- Head of Department of Eating and Weight Disorders. Villa Garda Hospital. Garda (Vr) ItalyThe unit has 18 inpatients b... moreHead of Department of Eating and Weight Disorders. Villa Garda Hospital. Garda (Vr) ItalyThe unit has 18 inpatients beds and 14 day-care beds for eating disorders patients, and 20 beds for patients with severe obesity. The inpatients program based on an original cognitive-behavioral treatment. The team is multidisciplinary and includes: 4 medical doctors, 5 psychologists, 4 dieticians, 4 nurses.Current researchThe main focus of my research is evaluating the treatment of eating disorders and obesity. Teaching activityDirector of the Master course for health professionals, primarily medical doctors and psychologists ‘1° Certificate in Eating Disorder and Obesity’.Part of teaching faculty for the cognitive behavioral psychotherapy school, Associazione di Psicologia Cognitiva di Roma, Italyedit
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Obesity is a heterogeneous condition which results from complex interactions among sex/gender, sociocultural, environmental, and biological factors. Obesity is more prevalent in women in most developed countries, and several clinical and... more
Obesity is a heterogeneous condition which results from complex interactions among sex/gender, sociocultural, environmental, and biological factors. Obesity is more prevalent in women in most developed countries, and several clinical and psychological obesity complications show sex-specific patterns. Females differ regarding fat distribution, with males tending to store more visceral fat, which is highly correlated to increased cardiovascular risk. Although women are more likely to be diagnosed with obesity and appear more motivated to lose weight, as confirmed by their greater representation in clinical trials, males show better outcomes in terms of body weight and intra-abdominal fat loss and improvements in the metabolic risk profile. However, only a few relatively recent studies have investigated gender differences in obesity, and sex/gender is rarely considered in the assessment and management of the disease. This review summarizes the evidence of gender differences in obesity prevalence, contributing factors, clinical complications, and psychological challenges. In addition, we explored gender differences in response to obesity treatments in the specific context of new anti-obesity drugs.
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An active lifestyle plays a central role in the management of obesity, favouring the maintenance of weight loss and reducing the health risk associated with the condition. Unfortunately, however, most patients with obesity have little... more
An active lifestyle plays a central role in the management of obesity, favouring the maintenance of weight loss and reducing the health risk associated with the condition. Unfortunately, however, most patients with obesity have little motivation to change their physical activity habits, and their adherence to exercise is further hampered by several physical, psychological and environmental barriers. The key role of these processes in the failure–success of exercise adherence suggests that without taking them into account, a simple traditional prescriptive approach to exercising is insufficient to produce long-term lifestyle alteration. With this in mind, Module 3 of cognitive behavioural therapy for obesity (CBT-OB) includes three main sections, described in detail below. The first prepares and motivates each patient to develop an active lifestyle and includes procedures to assess their eligibility and functional exercise capacity. The second involves a CBT-OB-recommended physical activity programme, and the third adopts several strategies for increasing patients’ adherence to exercise.
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Aims. To investigate the effects if inpatient cognitive behavioral therapy (CBT) on physical fitness of patients with Anorexia Nervosa (AN) and to evaluate the feasibility of the Eurofit Battery test (EB) in this population. Methods:... more
Aims. To investigate the effects if inpatient cognitive behavioral therapy (CBT) on physical fitness of patients with Anorexia Nervosa (AN) and to evaluate the feasibility of the Eurofit Battery test (EB) in this population. Methods: Physical fitness was assessed with an adapted version of the EB (Endurance: 6\u2019 walking test; Arm strength: hand grip; Abdominal: sit up; Leg strength: standing broad jump; Balance: flamingo balance; Flexibility: sit and reach) administered to 29 female AN patients (BMI: 14.35\ub11.51 kg/m2), pre and post treatment, and to fifty-eight healthy females (BMI: 21.17\ub12.57 kg/m2) of the same age (24.4\ub19.2 vs 25.9\ub19.1ys, respectively, z=1.39, p=0.165). AN group underwent test on the second day of the admission and the last week before the hospital discharge. Results: All Eurofit items showed good feasibility, but some AN patients refused to sustain some tests at the admission. CBT was associated with a significant improvement in BMI (from 14.3\ub11.5 to 18.8\ub11.2, Z=4.20, p<0.001) and in 4 out of 6 Eurofit tests (p<0.05) in the AN group. However, both in pre and post, AN patients generally showed lower scores compared to the control group (all p < 0.001) with the exception of sit up score. Conclusions: Adapted EB can be recommended for evaluating physical fitness parameters in AN patients. Physical fitness is lower in AN patients than in controls both at baseline and after weight restoration. These data suggest the need to associate to the classical inpatient treatment of AN specific therapeutic strategies to improve physical fitness
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Traditionally, weight-loss lifestyle-modification programmes based on behavioural therapy (BT-OB) have been predominantly administered to groups. Indeed, the group approach to obesity treatment does have several advantages over individual... more
Traditionally, weight-loss lifestyle-modification programmes based on behavioural therapy (BT-OB) have been predominantly administered to groups. Indeed, the group approach to obesity treatment does have several advantages over individual treatment, including lower treatment cost, social support, healthy competition, learning from others and developing a group mindset. However, the Look AHEAD study—a rigorous multicentre trial on preventing type 2 diabetes—examined a variety of group and individual approaches based on group BT-OB and concluded that individual contact is critical to retain participants in a multi-year intervention. Nevertheless, weight-loss lifestyle-modification programmes based on BT-OB remain poorly individualised and are still administered to groups over a prescribed order of sessions. As such they are unable to take into account the progress of each individual patient. To overcome this problem, we have adapted cognitive behavioural therapy for obesity (CBT-OB) for groups but retaining a highly personalised approach. In this way CBT-OB for groups maintains the advantages of group treatment while focusing on the individual. Group CBT-OB follows the protocol described in this book and includes the same number of sessions and stages as CBT-OB for individuals. However, to ensure that the needs of each participant are being met, the treatment is preceded by two individual sessions that will prepare them for group treatment.
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Module 6 coincides with the beginning of Phase 2 of cognitive behavioural therapy for obesity (CBT-OB). Patients now attend one session every 4 weeks, over the course of 48 weeks. During this period patients are encouraged to interrupt... more
Module 6 coincides with the beginning of Phase 2 of cognitive behavioural therapy for obesity (CBT-OB). Patients now attend one session every 4 weeks, over the course of 48 weeks. During this period patients are encouraged to interrupt any attempt to lose more weight and to work actively towards the long-term maintenance of the weight that they have already lost. As such, the main goal of Module 6 is to help patients develop the necessary cognitive and behavioural skills. As part of this process, patients are educated that weight maintenance is more difficult than weight loss, that some people—despite the biological and environmental pressures to regain weight—are able to maintain the weight lost in the long term and that it is necessary for them to develop and practise skills which will enable them to keep the weight off. Specific procedures introduced in this module include establishing weekly self-weighing and a weight-maintenance range, adopting eating and physical activity habits conducive to weight maintenance, constructing a mindset conducive to weight maintenance, preventing any lapses from becoming relapses and addressing any instances of weight regain. Towards the end of treatment, patients are encouraged to discontinue real-time monitoring of food intake and physical activity and to evaluate possible future weight-loss attempts, and the therapist helps them to prepare a weight-maintenance plan. Finally, patients are invited to attend post-treatment review sessions at 3-month intervals after the end of treatment for at least 1 year.
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Lifestyle modification programmes based on cognitive behavioural therapy for obesity (CBT-OB) are the cornerstone of treatment for weight management. However, a subgroup of patients has difficulties adopting the lifestyle modification... more
Lifestyle modification programmes based on cognitive behavioural therapy for obesity (CBT-OB) are the cornerstone of treatment for weight management. However, a subgroup of patients has difficulties adopting the lifestyle modification needed to manage their obesity, due to the powerful biological and environmental factors contrasting weight loss that promote excessive intake of food and reduced energy expenditure. In these cases, it may be useful to combine CBT-OB with weight-loss drugs or bariatric surgery (in patients with severe obesity), which have been specifically designed to address the biological obstacles to weight loss and weight maintenance. Data from some trials indicate that the association of weight-loss drugs with lifestyle modification programmes results in significantly greater weight loss than either therapy alone, because of the potentially complementary mechanisms of action of the two interventions. Similarly, some studies have shown that lifestyle modification p...
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Module 1 introduces self-monitoring of food intake and physical activity and weekly weighing. These two procedures are central to cognitive behavioural therapy of obesity (CBT-OB), because evidence has shown that the greater the use of... more
Module 1 introduces self-monitoring of food intake and physical activity and weekly weighing. These two procedures are central to cognitive behavioural therapy of obesity (CBT-OB), because evidence has shown that the greater the use of self-monitoring, the larger the amount of weight lost. Furthermore, regular checking of weight is associated with better long-term weight-maintenance outcomes. The Monitoring Record used in CBT-OB differs from a traditional food diary, since it is used to record both mealtimes and the food, drink and calories that the patient is planning to consume in advance and also to record in “real time” (i.e. in the precise moment at which the food is consumed), whether or not the patient adhered to their meal plan. By providing patients with a detailed picture of their eating habits, advance meal planning and real-time monitoring of eating can focus their attention on their specific obstacles to weight loss. It assists them to eat consciously and to interrupt d...
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Over the last decade, a new condition, which occurs in the presence of both sarcopenia and obesity, has been termed “sarcopenic obesity”. The term describes the coexistence of obesity, defined as the increase in body fat mass deposition,... more
Over the last decade, a new condition, which occurs in the presence of both sarcopenia and obesity, has been termed “sarcopenic obesity”. The term describes the coexistence of obesity, defined as the increase in body fat mass deposition, and sarcopenia, defined as the reduction in lean mass and muscle strength. However, many uncertainties still surround the condition of sarcopenic obesity in terms of its definition, the adverse short- and long-term health effects (i.e., medical disease, psychosocial functioning, quality of life and mortality) and its clinical management. The aim of this short communication is to emphasize some crucial aspects that future research should take into account in order to avoid bias and misinterpretations and to underline that the study of sarcopenic obesity should be considered a scientific and clinical priority, as reported by the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO).
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Obesity is an increasing global health problem, but its treatment is not yet optimal, especially in the long term. For this reason, preclinical studies have been conducted relating to a new therapeutic strategy for obesity based on... more
Obesity is an increasing global health problem, but its treatment is not yet optimal, especially in the long term. For this reason, preclinical studies have been conducted relating to a new therapeutic strategy for obesity based on adipose-derived mesenchymal stem cells (AD-MSCs). The aim of our systematic review is to summarize these findings deriving from the animal model in order to establish whether there is sufficient evidence to justify going forward to clinical studies. Literature searches, study selection, methods and quality appraisal were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were collated using a narrative approach. Of the 578 articles retrieved, seven studies met the inclusion criteria, and their analysis revealed several main findings. There was a strong evidence of the positive effect of AD-MSCs in obesity treatment in terms of body weight, glucose metabolism homeostasis, lipid profiles, non-al...
Research Interests: Obesity, Critical Appraisal, Medicine, Adipose tissue, Humans, and 9 moreAnimals, Mesenchymal Stem Cell, Systematic review, Clinical Sciences, Longitudinal Studies, Adipose derived Mesenchymal Stem Cells, Mesenchymal Stromal Cells, Biochemistry and cell biology, and Medical biochemistry and metabolomics
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Spinal muscular atrophy is a genetic neuromuscular disease characterised by muscle atrophy, hypotonia, weakness, and progressive paralysis. Usually, these patients display increased fat mass deposition and reductions in fat-free mass and... more
Spinal muscular atrophy is a genetic neuromuscular disease characterised by muscle atrophy, hypotonia, weakness, and progressive paralysis. Usually, these patients display increased fat mass deposition and reductions in fat-free mass and resting energy expenditure—an unfavourable condition that facilitates the development of obesity. However, weight management of these patients remains poorly described. Hence, the aim of this case report was to describe the clinical presentation and weight management of a 31-year-old male patient with spinal muscular atrophy type III, class I obesity, and metabolic syndrome treated for 1 year by means of a personalised multistep cognitive-behavioural treatment for obesity. The treatment produced a weight loss of 7.2 kg (7.1%), which was associated with a marked improvement in both the patient’s self-reported general conditions and obesity-related cardiometabolic profile, and no adverse effects in terms of spinal muscular atrophy (i.e., reductions in...
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No specific questionnaire that evaluates Health-Related Quality Of Life (HRQOL) in individuals with obesity is available in the Arabic language. The aim of this study was therefore to propose and examine the validity and reliability of an... more
No specific questionnaire that evaluates Health-Related Quality Of Life (HRQOL) in individuals with obesity is available in the Arabic language. The aim of this study was therefore to propose and examine the validity and reliability of an Arabic language version of the ORWELL 97, a validated obesity-related HRQOL questionnaire. The ORWELL 97 questionnaire was translated from English to Arabic language and administered to 318 Arabic-speaking participants (106 from clinical and 212 from community samples), and underwent internal consistency, test-retest reliability, construct and discriminative validity analysis. Internal consistency and the test-retest reliability were excellent for ORWELL 97 global scores in the clinical sample. Participants with obesity displayed significantly higher ORWELL 97 scores than participants from the community sample, confirming the good discriminant validity of the questionnaire. Confirmatory factor analysis in the clinical sample revealed a good fit for...
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This case report describes the management of a 49-year-old female with restricting-type anorexia nervosa and excessive compulsive exercising associated with rhabdomyolysis, high levels of serum creatine kinase (CK) (3,238 U/L), and marked... more
This case report describes the management of a 49-year-old female with restricting-type anorexia nervosa and excessive compulsive exercising associated with rhabdomyolysis, high levels of serum creatine kinase (CK) (3,238 U/L), and marked hyponatremia (Na+: 123 mEq/L) in the absence of purging behaviours or psychogenic polydipsia; it is the first case report to describe exercise-associated hyponatremia in a patient with anorexia nervosa. The patient, who presented with a body mass index (BMI) of 13.4 kg/m2, was successfully treated by means of an adapted inpatient version of an enhanced form of cognitive behavioural therapy (CBT-E). Within a few days, careful water restriction, solute refeeding, and the specific cognitive behavioural strategies and procedures used to address the patient’s excessive compulsive exercising and undereating produced a marked reduction in CK levels, which normalised within one week. Exercise-associated hyponatremia also gradually improved, with serum sodi...
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This paper describes a lenient treatment for anorexia nervosa patients. The method incorporates nutritional rehabilitation, psychoeducational groups, parental psychoeducational groups, physiotherapy and individual psychotherapy... more
This paper describes a lenient treatment for anorexia nervosa patients. The method incorporates nutritional rehabilitation, psychoeducational groups, parental psychoeducational groups, physiotherapy and individual psychotherapy (psychodynamically oriented). The model entails a multi‐level matching system where patients' needs are coordinated with the appropriate treatment setting. The three‐level system integrates: a hospital eating disorder unit; day care treatment as transition phase from inpatient to outpatient, and outpatient treatment. Patients shift between levels according to their progress. The therapeutic elements of the programme are presented in detail with results obtained from 44 patients.
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Research Interests: Psychology, Clinical Psychology, Psychiatry, Depression, Eating Disorders, and 15 moreControl, Medicine, Starvation, Humans, Female, Cognitive Therapy, Body Mass Index, Beck Depression Inventory, Clinical Sciences, Dietary restraint, Questionnaires, Food habits, Adult, Psychological Theory, and Cognitive behavioural
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Incretin-based medications for treating obesity produce substantial short-and long-term weight loss and improve obesityrelated comorbidities. However, associating lifestyle modification with new medications to treat obesity is generally... more
Incretin-based medications for treating obesity produce substantial short-and long-term weight loss and improve obesityrelated comorbidities. However, associating lifestyle modification with new medications to treat obesity is generally advisable for several reasons. Firstly, healthy eating patterns and physical activity may offer important additional benefits, enhancing the patient's health and well-being. In addition, regular specialist counselling in lifestyle modification can help patients maintain their motivation levels and develop specific skills for addressing obstacles during the lengthy process of weight loss and maintenance, potentially improving outcomes in the long term. Given the high efficacy of the new weight-loss drugs, it would be timely to streamline and simplify the current gold standard of obesity management based on lifestyle modification. For example, it now seems redundant to prescribe strict diets or meal replacements to reduce calorie intake, or to recommend patients practice 200 to 300 minutes of moderateto-vigorous-intensity exercise for enhanced weight loss. Moderate calorie restriction and, at least 150 minutes of moderate-intensity aerobic exercise and two sessions of muscle-strengthening activities per week may be more achievable and appropriate goals for sustainable weight loss in most patients on pharmaceutical obesity treatment. As regards lifestyle modification counselling, future studies should assess its optimal intensity and duration in the "new medications for obesity era".
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ObjectiveThe study aimed to evaluate the effectiveness of enhanced cognitive behaviour therapy (CBT‐E) on patients with anorexia nervosa (AN) aged 14 to 25 treated in a real‐world setting.MethodOne hundred and fifteen patients with AN... more
ObjectiveThe study aimed to evaluate the effectiveness of enhanced cognitive behaviour therapy (CBT‐E) on patients with anorexia nervosa (AN) aged 14 to 25 treated in a real‐world setting.MethodOne hundred and fifteen patients with AN (n = 61, age &lt;18 years) were recruited from consecutive referrals to a clinical eating disorder service offering outpatient CBT‐E. Body Mass Index (BMI), BMI centiles, Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment scores were recorded at admission, at the end of treatment, and at 20‐week follow‐up.ResultsThe seventy‐two patients (62.6%) who finished the programme showed considerable weight gain and reduced scores for clinical impairment and eating‐disorder and general psychopathology. Changes remained stable at 20 weeks. A comparison between adolescent and adult patients indicates similar improvements in eating‐disorder psychopathology.ConclusionsThe benchmark data yielded by this study suggest that CBT‐E is a well‐accepted and promising treatment that could be adopted to ensure continuity of care across the transitional age.
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Digital technology—the Internet, computers, mobile devices such as smartphones and mobile software applications (apps)—may be effectively implemented to overcome difficulties in disseminating and scaling up cognitive behavioural treatment... more
Digital technology—the Internet, computers, mobile devices such as smartphones and mobile software applications (apps)—may be effectively implemented to overcome difficulties in disseminating and scaling up cognitive behavioural treatment for obesity (CBT-OB). Two main interrelated general strategies can be used to this end. The first is to exploit digital technology to deliver the treatment, which will increase the availability of CBT-OB, and the second is to employ digital technology for training therapists, which may lower the barrier to treatment dissemination. Available data in patients indicate that Internet-based programmes are effective—even though to a lesser extent than face-to-face interventions—in terms of weight loss and weight-loss maintenance. Moreover, some strategies relying on digital self-monitoring tools of food intake, physical activity and weight seem to improve patients’ adherence to treatment.
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Satisfaction with the amount of weight lost is one the most important cognitive factors involved in long-term body weight maintenance. Moreover, a decline in weight-loss satisfaction about 4–5 months after the start of the treatment is... more
Satisfaction with the amount of weight lost is one the most important cognitive factors involved in long-term body weight maintenance. Moreover, a decline in weight-loss satisfaction about 4–5 months after the start of the treatment is associated with poor long-term weight-loss outcomes. To address these obstacles to weight maintenance, cognitive behavioural therapy for obesity (CBT-OB) incorporates Module 5, which is designed to help patients who report weight-loss dissatisfaction in the later phase of weight loss to arrive at the start of the weight-maintenance phase satisfied with the weight they have lost. Positively acceptance of the current weight and therefore the right attitude to establishing a long-term weight-maintenance mindset are essential at this stage. Hence, patients who report a decline in weight-loss satisfaction, assessed session by session using the Weight-Loss Obstacles Questionnaire, are helped to identify the reasons behind their weight-loss dissatisfaction. These reasons generally fall into three main, often interrelated, categories, unrealistic weight-loss expectations, dysfunctional primary goals for weight loss and negative body image, and are addressed in this module through a personalised set of specific strategies and procedures.
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Module 4 is designed to help the patient to identify and address their main individual obstacles to weight loss. Patients are actively involved in identifying these obstacles through a collaborative review of their Monitoring Records and... more
Module 4 is designed to help the patient to identify and address their main individual obstacles to weight loss. Patients are actively involved in identifying these obstacles through a collaborative review of their Monitoring Records and the session-by-session compilation of the “Weight-Loss Obstacles Questionnaire”. When an obstacle is identified, it is included in a personalised cognitive behavioural Formulation. This is a diagram which reports the main mechanisms hindering a patient’s adhesion to lifestyle changes and weight loss. These mechanisms generally fall into three main categories: (1) antecedent stimuli, (2) positive consequences and (3) problematic thoughts. The CBT-OB therapist should educate the patient to identify these mechanisms through real-time compilation of their Monitoring Record. Once the individual’s weight-loss obstacles have been identified and included in their Personal Formulation, specific strategies and procedures are introduced to help a patient manag...
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The aim of this study was to assess the association between weight-loss maintenance and weight-loss satisfaction, adherence to diet and weight loss, all measured session-by-session during the weight-loss phase of cognitive behavioral... more
The aim of this study was to assess the association between weight-loss maintenance and weight-loss satisfaction, adherence to diet and weight loss, all measured session-by-session during the weight-loss phase of cognitive behavioral therapy. The present exploratory study examined a subgroup of fifty-eight patients who participated in a randomized controlled trial and who lost at least the 10% of their baseline weight. Patients were grouped into weight-loss 'Maintainers' (i.e., those who maintained a weight loss of ≥ 10% of baseline body weight at 6 months after the weight-loss phase) and 'Regainers' (i.e., those who did not maintain > 10% weight loss at 6 months after the weight-loss phase). Body weight, adherence to diet and weight-loss satisfaction were measured session-by-session during the weight-loss phase. Thirteen patients (22.4%) were classified as 'Regainers', and 45 (77.6%) as 'Maintainers'. Compared to 'Maintainers', 'Regain...
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The Clinical Impairment Assessment (CIA) is a measure of functional impairment secondary to eating disorder symptoms. The aim of this study was to examine the psychometric proprieties of the Italian-language version of the CIA. The tool... more
The Clinical Impairment Assessment (CIA) is a measure of functional impairment secondary to eating disorder symptoms. The aim of this study was to examine the psychometric proprieties of the Italian-language version of the CIA. The tool was translated into Italian and administered to 259 Italian-speaking in- and outpatients with eating disorders and 102 healthy controls. The clinical group also completed the Eating Disorder Examination Questionnaire (EDE-Q) and the Brief Symptom Inventory (BSI). Confirmatory factor analysis revealed a good fit for the original three-factor structure. Internal consistency was high for both the global CIA and all subscale scores, and test-retest reliability was acceptable. The high correlation between CIA and EDE-Q and BSI confirmed the convergent validity of the instrument. T test indicated higher raw scores on CIA in patients with eating disorders than healthy controls, and a cut-off score of 16 on the CIA discriminated between eating disorder and g...
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Multistep cognitive behavioral therapy for obesity (CBT-OB) is a treatment that may be delivered at three levels of care (outpatient, day hospital, and residential). In a stepped-care approach, CBT-OB associates the traditional procedures... more
Multistep cognitive behavioral therapy for obesity (CBT-OB) is a treatment that may be delivered at three levels of care (outpatient, day hospital, and residential). In a stepped-care approach, CBT-OB associates the traditional procedures of weight-loss lifestyle modification, ie, physical activity and dietary recommendations, with specific cognitive behavioral strategies that have been indicated by recent research to influence weight loss and maintenance by addressing specific cognitive processes. The treatment program as a whole is delivered in six modules. These are introduced according to the individual patient's needs in a flexible and personalized fashion. A recent randomized controlled trial has found that 88 patients suffering from morbid obesity treated with multistep residential CBT-OB achieved a mean weight loss of 15% after 12 months, with no tendency to regain weight between months 6 and 12. The treatment has also shown promising long-term results in the management ...