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Objective: This pilot study assessed the short- and long-term effects of a modified cognitive behavioral treatment designed to facilitate obese patients' acceptance of a 5% to 10% reduction in initial weight., Research Methods and Procedures: Participants were 17 women with a mean age of 46.5 +/- 9.7 years and BMI of 34.7 +/- 2.9 kg/m2. They participated in a 40-week program that included four phases. The first discussed the benefits of modest weight losses and the potential adverse effects of unrealistic expectations. Phase II provided instruction in traditional cognitive behavioral methods of weight control Phase III focused on methods to improve body image and self-esteem. Phase IV addressed skills for weight maintenance. Changes in weight, self-esteem, body image, and quality of life were assessed at the end of treatment and 1 year later (week 92)., Results: At week 40, participants lost an average of 5.7 +/- 5.3% of initial weight, which was associated with significant improvements in body image, self-esteem, and quality of life. Improvements in psychosocial status were maintained at week 92, although mean weight loss at this time had declined to 2.9 +/- 5.6% of initial weight. Increased satisfaction with body weight at week 40 was associated with significantly better maintenance of weight loss at follow-up (r = -0.70; p = 0.02)., Discussion: Having participants seek only modest initial weight losses does not appear to facilitate weight maintenance. However, increasing patients' satisfaction with their body weight at the end of treatment may help improve weight maintenance. More research is needed on the relation between satisfaction with initial weight loss and long-term success.

Objective: This study was designed to assess physicians' attitudes toward obese patients and the causes and treatment of obesity., Research Methods and Procedures: A questionnaire assessed attitudes in 2 geographically representative national random samples of 5000 primary care physicians. In one sample (N = 2500), obesity was defined as a BMI of 30 to 40 kg/m(2), and in the other (N = 2500), obesity was defined as a BMI > 40., Results: Six hundred twenty physicians responded. They rated physical inactivity as significantly more important than any other cause of obesity (p < 0.0009). Two other behavioral factors-overeating and a high-fat diet-received the next highest mean ratings. More than 50% of physicians viewed obese patients as awkward, unattractive, ugly, and noncompliant. The treatment of obesity was rated as significantly less effective (p < 0.001) than therapies for 9 of 10 chronic conditions. Most respondents (75%), however, agreed with the consensus recommendations that a 10% reduction in weight is sufficient to improve obesity-related health complications and viewed a 14% weight loss (i.e., 78 +/- 5 kg from an initial weight of 91 kg) as an acceptable treatment outcome. More than one-half (54%) would spend more time working on weight management issues if their time was reimbursed appropriately., Discussion: Primary care physicians view obesity as largely a behavioral problem and share our broader society's negative stereotypes about the personal attributes of obese persons. Practitioners are realistic about treatment outcomes but view obesity treatment as less effective than treatment of most other chronic conditions.

In the treatment of obesity, assessment of resting energy expenditure (REE) can provide the basis for prescribing an individualized energy intake to attain a desired level of energy deficit. Indirect calorimetry is the most frequently used method to measure REE, but the great expense of equipment precludes its widespread use. As a result, REE is often estimated by predictive formulas based on weight, height, age, and gender. This paper examines the accuracy of these formulas in estimating REE among obese patients, discusses the assumptions underlying their use, and reviews the need for technological advances that will make the assessment of REE accurate, portable, and inexpensive.

Objective: This study assessed whether a 5% to 10% reduction in initial weight would be associated with as favorable long-term (i.e., 100 weeks) changes in lipids and lipoproteins, as have been observed on a short-term basis (i.e., 8 weeks)., Research Methods and Procedures: This was a prospective evaluation of 25 obese women, each of whom had lost > or =5% of initial weight during 48 weeks of treatment and had maintained a weight loss of this magnitude at 1-year follow-up (week 100). Lipids and lipoproteins were obtained at baseline and at weeks 8, 24, 48, and 100. All participants had a baseline total cholesterol > or =5.17 mmol/L (200 mg/dL)., Results: At the end of the first 8 weeks, weight fell an average of 11.7+/-2.8%, total cholesterol 20.6+/-7.5%, low-density-lipoprotein (LDL) cholesterol 23.0+/-18.1%, and triglycerides 26.0+/-20.1%. At week 48, weight had fallen to 20.1+/-7.0% below baseline, but total cholesterol and LDL cholesterol were reduced only 11.5+/-10.4% and 12.0+/-14.0% below baseline, respectively. These latter reductions were significantly (p<0.05) smaller than those observed at week 8, despite the larger weight loss at week 48. High-density-lipoprotein cholesterol declined significantly (p<0.05) during the first 8 weeks, but returned to baseline values by week 24. Patients gained 7.4+/-7.4 kg from weeks 48 to 100, during which time total and LDL cholesterol (but not triglycerides) rose significantly (p<0.05). Patients who, at week 100, maintained losses >10% of initial weight had significantly greater reductions in total and LDL cholesterol values than did patients who maintained losses of only 5% to 10% of initial weight., Discussion: Results of this study underscore the importance of assessing long-term changes in weight-related health complications when patients have lost weight but are no longer dieting (and exercising) as aggressively as they did during the initial months of treatment.

Objective: To assess weight loss, as well as the prevalence of valvular heart disease, in 21 obese women who completed 2 years of treatment by fenfluramine and phentermine (fen-phen) in June 1997., Research Methods and Procedures: Patients were 21 of 22 women who had completed a 1-year, open-label trial of fen-phen combined with lifestyle modification. This study describes the results of a second year of treatment. The presence of valvular heart disease, defined as aortic regurgitation of mild or greater severity and/or mitral regurgitation of moderate or greater severity, was assessed using two-dimensional, color Doppler and pulsed- and continuous-wave Doppler examinations., Results: At 2 years, the 21 patients had a mean reduction in initial weight of 13.9 + 10.0%, which was significantly (p<0.001) smaller than their 1-year loss of 17.1 +/- 8.7%. Nine of 21 patients reported that they took fen-phen irregularly during the last 4 months of the study because of fears of developing health complications. These nine patients had a 2-year weight loss of 8.7 +/- 7.5%, compared with a significantly (p<0.04) larger loss of 17.6 +/- 10.5% for participants who reported taking medication regularly. Six of 20 (30%) patients met criteria for valvular heart disease. None of the six had signs or symptoms of this condition., Discussion: Fenfluramine was withdrawn from the market on September 15, 1997 because of concerns that it was associated with valvular heart disease. The present findings are discussed in terms of the potentially favorable long-term benefits of combining lifestyle modification with weight loss medications that are both safe and effective.

This review summarizes studies on the psychological effects of weight cycling (i.e., weight loss and regain) in obese persons and proposes an agenda for future research on this topic. Among general psychological constructs, the current literature suggests that weight cycling is not associated with depression, other psychopathology, or depressogenic cognitive styles. Weight cycling is associated with decreased perceptions of health and well-being, although the clinical significance of this relationship is uncertain. Among weight- and eating-related constructs, weight cycling does not appear to be related to restraint, hunger, or personality traits associated with eating disorders. Weight cycling, however, does appear to be associated with clinically significant reductions in eating self-efficacy and weak but consistent increases in binge eating severity. Definitive conclusions about the presence or absence of the psychological consequences of weight cycling are premature, given the small number of studies, as well as a variety of methodological and interpretive concerns. A new generation of research is necessary to determine the extent and nature of the psychological sequelae of weight cycling.

This study examined a new method of providing brief, individual lifestyle modification to obese individuals treated by pharmacotherapy. Twenty-six women with a mean (+/- SD) age of 47.0 +/- 7.2 years, weight of 97.6 +/- 13.0 kg, and body mass index of 36.5 +/- 5.0 kg/m2 were prescribed 60 mg/d of fenfluramine and 15 mg/d of phentermine for one year. In addition, half of the women were randomly assigned to traditional group behavior modification, conducted by a nutritionist, which included 32 75-minute sessions during the year. The other half were provided lifestyle modification by a physician during 10 15-20 minute structured visits. All participants received identical treatment manuals and comparable assignments for behavior change. At the end of one year, patients in the physician group achieved the same highly successful weight losses as those treated by group behavior modification (13.9 +/- 9.6 kg vs. 15.4 +/- 7.9 kg, respectively). Treatment was associated with highly significant improvements in lipids and lipoproteins, as well as in mood and several measures of appetite. Weight loss the first four weeks, as well as patient completion of daily food records during the first 18 weeks, correlated positively with weight loss at weeks 18, 26, and 52. Results of this study await replication using larger samples but strongly suggest that effective lifestyle modification can be provided during brief, structured physician visits. The findings are discussed in terms of their implications for the treatment of obesity in primary care practice.

The prevalence of obesity among African American women approaches 50% and greatly exceeds rates for Caucasian women. In addition, black women lose less weight than white during obesity treatment and gain more weight when untreated. This study assessed resting energy expenditure (REE) and body composition in obese white (n = 122) and black (n = 44) women to explore the relationship between biological variables and these observed differences. REE and body composition were assessed by indirect calorimetry and densitometry, respectively, before weight loss. REE was significantly lower in black subjects (1637.6 +/- 236.9 kcal/d) than in white (1731.4 +/- 262.0) (p = 0.04). REE remained significantly lower in blacks than whites after adjusting for body weight (p = 0.02). REE, adjusted for fat-free mass, was also significantly lower in blacks than whites (p < 0.0001), although the overestimation of fat-free mass by densitometry in blacks may have contributed to this finding. There were no differences between the groups in respiratory quotient. These results suggest that a decreased REE may exist in obese black women, and it may be related to the observed differences between black and white women in the prevalence of obesity and in the response to weight loss treatment. These cross-sectional findings await confirmation in longitudinal studies.

This study examined the combination of sertraline, a selective serotonin reuptake inhibitor, and relapse prevention training in the maintenance of weight loss following treatment by a very-low-calorie diet. A total of 53 women who had lost a mean (+/- SD) of 22.9 +/- 7.1 kg from a pretreatment weight of 103.1 +/- 17.8 kg were randomly assigned to a 54-week weight maintenance program that was combined with either: 1) 200 mg/d of sertraline; or 2) placebo. During the first 6 weeks, sertraline subjects lost significantly more weight and reported significantly greater reductions in hunger and preoccupation with food than did subjects on placebo. After this time, however, women in both conditions regained weight steadily. The 13 sertraline subjects who completed the 54-week study regained 17.7 +/- 10.6 kg of their original 26.3 +/- 7.6 kg loss, equal to a regain of 70.9 +/- 41.7%. The 17 placebo completers regained 11.8 +/- 9.0 kg of their 23.4 +/- 7.8 kg loss, equal to a 46.5 +/- 34.6% regain. End-of-treatment differences between groups in weight change were not statistically significant. Nor were there significant differences between the two conditions at any time in changes in fat-free mass, resting metabolic rate or dysphoria, all of which tended to increase with weight regain. The results are discussed in relation to findings from other long-term studies that combined diet and medication.