Abstract
The identification of variables in the early stages of treatment that are related to successful weight loss provides practitioners with important information. These factors may be assessed to determine the likelihood of future success. Weight loss at the beginning of treatment, depressive symptomatology, and social support, each of these has been shown to be predictive of long-term outcomes for weight loss efforts.
The need for lifestyle interventions to successfully treat obesity is clear. As discussed in this issue by Hagobian and Phelanm 1 both short- and long-term weight losses have been demonstrated in multiple clinical trials.2-4 Furthermore, the effective lifestyle components that appear to have an impact on behavioral treatments have been identified. 1 Despite these advances in understanding how to best treat obesity, practitioners continue to face multiple barriers to successfully implement these treatments. 5 One of the largest problems faced by practitioners is attrition.6,7 Attrition has been shown to be related to multiple patient variables, including (but not limited to) stress8-10 and weight loss expectations.10,11 Understanding patient variables that are related to successful weight loss and reduced attrition is one way to assist practitioners in focusing on areas that promote weight loss efforts.
… weight loss at the beginning of treatment, depressive symptomatology, and social support are variables that have been consistently demonstrated to predict weight loss.
Numerous variables have been identified that are potentially related to weight loss. 10 For example, some evidence supports that individuals who have fewer previous weight loss attempts are more likely to be successful.12-14 Other variables such as body image, self-esteem, and weight related quality of life have limited support and are in need of further research to determine the role they possibly play in weight loss efforts. 10 Several variables have strong support in their ability to successfully predict weight loss. Currently, weight loss at the beginning of treatment,15-19 depressive symptomatology,15,20,21 and social support22-27 are variables that have been consistently demonstrated to predict weight loss.
Weight Loss at the Beginning of Treatment
Weight loss in the early weeks of treatment has been shown to be associated with long-term clinically significant decreases in weight15-19 and decreased rates of attrition. 15 The definition of how early in treatment weight loss should occur for optimal results is not consistent across studies. However, one study demonstrated weight losses as early as 3 weeks predicted long-term success. 15 These findings clearly support the concept that initial success promotes future success. Patients’ early improvements in weight are a strong reinforcer to continue engaging in the behaviors that have been recommended. On the other hand, lack of early success is likely to bring about feelings of discouragement which leads to decreased motivation. Managing a patient’s expectations for weight loss may be one way to deal with this issue; however, most people strongly desire weight loss to occur quickly and to an unrealistic degree. 28 The media portrayal of an ideal body image further supports unrealistic expectations. 29 Based on these factors, practitioners may experience considerable difficulty in convincing patients to lower their initial expectations.
Initial weight loss may also be a proxy for other variables such as motivation, adherence, or readiness for change. For example, patients may experience initial weight loss to a greater degree because they have greater readiness for change, which may also affect their motivation. These issues notwithstanding, practitioners should make every effort to support initial weight loss as it has been shown to influence long-term weight loss. Strategies aimed at reducing energy intake and increasing energy expenditure should be implemented with patients as early as possible or as is safe. 15
Depressive Symptomatology
Depression has been associated with decreased outcomes in many areas, including asthma, 30 cardiovascular disease, 31 diabetes, 30 and transplantation. 32 The role depressive symptomatology plays in obesity treatment is less clear because many studies exclude individuals with clinical levels of depression. 33 In fact, earlier reviews of weight loss studies have indicated that depressive symptoms do not predict outcomes. 10 However, increased depressive symptoms have been shown to predict both decreased long-term weight loss 15 and higher rates of attrition.15,20,21 Overall, patients with subclinical levels of depression appear to engage in fewer changes needed for weight loss. 15
Practitioners are faced with the issue of how to treat an individual with increased depressive symptomatology. For example, it is possible to treat depressive symptoms before initiating weight loss or to treat both conditions at the same time. If the conditions are treated at the same time, it may be necessary to assist these individuals by increasing the support provided. Specifically, support that focuses on increasing motivation, energy, and concentration may be critical as these characteristics are impacted by this condition.
Social Support
Although the social support reported by patients before initiating treatment is not a strong predictor of outcomes, social support during treatment is strongly associated with improved weight loss.22,23 In addition to viewing social support in a typical way (eg, family and peers), groups formed to treat obesity can also serve this role. 24 Evidence suggests that group approaches are superior to self-help approaches and may be more beneficial than even individual approaches.23-25 This is not surprising given that humans are very social and often solve problems in a social setting. 26 In implementing group interventions, creating alliances with other individuals facing similar struggles and creating a safe environment to engage in change are extremely important. 26
The treatment provider may also play a critical role in terms of social support. 27 This finding is consistent with evidence from psychotherapeutic outcomes. Specifically, some evidence suggests that the strength of the therapeutic relationship in psychotherapy may be one of the primary indicators of successful outcomes.34,35 In obesity management, support from care providers that the patient views as promoting autonomy as opposed to controlling has been associated with improved outcomes. 27 The importance of social support, in general, and the relationship between patient and care provider, specifically, in promoting weight loss should not be underestimated.
Conclusion
Weight loss treatment is a process that constantly evolves and progresses; however, variables have been identified that predict outcomes. These predictors may facilitate the early identification of individuals who are more likely to be successful with treatment. Conversely, attending to these factors also provides important information regarding individuals who have a decreased likelihood of being successful with their weight loss efforts. Using this approach is not without its limitations. For example, these predictive factors have been demonstrated across large groups of participants, but they may be less beneficial when used on an individual level. 36 Additionally, these predictors account for only 20% to 30% of the total variance in weight loss outcomes. 36 This suggests that many other factors play important roles. Whereas the practitioner is encouraged to monitor early weight loss, depressive symptomatolgoy, and social support, it will be of equal importance to determine the factors that are associated with improved outcomes on an individual level as well. In sum, the method of identifying variables that are associated with success at the group and individual level can greatly assist practitioners in customizing treatments to best meet patients’ needs.