Behavioral interventions that focus on diet, physical activity, and behavioral change have long helped people with obesity lose weight.

An ongoing question, however, is whether an individual or a group therapy approach works better.

Now, researchers have found that people less bothered by weight stigma, as assessed by higher-than-average self-esteem scores, may do better with group therapy.

The new study is a secondary analysis of an earlier clinical trial, when the same researchers found in-clinic group visits (but not telephone-based group visits) worked better than in-clinic individual ones, although the researchers said the differences were small in magnitude and of uncertain clinical importance.

For the new study, the researchers decided to dig further into the information already collected in the earlier study to determine if the degree of stigma a patient feels about excess weight might be a factor in one approach working better than another.

The new study “looks at the impact of self-esteem scores,” said study co-author Byron Gajewski, PhD, professor of biostatistics and data science at the University of Kansas Medical Center and Cancer Center, Kansas City. The researchers wanted to know: Do those who feel less stigmatized about weight do better in group settings?

Yes, they found. In fact, researchers reported:

• Participants with scores of 60 or higher on a 100-point scale did better with group visits.
• Those with the highest self-esteem scores (above 80) lost nearly 15 pounds in the group visit arm.
• Those with the highest self-esteem scores lost 8.6 pounds in the individual visit arm.
• Participants with scores of 60-80 lost nearly 12 pounds in group visits compared with nearly 8 pounds for those in individual visits.

The researchers used Bayesian modeling, incorporating the new data to calculate the probability of their hypothesis — that self-esteem has an impact on which approach works better.

When scores dropped below 60, the differences between group and individual weight losses were smaller. While those with higher self-esteem did better with group visits, the individual visits did produce a 6.6-pound loss, regardless of self-esteem score. But in the group visits, weight loss improved as self-esteem improved, up to a 15-pound loss in those with the highest scores.

Study in Detail

Researchers looked at the weight loss results after 24 months in 1220 participants (mean age, 55.4 years) who had been assigned in the original trial to in-clinic group visits, telephone group visits, or in-clinic individual visits at 36 rural primary care clinics in the Midwestern US. The visits were conducted from February 2016 through October 2017, and the final follow-up was completed in December 2019.

For this secondary analysis, the researchers looked at data collected but not analyzed in the earlier trial, with patients answering seven questions related to the influence of weight on self-esteem on the Impact of Weight on Quality of Life-Lite questionnaire. Among them: if excess weight makes them self-conscious, have lower self-esteem, avoid looking in mirrors or seeing photographs, and brings on embarrassment in public places.

The mean self-esteem score was 51.2, the researchers found, and 40% had scores above 60.

How To Explain Group Magic

For the new analysis, the researchers did not have information from participants about why the group might work better for some.

But Gajewski’s colleagues had some thoughts. “Lifestyle interventions delivered in a group format provide additional accountability, support, modeling, and helpful information among peers, all of whom are striving to make similar changes in their nutrition and physical activity habits,” Christie Befort, PhD, professor of population health at the University of Kansas Medical Center and a researcher on both studies, told Medscape Medical News in an email interview.

She finds this helps to “normalize the struggle” and can help some keep their motivation. 

The self-esteem finding makes sense to Allen Greiner, MD, MPH, professor and vice chair of family medicine and community health at the University of Kansas Medical Center and a co-author on both studies.

“In general, family medicine colleagues I have spoken to understand that group visits may be more powerful for producing weight loss than individual visits,” he said in an email interview. They also feel it makes sense that patients might need to have a certain level of self-esteem in order to successfully engage in group visits, he said. Clinicians’ goals are twofold: help patients lose weight and develop greater self-esteem.

He is hopeful the findings will help clinicians guide patients into the best intervention for them.

He suggests clinicians be aware of some patients’ vulnerability in group settings, at least initially, but he recalls a patient he referred to a group program who adjusted quickly after the initial hesitation.

Clinical Takeaways

The take-home, in Gajewski’s view, is that the new study “gives a finer estimation of what to expect.”

While both approaches can produce weight loss, the group was better for those with higher self-esteem, “and you can provide finer expectations [to patients] if you know their self-esteem score,” Gajewski said.

If a patient is interested, he said, a clinician might predict weight loss based on the score. For some, he said, it could be motivation.

Second Opinions

Not everyone who reviewed the findings for Medscape Medical News agreed with that, however.

“While the finding is important for future research,” it “should be interpreted with caution,” said Lindsay Fourman, MD, associate director of Lipid and Metabolism at the Massachusetts General Hospital in Boston, as association does not mean causality. “Moreover, weight-related self-esteem may reflect other factors that were not fully captured in this analysis, including extroversion or comfort participating in groups.”

She would not recommend routinely measuring weight-related quality of life solely to predict weight loss or decide on group or individual treatment.

It can be valuable to identify areas patients might need some support in, she said. In the end, she suggests sending patients to the intervention they believe they can engage in most consistently.

The new study “adds to the support for group-based treatment for obesity,” said Becca Krukowski, PhD, a spokesperson for The Obesity Society and professor and vice chair of investigator-initiated research in public health sciences at the University of Virginia School of Medicine in Charlottesville. She also co-leads the Community Cancer Control and Obesity Research Center there.

“This benefit of group-based treatment is likely due to the social support from a group, feelings of accountability, and the opportunity to engage in problem-solving within the group.”

None of the researchers reported having relevant disclosures.

This project was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. The trial was funded by a Patient-Centered Outcomes Research Institute award, RE-POWER.