life (SWL) and affective well-being (AWB); second, personal spirituality would positively predict SWB independently of stressors; and third, personal spirituality would moderate the relationship between stressors and SWB. Results showed that stressors predicted both dimensions of SWB and that personal spirituality significantly added to the prediction of SWL. Personal spirituality was also found to moderate the relationship between stressors and life satisfaction, accounting for a small yet significant portion of the variance. Personal spirituality is conceptualized as a useful resource among undergraduates for maintaining life satisfaction in the face of stressors. Questions are raised regarding the underlying mechanisms of the observed effects.

Two of the largest rallies ever held in the nation's capital were the 1995 Million Man March and the Promise Keepers rally of 1997. More remarkable than the size of these events is the fact that (a) both were spiritual in nature, (b) participation in each was restricted to males, and (c) participants of the Mill ion Man March were exclusively African Americans whereas the Promise Keepers rally was predominately attended by whites. Both sought to increase the spiritual commitment of men in bettering the condit ions of their families and communit ies. The assumption underlying the mobilization of these movements is that spirituality is positively related to a sense of well-being and other-directedness. While some point out that African American men perceive spirituality to be an important concept

America has come to develop two contrasting perceptions of African American male religiosity in the post-civil rights period. The press for racial inclusion throughout the Kennedy/Johnson era has forged the association of African American male religious involvement with political engagement (Arp & Boeckelman, 1997; Peterson, 1992). The urban image emerging in the post-Reagan climate endows him with a nonreligious quality, in that it depicts an individual who is nihilistic and antisocial. These two images are clearly contradictory. To the degree that religious involvement is prevalent among African American men and has positive effects, the latter image is called into question. So too is the former image, to the extent that diminishing concern for others is becoming characteristic of urban life. What, then, is the current state of African American male religiosity, and how does it affect his sense of wellbeing and other-directness? This article reviews the literature suggesting that religiosity varies across subgroups in society and can have two broad effects on the individual: It can shape one's attitudes and behaviors toward oneself, and it can shape one's attitudes and behaviors toward others. The level of religiosity and altruism (measured by reported

Predicting outcome in weight loss trials from baseline characteristics has proved difficult. Readiness to change is typically measured by self-report.Performance of a behavioral task, completion of food records, from the screening period in the Look AHEAD study (n = 549 at four clinical centers) was assessed. Completeness of records was measured by the number of words and Arabic numerals (numbers) recorded per day, the number of eating episodes per day, and days per week where physical activity was noted. The primary outcome was weight loss at one year.In univariable analysis, both the number of words recorded and the number of numbers recorded were associated with greater weight loss. In multivariable analysis, individuals who recorded 20-26, 27-33, and ≥34 words per day lost 9.12%, 11.40%, and 12.08% of initial weight, compared to 8.98% for individuals who recorded less than 20 words per day (P values of 0.87, 0.008, and0.001, respectively, compared to20 words per day).Participants who kept more detailed food records at screening lost more weight after 1 year than individuals who kept sparser records. The use of objective behavioral screening tools may improve the assessment of weight loss readiness.

Obesity and diabetes incidence and prevalence are rampant in our Westernized civilization; they are both increasing and carry with them many medical complications. There is clear evidence that aggressive treatment of these conditions, in particular preventing weight gain and ideally facilitating weight reduction in patients can minimize and reduce these complications. We review data supporting these observations, and review options and recommendations to support the practitioners in helping their patients achieve these goals safely.

Obesity and diabetes incidence and prevalence are rampant in our Westernized civilization; they are both increasing andcarry with them many medical complications. There is clear evidence that aggressive treatment of these conditions, in particular preventing weight gain and ideally facilitating weight reduction in patients can minimize and reduce these complications. We review data supporting these observations, and review options and recommendations to support the practitioners in helping their patients achieve these goals safely.

Obesity is related to increased risk of several health complications, including depression. Many studies have reported improvements in mood with weight loss, but results have been equivocal. The present meta-analysis examined changes in symptoms of depression that were reported in trials of weight loss interventions. Between-groups comparisons of different weight loss methods (for example, lifestyle modification, diet-alone and pharmacotherapy) were examined, as were within-group changes for each treatment type.MEDLINE was searched for articles published between 1950 and January 2009. Several obesity-related terms were intersected with terms related to depression. Results were filtered to return only studies of human subjects, published in English. Of 5971 articles, 394 were randomized controlled trials. Articles were excluded if they did not report mean changes in weight or symptoms of depression, included children or persons with psychiatric disorders (other than depression), or provided insufficient data for analysis. Thirty-one studies (n=7937) were included. Two authors independently extracted a description of each study treatment, sample characteristics, assessment methods and changes in weight and symptoms of depression. Treatments were categorized as lifestyle modification, non-dieting, dietary counseling, diet-alone, exercise-alone, pharmacotherapy, placebo or control interventions.Random effects models found that lifestyle modification was superior to control and non-dieting interventions for reducing symptoms of depression, and marginally better than dietary counseling and exercise-alone programs. Exercise-alone programs were superior to controls. No differences were found for comparisons of pharmacologic agents and placebos. Within-group analyses found significant reductions in symptoms of depression for nearly all active interventions. A meta-regression found no relationship between changes in weight and changes in symptoms of depression in lifestyle modification interventions.On average, obese individuals in weight loss trials experienced reductions in symptoms of depression. Future studies should examine incidence and resolution of clinically significant depressive disorders with weight loss interventions.

Previous studies have suggested that binge eating disorder (BED) impairs weight loss following bariatric surgery, leading some investigators to recommend that patients receive behavioral treatment for this condition before surgery. However, many of these investigations had significant methodological limitations. The present observational study used a modified intention-to-treat (ITT) population to compare 1-year changes in weight in 59 surgically treated participants, determined preoperatively to be free of a current eating disorder, with changes in 36 individuals judged to have BED. Changes in weight and binge eating in the latter group were compared with those in 49 obese individuals with BED who sought lifestyle modification for weight loss. BED was assessed using criteria proposed for the Diagnostic and Statistical Manual (DSM) 5. At 1 year, surgically treated participants without BED lost 24.2% of initial weight, compared with 22.1% for those with BED (P > 0.309). Both groups achieved clinically significant improvements in several cardiovascular disease (CVD) risk factors. Participants with BED who received lifestyle modification lost 10.3% at 1 year, significantly (P < 0.001) less than surgically treated BED participants. The mean number of binge eating days (in the prior 28 days) fell sharply in both BED groups at 1 year. These two groups did not differ significantly in BED remission rates or in improvements in CVD risk factors. The present results, obtained in carefully studied participants, indicate that the preoperative presence of BED does not attenuate weight loss or improvements in CVD risk factors at 1 year in surgically treated patients. Longer follow-up of participants is required.

Prior studies have reached contradictory conclusions concerning whether binge eating disorder (BED) is associated with greater psychopathology in extremely obese patients who seek bariatric surgery. This study used the Structured Clinical Interview for DSM-IV Diagnoses (SCID) to compare rates of axis I psychopathology in surgery candidates who were determined to have BED or to be currently free of eating disorders. The relationship of BED to other psychosocial functioning and weight loss goals also was examined. One hundred ninety five bariatric surgery patients completed the Weight and Lifestyle Inventory and the Beck Depression Inventory-II (BDI-II) and were later administered the Eating Disorder Examination. Of these 195, 44 who were diagnosed with BED, and 61 who were currently free of eating pathology, completed a telephone-administered SCID. Significantly more BED than non-BED participants had a current mood disorder (27.3% vs. 4.9%, p = 0.002) as well as a lifetime history of this condition (52.3% vs. 23.0%, p = 0.003). More BED than non-BED participants also had a current anxiety disorder (27.3% vs. 8.2%, p = 0.014) and lifetime anxiety disorder (36.4% vs. 16.4%, p = 0.019). BED also was associated with greater symptoms of depression, as measured by the BDI-II, as well as with lower self-esteem. BED and non-BED groups, however, did not differ in their desired weight loss goals following surgery. The present findings indicate that the presence of BED, in patients who seek bariatric surgery, is associated with an increased prevalence of axis I psychopathology, beyond the already elevated rate observed with severe (i.e., class III) obesity.

Attrition is a common problem in weight loss trials. The present analysis examined several baseline and early-treatment process variables, as predictors of attrition and outcome in a clinical trial that combined pharmacotherapy and behavior therapy for weight loss. Participants were 224 obese adults who were treated with sibutramine alone, lifestyle modification alone, combined therapy, or sibutramine plus brief lifestyle modification. Predictors included baseline characteristics (e.g., demographic, weight-related, psychological, and consumption-related variables), plus attendance, adherence, and weight loss in the early weeks of treatment. Outcomes were attrition and weight loss success (i.e.,or=5% reduction in body weight) at 1 year. Multivariable models, adjusting for other relevant variables, found that younger age and greater baseline depressive symptoms were related to increased odds of attrition (psor= 0.003). Greater early weight loss marginally reduced the odds of attrition (p = 0.06). Predictors of weight loss success at 1 year were Caucasian ethnicity (p = 0.04), lower baseline depressive symptoms (p = 0.04), and weight loss during the first 3 weeks of treatment (p0.001). Thus, depressive symptoms at baseline were a significant predictor of both attrition and weight loss success. As a process variable, early weight loss appears to have more predictive value than early attendance at treatment sessions or early adherence.

Clinical trials of obesity treatments have been limited by substantial dropout. Participant-level variables do not reliably predict attrition, and study-level variables have not yet been examined. We searched MEDLINE and identified 24 large randomized controlled trials of weight loss medications. These trials were comprised of 23 placebo and 32 drug groups. Two authors independently extracted the following for each treatment group: (i) treatment received; (ii) design characteristics (inclusion of a lead-in period, selection of participants with weight-related comorbidities, study location and number of study visits); (iii) sample characteristics (sample size, % female, and mean baseline age and body mass index); and (iv) attrition (total, adverse event [AE]-related and non-AE-related) at 1 year. The primary outcome was total attrition, which was significantly related to treatment (i.e. 34.9%, 28.6%, 28.3% and 35.1% in placebo, orlistat, sibutramine and rimonabant groups, respectively, P < 0.0001). In adjusted multivariable models, total attrition was significantly lower in groups that completed a pre-randomization lead-in period than in those that did not (29.1% vs. 39.9%, P < 0.01). Gender also was significantly related to total attrition; groups with more women had higher dropout (P < 0.01). The pattern was similar for predicting non-AE-related attrition. Findings suggest ways to design studies that maximize retention.

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/m(2)) 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%; P0.01). Mean BDI-II scores across all participants declined from 8.1 +/- 6.9 to 6.2 +/- 7.7 at 1 year (P0.001), with no significant differences among groups. Despite this favorable change, 13.9% of participants (across the four groups) reported potentially discernible increases (or= 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; P0.03). 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 popularity of bariatric surgery has increased the focus on the psychological aspects of extreme obesity. Although a growing literature has documented the psychosocial burden associated with extreme obesity, surprisingly little attention has been paid to the experience of weight-related stigmatization among extremely obese individuals. The present study investigated self-reported experiences of weight-related stigmatization, weight-related quality of life, and depressive symptoms among 117 extremely obese individuals (BMI = 48.2 +/- 7.5 kg/m2) who presented for bariatric surgery at the Hospital of the University of Pennsylvania. In general, these individuals reported infrequent weight-related stigma, which was unrelated to BMI. Some specific forms of stigmatization, however, appear to be related to body size. The occurrence of stigmatization was associated with poorer weight-related quality of life and greater symptoms of depression.

Psychologists play an important role as members of the bariatric surgery team. The current investigation examined the frequency with which psychologists recommend delay or denial of surgery for psychological reasons, the procedures they use in making their clinical decisions, and the reasons for such conclusions.A sample of 103 psychologists with experience in conducting pre-surgical psychological evaluations responded to a brief survey.There was significant variability in the number of evaluations psychologists complete and the instruments they use to make their clinical decisions. For most candidates, the evaluation results in psychological clearance for surgery. However, approximately 15%, on average, are delayed or denied for psychological reasons. The most common reasons for delaying or denying surgery were significant psychopathology (including psychosis or bipolar disorder), untreated or undertreated depression, and lack of understanding about the risks and postoperative requirements of surgery, which were reported by 51, 39, and 30% of respondents, respectively. Several other reasons were reported less frequently and many appeared to be idiosyncratic.Psychologists differ in their preoperative evaluation practices. Further research is needed to determine the reasons for the variability in clinical decision making and the long-term medical and psychosocial outcomes associated with the recommendation to delay or deny surgery for psychosocial reasons. When patients receive such a recommendation, they can be encouraged to seek a second opinion from a mental health professional with bariatric expertise.

To investigate weight loss expectations and goals among obese treatment seekers and to examine the relationships of these expectations and goals to treatment outcomes.Participants were 180 obese men and women (age 43.8+/-10.1 years; body mass index 37.6+/-4.2 kg/m(2)) 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.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.Across groups, we observed no negative consequences of having (and failing to meet) unrealistic expectations for weight loss.