Abstract
Background
Retatrutide, an agonist of glucose-dependent insulinotropic polypeptide, glucagon-like peptide-1, and glucagon receptors, is in development for the treatment of obesity. We interviewed participants exiting a phase 2 trial to understand the impact of retatrutide on eating behaviors, physical aspects, emotions, and lifestyle.
Methods
This was a qualitative exit interview study conducted in the US. Participants were adults with obesity or overweight and weight-related complications exiting the phase 2, double-blind, placebo-controlled trial of retatrutide (1, 4, 8, and 12 mg) (NCT04881760). Telephone interviews were conducted using a semi-structured interview guide. Interviews were recorded, transcribed, and analyzed using ATLAS.ti.
Results
Participants (N = 40; mean age 51 years; 52.5 % male) received retatrutide 4/8/12 mg (n = 23), retatrutide 1 mg (n = 13), or placebo (n = 4). Thirty-one of 36 retatrutide-treated participants reported changes in eating behaviors within the trial's first 8 weeks. Participants described eating less often or smaller portions, feeling hungry less often, feeling full after eating, having different food preferences, and feeling more in control of their eating. They also described feeling good about themselves or self-confident (n = 32) and feeling happy (n = 25). Participants reported improvements in mobility or ability to perform physical activities (n = 27), energy levels (n = 24), social activities involving food (n = 18), exercise (n = 19), and leisure activities (n = 17), as well as reduction in clothing size (n = 24). Some retatrutide-treated participants reported reduced participation in social activities due to adverse events (n = 2) or new eating habits (n = 2) and frustration due to disappointing weight loss (n = 3). Thirty of 36 retatrutide-treated participants had weight reduction as a goal, and 76.7 % reported achieving their goal.
Conclusion
In this exit interview analysis of adult study participants, those treated with retatrutide reported early changes in eating behavior, improved physical and emotional well-being, and weight reduction goal achievement. Some participants experienced social limitations or frustration due to adverse events or unmet expectations.
Keywords: Appetite and eating behaviors, Exit interviews, Obesity, Obesity management medication, Retatrutide
Graphical abstract
1. Introduction
The World Health Organization estimates that, worldwide, 2 billion adults have overweight and 650 million have obesity [1]. Obesity can lead to numerous complications such as type 2 diabetes, cardiovascular disease, hypertension, stroke, certain types of cancer, and mental health issues, and can reduce life expectancy [[2], [3], [4]]. Lifestyle interventions relating to or including dietary modification, physical activity, and behavioral therapy are foundational to weight management [5,6]. However, sustaining long-term weight reduction through lifestyle intervention alone is a challenge for most individuals with obesity. Adjunctive pharmacotherapy is suggested for adults with a body mass index (BMI) ≥30 kg/m2 and for those with a BMI ≥27 to <30 kg/m2 in the presence of ≥1 weight-related complication [5,7].
Newly available and emerging obesity-management medications (OMMs) have the potential to produce significant weight reduction and represent a major advancement in the treatment of obesity [8]. In the STEP-1 trial, weekly treatment with semaglutide (2.4 mg), a glucagon-like peptide-1 (GLP-1) receptor agonist, led to a 14.9 % mean weight reduction at week 68 in adults with obesity or overweight (without diabetes) [9]. In the SURMOUNT-1 trial, weekly treatment with tirzepatide (15 mg), a glucose-dependent insulinotropic polypeptide (GIP) receptor and GLP-1 receptor agonist, led to a 20.9 % mean weight reduction at week 72 in adults with obesity or overweight (with ≥1 obesity-related complication excluding diabetes) [10].
Retatrutide, an agonist targeting GLP-1, GIP and glucagon was studied in a 48-week, phase 2, double-blind, placebo-controlled clinical trial (NCT04881760) to examine the safety and efficacy of four different doses (1, 4, 8 and 12 mg) of once-weekly, subcutaneously administered retatrutide in adults with obesity (BMI ≥30 kg/m2) or with overweight (BMI ≥27 to <30 kg/m2) and ≥1 weight-related complications but without diabetes [12,13]. Treatment with retatrutide was associated with a mean weight reduction of up to 17.5 % (18.7 kg) at 24 weeks and up to 24.2 % (26.2 kg) at 48 weeks in the 12 mg group [11,12].
Qualitative interviews with clinical trial participants, including interviews conducted after they exit the trial, can supplement clinical trial results by providing a detailed insight into individuals' experiences with a treatment and thereby help incorporate the patient's voice into the drug development and evaluation process [14]. Qualitative data from exit interviews can provide a level of detail from the trial participants' perspective that cannot be captured using patient-reported outcome (PRO) instruments alone, and this is particularly useful for new OMMs where limited information exists about patients' experiences of treatment. Exit interviews have been recommended as a method for identifying treatment-related outcomes and changes that are meaningful to patients, and for providing supportive evidence to interpret other quantitative trial assessments (e.g., changes in PROs) [15]. When evaluating OMMs with new mechanisms of action, it is important to assess treatment-related changes, including physical, emotional, and lifestyle impacts, that are important to individuals with obesity or overweight, and identify any unmet treatment needs. In this qualitative study, we conducted exit interviews to gain in-depth insight into participants' treatment experiences in the phase 2 trial of retatrutide vs placebo (NCT04881760) and identify unmet treatment needs that would otherwise not have been captured in the clinical trial.
2. Methods
2.1. Study design
This was a cross-sectional, blinded, qualitative study involving one-on-one telephone interviews with 40 participants exiting the phase 2, double-blind, placebo-controlled trial of four retatrutide doses (1, 4, 8, and 12 mg) (NCT04881760). The sample size in this study was consistent with the sample sizes required to reach the point of saturation (the point at which no new information is forthcoming from the interviews) in qualitative concept elicitation interview studies reported in the literature [16]. The study design and methods of the clinical trial have been reported previously [12]. This study was conducted between November 2022 and January 2023 at nine clinical sites in the US. Three sites were in Florida, two in California, and one site each in Louisiana, Oklahoma, Tennessee, and Texas. Briefly, the treatment period lasted 48 weeks and was followed by a four-week safety follow-up period. Participants were interviewed after completing their trial safety visit, and before treatment allocation was revealed. The study was approved by Salus IRB (Austin, Texas, US). The study was conducted in accordance with the International Society for Pharmacoeconomics and Outcomes Research task force recommendations and applicable national laws. All participants provided informed consent electronically using the DocuSign® platform before the start of the study. All interview participants who completed the study interview were remunerated.
2.2. Study population
Participants exiting the phase 2 retatrutide trial after November 2022 were invited to take part in the qualitative interview study. Participants had to be able to read and understand English and be willing to be audio-recorded. Individuals with cognitive or visual impairment, hearing difficulty, or severe psychopathology, as well as anyone treating individuals with obesity as part of their occupation, were excluded. Additional details on the inclusion and exclusion criteria are presented in the Supplemental Appendix A. Clinical trial site staff screened and recruited participants for the study. Participant recruitment was conducted while maintaining the double-blind status regarding treatment group assignment.
2.3. Data collection
All interviews were conducted using a semi-structured interview guide by interviewers from an independent research team (i.e., not part of the clinical trial) that were trained in methods for qualitative research and the exit interview. Interviewers were blinded to treatment assignment and selected based on their experience in conducting qualitative interviews. All interviews were conducted by telephone in English, lasted 60–90 min, and were audio-recorded and transcribed. The interview guide focused on outcomes relating to eating behaviors, physical aspects, emotions, and lifestyle. Questions fell into four categories: i) participants' general experience with treatment for obesity before the trial, key motivators to join the trial, and main goal when joining the trial; ii) participants' experience with the study treatment during the trial; iii) effect of the treatment on eating behaviors, physical aspects, emotions, and lifestyle; and iv) participants’ unmet treatment needs.
2.4. Data analysis
For the exit interview study, participants were assigned unique patient identification numbers, which were used on all patient forms. Anonymized interview transcripts were analyzed using ATLAS.ti version 22. Qualitative data obtained during the interviews were reviewed by team members and key themes raised by participants were identified. A coding dictionary was developed based on the interview guide and themes and concepts that emerged during the interviews. The coders were blinded to treatment allocation. To pilot the coding dictionary, four pre-assigned coders independently coded two interview transcripts, followed by post-coding comparison and reconciliation. Any identified discrepancies were discussed among the coders and the interview study lead (HK). When there was sufficient agreement between coders (i.e., at least 80 % of key concepts were assigned a code in the same way), the remaining transcripts were divided equally between the four coders and coded.
The data were unblinded after the transcript coding was completed. Descriptive statistics were calculated to summarize participants’ responses and characterize their sociodemographic and clinical characteristics. Participants treated with >1 mg retatrutide were analyzed as a single group (retatrutide 4/8/12 mg group) and those treated with 1 mg retatrutide analyzed as a second group (retatrutide 1 mg group). Participants were enrolled while blinding was active, therefore, it was not possible to ensure an even distribution of participants across the two groups. Results for participants who received placebo are not reported as this subgroup was small (n = 4). Qualitative studies typically require a minimum sample size of 12 to reach saturation [[16], [17], [18]].
3. Results
3.1. Participants’ characteristics
Participants in the exit interviews were similar to those in the main trial in terms of age (mean [standard deviation, SD] 51.02 [±12.4] and 48.2 [±12.7] years, respectively), sex (female: 47.5 % and 48.0 %, respectively), and race (white: 85.0 % and 88.0 %, respectively [12].
Forty participants were included in the exit interview study (Table 1). Thirty-six participants had received the investigative treatment: 23 participants had received retatrutide 4/8/12 mg (57.5 %) and 13 participants had received retatrutide 1 mg (32.5 %). Four participants (10 %) had received the placebo.
Table 1.
Participant demographics.
| Total (N = 40) | Retatrutide 4/8/12 mga (N = 23) | Retatrutide 1 mg (N = 13) | Placebo (N = 4) | |
|---|---|---|---|---|
| Age, years | ||||
| Mean (SD) | 51.0 (12.4) | 45.9 (11.0) | 56.7 (12.2) | 61.8 (4.0) |
| (min; max) | (24; 75) | (24; 68) | (36; 75) | (57; 66) |
| Sex, n (%) | ||||
| Male | 21 (52.5) | 15 (65.2) | 5 (38.5) | 1 (25.0) |
| Female | 19 (47.5) | 8 (34.8) | 8 (61.5) | 3 (75.0) |
| Ethnicity, n (%) | ||||
| Hispanic/Latino | 6 (15.0) | 6 (26.1) | 0 (0.0) | 0 (0.0) |
| Not Hispanic/Latino | 32 (80.0) | 17 (73.9) | 12 (92.3) | 3 (75.0) |
| Not known | 2 (5.0) | 0 (0.0) | 1 (7.7) | 1 (25.0) |
| Race, n (%) | ||||
| Black/African American | 3 (7.5) | 1 (4.3) | 0 (0.0) | 2 (50.0) |
| White | 34 (85.0) | 22 (95.7) | 11 (84.6) | 1 (25.0) |
| Other | 3 (7.5) | 0 (0.0) | 2 (15.4) | 1 (25.0) |
| Employment Status, n (%) | ||||
| Full-timeb | 27 (67.5) | 17 (73.9) | 8 (61.5) | 2 (50.0) |
| Part-timec | 1 (2.5) | 0 (0.0) | 0 (0.0) | 1 (25.0) |
| Homemaker | 3 (7.5) | 3 (13.0) | 0 (0.0) | 0 (0.0) |
| Unemployed | 1 (2.5) | 0 (0.0) | 1 (7.7) | 0 (0.0) |
| Retired | 5 (12.5) | 1 (4.3) | 4 (30.8) | 0 (0.0) |
| Other | 3 (7.5) | 2 (8.7) | 0 (0.0) | 1 (25.0) |
| Education Level, n (%) | ||||
| Secondary/high school | 13 (32.5) | 9 (39.1) | 3 (23.1) | 1 (25.0) |
| Associate degree/technical/trade school | 10 (25.0) | 6 (26.1) | 3 (23.1) | 1 (25.0) |
| College/university degree | 13 (32.5) | 5 (21.7) | 7 (53.8) | 1 (25.0) |
| Post-graduate degree | 4 (10.0) | 3 (13.0) | 0 (0.0) | 1 (25.0) |
Abbreviations: SD, standard deviation.
The retatrutide 4/8/12 mg sample includes all patients who received a treatment dose >1 mg.
≥32 h/week.
<32 h/week.
Participants who had received retatrutide 1 mg (n = 13) were, on average, 10.8 years older than those who had received retatrutide 4/8/12 mg (n = 23) (mean [SD] = 56.7 [12.2] years and 45.9 [11.0] years, respectively). A higher proportion of participants in the retatrutide 1 mg group were female (61.5 %) compared to the retatrutide 4/8/12 mg group (34.8 %). Most retatrutide-treated participants were non-Hispanic/Latino (n = 12; 92.3 % in the retatrutide 1 mg group and n = 17; 73.9 % in the retatrutide 4/8/12 mg group) and White (n = 11; 84.6 % in the retatrutide 1 mg group and n = 22; 95.7 % in the retatrutide 4/8/12 mg group). Most participants (>75 %) in both retatrutide treatment groups were interviewed 5–16 weeks after their safety follow-up visit (Table 2).
Table 2.
Participants’ clinical characteristics.
| Total (N = 40) | Retatrutide 4/8/12 mga (N = 23) | Retatrutide 1 mg (N = 13) | Placebo (N = 4) | |
|---|---|---|---|---|
| Years clinically overweight | ||||
| Mean (SD) | 11.5 (9.5) | 9.8 (8.9) | 15.1 (10.7) | 9.8 (8.0) |
| Median (min; max) | 8.0 (1; 38) | 8.0 (1; 28) | 10.0 (4; 38) | 8.5 (2; 20) |
| BMI: baseline | ||||
| Mean (SD) | 37.5 (5.4) | 37.7 (5.3) | 37.1 (6.5) | 37.2 (3.7) |
| Median (min; max) | 36.0 (27; 49) | 37.1 (31; 49) | 34.5 (27; 48) | 36.8 (34; 41) |
| Weight change: baseline to EOT (kg) | ||||
| Mean (SD) | −18.4 (14.3) | −26.2 (12.0) | −10.7 (9.0) | 1.5 (4.7) |
| Median (min; max) | −16.0 (−53; 6) | −27.0 (−53; −5) | −9.0 (−38; −3) | 1.5 (−3; 6) |
| Weight change: baseline to EOT (%) | ||||
| Mean (SD) | −16.8 (12.5) | −23.8 (10.4) | −9.9 (7.1) | 1.2 (4.7) |
| Median (min; max) | −15.8 (−41; 6) | −24.8 (−41; −4) | −7.5 (−29; −3) | 1.1 (−3; 6) |
| BMI change: baseline to EOT | ||||
| Mean (SD) | −6.3 (4.8) | −8.9 (4.0) | −3.7 (2.9) | 0.5 (1.7) |
| Median (min; max) | −6.1 (−16; 2) | −9.6 (−16; −1) | −2.9 (−12; −1) | 0.5 (−1; 2) |
| Duration in trial (months) | ||||
| Mean (SD) | 11.2 (0.5) | 11.2 (0.5) | 11.1 (0.4) | 11.2 (0.7) |
| Median (min; max) | 11.0 (11; 12) | 11.0 (11; 12) | 10.9 (11; 12)b | 10.9 (11; 12)b |
| Timeframe from safety follow-up visit to interview date (weeks) | ||||
| Mean (SD) | 14.0 (5.4) | 13.1 (4.6) | 14.7 (6.3) | 16.6 (6.7) |
| Median (min; max) | 13.4 (5; 28) | 12.6 (5; 23) | 14.7 (6; 28) | 15.6 (10; 25) |
Abbreviations: BMI, body mass index; EOT, end of trial; max, maximum; min, minimum; SD, standard deviation.
The retatrutide 4/8/12 mg sample includes all patients who received a treatment dose >1 mg.
Due to rounding rules for presenting minimum and maximum values (i.e., round up to the nearest whole number when the value after the decimal is ≥5), the minimum values are larger than the median values.
Participants receiving retatrutide reported living with obesity or overweight for an average of 11.5 years (SD = 9.5). The mean BMI at baseline was similar in the two retatrutide groups (mean [SD] 37.1 [6.5] kg/m2 in the retatrutide 1 mg group and mean [SD] = 37.7 [5.3] kg/m2 in the retatrutide 4/8/12 mg group).
At least two-thirds of participants in each of the retatrutide groups reported attempting to manage their weight through diet, exercise, or another treatment or therapy before joining the trial (Supplemental Table 1). One-third of retatrutide-treated participants described using exercise and diet together to manage their weight (n = 4; 30.8 % in the retatrutide 1 mg group and n = 7; 30.4 % in the 4/8/12 mg group). Seven participants (n = 4 retatrutide 1 mg and n = 3 retatrutide 4/8/12 mg) reported that they had not attempted to manage their weight before the trial.
Participants in both retatrutide groups reported the possibility of losing weight as the most common motivator for joining the trial (n = 8; 61.5 % for retatrutide 1 mg group and n = 14; 60.9 % for retatrutide 4/8/12 mg group) (Supplemental Table 1). Almost 85 % of participants in both retatrutide groups reported that weight reduction was a goal for the trial (i.e., their main goal or in addition to other goals) (n = 11; 84.6 % in the retatrutide 1 mg group and 19; 82.6 % in the retatrutide 4/8/12 mg group). Most retatrutide-treated participants described achieving their goals as ‘very important’ (n = 12; 92.3 % in the retatrutide 1 mg group and n = 22; 95.7 % in the retatrutide 4/8/12 mg group).
3.2. Retatrutide and weight
Participants’ experiences during the clinical trial are described for the retatrutide 4/8/12 mg group (n = 23) and retatrutide 1 mg group (n = 13). As described in the methods, results for the participants who received placebo are not reported separately as this group was small (n = 4).
All participants receiving retatrutide lost weight during the trial (n = 36; 100.0 %). Participants receiving retatrutide 4/8/12 mg experienced the highest mean reduction in weight (−26.2 kg; 23.8 % reduction) from baseline to the end of the trial compared to those receiving retatrutide 1 mg (−10.7 kg; 9.9 % reduction) (Table 2).
Thirty-four participants receiving retatrutide (94.4 %) reported satisfaction with their weight loss during the clinical trial on a scale from 1 (least satisfied) to 10 (most satisfied). Two participants (5.6 %) did not provide a satisfaction score (n = 1 each in the retatrutide 4/8/12 mg and retatrutide 1 mg groups). Overall, participants who reported high satisfaction (score 8–10) (n = 28; 82.4 %) had an average percentage weight loss of 19.7 % (range: 17.3 %–3.2 %), those with moderate satisfaction scores (scores 5–7) (n = 4; 11.8 %) had an average percentage weight loss of 5.3 % (range: 2.7–7.8 %), and those with low satisfaction (score 1–4) (n = 2; 5.9 %) had an average percentage weight loss of 5.1 % (Supplemental Fig. 1). Among those reporting on their satisfaction with weight loss, over 50 % of participants in the retatrutide 1 mg group (n = 7; 58.3 %) and almost all participants in the retatrutide 4/8/12 mg group (n = 21; 95.5 %) reported high satisfaction (score 8–10), with 15 participants in the retatrutide 4/8/12 mg group (68.2 %) rating their satisfaction as 10 out of 10 (most satisfied). Two participants who received retatrutide 1 mg (16.7 %) reported low satisfaction with their weight loss.
3.3. Appetite and eating behaviors
Most retatrutide-treated participants (n = 35; 97.2 %) reported experiencing changes in appetite or eating behavior during the trial (92.3 % in the retatrutide 1 mg group and 100.0 % in the retatrutide 4/8/12 mg group), and of those, over 50 % reported that the changes were consistent during the trial. Eighty-six percent of the participants who received retatrutide (n = 31), 20 of whom were receiving retatrutide 4/8/12 mg (64.5 %), reported perceiving changes in appetite or eating behaviors within the first 8 weeks of the clinical trial (Supplemental Fig. 2). Participants in the retatrutide 4/8/12 mg group most frequently described eating less i.e., eating smaller portions, or eating less often (n = 23; 100.0 %), feeling hungry less often (n = 22; 95.7 %), feeling full more easily after eating (n = 20; 87.0 %), and having different food preferences (n = 19; 82.6 %) (Fig. 1). Participants in the retatrutide 1 mg group most frequently reported eating less or eating less often (n = 11; 84.6 %), feeling more in control of their eating (n = 11; 84.6 %), feeling full more easily after eating (n = 10; 76.9 %), eating less between meals (n = 10; 76.9 %), and feeling hungry less often (n = 9; 69.2 %).
Fig. 1.
Frequency of reported changes in appetite and eating behaviors during the trial (seven most frequently reported changes) (n = 36)a. a Percentage of participants who reported changes in appetite or eating behavior during the trial by retatrutide treatment group. ∗ Participants who endorsed both concepts are included only once.
Thirty-five (97.2 %) participants receiving retatrutide reported on changes in appetite or eating behaviors that were most important to them and described eating less (i.e., eating smaller portions) (n = 16; 45.7 %), eating different types of food (n = 4; 11.4 %), and having the desire to eat healthy foods (n = 4; 11.4 %) (Supplemental Fig. 3). Participants treated with retatrutide 4/8/12 mg who had experienced at least one change in appetite or eating behavior most frequently described eating smaller portions (n = 13; 56.5 %) as the most important change. Participants treated with retatrutide 1 mg most frequently described eating smaller portions (n = 3; 25.0 %) and how restrained they were with eating (n = 3; 25.0 %) as the most important change in appetite or eating behaviors.
“Before, I didn’t feel full, but again I would tend to overeat and get second helpings. Even sometimes and after this trial, I rarely get second helpings. And I definitely would feel full before I finish my plate” (retatrutide 4/8/12 mg group).
“I didn’t crave the sweets like I usually did before the trial” (retatrutide 4/8/12 mg group).
3.4. Physical aspects
When asked if they had noticed any physical changes during the trial, participants who had received retatrutide (n = 36) most frequently reported positive changes in general mobility or ability to perform physical activity (n = 27; 75.0 %), energy levels (n = 24; 66.7 %), and clothing size (n = 24; 66.7 %). Over half of the retatrutide sample (n = 20; 55.6 %) reported other physical changes including lower blood pressure, less sciatic nerve problems, and less cellulite. Participants in the retatrutide 4/8/12 mg group most frequently reported improved mobility or ability to perform physical activity (n = 19; 82.6 %) and a decrease in clothing size (n = 17; 73.9 %) (Fig. 2).
“Well, because of the lost weight, I’m more active. I’m happier. I can do more things, like if we go on vacation, I’m not the one, you know, that can’t walk around or hike or do any of that, because I can actually move. I can actually do stuff.” (retatrutide 4/8/12 mg group).
Fig. 2.
Frequency of reported positive impacts on physical aspects during the trial (n = 36)a, b. a Percentage of participants who reported positive impacts on physical aspects by retatrutide treatment group. b Negative physical impacts (not shown in figure) reported by participants included changes in clothing size (n = 1); dislike of appearance due to excess skin (n = 2); loss of strength or feeling weaker (n = 4); and nausea, heartburn, difficult bowel movements, or frequent thirst (n = 2; 8.7 %). ∗ Participants who endorsed both concepts are included only once. ∗∗ Excess skin was considered positive as it indicated weight loss or was regarded as “better than fat.”
Although viewed favorably by most participants, a few in the retatrutide 4/8/12 mg group regarded changes in clothing size as negative (n = 1; 4.3 %) or as both positive (reduced clothing size) and negative (need to buy new clothes) (n = 4; 17.4 %). A few participants in the retatrutide 4/8/12 mg group also regarded excess skin as negative due to a dislike of the appearance (n = 2; 8.7 %) or both positive (weight loss) and negative (n = 1; 4.3 %). Other changes regarded as negative by some participants in the retatrutide 4/8/12 mg group included loss of strength or feeling weaker (n = 4; 17.4 %) and nausea, heartburn, difficult bowel movements, or frequent thirst (n = 2; 8.7 %).
Participants treated with retatrutide 1 mg most frequently reported increased energy levels (n = 10; 76.9 %) and improved mobility or ability to perform physical activities (n = 8; 61.5 %) (Fig. 2).
3.5. Emotions
Participants who received retatrutide during the trial (n = 36) reported feeling good about themselves or self-confident (n = 32; 88.9 %), motivated or energetic (n = 25; 69.4 %), and feeling happy (n = 25; 69.4 %).
“When you don't have to eat as much and you're losing weight, you're achieving your goal, it emotes a positive response.” (retatrutide 4/8/12 mg group).
Participants in the retatrutide 4/8/12 mg group reported feeling good about themselves or being self-confident (n = 22; 95.7 %) and happy (n = 18; 78.3 %) (Fig. 3). Participants treated with retatrutide 1 mg most frequently reported feeling good about themselves or self-confident (n = 10; 76.9 %) and motivated or energetic (n = 9; 69.2 %).
“I definitely felt happier when I was able to like visually and physically notice a change and just being able to be more content in how I looked.” (retatrutide 4/8/12 mg group).
“Absolutely. In every positive – it affects you in such a happy manner, opportunity, it made you optimistic, it made you happy. Weight loss is a big accomplishment. So it's an amazing feeling.” (retatrutide 4/8/12 mg group).
Fig. 3.
Frequency of reported positive impacts on emotions during the trial (n = 36)a, b, c. a Percentage of participants who reported positive impacts on emotions by retatrutide treatment group. b The lack of report of a certain emotion means that it was not reported/mentioned by the participant. c Negative emotional impacts reported by participants included frustration due to disappointing weight loss (n = 3), increased worry about not being able to lose weight (n = 2), and increased concern about what would happen when they stopped taking the medication (n = 2). ∗ Participants who endorsed both concepts are included only once.
Some retatrutide-treated participants also reported negative impacts of treatment, such as frustration due to disappointing weight loss (n = 1; 4.3 % in the retatrutide 4/8/12 mg group and n = 2; 15.4 % in the retatrutide 1 mg group), increased worry about not being able to lose weight (n = 2; 15.4 % in the retatrutide 1 mg group), and increased concern about what would happen when they stopped taking the medication (n = 2; 8.7 % in the retatrutide 4/8/12 mg group).
3.6. Lifestyle
Lifestyle-related changes reported by participants who received retatrutide during the trial included positive impacts on social activities involving food (e.g., eating healthier foods, “not cheating” when going to social events) (n = 18; 50.0 %), exercise (n = 19; 52.7 %), choice of clothes (e.g., being able to wear shorts) (n = 18; 50.0 %), and leisure activities (e.g., socializing with family and friends, participating in recreational sports, traveling) (n = 17; 47.2 %).
“Well, so before the study, I was not exercising. But during the study, I tried different forms of exercising, and I was motivated to do that because I wanted to succeed. And so I tried several different things, and I actually found a couple that I really, really like that I stick with. So exercise isn’t exercise to me. It’s more of I look forward to doing it.” (retatrutide 1 mg group).
“I had more energy and that became more and more so it became better during the trial because of obviously losing the weight and feeling better and doing stuff and start going to the gym a little bit or move more around.” (retatrutide 4/8/12 mg group).
Participants also reported positive changes at work or school due to improved energy levels (n = 11; 36.7 %).
“I wasn't as tired during the day … I felt like I got some sleep. So it helped with work and everything.” (retatrutide 4/8/12 mg group).
Positive changes were also reported in relation to activities of daily living (n = 11; 36.7 %).
“I’m more mobile … I can reach for things better. I can, you know, even bending down to tie my shoes, I can obviously do it better, because I don’t have the weight in the middle blocking it.” (retatrutide 4/8/12 mg group).
Nearly one-fourth of the participants who had received retatrutide reported that their relationships (i.e., with spouse, family, friends, colleagues) had improved (n = 7; 23.3 %). One participant (2.8 %) regarded his weight loss as both positive and negative because it impacted his relationship with his wife (his weight had dropped lower than hers).
“There was only one issue that I have with one of my relationships, and there was a period my weight dropped below what my wife’s weight was. And that kind of was an issue for a minute … it was a negative impact because it made her feel bad, but at the same time, it was a positive thing because of the fact that I had lost so much weight.” (retatrutide 4/8/12 mg group).
More than half of the participants treated with retatrutide 4/8/12 mg described a positive impact on exercise (n = 14; 60.9 %), social activities involving food (due to better self-regulation) (n = 11; 47.8 %), leisure activities (n = 12; 52.2 %), and choice of clothes (n = 13; 56.5 %) (Fig. 4). Participants treated with retatrutide 1 mg most frequently reported a positive impact on social activities involving food (n = 7; 53.8 %).
Fig. 4.
Frequency of reported positive impacts on lifestyle during the trial (n = 36)a, b. a Percentage of participants who reported positive impacts on lifestyle by retatrutide treatment group. b Negative lifestyle impacts reported by participants included reduced participation in leisure (n = 2) or social activities (n = 2) due to treatment-related adverse events (AEs) or new eating habits. ∗ Social activities involving food included family reunions, cultural traditions, and dining out; leisure activities included hobbies; activities of daily living included dressing, bathing, driving, and going places; and relationships included those with friends, colleagues, family, and spouses.
Some participants in the retatrutide 4/8/12 mg group reported negative impacts such as reduced participation in leisure (n = 2; 8.7 %) or social activities (n = 2; 8.7 %) due to treatment-related adverse events (AEs) or new eating habits.
3.7. Participants’ met and unmet treatment needs
Among retatrutide-treated participants who identified losing weight as a goal, 17 of 19 (89.5 %) of those in the retatrutide 4/8/12 mg group and 6 of 11 (54.5 %) of participants in the retatrutide 1 mg group reported meeting or exceeding that goal (Supplemental Tables 1 and 2).
“I noticed a lot of changes. I lost a lot of weight. That's the first time in my life that I lost so much weight … number 10.” (10 = Most satisfied) (retatrutide 4/8/12 mg group).
Two participants in the retatrutide 4/8/12 mg group (8.7 %) and five participants in the retatrutide 1 mg group (45.5 %) reported that their weight reduction goals were not met by the end of the trial.
One participant (4.3 %) had hoped for a treatment with ‘less side effects’, and another (4.3 %) reported that they would have liked to receive nutritional advice during the trial. Both participants received retatrutide 4/8/12 mg. One participant (7.7 %) in the retatrutide 1 mg group would have liked to stay longer in the trial.
4. Discussion
The phase 2 trial of retatrutide vs placebo investigated the safety and efficacy of retatrutide in adults with obesity or overweight [11,12]. While the trial demonstrated significant weight reduction with retatrutide compared to placebo [11,12], this qualitative exit interview study with trial participants investigated the impact of this weight loss on their lives. All interview study participants who had received retatrutide lost weight during the trial. Among retatrutide-treated participants who cited losing weight as a goal, over half stated that their goal was met or exceeded. All but one participant in the retatrutide 4/8/12 mg group (95.4 %) reported high satisfaction with their weight loss.
Lifestyle modification, including a healthy diet and physical activity, is a cornerstone of treatment for obesity [5,6]. However, weight loss can trigger adaptive changes in hunger and satiety hormones which persist over time and favor weight regain, making long-term maintenance of weight reduction more challenging [19]. Previous studies have reported that many individuals with obesity experience difficulty in controlling their eating behavior, including their frequency of eating and portion sizes [20]. Emotional eating has also been reported, and emerging data suggests that the neuroendocrine regulation of pathways involved with appetite and reward may be impaired in obesity [21]. In the current study, participants noted changes in their appetite or eating behaviors during the trial, including eating smaller portions, feeling full more easily after eating, having different food preferences, feeling hungry less often, and eating less often. Further, these changes in appetite and eating behaviors were reported more frequently in the retatrutide 4/8/12 mg group compared to the retatrutide 1 mg group. The change in eating behavior that was regarded as most important to participants receiving retatrutide was eating smaller portions. These participant-reported changes in appetite and food intake are consistent with that observed in a phase 1 clinical trial of retatrutide [22], however, some of the changes identified in this study (e.g., feeling full more easily after eating) may be specific to a trial population for OMMs and others (e.g., eating in response to negative emotions) may be more universally relevant.
Although weight management and physical fitness improvement have been reported as key motivations for physical activity in individuals with obesity, excess weight and low physical fitness are also physical activity barriers [23,24]. Musculoskeletal pain is common in individuals with obesity, and chronic musculoskeletal pain is a barrier to participating in regular exercise programs and performing normal physical activities [25]. Obesity also has adverse occupation-related consequences (e.g., increased absences from work due to health issues and impaired work performance) [26]. Individuals with obesity have previously been found to have more than double the work limitation of those who have normal weight [27]. In this study, physical changes most often reported by participants who received retatrutide included greater ability to perform physical activities, increases in energy levels, and reductions in clothing size. Participants also reported having more energy for their work and a greater ability to undertake activities of daily life. A larger proportion of participants in the retatrutide 4/8/12 mg group than in the retatrutide 1 mg group described experiencing physical changes. Reduction in clothing size and increased energy levels were the physical changes most frequently reported by participants in the retatrutide 4/8/12 mg group. Interestingly, both male and female participants in this study who had received retatrutide 4/8/12 mg reported having a greater choice of clothes to wear as a positive change. Previous studies have reported that, in women, a greater availability of clothing in one's size predicts higher body satisfaction [28]. Conversely, as clothing fit may be used by women to assess their weight, the lack of availability of larger sized clothing may lead to the perception that their bodies were outside acceptable size norms [28,29]. Although participants mostly rated these changes as positive, some expressed concern regarding the need to buy new clothes and the appearance of excess skin due to weight loss.
Obesity is associated with a significant socioemotional burden, including sleep disorders, anxiety, depression, low self-esteem, eating disorders, and impaired body image [20,[30], [31], [32], [33], [34]]. In this study, particularly among participants in the retatrutide 4/8/12 mg group, the experience of weight loss was accompanied by positive changes in emotions such as feeling better about oneself, feeling happy, more self-confident, and more energetic. However, some participants were concerned about regaining weight when they stopped taking the study treatment.
Obesity is associated with a lower quality of life [[35], [36], [37]]. Many participants in this study who had received retatrutide reported that their weight loss had a positive effect on their quality of life and daily activities, such as exercise, leisure activities, and work. Lifestyle-related changes regarded as positive included better self-regulation in social activities involving food (e.g., family reunions, cultural traditions, dining out), exercising more, and greater involvement in leisure activities. A small proportion of participants reported reduced participation in social activities, which was due to dietary changes or treatment-related AEs. These AEs were non-serious and consistent with AEs previously reported for retatrutide [11].
This study has identified concepts of eating behaviors, physical aspects, emotions, and lifestyle that are important to individuals with obesity or overweight and that are amenable to treatment-related change. The study findings underline the importance of appetite and eating behaviors as well as the emotional and physical benefits in the treatment of obesity. There is a need to further examine whether these concepts can be examined using currently available PRO instruments within clinical trials.
5. Limitations
This study has some limitations. Participants were drawn from among those enrolled in a phase 2 retatrutide trial, and although the sociodemographic characteristics of the interview sample generally matched that of the trial participants, we cannot derive from this sample that they are representative of all patients with obesity. Further, as the interviews were voluntary, the sample of individuals choosing to participate in the exit interview may not be representative of the overall study population. Although interview questions were carefully framed to focus specifically on the trial period, as interviews were conducted at a single timepoint at the end of the trial, data collected in this study may have been affected by recall bias.
In addition, the cross-sectional nature of the interviews did not allow an exploration of changes over time (i.e., trajectory analysis). The sample sizes in this qualitative study did not permit analyses based on individual doses of retatrutide in the retatrutide 4/8/12 mg group. Similarly, only four participants who received placebo were interviewed, so the perspectives of these participants could not be analyzed meaningfully. Because participants were enrolled while blinding was active, quotas could not be applied to ensure an even distribution of participants across treatment allocations. Further, all participants in this study lived in the US. Therefore, perspectives of individuals with obesity or overweight living outside the US were not captured in this study.
6. Conclusion
This exit interview study provides qualitative evidence to support the interpretation of the clinical trial findings for retatrutide in the treatment of obesity, with detailed descriptions from participants of positive experiences relating to weight loss, eating behaviors, physical aspects, emotions, and lifestyle. The study illustrates the valuable insights gained by exit interviews into the impact of retatrutide on patients’ lives, which could not have been obtained from quantitative clinical trial data alone. Patients treated with retatrutide reported impacts beyond weight loss, including positive changes in their eating behaviors, physical aspects, emotions, and lifestyle. These concepts are important to patients and should be examined using PRO instruments within clinical trials.
7. Takeaway messages
-
•
Retatrutide is a novel synthetic molecule, which is an agonist of glucose-dependent insulinotropic polypeptide, glucagon-like peptide-1, and glucagon receptors. It is currently in development for the treatment of obesity.
-
•
In a phase 2, double-blind, placebo-controlled trial of retatrutide vs placebo (NCT04881760), adults with obesity or with overweight and obesity-related complications but without diabetes who were treated with retatrutide achieved a mean weight reduction of up to 17.5 % at 24 weeks (primary endpoint) and up to 24.2 % at 48 weeks in the 12 mg group.
-
•
Overall, in this exit interview study, participants treated with retatrutide (NCT04881760) reported meaningful weight loss and changes in appetite and eating behaviors, physical aspects, emotions, and lifestyle.
-
•
Most participants (76.7 %) who had listed weight reduction as a goal reported achieving that goal.
-
•
This study identified eating behaviors, physical aspects, emotions, and lifestyle factors that are important to individuals with obesity and overweight.
Author contributions
I.A.G contributed to the conceptualization and design of the study, oversight and leadership, as well as critical review of the manuscript. C.K. contributed to the study methodology and critical review of the manuscript. A.H. contributed to the conceptualization of the study and critical review of the manuscript. C.J-M. contributed to the study design, study conduct, and data analysis. H.K. contributed to the study methodology, study conduct and the critical review of the manuscript. M.K. was involved in the study conduct, data analysis, and critical review of the manuscript. L.M.N. contributed to the study design, data analysis and interpretation, and was involved in revising the work critically for important intellectual content. K.S.B. contributed to the conceptualization and design of the study, oversight and leadership, and critical review of the manuscript. All authors read and approved the final version of the manuscript.
Ethics
The study was approved by Salus IRB (Austin, Texas, US). The study was conducted in accordance with the International Society for Pharmacoeconomics and Outcomes Research task force recommendations and applicable national laws. All participants provided informed consent electronically using the DocuSign® platform before the start of the study.
Artificial intelligence
The authors did not use artificial intelligence-assisted technologies during the development of this manuscript.
Funding
This study was funded by Eli Lilly and Company.
Conflicts of interest
I.A.G., C.K., A.H., L.M.N., and K.S.B. are employees and shareholders of Eli Lilly and Company, which funded this study. C.J.M. was an employee of Evidera when this study was conducted and is currently an employee of Kielo Research (UK). H.K. and M.K. are current employees of Evidera-PPD, which was paid by Eli Lilly and Company to conduct this study.
Acknowledgements
Medical writing was provided by Surayya Taranum, PhD, CMPP (PPD clinical research business of Thermo Fisher Scientific) in accordance with guidelines for Good Publication Practice (GPP 2022) and was funded by Eli Lilly and Company.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.obpill.2025.100220.
Contributor Information
Iris A. Goetz, Email: goetz_iris@lilly.com.
Chisom Kanu, Email: kanu_chisom@lilly.com.
Anastasia Hoover, Email: anastasia.hoover@lilly.com.
Cecilia Jimenez-Moreno, Email: aceciliajm@gmail.com.
Hayley Karn, Email: hayley.karn@thermofisher.com.
Miriam Kimel, Email: Miriam.Kimel@thermofisher.com.
Lisa M. Neff, Email: neff_lisa@lilly.com.
Kristina S. Boye, Email: boye_kristina_secnik@lilly.com.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
References
- 1.Boutari C., Mantzoros C.S. A 2022 update on the epidemiology of obesity and a call to action: as its twin COVID-19 pandemic appears to be receding, the obesity and dysmetabolism pandemic continues to rage on. Metabolism. Aug 2022;133 doi: 10.1016/j.metabol.2022.155217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Neeland I.J., Poirier P., Després J.P. Cardiovascular and metabolic heterogeneity of obesity: clinical challenges and implications for management. Circulation. Mar 27 2018;137(13):1391–1406. doi: 10.1161/circulationaha.117.029617. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Guh D.P., et al. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health. Mar 25 2009;9:88. doi: 10.1186/1471-2458-9-88. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Whitlock G., et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet. Mar 28 2009;373(9669):1083–1096. doi: 10.1016/s0140-6736(09)60318-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Yumuk V., et al. European guidelines for obesity management in adults. Obes Facts. 2015;8(6):402–424. doi: 10.1159/000442721. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Vetter M.L., Amaro A., Volger S. Nutritional management of type 2 diabetes mellitus and obesity and pharmacologic therapies to facilitate weight loss. Postgrad Med J. Jan 2014;126(1):139–152. doi: 10.3810/pgm.2014.01.2734. [DOI] [PubMed] [Google Scholar]
- 7.Wharton S., et al. Obesity in adults: a clinical practice guideline. CMAJ (Can Med Assoc J) Aug 4 2020;192(31):E875–e891. doi: 10.1503/cmaj.191707. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Jastreboff A.M., Kushner R.F. New frontiers in obesity treatment: GLP-1 and nascent nutrient-stimulated hormone-based therapeutics. Annu Rev Med. Jan 27 2023;74:125–139. doi: 10.1146/annurev-med-043021-014919. [DOI] [PubMed] [Google Scholar]
- 9.Wilding J.P.H., et al. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. Mar 18 2021;384(11):989–1002. doi: 10.1056/NEJMoa2032183. [DOI] [PubMed] [Google Scholar]
- 10.Jastreboff A.M., et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med. 2022;387(3):205–216. doi: 10.1056/NEJMoa2206038. [DOI] [PubMed] [Google Scholar]
- 11.Urva S., et al. LY3437943, a novel triple GIP, GLP-1, and glucagon receptor agonist in people with type 2 diabetes: a phase 1b, multicentre, double-blind, placebo-controlled, randomised, multiple-ascending dose trial. Lancet. Nov 26 2022;400(10366):1869–1881. doi: 10.1016/s0140-6736(22)02033-5. [DOI] [PubMed] [Google Scholar]
- 12.Jastreboff A.M., et al. Triple-hormone-receptor agonist retatrutide for obesity - a phase 2 trial. N Engl J Med. Aug 10 2023;389(6):514–526. doi: 10.1056/NEJMoa2301972. [DOI] [PubMed] [Google Scholar]
- 13.ClinicalTrials.gov NCT04881760, A study of LY3437943 in participants who have obesity or are overweight. 2023. https://clinicaltrials.gov/ct2/show/NCT04881760
- 14.FDA . Center for Biologics Evaluation and Research (CBER). US Department of Health and Human Services; 2022. 17 November, 2023. Patient-focused drug development: methods to identify what is important to patients guidance for industry, food and drug administration staff, and other stakeholders. [Google Scholar]
- 15.Staunton H., et al. An overview of using qualitative techniques to explore and define estimates of clinically important change on clinical outcome assessments. J Patient-Rep Outcomes. Mar 4 2019;3(1):16. doi: 10.1186/s41687-019-0100-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Turner-Bowker D.M., et al. Informing a priori sample size estimation in qualitative concept elicitation interview studies for clinical outcome assessment instrument development. Value Health. Jul 2018;21(7):839–842. doi: 10.1016/j.jval.2017.11.014. [DOI] [PubMed] [Google Scholar]
- 17.Clarke V., Braun V. Teaching thematic analysis: overcoming challenges and developing strategies for effective learning. Psychol. 2013;26(2):120–123. [Google Scholar]
- 18.Guest G., Bunce A., Johnson L. How many interviews are enough?:An experiment with data saturation and variability. Field Methods. 2006;18(1):59–82. doi: 10.1177/1525822x05279903. [DOI] [Google Scholar]
- 19.Sumithran P., et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. Oct 27 2011;365(17):1597–1604. doi: 10.1056/NEJMoa1105816. [DOI] [PubMed] [Google Scholar]
- 20.Sarwer D.B., Polonsky H.M. The psychosocial burden of obesity. Endocrinol Metab Clin N Am. Sep 2016;45(3):677–688. doi: 10.1016/j.ecl.2016.04.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Theilade S., et al. An overview of obesity mechanisms in humans: endocrine regulation of food intake, eating behaviour and common determinants of body weight. Diabetes Obes Metabol. Feb 2021;23(Suppl 1):17–35. doi: 10.1111/dom.14270. [DOI] [PubMed] [Google Scholar]
- 22.Coskun T., et al. LY3437943, a novel triple glucagon, GIP, and GLP-1 receptor agonist for glycemic control and weight loss: from discovery to clinical proof of concept. Cell Metab. Sep 6 2022;34(9):1234–1247.e9. doi: 10.1016/j.cmet.2022.07.013. [DOI] [PubMed] [Google Scholar]
- 23.Baillot A., et al. Physical activity motives, barriers, and preferences in people with obesity: a systematic review. PLoS One. 2021;16(6) doi: 10.1371/journal.pone.0253114. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Kudchadkar G., et al. Shedding the weight of exercise for obesity management. Int J Obes. 2024/05/01 2024 doi: 10.1038/s41366-024-01527-1. [DOI] [PubMed] [Google Scholar]
- 25.Zdziarski L.A., Wasser J.G., Vincent H.K. Chronic pain management in the obese patient: a focused review of key challenges and potential exercise solutions. J Pain Res. 2015;8:63–77. doi: 10.2147/jpr.S55360. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Yarborough C.M., 3rd, et al. Obesity in the workplace: impact, outcomes, and recommendations. J Occup Environ Med. Jan 2018;60(1):97–107. doi: 10.1097/jom.0000000000001220. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Hertz R.P., et al. The impact of obesity on work limitations and cardiovascular risk factors in the U.S. workforce. J Occup Environ Med. Dec 2004;46(12):1196–1203. [PubMed] [Google Scholar]
- 28.Grogan S., et al. Body mass index and body satisfaction: does availability of well-fitting clothes matter? Cloth Text Res J. 2021;39(4):251–263. doi: 10.1177/0887302x20915528. [DOI] [Google Scholar]
- 29.Grogan S., et al. Dress fit and body image: a thematic analysis of women's accounts during and after trying on dresses. Body Image. Jun 2013;10(3):380–388. doi: 10.1016/j.bodyim.2013.03.003. [DOI] [PubMed] [Google Scholar]
- 30.Taylor V.H., et al. The impact of obesity on quality of life. Best Pract Res Clin Endocrinol Metabol. Apr 2013;27(2):139–146. doi: 10.1016/j.beem.2013.04.004. [DOI] [PubMed] [Google Scholar]
- 31.Chu D.-T., et al. An update on obesity: mental consequences and psychological interventions. Diabetes Metabol Syndr: Clin Res Rev. 2019/01/01/2019;13(1):155–160. doi: 10.1016/j.dsx.2018.07.015. [DOI] [PubMed] [Google Scholar]
- 32.Scott K.M., et al. Obesity and mental disorders in the general population: results from the world mental health surveys. Int J Obes. 2008/01/01 2008;32(1):192–200. doi: 10.1038/sj.ijo.0803701. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Simon G.E., et al. Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry. Jul 2006;63(7):824–830. doi: 10.1001/archpsyc.63.7.824. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Holt R.I., Peveler R.C. Obesity, serious mental illness and antipsychotic drugs. Diabetes Obes Metabol. Jul 2009;11(7):665–679. doi: 10.1111/j.1463-1326.2009.01038.x. [DOI] [PubMed] [Google Scholar]
- 35.Stephenson J., et al. The association between obesity and quality of life: a retrospective analysis of a large-scale population-based cohort study. BMC Public Health. Nov 3 2021;21(1):1990. doi: 10.1186/s12889-021-12009-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Abiri B., et al. Mental health and quality of life in different obesity phenotypes: a systematic review. Health Qual Life Outcome. Apr 19 2022;20(1):63. doi: 10.1186/s12955-022-01974-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Vallis M. Quality of life and psychological well-being in obesity management: improving the odds of success by managing distress. Int J Clin Pract. Mar 2016;70(3):196–205. doi: 10.1111/ijcp.12765. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.