**Does Bypass of the Proximal Small Intestine Impact Food Intake, Preference, and Taste Function in Humans? An Experimental Medicine Study Using the Duodenal-Jejunal Bypass Liner**

**Madhawi M. Aldhwayan 1, Werd Al-Najim 2,\*, Aruchuna Ruban 3, Michael Alan Glaysher 4, Brett Johnson 5, Navpreet Chhina 6, Georgios K. Dimitriadis 7, Christina Gabriele Prechtl 8, Nicholas A. Johnson 8, James Patrick Byrne 4, Anthony Peter Goldstone 6, Julian P. Teare 3, Carel W. Le Roux 2,9 and Alexander Dimitri Miras 5,9**


**Abstract:** The duodenal-jejunal bypass liner (Endobarrier) is an endoscopic treatment for obesity and type 2 diabetes mellitus (T2DM). It creates exclusion of the proximal small intestine similar to that after Roux-en-Y Gastric Bypass (RYGB) surgery. The objective of this study was to employ a reductionist approach to determine whether bypass of the proximal intestine is the component conferring the effects of RYGB on food intake and sweet taste preference using the Endobarrier as a research tool. A nested mechanistic study within a large randomised controlled trial compared the impact of lifestyle modification with vs. without Endobarrier insertion in patients with obesity and T2DM. Forty-seven participants were randomised and assessed at several timepoints using direct and indirect assessments of food intake, food preference and taste function. Patients within the Endobarrier group lost numerically more weight compared to the control group. Using food diaries, our results demonstrated similar reductions of food intake in both groups. There were no significant differences in food preference and sensory, appetitive reward, or consummatory reward domain of sweet taste function between groups or changes within groups. In conclusion, the superior weight loss seen in patients with obesity and T2DM who underwent the Endobarrier insertion was not due to a reduction in energy intake or change in food preferences.

**Keywords:** Endobarrier; obesity; food preferences; eating behaviour; taste function

**Citation:** Aldhwayan, M.M.; Al-Najim, W.; Ruban, A.; Glaysher, M.A.; Johnson, B.; Chhina, N.; Dimitriadis, G.K.;

#### Prechtl, C.G.; Johnson, N.A.; Byrne, J.P.; et al. Does Bypass of the Proximal Small Intestine Impact Food Intake, Preference, and Taste Function in Humans? An Experimental Medicine Study Using the Duodenal-Jejunal Bypass Liner. *Nutrients* **2022**, *14*, 2141. https://

Academic Editor: Javier Gómez-Ambrosi

doi.org/10.3390/nu14102141

Received: 29 April 2022 Accepted: 16 May 2022 Published: 20 May 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

#### **1. Introduction**

The impressive weight loss observed after RYGB surgery is caused predominantly through a reduction in appetite and hence food intake [1,2]. However, a subgroup of patients also change other aspects of their eating behaviour, including food preference [1]. This shift away from energy-dense sweet and/or fatty foods to less energy-dense options is thought to be an additional mechanism underlying weight loss [3,4]. The gap in our current knowledge is which component of the RYGB gut manipulations underlies the observed changes in dietary behaviour.

The manipulations with RYGB include the formation of a small gastric pouch which is anastomosed to the proximal jejunum, bypass of the stomach and proximal small intestine through which the biliopancreatic secretions still flow and mix with food at the jejunojejunal anastomosis and throughout the common channel.

Animal models of the duodenal-jejunal bypass operation have contributed to our understanding of the role of proximal intestinal bypass on eating behaviour. Mice that underwent duodenal-jejunal bypass (DJB) surgery exhibited lower sugar intake in a sweetseeking task compared to sham-operated mice [5]. The mechanism was thought to involve disrupted gut-brain signalling in the DJB mice, in which duodenal glucose infusions caused a higher release of dopamine than jejunal glucose infusions in the dorsal striatum of sham mice. This effect was significantly diminished in DJB mice [5]. This observation leads to the hypothesis that bypass of the proximal small intestine might be the component of the RYGB manipulations responsible for the reduction in the preference for sweet/fatty foods after surgery.

We adopted a reductionist approach and used the duodenal-jejunal bypass liner (Endobarrier device, GI Dynamics, Lexington, MA, USA) as a research tool to enable us to address our hypothesis in humans. The Endobarrier is a 60 cm fluoropolymer sheath that is inserted endoscopically, anchored at the duodenal bulb and lines 60 cm of the proximal small intestine. We previously demonstrated in the largest RCT in the field that the Endobarrier causes superior weight loss to lifestyle modification in people with obesity and T2DM [6].

The aim of this experimental medicine study was to determine the impact of the Endobarrier device on food intake, food preferences and taste function in humans.

#### **2. Materials and Methods**

#### *2.1. Patients and Study Design*

This was a nested mechanistic study within a larger randomised controlled trial comparing the impact of lifestyle modification with vs. without Endobarrier insertion in patients with obesity and T2DM [6]. The study took place in two academic centres, investigational sites—Imperial College London and University of Southampton. Patients were recruited and followed up in the NIHR Imperial and Southampton Clinical Research Facilities. A complete description of the trial protocol was previously published [7]. In brief, the trial was conducted over 2 years (1 year of treatment and 1 year follow up), 160 participants were randomized at a 1:1 ratio to one of the two study arms. For this nested study, data were collected at 5 time points (mechanistic visits): at baseline (2 weeks before intervention), 10 days, 6 months, 12 months, and 24 months post-intervention (Figure 1).

The Endobarrier is an impermeable fluoropolymer sleeve inserted endoscopically through the duodenum and into the jejunum. The sleeve is open at both ends allowing for chyme passage from the stomach into the lower jejunum, bypassing nutrient absorption along its length by creating a barrier between the partially digested food and the absorptive surface of the small intestine [8]. Implanting the device takes an average of 45 min, and the implant is performed under general anaesthetic. The device barbs are anchored to the duodenal bulb 5–10 mm away from the pylorus. The sleeve then extends for 60 cm through the duodenum by peristalsis movement. Device explant is also done under general

anaesthesia, taking, on average, 30 min to perform. The participant is usually discharged to home the same day following recovery from the anaesthetic.

**Figure 1.** Trial design.

#### *2.2. Dietary and Physical Activity Counselling*

All participants' dietary history and current dietary behaviour were assessed at baseline. A qualified dietitian counselled participants regarding their diet and physical activity. The dietary counselling programme was intended to provide each participant with lifestyle and behavioural modification information and impart good eating practices. Guidelines for daily total requirements were between 1200 and 1500 kilocalories for women and between 1500 and 1800 kilocalories for men. Participants were advised to eat regularly every day (five times/day), to control their portion sizes, to increase their intake of low glycaemic index (GI) and high-protein foods, and to reduce their intake of foods high in fat, sugar, and alcohol.

Participants in both groups were advised to include more physical activity in their daily routine, like walking more every day and climbing the stairs instead of taking the lift or escalators. They were also asked to start with short periods of low-intensity exercise and increase the intensity and duration slowly. Their goal was to include 150 min/week of moderate-intensity and 75 min/week of vigorous-intensity aerobic activity and musclestrengthening activities more than two days a week.

#### *2.3. Liquid Diet*

All participants followed a liquid diet during the seven days before and 13 days (±3 days) after the DJBL insertion, or the fourth clinical visit for the control group. The liquid diet was based on a liquid meal replacement—Fortisip compact® meal replacements (Nutricia Ltd., Trowbridge, UK): four bottles (125 mL each, energy: 300 kcal; carbohydrates: 49%; fat: 35%; protein: 16%) for women and five bottles for men daily. Allowed in addition to this were: milk, flavoured milk, water, low-sugar squashes, vegetable juices, tea or coffee without sugar, unsweetened puree fruit juice, or clear soups. After the liquid diet, participants in both groups were advised to follow a low-calorie diet.

#### *2.4. Anthropometric Measurements*

Weight was measured at all visits, in bare feet, and wearing light clothes. Height without shoes was recorded at the baseline visit. Body mass index (BMI) was calculated. Percentage of body composition (fat mass, fat-free mass in kg and %) were obtained using a bio-electrical impedance analysis machine MC-780MA (TANITA Corporation, Japan).

#### *2.5. Food Intake and Macronutrient Selection*

Participants were asked to complete a weighed food diary for 3 days, 2 weekdays and 1 weekend at baseline (2 weeks before intervention), 10 days, 6 months, 12 months, and 24 months post-intervention. Information from the diaries was entered and analysed using Dietplan7 software (Forestfield Software Ltd. West Sussex, UK) to obtain total daily caloric intake and percentage contribution from carbohydrates, protein, and fat.

#### *2.6. Assessment of Taste Function*

#### 2.6.1. Sensory Domain of Sweet Taste

The detection threshold for sweet taste was measured using the method of constant stimuli [9]. In brief, 112 polystyrene cups were presented in 8 blocks; each block consists of 14 cups, including 7 concentrations of sucrose and 7 water stimuli randomly organised. An amount of 15 mL of the sucrose solution and water was presented in each cup. Participants were asked to taste the solution, swirl it around properly and expel it without swallowing. Then they were asked to describe the quality of the solution they were testing, if it was sweet or water. After each stimulus participants were asked to rinse their mouth with water (the same water used to prepare the solutions) before tasting the next stimulus. Participant answers were recorded on a template scoring sheet. The detection test was performed on the morning of the study day after an overnight fast. All solutions were prepared using water (Caledonian Still Natural Mineral Water, Sainsbury's Supermarkets Ltd., London, UK) and sucrose (Sigma-Aldrich, Dorset, UK) and presented at room temperature. Seven

sucrose concentrations were used (2.1, 6.25, 12.5, 25, 50, 100, and 300 mM). All participants performed the above-described test at baseline (2 weeks before intervention), at 10 days, and at 6 months. Participants were asked to come to the research facility at 8 am after over-night fast. Each visit had a different random arrangement of the cups to minimise learning and familiarisation.

The data collected from the sucrose detection test allows for the derivation of a psychometric function, which is a mathematical equation that plots the performance of participants against the physical aspect (concentration) of the stimulus. The performance was measured as a percentage of correct responses (responses where the participant was able to detect the stimulus correctly).

A 'hit' was defined as when the participant correctly reported that the stimulus was different from water when sucrose was presented. A 'false alarm' (FA) was defined when the participant incorrectly reported that the stimulus was different from water when water was presented. The hit rate for a given sucrose concentration was adjusted for the false alarm rate to derive a 'corrected hit rate' using the following equation:

$$Corrected\ hit\ rate = \frac{P(hit) - P(FA)}{1.0 - P(FA)}$$

where *P*(*hit*) = the proportion of sucrose trials (cups) of a given concentration that were hit, and *P*(*FA*) = the proportion of water trials that were false alarms. Thus, when the uncorrected hit rate is equal to the false alarm rate, the corrected hit rate = 0.

Concentration–response curves were fitted to the corrected hit rate values for each participant for the three tested occasions (2 weeks pre, 10-days and 6 months post-intervention) to derive a family of individual psychometric functions using the following logistic equation:

$$f(\mathbf{x}) = \frac{\mathbf{a}}{1 + 10^{\left(\log 10(\mathbf{x}) - \mathbf{c}\right) \bullet \mathbf{b}}}$$

where log10(x) = log10 concentration, a = the upper asymptote of performance (maximum performance = 1), b = slope, and c = the log10 concentration at 1/2 a performance (i.e., EC50, defined as half-maximal effective concentration). We defined the c parameter as the threshold because it represents the inflexion point of the psychometric function and thus optimally represents horizontal shifts in the sensitivity.

Only c-values of the individual curve fits for the participants who had fits that accounted for at least 85% of the variance were compared. C-values were calculated using Mystat® (Systat® 12) software (Cranes Software International Ltd., Palo Alto, CA, USA). The shifts in the c parameters between groups and within groups were assessed.

#### 2.6.2. Appetitive Reward Domain of Taste Function

The appetitive reward value of sweet/fat taste was measured using the validated method of the progressive ratio task [10]. In brief, this is a computer task in which participants were seated in front of a screen with a plate of 20 chocolate candies (M&M® crispy candies, Mars UK Limited, Slough, UK), each one containing approximately 4 kcal (energy contribution: 43.7% sugars, 44.1% fat). They were asked to click on the mouse button continuously until they received a message on the screen, allowing them to consume their reward (one M&M's only). The required number of clicks increased progressively after each reward (candy). The first ratio was ten clicks with a geometric increase of two (i.e., 10, 20, 40, 80, etc.) for every ratio afterwards. Participants were allowed to terminate the task at any point by pressing the spacebar button on the keyboard. This test was carried out on two occasions, two weeks pre- and six months post-intervention. Testing occurred 3 h after consuming a standardised meal of 250 mL of Fortisip Compacts vanilla flavour, (Energy: 600 kcal, carbohydrates: 74.2 g, fat: 23.2 g, protein: 24 g). The total number of clicks and clicks in the last completed ratio (breakpoint) were recorded. In addition, the number of consumed and remaining candies were calculated from the plate after the termination of

the task to cross-check and validate the participants followed the instructions. Comparisons between groups and within groups were assessed.

#### 2.6.3. Consummatory Reward Domain of Taste Function

The consummatory reward value of sweet taste was measured using a validated methodology [9]. In brief, 30 polystyrene cups were presented in 3 blocks; each block consists of 10 cups, comprising 5 cups of the 5 different sucrose concentrations and 5 cups of water for rinsing after sweet solutions. Odd number cups contained the sucrose solutions, and even number cups contained the rinsing water. An amount of 15 mL of the sucrose solution and water was presented in each cup. All solutions were stored at 4 ◦C and presented cold for testing. Solutions were prepared using still water (Caledonian Still Natural Mineral Water, Sainsbury's Supermarkets Ltd., London, UK: pH 7.4, calcium 27 mg/L, chloride 6.4 mg/L, bicarbonate 103 mg/L, magnesium 6.9 mg/L, sulphate 10.6 mg/L, sodium 6.6 mg/L). Sucrose was from (Sigma-Aldrich, Dorset, UK), five different concentrations of sucrose were used (0, 50, 100, 200, 400 mM). Two different visual analogue scales were used to assess the liking of the sweet drinks as follows:

The Hedonic General Labeled Magnitude Scale: This visual analogue scale was used to rate the pleasantness of the sweetness of the solution relative to any liking feeling they had ever experienced. This is a vertical scale with the middle anchor representing the ideal rating ('Neutral') with a value of zero (0), and measurements of the most positive ('Strongest liking of any kind') representing the highest value of +100, and most negative rating ('Strongest disliking of any kind') with the least value of −100 located at the lowest end of the scale.

The 'Just About Right' scale: This visual analogue scale was used to compare the sweetness of the solution as compared to the ideal sweetness of the participant's preferred soft drink. This was a vertical visual analogue scale, having a middle point where the ideal rating was situated *('Just right: My ideal sweetness in a drink')* which corresponded to the value of zero (0), while the upper end of the scale measured the most positive *('Far too sweet: I would never drink it)* corresponded to a value of +100, and the most negative rating *('Far too little sweetness: I would never drink it')* which corresponded to a value of −100, and this was at the lower end of the scale.

All participants performed the above-described test on three occasions: 2 weeks preintervention, 10 days, and 6 months post-intervention. Participants completed this test after the sensory domain task and still in the fasting state. Each visit had a different random arrangement of the cups to minimise learning and familiarisation.

#### *2.7. Statistical Analyses*

The mixed model analysis was used to investigate the treatment effect on the variables of interest over time, allowing us to perform both between-groups and within-group comparisons. The model included fixed effects for the visit (time of assessment), group (DJBL or control) and their corresponding interaction (group×visit), as well as a random intercept effect for each patient. The model was adapted to include a third level where appropriate (for example, sucrose concentrations).

All participants who attended baseline and at least one visit were included in the analysis. Analysis results are presented in the form of Type-III test results of fixed effects (*p*-values) and their subsequent estimates (mean ± SD). Any parameter that produced a significant result (*p* < 0.05) in the analysis was considered for post-hoc testing of least-square means to investigate any potential effect in more detail. The Pearson test was used for linear regressions. Statistical analysis was completed using IBM statistics SPSS 24, and graphs were generated using GraphPad Prism version 8.

The trial was approved by the Fulham Research Ethics Committee on 10 July 2014 (reference 14/LO/0871) and conducted in accordance with the Declaration of Helsinki.

#### **3. Results**

#### *3.1. Baseline Characteristics*

Forty-seven participants took part in this study, 27 in the Endobarrier group and 20 in the control group, 55% of the participants were male (Table 1). Within the control group, 1 participant withdrew from the study at visit 5 (10 days after intervention), 4 participants withdrew at visit 8 (6 months after intervention). Within the Endobarrier group, 2 participants withdrew from the study at visit 5 (10 days after intervention), 5 participants withdrew at visit 8 (6 months after intervention).

**Table 1.** Baseline characteristics of participants.


Data are presented as mean ± SD or median (range).

#### *3.2. Body Weight*

There was a significant reduction in total body weight within each group at 10 days, 6 and 12 months compared to baseline (*p* < 0.001) but no significant differences between groups. At 12 months the Endobarrier group lost 11 ± 5% total body weight vs. 8 ± 8% in the control group, while at 24 months, the Endobarrier group lost 4 ± 5% vs. 7 ± 7% in the control group ((*p* < 0.02, Figure 2).

**Figure 2.** Percentage weight loss throughout the study. \* *p* < 0.05, \*\*\* *p* < 0.001 compared to baseline within the same group. Data given as mean ± SD.

#### *3.3. Food (Energy) Intake and Macronutrient Selection*

Total daily caloric intake from the three-day food diary was significantly reduced within both groups at all time points compared to baseline, but there were no significant differences between the groups (Table 2).

Within the Endobarrier group, there was a significant increase in the % contribution from carbohydrates at 10 days, a significant increase in the % contribution from protein at 12 months, and a significant decrease in the % contribution from fat at 10 days. Within the control group, there was a significant increase in the % contribution from carbohydrates at 10 days, a significant decrease in the % contribution from protein at 10 days and an increase at 6 months. However, there were no significant differences between groups (Table 3).


**Table 2.** Total daily caloric intake (kcal).

Results presented as mean ± SD. \* *p* < 0.05 \*\* *p* < 0.01 \*\*\* *p* < 0.001 compared to baseline within the same group.

**Table 3.** Percentage contribution of macronutrient to daily energy intake.


Results presented as mean ± SD. \* *p* < 0.05 compared to baseline within the same group. \*\* *p* < 0.01 compared to baseline within the same group.

#### *3.4. Sensory Domain of Sweet Taste*

There was no significant change in the curves of mean corrected hit rate both within and between groups at baseline, 10 days, and 6 months post intervention (Figure 3).

**Figure 3.** Sweet taste detection. Curves of the mean corrected hit rate over time for (**A**) controls (blue) *n* = 16 and (B) Endobarrier (red) *n* = 25 groups as a function of sucrose concentration. The EC50 was derived from the c-parameter in the curve fit and represented the concentration at which the corrected hit rate reaches 50% of the maximum asymptote.

#### *3.5. Appetitive Reward Value of Sweet Taste*

There was no significant change in the breakpoint either within or between groups (*p* = 0.12 for group × time interaction) (Figure 4).

**Figure 4.** Breakpoint at the progressive ratio task. Box plot of the breakpoint for chocolate candies in control (blue) *n* = 9 and Endobarrier (red) *n* = 11 groups. The lower and upper boundaries of the box represent 25th and 75th percentiles, respectively. Lower and upper whiskers represent 10th and 90th percentiles, respectively. The line in the middle of the box represents the median.

#### *3.6. Consummatory Reward Value of Sweet Taste*

There was no significant change in the consummatory reward value of sweet taste both within and between groups using Just About Right scale (Figure 5) and Hedonic General Labeled Magnitude Scale (Figure 6) at baseline, 10 days, and 6 months post intervention.

**Figure 5.** Just About Right scale ratings of sweet taste. Consummatory reward value of sweet taste assessed by Just About Right scale for (**A**) controls *n* = 19 (blue) and (**B**) Endobarrier *n* = 24 (red groups). Data are presented as the mean rating at each concentration ± SD.

**Figure 6.** Hedonic general Labeled Magnitude Scale ratings of sweet taste. Consummatory reward value of sweet taste assessed by the Hedonic general Labeled Magnitude Scale for (**A**) control *n* = 19 (blue) and (**B**) Endobarrier *n* = 24 (red) groups. Data are presented as the mean rating at each concentration ± SD.

#### **4. Discussion**

This is, to our knowledge, the first experimental medicine study to assess the mechanisms of action of the Endobarrier device on weight loss as a nested study within an RCT. Patients in the Endobarrier group lost numerically more weight than the control group. We assessed several measures of dietary behaviour and identified significant changes on specific aspects within groups but no significant differences between groups.

To date, there has been limited literature on the effect of Endobarrier on food intake. Using food diaries, our results demonstrated similarly reduced food intake within both the Endobarrier and the control groups. Similarly, a recent case series study of patients with obesity and T2DM demonstrated reduced food intake at 36 weeks after the Endobarrier implant using a semi-quantitative Food Frequency Questionnaire [11]. In contrast, a prospective observational study of two groups, a group of patients with obesity and normal glucose-tolerance, and another group of matched metformin-treated patients T2DM who underwent Endobarrier implant, demonstrated lower food intake only at one week [12]. This was followed by a return to baseline food intake at explantation (26 weeks), despite ongoing weight loss. This was the only human study so far to use an ad libitum meal to assess food intake. Of note, this study also did not include a control group for comparison [12]. Among animal models, a study comparing food intake between diet-induced obese rats after endoluminal sleeve insertion and sham-operated controls showed reduced food intake in the sleeve group compared to no change in the control group at eight weeks [13].

Alternative mechanisms of weight loss after Endobarrier have been proposed including increased energy expenditure in both human and animal models. We cannot exclude that the numerically superior weight loss observed among our Endobarrier group might be attributed to an increase in energy expenditure. Rohde et al. reported an increase in resting energy expenditure using indirect calorimetry in patients with obesity but not among patients with T2DM after Endobarrier implant [12]. Similarly, Munoz et al. in their animal model, demonstrated an increase of 13% in total and 9% in resting energy expenditure among Endoluminal sleeve treated rats compared to shams [13].

Nutrient malabsorption has been proposed as a possible mechanism of weight loss after the Endobarrier, due to the bypass of 60 cm of the small intestine. However, when fat malabsorption was measured using 13C mixed triglyceride breath test in patients with obesity and T2DM, there was no evidence of reduced intraluminal lipolytic activity suggesting that fat malabsorption does not take place [14]. Similarly, no evidence of food malabsorption was found in rats treated with an endoluminal sleeve, as measured by the difference in calories consumed and excreted in the stool using direct calorimetry [13].

Another plausible mechanism that could explain the weight loss in the Endobarrier group is gut inflammation. The insertion of a foreign body in the intestine could have triggered a low-grade inflammatory state. Gut inflammation can cause weight loss due to several mechanisms including increased resting energy expenditure, and the action of proinflammatory cytokines [15]. Against this hypothesis is the fact that we measured plasma concentrations of C-reactive protein in the main clinical RCT [6] and were not found to be elevated after intervention. We would also have expected gut inflammation to decrease appetite and thus total daily energy intake, but we did not observe this in our study. In this report we do not present appetite ratings or gut hormone measurements. Whilst enhanced post-prandial concentrations of plasma GLP-1 and PYY were reported in some studies [16–18], the magnitude of the increase was modest and the findings inconsistent [16,19].

Weight regain after Endobarrier explant is reported in several studies. Interestingly, in the studies that had a control group, the Endobarrier group had the most weight regain compared to the control group [20]. This was in line with our findings, where the Endobarrier group had around 7% weight regain compared to 1% in the control group. Similarly, Villarasa et al., in their recent prospective trial concluded a total percentage weight loss of about 15% at the time of explantation (48 weeks) followed by weight regain during the next year, maintaining only 7% of the total weight loss; there was no control group in this study [17].This rebound demonstrates that the Endobarrier works only when it is in situ and does not have any long term learning effects on eating behaviour. One explanation for the magnitude of the rebound might be attributed to the absence of abdominal discomfort that patients commonly report, resulting in increased meal size, caloric intake and subsequent weight regain.

The role of the duodenum in food preferences and reward has been investigated in animal models of the DJB procedure, which like the Endobarrier, involves bypass of the proximal small intestine [5]. In line with our results, Qu et al. recently demonstrated that sweet preference was not different between DJB mice and sham-operated mice in a two-bottle sweet preference test [21]. Reduced preference appeared only after prolonged exposure to the sweet solutions indicating a learning effect [21]. Similarly, in their animal model, Zhang et al. demonstrated that DJB mice preferred the flavours of intragastric infusions of metabolised glucose compared to the flavours of non-metabolised glucose [22]. Nevertheless, the surgical duodenal bypass did not affect the ability of mice to differentiate (prefer) between the flavours of metabolised versus non-metabolised glucose solutions [22]. The same study also showed that reward circuits in the brain responded to intra-portal mesenteric infusions of the metabolised glucose only, suggesting a post-absorptive role for glucose preference and reward.

The absence of changes in food preference and taste function are reminiscent of some of the studies in humans and animals undergoing RYGB [23,24]. In one of the most comprehensive studies in the literature, food preferences did not change in a group of patients undergoing RYGB, but the subgroup of patients who experiences changes in food preferences lost more weight [2]. This finding suggests that changes in food preferences do not take place in everyone but in those that do, they contribute to weight loss as an additional mechanism.

The strengths of this study include its randomised design, two trial sites, length of follow-up, multidisciplinary team involved in patients care, and delivery of an intensive medical intervention throughout the study period. In addition, we used complementary measures of eating behaviour, including assessment of food intake, taste detection thresholds, appetitive and consummatory reward value of sweet taste with various sweet concentrations. Despite the length of the study, the same two dietitians carried out dietary analyses throughout the study period to reduce variability. In addition, participants in both groups received the exact behavioural and dietary modification instructions from a single dietitian throughout the study.

The major limitation in our study was its unblinded design. In addition, in the smaller mechanistic sub-set of participants having these dietary assessments, the Endobarrier insertion resulted in numerically superior weight loss, which was not as pronounced as in the main RCT [6]. There are also inherent limitations to using verbal/written reports, especially in a trial that is not double-blinded. The problem of under-reporting of food intake among patients with and without obesity is common when using indirect measures of food intake [25]. It would have been preferable to measure these aspects of eating behaviour using a buffet meal or a 24-h residential stay. The study days were long and included numerous tasks which might have contributed to participant fatigue, which could have been avoided if the tasks had been performed on separate days. Only sweet taste assessments were made and not fat or combined sweet/fat (other than the progressive ratio task). Assessments were generally performed in the fasted state and may have been different in the post-prandial state, except for the progressive ratio task, which was assessed post prandially Furthermore, sample sizes declined over time due to drop-out during the trial. Finally, we did not measure energy expenditure or calorie malabsorption as alternative mechanisms causing weight loss after the Endobarrier.

#### **5. Conclusions**

In conclusion, this experimental medicine study demonstrated that reduction of selfreported energy intake, changes in food preferences, and sweet taste were not the mechanisms underlying the weight loss observed after Endobarrier insertion in people with obesity and T2DM.

**Author Contributions:** Conceptualization, W.A.-N., A.R., M.A.G., C.G.P., J.P.B., A.P.G., J.P.T., C.W.L.R. and A.D.M.; Data curation, M.M.A., W.A.-N., N.A.J. and J.P.B.; Formal analysis, M.M.A., W.A.-N., N.A.J., A.P.G., J.P.T., C.W.L.R. and A.D.M.; Funding acquisition, C.G.P., A.P.G. and J.P.T.; Investigation, M.M.A., W.A.-N., A.R., M.A.G., N.C., G.K.D., C.G.P., J.P.B., A.P.G., J.P.T., C.W.L.R. and A.D.M.; Methodology, W.A.-N., N.C., C.G.P., N.A.J., J.P.B., A.P.G., J.P.T., C.W.L.R. and A.D.M.; Project administration, M.M.A., W.A.-N., A.R., M.A.G., B.J., C.G.P., A.P.G., J.P.T., C.W.L.R. and A.D.M.; Resources, C.G.P., A.P.G. and J.P.T.; Software, C.G.P. and A.P.G.; Supervision, C.G.P., J.P.B., A.P.G., J.P.T., C.W.L.R. and A.D.M.; Visualization, M.M.A.; Writing—original draft, M.M.A., A.P.G., J.P.T., C.W.L.R. and A.D.M.; Writing—review and editing, M.M.A., W.A.-N., A.R., M.A.G., B.J., N.C., G.K.D., C.G.P., N.A.J., J.P.B., A.P.G., J.P.T., C.W.L.R. and A.D.M. All authors have read and agreed to the published version of the manuscript.

**Funding:** This study was funded by the Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership reference 12/10/04. C.W.R is funded by the Irish Research Council (IRCLA/2017/234) and The Health Research Board (USIRL-2016-2). A.D.M. has been supported from grants from the JP Moulton Charitable Foundation, National Institute of Health Research, Imperial College Healthcare Charity and Novo Nordisk; N.C. has been supported by grants from Wellcome Trust. The Division of Diabetes, Endocrinology and Metabolism is funded by grants from the UK Medical Research Council (MRC), Biotechnology and

Biological Sciences Research Council, and the NIHR; an Integrative Mammalian Biology Capacity Building Award; and an FP7- HEALTH-2009–241592 EuroCHIP grant. It is also supported by the NIHR Biomedical Research Center Funding Scheme. M.A. was funded by the Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.

**Institutional Review Board Statement:** The trial was approved by the Fulham Research Ethics Committee on 10 July 2014 (reference 14/LO/0871) and conducted in accordance with the Declaration of Helsinki.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy.

**Acknowledgments:** The devices and nutritional supplements were kindly provided free of charge by GI Dynamics and Nutricia Advanced Medical Nutrition respectively. Infrastructure support was provided by the NIHR Imperial Biomedical Research Center, NIHR Imperial and Clinical Research Facility, London, NIHR Southampton Biomedical Research Center UK and NIHR Southampton clinical research facility, Southampton, UK.

**Conflicts of Interest:** A.R. received travel fees support from GI Dynamics. A.D.M. has received honoraria for presentations and advisory board contribution by Novo Nordisk, Boehringer Ingelheim, AstraZeneca, Johnson & Johnson and research grant funding from Fractyl. A.P.G. reports funding supported by UK Medical Research Council and Wellcome Trust, outside of the submitted work, was on a Data Safety Monitoring Board for Novo Nordisk, and has received honoraria for presentations and advisory board contribution by Janssen, Pfizer, Novo Nordisk, Zafgen, Soleno Therapeutics Inc, and Millendo Theapeutics Inc, and Merck. C.W.R. is a member of scientific advisory board for Herbalife, GI Dynamics, NovoNordisk, Keyron, Sanofi, has provided ad hoc consulting for Ethicon and Fractyl, occasional speaking engagement for MSD, Boehringer Ingelheim and Lilly. J.P.T. received travel fees support from GI Dynamics. W.A. has received honoraria for presentations and educational grants from Novo Nordisk. The rest of the authors report no conflicts of interest. "The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results".

#### **References**


## *Article* **Are People with Obesity Attracted to Multidisciplinary Telemedicine Approach for Weight Management?**

**Luisa Gilardini 1,\*, Raffaella Cancello 1, Luca Cavaggioni 1, Amalia Bruno 1, Margherita Novelli 1, Sara P. Mambrini 2,3, Gianluca Castelnuovo 4,5 and Simona Bertoli 1,3**


**Abstract:** The forced isolation due to the COVID-19 pandemic interrupted the lifestyle intervention programs for people with obesity. This study aimed to assess: (1) the behaviors of subjects with obesity towards medical care during the pandemic and (2) their interest in following a remotely delivered multidisciplinary program for weight loss. An online self-made survey addressed to subjects with obesity was linked to the official website of our institute. Four hundred and six subjects completed the questionnaire (90% females, 50.2 ± 11.6 years). Forty-six percent of the subjects cancelled any scheduled clinical assessments during the pandemic, 53% of whom had chronic disease. Half of the subjects were prone to following a remotely delivered lifestyle intervention, especially with a well-known health professional. About 45% of the respondents were favorable towards participating in remote psychological support and nutritional intervention, while 60% would practice physical activity with online tools. Male subjects and the elderly were more reluctant than those female and younger, especially for online psychological support. Our survey showed an interest on the part of the subjects with obesity to join a multidisciplinary weight loss intervention remotely delivered. Male subjects and the elderly seem less attracted to this intervention, and this result highlights that, even with telemedicine, the approach to weight management should be tailored.

**Keywords:** obesity; lifestyle intervention; telemedicine; COVID-19 pandemic

#### **1. Introduction**

Coronavirus disease 2019 (COVID-19) is a severe acute respiratory syndrome caused by SARS-CoV-2 that was first discovered in Wuhan, China in December 2019 and rapidly spread to the rest of the world [1]. The infection is highly transmissible, and the number of those infected with COVID-19 has now reached more than 364 million patients and over 5,500,000 deaths.

To contrast and contain the pandemic, at the beginning of March 2020, the Italian Government adopted restriction measurements consisting of a temporary closure of all nonessential activities, strengthening the measures aimed to increase personal hygiene, symptom monitoring, early diagnosis, and patient isolation [2]. The lockdown was repeated in November 2020 and March 2021. All these restrictions required individuals to stay at home, leading to modifications in lifestyles and daily life habits, especially for those in frail categories, such as subjects with obesity. In this context, people are prone in buying large

**Citation:** Gilardini, L.; Cancello, R.; Cavaggioni, L.; Bruno, A.; Novelli, M.; Mambrini, S.P.; Castelnuovo, G.; Bertoli, S. Are People with Obesity Attracted to Multidisciplinary Telemedicine Approach for Weight Management? *Nutrients* **2022**, *14*, 1579. https://doi.org/10.3390/ nu14081579

Academic Editor: Javier Gómez-Ambrosi

Received: 11 March 2022 Accepted: 8 April 2022 Published: 11 April 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

quantities of ultra-processed, unhealthy food to cope with fear, boredom, or anxiety evoked by the worldwide pandemic [3,4]. Moreover, in this difficult situation, individuals with eating disorders may be at a high risk of relapsing or of a worsening of the severity of their disorder [5,6]. Combined with a decrease in the levels of physical activity registered [7], the impaired nutritional habits could lead to weight gain. An Italian study in a small cohort of individuals with obesity showed a significant weight gain 1 month after the beginning of the lockdown period [8]. The increased risk of weight gain during lockdown and the evidence that any degree of obesity has been associated with poor prognosis in patients with SARS-CoV-2 infection [9] have pointed out the importance of ongoing support for obese subjects to manage the disease during the pandemic. Indeed, in Italy, all non-urgent medical visits, including clinical practices planned for obesity management, were deferred to ensure social distancing and reduce the virus spread. Since the resumption of clinical activities after the lockdowns, the fear of contracting the infection in healthcare places, such as hospitals and clinics, has grown in people, and there is still a significant reduction in access to clinical care programs, including metabolic rehabilitation for obesity. The global COVID-19 pandemic has led to a revolution in many fields, promoting alternative strategies with the use of technology. In addition to this, the medical sector has also promoted the usefulness of telehealth and telemedicine, but benefits and barriers in using technology should be considered when dealing with patients [10]. It is worth noticing that telemedicine may represent a novel, effective option in obesity management. In fact, it has previously been demonstrated that video visits with physicians and dieticians can be effective in driving weight loss compared to the standard care [11,12]. IRCCS Istituto Auxologico Italiano (https://www.auxologico.it/, accessed on 10 March 2022) is a specialized national center for obesity care. In Italy, the prevalence of obesity was estimated as 10.9% in 2019, and it is higher in men (11.7%) than in women (10.3%), with increasing prevalence from the north to the south of the country [13]. In our institute, we conduct a 3-month multidisciplinary program aimed at weight loss in obesity-suffering subjects with the involvement of dieticians, physicians, psychologists, and exercise physiologists. The intervention includes individual interviews with the health professionals, nutritional/psychological group sessions, and a one-hour session of moderate intensity physical activity under the supervision of a physical trainer [14]. At the end of the rehabilitation, patients were given an appointment for the regular three months of follow-up visits. During the pandemic, we were forced to stop this rehabilitation program, and we wondered what the barriers were for the patients with obesity to perform the intervention with telemedicine. We conducted a self-reported online survey among the newsletter readers of Istituto Auxologico Italiano from October 2020 to March 2021 to observe the perception of telemedicine of patients with obesity.

The purpose of this survey was to investigate (1) the behaviors of obese subjects towards medical care during the pandemic and (2) their opinion on the possibility of following a remotely delivered program for weight loss, including psychological, nutritional, and physical activity interventions.

#### **2. Materials and Methods**

The present study is a cross-sectional design carried out using an online self-made questionnaire (from October 2020 to March 2021) adopting a Google online survey platform (Google LLC, Mountain View, CA, USA). A link to the electronic survey is present on the official website of the IRCCS Istituto Auxologico Italiano (www.auxologico.it, accessed on 10 March 2022) and was shared via the local institute newsletter. Registration to receive the newsletter is open to everyone, but usually, the subscribers are patients who use the services of our institute for healthcare. All participants were requested to provide informed consent through an appropriate checkbox in the survey regarding research purposes. Participants' answers were anonymous, in accordance with Google's privacy policy (https://policies.google.com/privacy?hl=it, accessed on 20 February 2022). Each participant was identified by a progressive anonymous number. The self-made survey included a questionnaire composed by 34 questions broken down into three sections: (1) personal anonymous data (age, gender, zip code, education, current work, presence of chronic diseases, availability of an IT tool, weight, and height); (2) disease management during the pandemic (we asked if the patient missed scheduled control visits for any health issue, if they contacted the doctor, and by what means); and (3) obesity management during the pandemic and opinion on the use of telemedicine (whether the patient is prone to following a nutritional, psychological, and physical activity program remotely, what is the best modality, and what are the critical issues).

The text of the questionnaire is linked as an annex (Supplementary Materials S1). The inclusion criteria were body mass index values ≥ 30 kg/m<sup>2</sup> and ages ≥ 18 years. Participants with lower BMI values were excluded by statistical analysis. The participants were asked multiple- or single-choice questions or questions whose answers required the interviewee to enter numeric data. For example: Enter your weight.

The study was conducted in full agreement with the national and international regulations and the Declaration of Helsinki (2000). Participants independently completed an anonymous online questionnaire, explicitly agreeing to participate in the survey. Participants' personal information were made anonymous to maintain and protect confidentiality. The anonymous nature of the web survey did not allow us to trace in any way sensitive personal data. Therefore, the present web survey study did not require approval by ethics committee. Once completed, each questionnaire was transmitted to the Google platform, and the final database was downloaded as a Microsoft Excel sheet.

#### *Statistical Analysis*

Continuous variables were expressed as the mean ± standard deviation (SD) and categorical data as frequencies and proportions. Differences between groups were calculated using the Student's *t*-test for independent samples and analysis of variance for the comparison of multiple groups. Frequencies were compared using a χ2 test. All analyses were performed using SPSS version 26.0 (SPSS Inc., Chicago, IL, USA). A *p*-value < 0.05 was considered statistically significant.

#### **3. Results**

In total, 465 subjects completed the entire questionnaire. Fifty-nine subjects were only overweight and were excluded. Table 1 showed the characteristics of 406 obese subjects. The subjects were prevalently female, and the age group with the highest frequency (59.4 percent) was 41–60 years old. The mean BMI was 38.0 ± 6.1 kg/m2. Men had more severe degrees of obesity compared to women (40.1 ± 5.8 vs. 37.8 ± 5.8 kg/m2, *<sup>p</sup>* < 0.05), had fewer previous diet attempts (more than three diets: 62.5% vs. 83.7%, *p* < 0.001), and tended to have more obesity-related chronic diseases (52.4% vs. 68.3%, *p* = 0.05) than women. There were no differences in age and education levels between the sexes. The percentage of subjects with obesity-related chronic diseases increased with age (34% in subjects aged <40 years (y), 56% in subjects aged 41–60 y, and 71% in subjects aged >60 y, *p* < 0.0001) but not with the degree of obesity. The degree of obesity, gender, and education level were similar across the age groups. Only four subjects (all females) had no electronic tools, three of whom were >65 years. A sedentary behavior was present in 41%. The most declared activity by physically active subjects was "walking".


**Table 1.** Characteristics of 406 subjects with obesity who answered the questionnaire.

Data are expressed as mean ± SD or percentage (%).

#### *3.1. Disease Management during Pandemic*

The answers given by the participants to the questions about healthcare during pandemic and their opinions on remote visits are summarized in Table 2. Patients who cancelled or postponed a scheduled medical examination (46%) were similar in age, sex, and degree of obesity compared to those who did not but had more frequent chronic diseases (53.2% vs. 37.8%, *p* < 0.005). Of the subjects who cancelled a visit, fifty-three percent contacted the medical doctor in another way, especially by phone, mail, and the WhatsApp (WhatsApp Inc. 2020, Manlo Park, CA, USA). These subjects had more chronic diseases (57.7% vs. 45.7%, *p* < 0.05) than those who did not contact the doctor. Only 24% of subjects believed that the doctor could understand their state of health well through a video consultation, but the percentage rose to 62% if the subject had already met the therapist in a face-to-face visit.

**Table 2.** Answers given by the participants to questions about medical care during the pandemic with relative percentage (%).


#### *3.2. Obesity Management and Telemedicine*

Fifty-five percent of subjects were open to following a remotely delivered lifestyle intervention, 23% only if the health professional was known, 15.4% were undecided, and 6.6% refused. There was no difference in age, sex, degree of obesity, and having a chronic disease in the four groups (Figure 1). Most patients believed that the cost of the online lifestyle intervention should be provided by the national health system. Forty-five percent of the respondents to the survey felt favorably about participating in remote psychological regular support. Men were more reluctant than women (37.5% of males refused this type of therapy vs. 18% of females, *p* < 0.005). Subjects older than 60 years and with chronic diseases tended to be less disposed toward remote psychological therapy than younger subjects and those without chronic diseases (Figure 2). Most people would prefer a video consultation with the psychologist once a week. Another preferred modality is an online interview as needed. The minority would like to have two talks a week. An online nutritional intervention would have been accepted by 46% of the subjects. Males and the elderly were more opposed or indecisive towards this intervention than females and those younger (Figure 3). According to most, nutritional therapy should take place by teleconsulting with a dietician once a week. They also welcomed the sending of video conferencing/written materials concerning diet/nutrition/health. Group activities online once a week was the least welcome option. About 60% of subjects would practice physical activity with online tools supervised by a trainer, while 14% are not interested. The subjects who were more predisposed toward the online program were females and those younger (Figure 4). Concerning physical activity, most of the samples in the study believed that the best way to practice physical activity at a distance was real-time online group lessons, once a week, followed by the reception of training tables and one-on-one meetings via the video platform with an exercise physiologist. The deterring factors of the possibility of doing physical activity online were in order of frequency: laziness, no deterrent, the lack of an appropriate space at home, the difficulty of using electronic tools, and the fear of getting hurt.

**Figure 1.** The figure shows the answer to the question: "Would you be like to start an online multidisciplinary intervention for weight management?". The responders are divided by age, sex, degree of obesity, and the presence of chronic diseases.

**Figure 2.** The figure shows the answer to the question: "Would you undergo a remotely delivered psychological intervention?". The responders are divided by age, sex, degree of obesity, and the presence of chronic diseases. \* *p* < 0.005 vs. females.

**Figure 3.** The figure shows the answer to the question: "Would you will join an online nutritional intervention?". The responders are divided by age, sex, degree of obesity, and the presence of chronic diseases.

**Figure 4.** The figure shows the answer to the question: "Would you like to practice physical activity online supervised by an exercise physiologist?". The responders are divided by age, sex, degree of obesity, and the presence of chronic diseases.

#### **4. Discussion**

Our study is the first investigation detecting habits and behaviors of obese subjects towards medical care during the pandemic and providing the opinions of subjects with obesity of a remotely delivered program for weight loss, including psychological, nutritional, and physical activity interventions through telemedicine. The COVID-19 pandemic has had not only deleterious effects on infected people but also on the non-COVID-19 patients who have not been able to receive the same level of assistance as before. In Italy, from 15 March 2020, outpatient visits were limited to no deferrable ones, while other appointments were postponed or cancelled to conserve resources and reduce the risk of viral transmission. Our survey highlighted that half of the individuals with obesity responders missed all scheduled medical examinations, especially those with chronic diseases. In according with this finding, a questionnaire coordinated by the Italian National Institute of Health and aimed at people over 65 years revealed that 44% of 1200 subjects interviewed were resigned during the pandemic to missing at least one medical examination (or diagnostic test) that they would need [15]. Bonora et al. showed that the number of visits for diabetic subjects performed during the lockdown period was 47.7% lower than in the same month of the previous 2 years and that the reduction of visits was significantly greater for aged type 2 diabetes patients with heavier complication burdens and complex pharmacotherapies than for younger ones with less complicated diabetes [16]. A study conducted in North Carolina (USA) reported that 53% of outpatient cardiology encounters were cancelled in 2020, and individuals who utilized telehealth tended to be younger, with fewer comorbidities, than those cancelled or referred care [17]. In our survey, patients contacted the doctor, especially via email and WhatsApp, indicating that these media are replacing telephone calls. Although about 60% of the survey participants thought that online consulting might decrease the risk of being infected, only 24% believed that the doctor could perceive their health conditions without an in-person visit. The percentage increased if the subject met the health professional during a previous face-to-face visit. Telemedicine could be a huge opportunity for obesity management during the COVID-19 pandemic, but acceptance by subjects with obesity could be a critical issue. Obesity is a disease in which physician– patient communication is fundamental, and the relationship between the patient and the health professional is important for the success of the intervention [18].

For this reason, it was important to investigate how remotely delivered interventions could be perceived in these patients and if there were any phenotypes of patients who were more reluctant toward telemedicine. Our study demonstrated that more than half of the subjects with obesity were willing to participate in an online multidisciplinary lifestyle intervention, but familiarity with the therapist was a conditional factor in the greater acceptance of the therapy. When we analyzed the perceptions of the three interventions separately (psychological, nutritional, and physical activity), we found that the subjects were more reluctant toward online psychological and nutritional therapy than a physical activity program. Men and the elderly tended to be less interested to an online intervention than women and those younger. In particular, about 40% of men with obesity refused online psychological therapy. It is known that men remain less likely than women to access psychotherapy or participate in lifestyle modification programs, including weight loss intervention [19,20]. In our cohort, men had a more severe degree of obesity and associated chronic diseases than women, suggesting that men seek help for their condition (in this case, were attracted by a survey on a weight loss program) later than women and when their health is already compromised with other complications. Thus, appealing and innovative approaches that improve their weight status are needed for men. In a study investigating men's experiences and perspectives regarding social support after bariatric surgery, male patients reported feeling alone and isolated during the weight loss support groups consisting primarily of women, and they preferred online social support [21]. Other studies confirmed a positive and good response by men to telemedicine [22,23]. Despite this, in our study, we found some reluctance by men to participate in an online weight loss program, especially as regards psychological intervention. Since, as already mentioned above, physician–patient communication is fundamental in obesity management, a faceto-face consultant with the healthcare professional is necessary to explain the modalities and benefits of online lifestyle interventions and to decrease men's distrust of this type of approach.

Few studies have examined telemedicine weight loss interventions for older people [24]. Telemedicine may have several advantages, eliminating mobility impediments and the risk of COVID-19 infection. Indeed, older obese subjects have the major risk of severe disease and/or death from COVID-19. In our study, about 20% of subjects were >60 years old, and they had more chronic diseases than those younger. They were less attracted to telemedicine, probably because they felt fragile and needed an in-person consultation with the healthcare professional, including to monitor in their presence their health status. Furthermore, although most of them had an electronic tool and the educational level was no different compared to young subjects, it is possible that they had an inability to manipulate the technology, as well as a cognitive impairment issue.

It is necessary to promote remotely delivered weight loss interventions tailored for older people that overcome technological and cognitive barriers. The responders chose as the best mode for a nutritional intervention an online visit with a dietician, while real-time group lessons were with an exercise physiologist to practice physical activity at home. The online consultation was probably preferred, because it allows to create interactions between users through facial expressions and voice tone, confirming how important the relationship is with a therapist in the nutritional intervention in obesity management. The online physical activity group lessons have an advantage in that the exercise physiologist can give a visual demonstration of the exercises and that group members can support each other. As a matter of fact, telemedicine may represent a novel, effective option when treating obese patients, but the benefits and barriers in using technology should be carefully considered [10].

Our findings suggest that we could use a "hybrid" model for the management of weight loss during the pandemic. From a practical viewpoint, we could speculate on using a face-to-face consultation for the initial evaluation in order to create a strong patient– physician relationship, and the subsequent visits could be performed remotely, interspersed with traditional visits, especially with frail subjects (i.e., men and elderly). Finally, it is plausible to use telemedicine in providing physical activity group lessons.

The limitations of this survey are also worthy of discussion: (1) It was a self-reported survey, and the study group may not be representative of all the population with obesity, because the survey was addressed and diffused through the newsletter of our institute. In fact, although the newsletter was open to everyone, some subjects may have been unintentionally excluded—in particular, those who did not have an electronic tool or the needed knowledge and skills to carry out the online survey. (2) The gender disproportion confirms the lower interest of men in weight loss issues than women. (3) Information on a previous SARS-CoV-2 infection was not investigated in this survey. This point may have played a role in patients' decisions to accept or refuse a remote management approach. (4) The questionnaire did not investigate the knowledge of the subjects on how to use the technological aspect of telemedicine. Although almost all the interviewees stated that they have a technological tool (smartphone, computer, or tablet), this does not mean that they were able to use it. This is especially true for the elderly and for those with lower education levels.

#### **5. Conclusions**

In conclusion, our survey showed an interest on the part of subjects with obesity to join a multidisciplinary weight loss intervention remotely delivered. Even if with caution, given a possible bias during the recruitment, we noticed that men and the elderly were more reluctant than women and those younger to participate in an online nutritional and psychological intervention. This result highlights once again that, even with telemedicine, the approach to weight management should be tailored. As our survey revealed an interest in telemedicine on the part of people with obesity, we can imagine using this approach also in the post-COVID-19 period. In fact, the implementation of telemedicine in obesity care could minimize patient travel time and missed work, expanding the possibility of treatment to a greater number of subjects with obesity in order to sustain higher adherence to lifestyle changes.

**Supplementary Materials:** The following supporting information can be downloaded at https: //www.mdpi.com/article/10.3390/nu14081579/s1: Supplementary Material S1: The questionnaire.

**Author Contributions:** Conceptualization, L.G., S.B., R.C., L.C. and G.C.; methodology, S.B., R.C., L.C., M.N. and A.B.; data curation, L.G., R.C, A.B. and S.P.M.; writing—original draft preparation, L.G., S.B., R.C. and L.C.; and writing—review and editing and supervision, L.G., S.B., R.C., L.C. and G.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by Italian Ministry of Health.

**Institutional Review Board Statement:** The study was conducted in full agreement with the national and international regulations and the Declaration of Helsinki. The anonymous nature of the web survey did not allow to trace, in any way, sensitive personal data. Therefore, the present web survey study did not require approval by an ethics committee.

**Informed Consent Statement:** All participants were requested to provide informed consent through an appropriate checkbox in the survey regarding research purposes.

**Data Availability Statement:** The datasets used during the current study are available from the corresponding author upon reasonable request.

**Acknowledgments:** The authors acknowledge Daniela Barzaghi and Greta Giuliani (IRCCS Istituto Auxologico Italiano Marketing and Communication Office) for the technical support given.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

