title: Successful behavior change in obesity interventions in adults: a systematic review of self-regulation mediators.
abstract: BACKGROUND
  Relapse is high in lifestyle obesity interventions involving behavior and weight change. Identifying mediators of successful outcomes in these interventions is critical to improve effectiveness and to guide approaches to obesity treatment, including resource allocation. This article reviews the most consistent self-regulation mediators of medium- and long-term weight control, physical activity, and dietary intake in clinical and community behavior change interventions targeting overweight/obese adults.
  
  
  METHODS
  A comprehensive search of peer-reviewed articles, published since 2000, was conducted on electronic databases (for example, MEDLINE) and journal reference lists. Experimental studies were eligible if they reported intervention effects on hypothesized mediators (self-regulatory and psychological mechanisms) and the association between these and the outcomes of interest (weight change, physical activity, and dietary intake). Quality and content of selected studies were analyzed and findings summarized. Studies with formal mediation analyses were reported separately.
  
  
  RESULTS
  Thirty-five studies were included testing 42 putative mediators. Ten studies used formal mediation analyses. Twenty-eight studies were randomized controlled trials, mainly aiming at weight loss or maintenance (n = 21). Targeted participants were obese (n = 26) or overweight individuals, aged between 25 to 44 years (n = 23), and 13 studies targeted women only. In terms of study quality, 13 trials were rated as "strong", 15 as "moderate", and 7 studies as "weak". In addition, methodological quality of formal mediation analyses was "medium". Identified mediators for medium-/long-term weight control were higher levels of autonomous motivation, self-efficacy/barriers, self-regulation skills (such as self-monitoring), flexible eating restraint, and positive body image. For physical activity, significant putative mediators were high autonomous motivation, self-efficacy, and use of self-regulation skills. For dietary intake, the evidence was much less clear, and no consistent mediators were identified.
  
  
  CONCLUSIONS
  This is the first systematic review of mediational psychological mechanisms of successful outcomes in obesity-related lifestyle change interventions. Despite limited evidence, higher autonomous motivation, self-efficacy, and self-regulation skills emerged as the best predictors of beneficial weight and physical activity outcomes; for weight control, positive body image and flexible eating restraint may additionally improve outcomes. These variables represent possible targets for future lifestyle interventions in overweight/obese populations.
authors.affiliation: Interdisciplinary Centre for the Study of Human Performance (CIPER), Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal. pteixeira@fmh.ulisboa.pt.
authors.forename: Pedro J
authors.initials: PJ
authors.lastname: Teixeira
authors.affiliation: Interdisciplinary Centre for the Study of Human Performance (CIPER), Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal. ecarraca@fmh.ulisboa.pt.
authors.forename: Eliana V
authors.initials: EV
authors.lastname: Carraça
authors.affiliation: Interdisciplinary Centre for the Study of Human Performance (CIPER), Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal. martamarques@fmh.ulisboa.pt.
authors.forename: Marta M
authors.initials: MM
authors.lastname: Marques
authors.affiliation: European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, UK. harry.rutter@lshtm.ac.uk.
authors.forename: Harry
authors.initials: H
authors.lastname: Rutter
authors.affiliation: Department of Nutrition Pitié-Salpetrière (AP-HP), Université Pierre et Marie Curie-Paris 6, Paris, France. jean-michel.oppert@psl.aphp.fr.|UREN (Nutritional Epidemiology Research Unit), Université Paris 13, Sorbonne Paris Cité, Inserm (U557), Inra (U1125), Cnam, F-93017, Bobigny, France. jean-michel.oppert@psl.aphp.fr.
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Oppert
authors.affiliation: Department of Movement and Sport Sciences, Ghent University, Ghent, Belgium. ilse.debourdeaudhuij@ugent.be.
authors.forename: Ilse
authors.initials: I
authors.lastname: De Bourdeaudhuij
authors.affiliation: Department of General Practice and Elderly Care, The EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands. j.lakerveld@vumc.nl.
authors.forename: Jeroen
authors.initials: J
authors.lastname: Lakerveld
authors.affiliation: Department of Epidemiology and Biostatistics, The EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands. j.brug@vumc.nl.
authors.forename: Johannes
authors.initials: J
authors.lastname: Brug
mesh_terms: D001521:Behavior Therapy / Q000379:methods*; D004032:Diet / Q000523:psychology*; D006801:Humans; D008019:Life Style; D009043:Motor Activity; D009765:Obesity / Q000523:psychology* / Q000534:rehabilitation*; D050177:Overweight / Q000523:psychology / Q000534:rehabilitation; D015431:Weight Loss