Designing and validating the cognitive rehabilitation protocol and effect on attention bias, self-regulation, and food craving in women with obesity

Obesity is associated with many comorbidities, such as cardiovascular disease, type II diabetes mellitus, hypertension, and various cancers. Moreover, the risk for dementia and Alzheimer’s disease is also increased. In addition, individuals with obesity have significant cognitive deficits, especially in executive functions. Indicatively, obesity and being overweight are estimated to account for nearly 3.4 million deaths per year, which corresponds to the fifth leading cause of death worldwide. In today's society, high-calorie palatable food is abundantly available, and most people have a largely sedentary lifestyle, often leading to an imbalance in energy intake and expenditure. Excess energy is converted into fat, which results in weight gain and obesity. Cognitive and psychological problems play a vital role in the course, prognosis, and treatment of obesity. The present study aimed to design and validate the cognitive rehabilitation program and its effect on attention bias, self-regulation, and food craving in women with obesity.

The present study used a (group: training group vs. control group) between- and within-subjects (time-point: baseline, post-intervention, and follow-up two months later) design to test the effects of the training program on the dependent variables. Participants in this study included 40 female obese patients living in Urmia who were randomly assigned to two groups cognitive rehabilitation (n=20) and control (n=20). The experimental group received cognitive rehabilitation intervention in 16 sessions. The dot-probe task, self-regulating scale, and food craving scale in the pre-test, post-test, and follow-up stages were used for both groups, and the findings were analyzed using a mixed analysis of variance test. Notably, after the end of the course, the control group also received cognitive rehabilitation intervention.Measures: The current study used a modified dot-probe task for assessing attention bias. Forty food-related words and 40 neutral words were collected and validated in our previous studies. The trial consisted of four sections separated by one-minute intervals. The same 40 pairs of words were presented in random order in each section. Each trial started with a fixation point presented in the center of the monitor for 500 Ms. A pair of words, one food-related and another neutral were then presented above and below the fixation point (position counterbalanced across trials). Each pair of words were shown, followed by a cue (letter ‘p’ or ‘q’). Participants were asked to press ‘p’ or ‘q,’ which appeared randomly in the location of either the food-related word or neutral word, as quickly as possible. After the participant pressed the key (or following 1500 MS if participants did not respond), the cues disappeared. Each trial was presented four times, and each pair of words randomly appeared in these trials.The Food Cravings Questionnaire–Trait (FCQ–T): Measures the frequency and intensity of food craving experiences in general. The questionnaire has 39 items, and response categories range from 1=never to 6=always. There are no inverted items. Responses to all items are summed up for a total score. Thus, higher scores represent more frequent and intense food cravings. Several subscale scores can also be calculated.Self-Regulation Questionnaire-Short Form: This scale has 16 items, two subscales of changing behavior to achieve remarkable goals, and the factor of obtaining satisfaction and well-being. Subjects answer the questions on a 6-option Likert scale from 1=very weak to 6=very strong, and a higher score in this questionnaire indicates better self-regulation.

 Data Analysis Plan: 

This research conducted a series of two (group: cognitive rehabilitation vs control) x three (time: baseline, post-intervention, follow-up) mixed analyses of variances (ANOVAs), a) with attention bias scores, b) food craving, and c) self-regulation as the dependent variables. Eta squared effect sizes were calculated and reported for ANOVA analyses, with 0.01 considered small, 0.06 considered medium, and 0.14 considered large.

In the first stage of program validation, along with the face validity method, the content validity method was used quantitatively and qualitatively method with a panel of ten experts and Content Validity Ratio (CVR) and Content Validity Index (CVI). The minimum and maximum CVRs for each item or component of the program were calculated as 0.85 and 1, respectively. Furthermore, the minimum and maximum CVIs for each item or component of the program were calculated as 0.90 and 1, respectively. Finally, the average content validity index (S-CVI/Ave) for the entire program was calculated as 0.95. Similarly, compared to the control group, cognitive rehabilitation significantly reduced attention bias, improved self-regulation, and decreased food cravings at post-intervention and follow-up.

cognitive rehabilitation may be a practical intervention for women with obesity in Iran with cognitive deficits. Therefore, specialists, researchers, and therapists in this field can use this intervention as an effective treatment option to improve the cognitive functions and psychological neuropathy of obese and overweight patients and consequently improve their mental health of these patients.