Changes in obesity-specific quality of life after a therapeutic patient education program in primary care: a prospective before–after study

Changes in obesity-specific quality of life after a therapeutic patient education program in primary care: a prospective before–after study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Changes in obesity-specific quality of life after a therapeutic patient education program in primary care: a prospective before–after study Eloïse Deliry, Emilie Lanoy, Cécile Ross, Sandrine Katsahian, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9071737/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Obesity is a chronic disease associated with substantial physical, psychological, and social burden. Primary care plays a central role in the long-term management of obesity and in coordinating multidisciplinary interventions. Although therapeutic patient education (TPE) is recommended as part of comprehensive obesity care, evidence regarding its impact on obesity-specific quality of life in real-world primary care settings remains limited. This study aimed to evaluate short-term changes in obesity-specific quality of life among adults participating in a structured TPE program delivered within coordinated primary care. Methods We conducted a prospective single-arm before–after study between June 2023 and December 2024 to evaluate the impact of a real-world therapeutic patient education program implemented in a coordinated primary care setting in Paris, France. Adults aged ≥ 18 years with body mass index (BMI) ≥ 30 kg/m² were eligible. Quality of life was assessed at baseline and after completion of the three-month program using the validated French EQVOD questionnaire, an obesity-specific instrument. The primary outcome was the change in global EQVOD score (0–100 scale). Paired comparisons were performed using non-parametric tests. Domain-specific analyses included adjustment for multiple comparisons. A sensitivity analysis was conducted to assess the impact of missing follow-up data. Results Thirty-one participants were included, of whom 25 completed both baseline and follow-up assessments. Mean BMI was 37.4 ± 4.6 kg/m², and 68% were women. The mean global EQVOD score increased from 57.4 at baseline to 65.0 after the intervention, corresponding to a mean improvement of 7.6 points (95% CI 3.6–11.7; p = 0.002). Statistically significant improvements were observed in psychosocial impact (+ 9.3 points; p = 0.005) and food-related well-being (+ 7.9 points; p = 0.004). Results were consistent in sensitivity analyses. No association was observed between baseline BMI and baseline quality-of-life score. Conclusions Participation in this structured therapeutic patient education program implemented in primary care was associated with short-term improvement in obesity-specific quality of life, particularly in psychosocial and food-related domains. These findings suggest that therapeutic education programs integrated into primary care may contribute to improving patient-reported outcomes in obesity management. Larger controlled studies with longer follow-up are needed to confirm these results. Obesity Primary care Therapeutic patient education Quality of life Patient-reported outcomes Multidisciplinary care Lifestyle intervention Figures Figure 1 Figure 2 Figure 3 Background Obesity is a chronic, multifactorial, and progressive disease whose prevalence continues to rise worldwide. According to the World Health Organization, approximately one in eight individuals globally is affected [ 1 ]. In France, recent epidemiological data indicate that nearly 17% of adults are living with obesity, with a particularly marked increase among socioeconomically disadvantaged populations [ 2 , 3 ]. This growing prevalence represents a major public health concern. Obesity is associated with an increased risk of numerous cardiometabolic and oncologic conditions, including type 2 diabetes, hypertension, cardiovascular disease, and several forms of cancer [ 4 – 7 ]. Beyond its somatic consequences, obesity also has profound psychological and social effects. Individuals living with obesity frequently report weight-related stigma, social discrimination, depressive symptoms, and impaired self-esteem [ 8 ]. These psychosocial dimensions contribute substantially to reduced health-related quality of life (HRQoL) [ 9 , 10 ]. In addition, the economic burden associated with overweight and obesity is considerable, affecting healthcare systems and broader societal productivity [ 11 – 13 ]. Given its complex etiology and multidimensional consequences, obesity management requires comprehensive and coordinated care strategies [ 14 ]. Primary care plays a central role in the long-term management of obesity by providing continuity of care and coordinating multidisciplinary interventions. In this context, therapeutic patient education (TPE) programs have emerged as an important component of chronic disease management. In France, TPE programs are structured interventions designed to improve patients’ knowledge, self-management skills, autonomy, and long-term engagement in care [ 15 ]. In obesity management, these programs typically integrate nutritional counselling, promotion of physical activity, and psychological support within a multidisciplinary framework. Historically, obesity interventions have primarily focused on weight reduction as the principal indicator of therapeutic success. However, weight loss alone does not fully capture the patient’s lived experience or the broader impact of care [ 16 – 18 ]. Recent clinical guidelines emphasize the importance of incorporating quality-of-life assessment into obesity management pathways [ 14 ]. HRQoL reflects not only physical functioning but also psychological well-being, social participation, and self-perception, all of which are central to patient-centered care. A substantial body of evidence demonstrates that obesity is associated with impaired HRQoL across physical and mental domains [ 19 – 22 ]. While generic instruments such as the SF-36 are frequently used [ 23 ], obesity-specific questionnaires may provide greater sensitivity to dimensions uniquely affected by excess weight, including body image, stigma, eating behaviour, and dietary restriction. The Quality of Life, Obesity and Dietetics (QOLOD) scale, known in France as EQVOD, was specifically developed and validated to assess these domains within the French sociocultural context [ 24 ]. Multidisciplinary lifestyle interventions have been shown to improve HRQoL in individuals with obesity [ 25 , 26 ]. However, most studies concern hospital-based programs or surgical interventions, and relatively few have evaluated structured therapeutic patient education programs delivered in coordinated primary care settings. Furthermore, the specific impact of such programs on obesity-specific quality of life, rather than on generic HRQoL measures alone, remains insufficiently documented. Evaluating patient-reported outcomes in real-world primary care interventions is therefore essential. However, the impact of structured therapeutic patient education programs delivered in coordinated primary care on obesity-specific quality of life remains insufficiently documented. The aim of this study was to evaluate changes in obesity-specific quality of life among adults participating in a structured therapeutic patient education program implemented in coordinated primary care using a prospective before–after design. Subjects and Method Study design We conducted a prospective single-arm before–after study to evaluate a therapeutic patient education (TPE) program implemented in a coordinated primary care setting in Paris, France, between June 2023 and December 2024. The program was delivered as part of routine care within a multidisciplinary primary care network. This study was designed as a real-world evaluation of an existing care pathway implemented in primary care. All eligible participants enrolled during the study period were consecutively included. As the objective was exploratory and pragmatic, no formal sample size calculation was performed prior to inclusion. The study is reported in accordance with STROBE recommendations for observational studies. Setting The study was conducted within the RESOBE program, implemented in the 15th arrondissement of Paris, France. The program is coordinated by a Territorial Professional Health Community (Communauté Professionnelle Territoriale de Santé, CPTS) in collaboration with the Georges Pompidou European Hospital and the ROMDES network (Multidisciplinary Obesity Network of Essonne and Seine-et-Marne). The program operates within coordinated primary care and is approved by the Regional Health Agency. It is part of a structured pathway designed to improve access to multidisciplinary obesity management in community settings. Participants Adults aged 18 years or older with a body mass index (BMI) ≥ 30 kg/m² who enrolled in the RESOBE program between June 2023 and December 2024 were eligible for inclusion. Exclusion criteria were: Legal incapacity or guardianship status Inability to understand or complete questionnaires in French Participants were referred by their general practitioners. After obtaining patient agreement to be contacted, the CPTS coordinator provided information about the study. All participants gave written informed consent for the use of their anonymized data for research purposes. Recruitment was discontinued in early 2025 following organizational changes in the program structure. Intervention The RESOBE therapeutic education program lasted approximately three months and included: An initial individual educational assessment Four structured group workshops A final individual assessment Each group workshop included 6 to 8 participants and lasted approximately two hours. Sessions were co-facilitated by trained healthcare professionals, including dietitians, psychologists, an adapted physical activity coach, and a physiotherapist. All facilitators had completed certified training in therapeutic patient education (minimum 40 hours). The workshops addressed the following themes: Understanding obesity as a chronic disease and its associated comorbidities Eating behavior, including recognition of hunger and satiety cues Adapted physical activity and reduction of sedentary behavior Consolidation of acquired knowledge and individualized care planning The initial and final individual assessments were conducted by the same professional whenever possible and aimed to evaluate patient needs, goals, and progress. Outcome measure Quality of life was assessed using the French-validated EQVOD questionnaire [ 20 ], an obesity-specific instrument derived from the IWQOL-Lite. The questionnaire includes 36 items grouped into five domains: Physical impact Psychosocial impact Sexual life Food-related well-being Experience of dietary restriction Participants rated each item using a five-point Likert scale. Raw scores were converted to a standardized scale ranging from 0 to 100 to facilitate interpretation. Higher scores indicate better perceived quality of life. The primary outcome was the change in global EQVOD score between baseline (prior to the start of the program) and completion of the intervention (approximately three months later). Secondary analyses examined changes within each of the five domains. Data collection Participants completed the EQVOD questionnaire at two time points: At baseline, during the initial educational assessment At the end of the program, during the final assessment Questionnaires were administered either in paper format or electronically using the LimeSurvey platform, according to participant preference. All data were anonymized using a unique study identification number assigned to each participant. No directly identifying information was included in the analysis dataset. Statistical analysis Baseline characteristics were described using appropriate summary statistics. Continuous variables are presented as mean ± standard deviation or median (interquartile range), depending on distribution. Categorical variables are presented as counts and percentages. Quality-of-life scores were compared between baseline (program inclusion) and follow-up (end of intervention). Because of the modest sample size, changes in EQVOD scores were analyzed using the non-parametric Wilcoxon signed-rank test. For the primary outcome (global EQVOD score), statistical significance was defined using a two-sided p-value threshold of 0.05. For analyses of the five EQVOD domains, adjustment for multiple comparisons was performed using the Bonferroni correction. The conventional alpha level (0.05) was divided by the number of domain-level tests (n = 5), resulting in an adjusted significance threshold of 0.01. This conservative approach was chosen to limit the risk of type I error associated with multiple testing. To assess the robustness of findings in the presence of missing follow-up data, a sensitivity analysis was conducted including all participants initially enrolled in the study. Missing post-intervention quality-of-life scores were imputed using the Last Observation Carried Forward (LOCF) method, whereby baseline values were substituted for missing follow-up data. This approach assumes no change among non-respondents and therefore represents a conservative estimate of intervention effect. The association between baseline body mass index (BMI) and baseline global EQVOD score was explored using Spearman rank correlation, given the non-normal distribution of variables. All tests were two-sided. Statistical analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria). Results Participant flow and baseline characteristics Baseline characteristics of participants are presented in Table 1 . Table 1 Baseline characteristics of study participants (n = 31). Characteristic N = 31 Sex Female 21 (67.7%) Male 10 (32.3%) Age, years 52.2 ± 12.7; 53.0 (44.0–57.0) BMI category, kg/m² 30–35.9 10 (34.5%) 35–39.9 10 (34.5%) ≥ 40 9 (31.0%) Note. BMI data were missing for 2 participant(s); percentages are calculated based on available data. Between June 2023 and December 2024, 38 individuals enrolled in the RESOBE therapeutic education program. Of these, 31 met the inclusion criteria and were included in the study. All 31 participants completed the baseline assessment. Twenty-five participants completed the follow-up quality-of-life assessment at the end of the program, while six did not return the final questionnaire and were excluded from the primary paired analysis. The participant flow diagram is presented in Fig. 1 . The study population was predominantly female (21 women, 68%), with 10 men (32%). Participants’ ages ranged from 35 to 78 years, with a median age of 53.5 years. The mean baseline body mass index (BMI) was 37.4 ± 4.6 kg/m². Regarding obesity severity, 35.7% of participants had class I obesity (BMI 30–34.9 kg/m²), 35.7% had class II obesity (BMI 35–39.9 kg/m²), and 28.6% had class III obesity (BMI ≥ 40 kg/m²). At baseline, the mean global EQVOD score was 57.4 (on a 0–100 scale), indicating moderate impairment in obesity-specific quality of life. Change in global EQVOD score Changes in global EQVOD score are illustrated in Fig. 2 . Descriptive statistics of global EQVOD scores are shown in Table 2 . Table 2 Descriptive statistics of global EQVOD scores (0–100) before and after intervention. Time point n Mean ± SD Median (IQR) Baseline 25 57.4 ± 11.8 58.3 (48.3–66.7) Follow-up 25 65.0 ± 11.1 63.3 (57.8–76.1) Note. Descriptive statistics are based on paired observations (n = 25). Wilcoxon signed-rank test (paired): p = 0.002. Among the 25 participants with complete paired data, the mean global EQVOD score increased from 57.4 at baseline to 65.0 after completion of the three-month program. This corresponds to a mean improvement of 7.6 points (95% confidence interval 3.6 to 11.7). The change was statistically significant (paired Wilcoxon signed-rank test, p = 0.002), with a moderate effect size. Individual-level changes are illustrated in Fig. 2 . The majority of participants exhibited an increase in their global EQVOD score between baseline and follow-up, while a minority showed stable or slightly decreased scores. Sensitivity analysis for missing data Sensitivity analysis results are presented in Table 3 . Table 3 Descriptive statistics of global EQVOD scores (0–100) before and after intervention using the LOCF method. Time point n Mean ± SD Median (IQR) Baseline 31 56.8 ± 12.1 56.1 (46.1–66.7) Follow-up 31 65.5 ± 12.6 61.7 (56.4–71.9) Note. Descriptive statistics are based on paired observations (n = 31). Wilcoxon signed-rank test (paired): p = 0.001. To assess the robustness of these findings in the presence of missing follow-up data, a sensitivity analysis was conducted using a conservative imputation strategy in which missing post-intervention scores were replaced by baseline values. When all 31 participants were included under this assumption, the mean global EQVOD score increased from 56.8 at baseline to 65.6 at follow-up, corresponding to a mean improvement of 8.7 points. This change remained statistically significant (p = 0.001), indicating that the primary findings were not materially affected by missing data. Domain-specific changes in quality of life Changes across EQVOD domains are presented in Fig. 3 and are summarized in Table 4 . Table 4 EQVOD domain scores (0–100) at baseline and follow-up. Domain n Baseline Mean ± SD Baseline Median (IQR) Follow-up Mean ± SD Follow-up Median (IQR) p-value Physical impact 25 60.8 ± 14.6 61.8 (56.4–69.1) 66.8 ± 13.0 67.3 (56.4–74.5) 0.013 Psychosocial impact 25 59.9 ± 16.8 61.8 (47.3–69.1) 69.2 ± 17.8 69.1 (54.5–85.5) 0.005 Sexual life 25 63.2 ± 25.7 65.0 (40.0–80.0) 68.8 ± 27.6 70.0 (50.0–95.0) 0.075 Food-related well-being 25 47.5 ± 18.8 48.0 (32.0–60.0) 55.4 ± 17.3 60.0 (44.0–68.0) 0.004 Experiences related to dietary restrictions 25 49.9 ± 15.4 48.0 (40.0–56.0) 58.7 ± 13.0 60.0 (52.0–64.0) 0.020 Note. P-values are from paired Wilcoxon signed-rank tests. For domain-level comparisons (5 tests), a Bonferroni-adjusted significance threshold of 0.01 was used. Changes in each of the five EQVOD domains were analyzed separately. Mean differences and corresponding confidence intervals are presented in Fig. 3 . Improvements were observed across all domains. After adjustment for multiple comparisons, statistically significant improvements were identified in: Psychosocial impact (+ 9.3 points; p = 0.005) Food-related well-being (+ 7.9 points; p = 0.004) Although increases were also observed in the physical impact, sexual life, and experience of dietary restriction domains, they did not remain significant after Bonferroni correction (α = 0.01). The psychosocial domain exhibited the largest absolute mean increase among all dimensions. Association between BMI and baseline quality of life Exploratory analysis of the relationship between baseline BMI and baseline global EQVOD score showed no statistically significant association (Spearman ρ = −0.006; p = 0.978). The severity of obesity as measured by BMI was therefore not directly correlated with perceived quality of life in this sample. Discussion In this prospective real-world evaluation, participation in a structured therapeutic patient education program delivered within coordinated primary care was associated with a statistically significant improvement in obesity-specific quality of life over a three-month period. The observed mean increase of 7.6 points on the EQVOD scale suggests a meaningful enhancement in patient-perceived well-being. Interpretation of main findings The most pronounced improvements were observed in the psychosocial and food-related well-being domains. These findings are particularly relevant given the well-documented psychological and social burden associated with obesity. Individuals living with obesity frequently experience stigma, discrimination, and internalized weight bias, all of which contribute to impaired health-related quality of life [ 8 , 19 , 20 ]. The improvement observed in psychosocial impact may reflect mechanisms intrinsic to therapeutic education programs. Group-based sessions provide opportunities for peer interaction, normalization of shared experiences, and reduction of social isolation. Reframing obesity as a chronic disease rather than a personal failure may also reduce self-blame and enhance self-efficacy. These mechanisms are consistent with broader evidence linking structured behavioural interventions to improvements in perceived well-being and patient experience [ 16 – 18 ]. Similarly, the improvement in food-related well-being suggests a qualitative change in participants’ relationship with eating behaviours. Traditional weight-centred approaches often emphasize restriction, which may reinforce cycles of guilt and perceived failure. In contrast, therapeutic education promotes awareness of hunger cues, emotional regulation, and sustainable behavioural changes. Such approaches may reduce the psychological distress frequently associated with dieting attempts and contribute to improved perceptions of well-being. Quality of life beyond anthropometric outcomes Interestingly, no association was observed between baseline BMI and baseline quality-of-life score. This observation is consistent with previous research showing that the perceived burden of obesity does not necessarily correlate linearly with anthropometric severity [ 21 , 22 ]. Psychological vulnerability, social context, and prior experiences of weight stigma may exert a stronger influence on quality of life than BMI alone. Historically, obesity interventions have primarily focused on weight reduction as the main indicator of therapeutic success. However, weight loss alone does not fully capture patient experience or functional improvement [ 16 – 18 ]. Increasingly, clinical guidelines emphasize the importance of integrating patient-reported outcomes into obesity management pathways [ 14 ]. Quality of life reflects multiple dimensions, including physical functioning, psychological well-being, social participation, and self-perception, and therefore provides a broader evaluation of therapeutic benefit. Comparison with existing literature The present findings are consistent with the conceptual framework of therapeutic patient education, which emphasizes the development of self-management skills and psychosocial empowerment beyond biomedical targets. Recent narrative syntheses highlight that the effectiveness of therapeutic patient education in obesity and diabetes should not be assessed solely through biomedical indicators such as weight or glycaemic control, but also through improvements in quality of life and behavioural adaptation [ 27 ]. Our results support this multidimensional perspective. Previous studies have also shown that multidisciplinary lifestyle interventions combining nutritional counselling, physical activity, and psychological support can improve health-related quality of life in individuals with obesity [ 25 , 26 ]. However, much of this evidence originates from hospital-based interventions or bariatric surgery contexts, where improvements in HRQoL are often associated with substantial weight loss [ 26 ]. By contrast, relatively few studies have evaluated structured therapeutic patient education programs delivered in coordinated primary care settings. Furthermore, many investigations rely on generic instruments such as the SF-36 [ 23 ], which may be less sensitive to obesity-specific domains such as body image, eating-related distress, or experiences associated with dietary restriction. The present study contributes to the literature by employing a validated obesity-specific instrument (EQVOD) [ 24 ], allowing domain-level analysis tailored to the sociocultural context of obesity in France. The use of an obesity-specific quality-of-life instrument may provide greater sensitivity to psychosocial and behavioural dimensions affected by excess weight compared with generic HRQoL measures. By evaluating a real-world intervention embedded in community care, this study also supports the growing recognition of multidisciplinary primary care approaches in chronic disease management [ 14 , 15 ]. Clinical implications The magnitude of improvement observed in psychosocial and food-related domains suggests that therapeutic education programs may provide benefits extending beyond weight-related outcomes alone. Early improvements in perceived well-being may enhance motivation, support behavioural change, and promote sustained engagement in care. These findings support the integration of patient-reported outcome measures into routine obesity management. Assessing quality of life may help clinicians identify priority areas of distress and tailor interventions accordingly. In chronic conditions such as obesity, where long-term management is essential, improvements in perceived well-being may represent an important therapeutic objective alongside traditional clinical outcomes. Strengths and limitations This study has several strengths. First, it employed a validated obesity-specific questionnaire [ 24 ], enabling precise assessment of domains uniquely affected by obesity. Second, it evaluated a structured therapeutic education program implemented within coordinated primary care, thereby enhancing ecological validity. Third, sensitivity analyses addressing missing follow-up data produced consistent results, supporting the robustness of the primary findings. However, several limitations should be considered. The relatively small sample size limits the generalisability of the findings. The before–after design without a control group also restricts the ability to attribute observed improvements solely to the intervention. Changes in quality of life may partly reflect temporal trends, participant motivation, regression to the mean, or expectancy effects. In addition, the short follow-up period does not allow assessment of the long-term sustainability of the observed improvements. Although conservative, the use of LOCF for handling missing follow-up data has recognised methodological limitations. Finally, anthropometric or metabolic outcomes were not assessed alongside quality-of-life measures, preventing evaluation of potential relationships between clinical and patient-reported outcomes. Future research should therefore include controlled study designs, larger sample sizes, longer follow-up periods, and the combined assessment of patient-reported and objective clinical outcomes in order to better understand the durability and mechanisms of the observed benefits. Implications for primary care These findings suggest that therapeutic patient education programs implemented in primary care may contribute to improving obesity-specific quality of life. Integrating structured educational interventions into coordinated primary care pathways could therefore represent a relevant strategy to support patients living with obesity and to promote more patient-centred evaluation of treatment outcomes. Conclusion In this prospective real-world evaluation, participation in a structured therapeutic patient education program delivered within coordinated primary care was associated with short-term improvement in obesity-specific quality of life. The most substantial gains were observed in psychosocial and food-related domains, highlighting the multidimensional nature of therapeutic benefits beyond anthropometric measures alone. These findings support the integration of validated patient-reported outcome measures into routine obesity care pathways. In chronic conditions such as obesity, where psychological and social burden is substantial, quality of life should be considered a key outcome when evaluating therapeutic interventions. Although causal inference cannot be established due to the absence of a control group and the limited sample size, the observed improvements suggest that structured therapeutic patient education programs delivered in primary care may contribute to enhancing patient-perceived well-being. Further controlled studies including larger populations, longer follow-up periods, and combined assessment of clinical and patient-reported outcomes are needed to confirm these findings and better understand the mechanisms underlying the observed improvements. Declarations Ethics approval and consent to participate This study was conducted in accordance with the MR-004 reference methodology of the French Data Protection Authority (CNIL) governing non-interventional research using personal health data. Ethical approval was obtained from CERAPHP Centre prior to study initiation (IRB registration #00011928). Participants received written information regarding the use of their data for research purposes and were informed of their right to object to the use of their data. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution ED conducted the research and drafted the manuscript. AIT supervised the research and contributed to manuscript writing. EL contributed to the study methodology and validated the analytical approach. CR participated in the implementation of the therapeutic education program. SK supervised the overall scientific work and provided methodological guidance. All authors reviewed the manuscript, contributed to the interpretation of the results, and approved the final version of the manuscript.ED – Eloïse DeliryAIT – Anne-Isabelle TropeanoEL – Emilie LanoyCR – Cécile RossSK – Sandrine Katsahian Acknowledgement The authors thank all those who contributed to the implementation of this project. They would like to extend special thanks to the Résobé team, coordinator Brian Ahting and the other members of the CPTS in Paris's 15th arrondissement. The authors would like to acknowledge the ROMDES network (Réseau Obésité de l’Adulte en Île-de-France) for initiating and developing the therapeutic patient education program evaluated in this study. They also wish to thank the Public Health Department representative of the Regional Health Agency (ARS Île-de-France) for their support and commitment to the implementation of this program. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References World Health Organization. Obesity and overweight. 2024. Available from: https://www.who.int/fr/news-room/fact-sheets/detail/obesity-and-overweight . Accessed 10 Oct 2024. Cara G. Obesity and overweight: nearly one in two people in France affected. Inserm Press Room. 2023. Available from: https://presse.inserm.fr/obesite-et-surpoids-pres-dun-francais-sur-deux-concerne/ . Accessed 7 Jun 2023. 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Huang IC, Frangakis C, Wu AW. The relationship of excess body weight and health-related quality of life: evidence from a population study in Taiwan. Int J Obes (Lond). 2006;30(8):1250–9. 10.1038/sj.ijo.0803250 . Ul-Haq Z, Mackay DF, Fenwick E, Pell JP. Meta-analysis of the association between body mass index and health-related quality of life among adults, assessed by the SF-36. Obes (Silver Spring). 2013;21(3):E322–7. 10.1002/oby.20107 . Ziegler O, Filipecki J, Girod I, Guillemin F. Development and validation of a French obesity-specific quality of life questionnaire: Quality of Life, Obesity and Dietetics (QOLOD) rating scale. Diabetes Metab. 2005;31(3):273–83. 10.1016/S1262-3636(07)70194-5 . Warkentin LM, Das D, Majumdar SR, Johnson JA, Padwal RS. The effect of weight loss on health-related quality of life: systematic review and meta-analysis of randomized trials. Obes Rev. 2014;15(3):169–82. 10.1111/obr.12113 . Karlsson J, Taft C, Ryden A, Sjostrom L, Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes (Lond). 2007;31(8):1248–61. 10.1038/sj.ijo.0803573 . Correia JC, Waqas A, Golay A, Pataky Z. Evolution and effectiveness of therapeutic patient education for obesity and diabetes. Rev Med Suisse. 2022;18(774):512–5. 10.53738/REVMED.2022.18.774.512 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 29 Apr, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviewers invited by journal 03 Apr, 2026 Editor invited by journal 11 Mar, 2026 Editor assigned by journal 10 Mar, 2026 Submission checks completed at journal 10 Mar, 2026 First submitted to journal 09 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9071737","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":618645970,"identity":"fd1a6b2b-2654-4f30-843b-eb84138aabd0","order_by":0,"name":"Eloïse Deliry","email":"","orcid":"","institution":"Université Paris Cité","correspondingAuthor":false,"prefix":"","firstName":"Eloïse","middleName":"","lastName":"Deliry","suffix":""},{"id":618645971,"identity":"ec56c75a-b8d1-4db5-ab5d-2197b1fb3e5c","order_by":1,"name":"Emilie Lanoy","email":"","orcid":"","institution":"AP-HP, Hôpital Européen Georges Pompidou, APHP Centre","correspondingAuthor":false,"prefix":"","firstName":"Emilie","middleName":"","lastName":"Lanoy","suffix":""},{"id":618645972,"identity":"6615bb8c-670d-400c-800d-d91b9ea98e6a","order_by":2,"name":"Cécile Ross","email":"","orcid":"","institution":"MD","correspondingAuthor":false,"prefix":"","firstName":"Cécile","middleName":"","lastName":"Ross","suffix":""},{"id":618645973,"identity":"7fe0fcc2-033a-44fb-aea5-29ca07dd44f5","order_by":3,"name":"Sandrine Katsahian","email":"","orcid":"","institution":"Université Paris Cité","correspondingAuthor":false,"prefix":"","firstName":"Sandrine","middleName":"","lastName":"Katsahian","suffix":""},{"id":618645974,"identity":"bb0f55c4-d61e-4924-a43a-4e1beade3e9a","order_by":4,"name":"Anne-Isabelle Tropeano","email":"data:image/png;base64,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","orcid":"","institution":"AP-HP, Hôpital Européen Georges Pompidou, APHP Centre","correspondingAuthor":true,"prefix":"","firstName":"Anne-Isabelle","middleName":"","lastName":"Tropeano","suffix":""}],"badges":[],"createdAt":"2026-03-09 10:39:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9071737/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9071737/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106546554,"identity":"86c54845-62e2-4c74-80b0-f569a7097459","added_by":"auto","created_at":"2026-04-09 17:04:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1544856,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of participant enrollment, inclusion, follow-up, and final analysis in the therapeutic patient education (TPE) program.\u003c/p\u003e","description":"","filename":"FIG1.png","url":"https://assets-eu.researchsquare.com/files/rs-9071737/v1/921d10c3d09e5c8e8b44b006.png"},{"id":106726682,"identity":"58dd6663-df5f-47fd-bbae-06546a81a4d7","added_by":"auto","created_at":"2026-04-12 18:37:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":162825,"visible":true,"origin":"","legend":"\u003cp\u003eIndividual changes in global EQVOD score (0–100) between baseline and follow-up among participants with paired data (n = 25). Boxplots display median and interquartile range; whiskers represent 1.5×IQR. Paired differences were analyzed using the Wilcoxon signed-rank test.\u003c/p\u003e","description":"","filename":"FIG2.png","url":"https://assets-eu.researchsquare.com/files/rs-9071737/v1/cb9bf7fc28c7bd0631208870.png"},{"id":106725272,"identity":"d63a0178-f442-4ee4-979a-74e13a3a75fa","added_by":"auto","created_at":"2026-04-12 18:32:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":157111,"visible":true,"origin":"","legend":"\u003cp\u003eMean change in EQVOD domain scores (0–100) from baseline to follow-up among participants with paired data. Points represent mean within-participant changes (follow-up minus baseline), and horizontal bars indicate 95% confidence intervals. The vertical reference line at 0 indicates no change.\u003c/p\u003e","description":"","filename":"FIG3.png","url":"https://assets-eu.researchsquare.com/files/rs-9071737/v1/7596b91212af7dbfad459c21.png"},{"id":106728005,"identity":"c4511135-1958-4fb1-9a84-acfb0d971f4f","added_by":"auto","created_at":"2026-04-12 18:41:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2546161,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9071737/v1/1faaa099-8963-4b6a-a8ac-ec8608d824d1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Changes in obesity-specific quality of life after a therapeutic patient education program in primary care: a prospective before–after study","fulltext":[{"header":"Background","content":"\u003cp\u003eObesity is a chronic, multifactorial, and progressive disease whose prevalence continues to rise worldwide. According to the World Health Organization, approximately one in eight individuals globally is affected [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In France, recent epidemiological data indicate that nearly 17% of adults are living with obesity, with a particularly marked increase among socioeconomically disadvantaged populations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This growing prevalence represents a major public health concern.\u003c/p\u003e \u003cp\u003eObesity is associated with an increased risk of numerous cardiometabolic and oncologic conditions, including type 2 diabetes, hypertension, cardiovascular disease, and several forms of cancer [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Beyond its somatic consequences, obesity also has profound psychological and social effects. Individuals living with obesity frequently report weight-related stigma, social discrimination, depressive symptoms, and impaired self-esteem [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These psychosocial dimensions contribute substantially to reduced health-related quality of life (HRQoL) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In addition, the economic burden associated with overweight and obesity is considerable, affecting healthcare systems and broader societal productivity [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven its complex etiology and multidimensional consequences, obesity management requires comprehensive and coordinated care strategies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Primary care plays a central role in the long-term management of obesity by providing continuity of care and coordinating multidisciplinary interventions. In this context, therapeutic patient education (TPE) programs have emerged as an important component of chronic disease management. In France, TPE programs are structured interventions designed to improve patients\u0026rsquo; knowledge, self-management skills, autonomy, and long-term engagement in care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In obesity management, these programs typically integrate nutritional counselling, promotion of physical activity, and psychological support within a multidisciplinary framework.\u003c/p\u003e \u003cp\u003eHistorically, obesity interventions have primarily focused on weight reduction as the principal indicator of therapeutic success. However, weight loss alone does not fully capture the patient\u0026rsquo;s lived experience or the broader impact of care [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Recent clinical guidelines emphasize the importance of incorporating quality-of-life assessment into obesity management pathways [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. HRQoL reflects not only physical functioning but also psychological well-being, social participation, and self-perception, all of which are central to patient-centered care.\u003c/p\u003e \u003cp\u003eA substantial body of evidence demonstrates that obesity is associated with impaired HRQoL across physical and mental domains [\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. While generic instruments such as the SF-36 are frequently used [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], obesity-specific questionnaires may provide greater sensitivity to dimensions uniquely affected by excess weight, including body image, stigma, eating behaviour, and dietary restriction. The Quality of Life, Obesity and Dietetics (QOLOD) scale, known in France as EQVOD, was specifically developed and validated to assess these domains within the French sociocultural context [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMultidisciplinary lifestyle interventions have been shown to improve HRQoL in individuals with obesity [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, most studies concern hospital-based programs or surgical interventions, and relatively few have evaluated structured therapeutic patient education programs delivered in coordinated primary care settings. Furthermore, the specific impact of such programs on obesity-specific quality of life, rather than on generic HRQoL measures alone, remains insufficiently documented.\u003c/p\u003e \u003cp\u003eEvaluating patient-reported outcomes in real-world primary care interventions is therefore essential. However, the impact of structured therapeutic patient education programs delivered in coordinated primary care on obesity-specific quality of life remains insufficiently documented.\u003c/p\u003e \u003cp\u003e The aim of this study was to evaluate changes in obesity-specific quality of life among adults participating in a structured therapeutic patient education program implemented in coordinated primary care using a prospective before\u0026ndash;after design.\u003c/p\u003e"},{"header":"Subjects and Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eWe conducted a prospective single-arm before\u0026ndash;after study to evaluate a therapeutic patient education (TPE) program implemented in a coordinated primary care setting in Paris, France, between June 2023 and December 2024. The program was delivered as part of routine care within a multidisciplinary primary care network.\u003c/p\u003e \u003cp\u003eThis study was designed as a real-world evaluation of an existing care pathway implemented in primary care. All eligible participants enrolled during the study period were consecutively included. As the objective was exploratory and pragmatic, no formal sample size calculation was performed prior to inclusion.\u003c/p\u003e \u003cp\u003eThe study is reported in accordance with STROBE recommendations for observational studies.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted within the RESOBE program, implemented in the 15th arrondissement of Paris, France. The program is coordinated by a Territorial Professional Health Community (Communaut\u0026eacute; Professionnelle Territoriale de Sant\u0026eacute;, CPTS) in collaboration with the Georges Pompidou European Hospital and the ROMDES network (Multidisciplinary Obesity Network of Essonne and Seine-et-Marne).\u003c/p\u003e \u003cp\u003eThe program operates within coordinated primary care and is approved by the Regional Health Agency. It is part of a structured pathway designed to improve access to multidisciplinary obesity management in community settings.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eAdults aged 18 years or older with a body mass index (BMI)\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2; who enrolled in the RESOBE program between June 2023 and December 2024 were eligible for inclusion.\u003c/p\u003e \u003cp\u003eExclusion criteria were:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLegal incapacity or guardianship status\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eInability to understand or complete questionnaires in French\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eParticipants were referred by their general practitioners. After obtaining patient agreement to be contacted, the CPTS coordinator provided information about the study. All participants gave written informed consent for the use of their anonymized data for research purposes.\u003c/p\u003e \u003cp\u003eRecruitment was discontinued in early 2025 following organizational changes in the program structure.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe RESOBE therapeutic education program lasted approximately three months and included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAn initial individual educational assessment\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFour structured group workshops\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA final individual assessment\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eEach group workshop included 6 to 8 participants and lasted approximately two hours. Sessions were co-facilitated by trained healthcare professionals, including dietitians, psychologists, an adapted physical activity coach, and a physiotherapist. All facilitators had completed certified training in therapeutic patient education (minimum 40 hours).\u003c/p\u003e \u003cp\u003eThe workshops addressed the following themes:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUnderstanding obesity as a chronic disease and its associated comorbidities\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEating behavior, including recognition of hunger and satiety cues\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAdapted physical activity and reduction of sedentary behavior\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eConsolidation of acquired knowledge and individualized care planning\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe initial and final individual assessments were conducted by the same professional whenever possible and aimed to evaluate patient needs, goals, and progress.\u003c/p\u003e\n\u003ch3\u003eOutcome measure\u003c/h3\u003e\n\u003cp\u003eQuality of life was assessed using the French-validated EQVOD questionnaire [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], an obesity-specific instrument derived from the IWQOL-Lite.\u003c/p\u003e \u003cp\u003eThe questionnaire includes 36 items grouped into five domains:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePhysical impact\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePsychosocial impact\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSexual life\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFood-related well-being\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExperience of dietary restriction\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eParticipants rated each item using a five-point Likert scale. Raw scores were converted to a standardized scale ranging from 0 to 100 to facilitate interpretation. Higher scores indicate better perceived quality of life.\u003c/p\u003e \u003cp\u003eThe primary outcome was the change in global EQVOD score between baseline (prior to the start of the program) and completion of the intervention (approximately three months later).\u003c/p\u003e \u003cp\u003eSecondary analyses examined changes within each of the five domains.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eParticipants completed the EQVOD questionnaire at two time points:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAt baseline, during the initial educational assessment\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAt the end of the program, during the final assessment\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eQuestionnaires were administered either in paper format or electronically using the LimeSurvey platform, according to participant preference.\u003c/p\u003e \u003cp\u003eAll data were anonymized using a unique study identification number assigned to each participant. No directly identifying information was included in the analysis dataset.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eBaseline characteristics were described using appropriate summary statistics. Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range), depending on distribution. Categorical variables are presented as counts and percentages.\u003c/p\u003e \u003cp\u003eQuality-of-life scores were compared between baseline (program inclusion) and follow-up (end of intervention). Because of the modest sample size, changes in EQVOD scores were analyzed using the non-parametric Wilcoxon signed-rank test.\u003c/p\u003e \u003cp\u003eFor the primary outcome (global EQVOD score), statistical significance was defined using a two-sided p-value threshold of 0.05.\u003c/p\u003e \u003cp\u003eFor analyses of the five EQVOD domains, adjustment for multiple comparisons was performed using the Bonferroni correction. The conventional alpha level (0.05) was divided by the number of domain-level tests (n\u0026thinsp;=\u0026thinsp;5), resulting in an adjusted significance threshold of 0.01. This conservative approach was chosen to limit the risk of type I error associated with multiple testing.\u003c/p\u003e \u003cp\u003eTo assess the robustness of findings in the presence of missing follow-up data, a sensitivity analysis was conducted including all participants initially enrolled in the study. Missing post-intervention quality-of-life scores were imputed using the Last Observation Carried Forward (LOCF) method, whereby baseline values were substituted for missing follow-up data. This approach assumes no change among non-respondents and therefore represents a conservative estimate of intervention effect.\u003c/p\u003e \u003cp\u003eThe association between baseline body mass index (BMI) and baseline global EQVOD score was explored using Spearman rank correlation, given the non-normal distribution of variables.\u003c/p\u003e \u003cp\u003eAll tests were two-sided. Statistical analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant flow and baseline characteristics\u003c/h2\u003e \u003cp\u003eBaseline characteristics of participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of study participants (n\u0026thinsp;=\u0026thinsp;31).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;31\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (67.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (32.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7; 53.0 (44.0\u0026ndash;57.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI category, kg/m\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;35.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (34.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;39.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (34.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (31.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote. BMI data were missing for 2 participant(s); percentages are calculated based on available data.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBetween June 2023 and December 2024, 38 individuals enrolled in the RESOBE therapeutic education program. Of these, 31 met the inclusion criteria and were included in the study. All 31 participants completed the baseline assessment. Twenty-five participants completed the follow-up quality-of-life assessment at the end of the program, while six did not return the final questionnaire and were excluded from the primary paired analysis. The participant flow diagram is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe study population was predominantly female (21 women, 68%), with 10 men (32%). Participants\u0026rsquo; ages ranged from 35 to 78 years, with a median age of 53.5 years. The mean baseline body mass index (BMI) was 37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 kg/m\u0026sup2;. Regarding obesity severity, 35.7% of participants had class I obesity (BMI 30\u0026ndash;34.9 kg/m\u0026sup2;), 35.7% had class II obesity (BMI 35\u0026ndash;39.9 kg/m\u0026sup2;), and 28.6% had class III obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;40 kg/m\u0026sup2;).\u003c/p\u003e \u003cp\u003eAt baseline, the mean global EQVOD score was 57.4 (on a 0\u0026ndash;100 scale), indicating moderate impairment in obesity-specific quality of life.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eChange in global EQVOD score\u003c/h2\u003e \u003cp\u003eChanges in global EQVOD score are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Descriptive statistics of global EQVOD scores are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of global EQVOD scores (0\u0026ndash;100) before and after intervention.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e57.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.3 (48.3\u0026ndash;66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e65.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63.3 (57.8\u0026ndash;76.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote. Descriptive statistics are based on paired observations (n\u0026thinsp;=\u0026thinsp;25). Wilcoxon signed-rank test (paired): p\u0026thinsp;=\u0026thinsp;0.002.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong the 25 participants with complete paired data, the mean global EQVOD score increased from 57.4 at baseline to 65.0 after completion of the three-month program. This corresponds to a mean improvement of 7.6 points (95% confidence interval 3.6 to 11.7).\u003c/p\u003e \u003cp\u003eThe change was statistically significant (paired Wilcoxon signed-rank test, p\u0026thinsp;=\u0026thinsp;0.002), with a moderate effect size. Individual-level changes are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The majority of participants exhibited an increase in their global EQVOD score between baseline and follow-up, while a minority showed stable or slightly decreased scores.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSensitivity analysis for missing data\u003c/h2\u003e \u003cp\u003eSensitivity analysis results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of global EQVOD scores (0\u0026ndash;100) before and after intervention using the LOCF method.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e56.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.1 (46.1\u0026ndash;66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e65.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.7 (56.4\u0026ndash;71.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote. Descriptive statistics are based on paired observations (n\u0026thinsp;=\u0026thinsp;31). Wilcoxon signed-rank test (paired): p\u0026thinsp;=\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo assess the robustness of these findings in the presence of missing follow-up data, a sensitivity analysis was conducted using a conservative imputation strategy in which missing post-intervention scores were replaced by baseline values.\u003c/p\u003e \u003cp\u003eWhen all 31 participants were included under this assumption, the mean global EQVOD score increased from 56.8 at baseline to 65.6 at follow-up, corresponding to a mean improvement of 8.7 points. This change remained statistically significant (p\u0026thinsp;=\u0026thinsp;0.001), indicating that the primary findings were not materially affected by missing data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDomain-specific changes in quality of life\u003c/h2\u003e \u003cp\u003eChanges across EQVOD domains are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEQVOD domain scores (0\u0026ndash;100) at baseline and follow-up.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBaseline Median (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFollow-up Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFollow-up Median (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e60.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.8 (56.4\u0026ndash;69.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e66.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e67.3 (56.4\u0026ndash;74.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychosocial impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e59.9\u0026thinsp;\u0026plusmn;\u0026thinsp;16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.8 (47.3\u0026ndash;69.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e69.2\u0026thinsp;\u0026plusmn;\u0026thinsp;17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e69.1 (54.5\u0026ndash;85.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e63.2\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.0 (40.0\u0026ndash;80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e68.8\u0026thinsp;\u0026plusmn;\u0026thinsp;27.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e70.0 (50.0\u0026ndash;95.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood-related well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e47.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.0 (32.0\u0026ndash;60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e55.4\u0026thinsp;\u0026plusmn;\u0026thinsp;17.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e60.0 (44.0\u0026ndash;68.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperiences related to dietary restrictions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e49.9\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.0 (40.0\u0026ndash;56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e58.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e60.0 (52.0\u0026ndash;64.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote. P-values are from paired Wilcoxon signed-rank tests. For domain-level comparisons (5 tests), a Bonferroni-adjusted significance threshold of 0.01 was used.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eChanges in each of the five EQVOD domains were analyzed separately. Mean differences and corresponding confidence intervals are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eImprovements were observed across all domains. After adjustment for multiple comparisons, statistically significant improvements were identified in:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePsychosocial impact (+\u0026thinsp;9.3 points; p\u0026thinsp;=\u0026thinsp;0.005)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFood-related well-being (+\u0026thinsp;7.9 points; p\u0026thinsp;=\u0026thinsp;0.004)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAlthough increases were also observed in the physical impact, sexual life, and experience of dietary restriction domains, they did not remain significant after Bonferroni correction (α\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eThe psychosocial domain exhibited the largest absolute mean increase among all dimensions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAssociation between BMI and baseline quality of life\u003c/h2\u003e \u003cp\u003eExploratory analysis of the relationship between baseline BMI and baseline global EQVOD score showed no statistically significant association (Spearman ρ = \u0026minus;0.006; p\u0026thinsp;=\u0026thinsp;0.978). The severity of obesity as measured by BMI was therefore not directly correlated with perceived quality of life in this sample.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this prospective real-world evaluation, participation in a structured therapeutic patient education program delivered within coordinated primary care was associated with a statistically significant improvement in obesity-specific quality of life over a three-month period. The observed mean increase of 7.6 points on the EQVOD scale suggests a meaningful enhancement in patient-perceived well-being.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation of main findings\u003c/h2\u003e \u003cp\u003eThe most pronounced improvements were observed in the psychosocial and food-related well-being domains. These findings are particularly relevant given the well-documented psychological and social burden associated with obesity. Individuals living with obesity frequently experience stigma, discrimination, and internalized weight bias, all of which contribute to impaired health-related quality of life [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe improvement observed in psychosocial impact may reflect mechanisms intrinsic to therapeutic education programs. Group-based sessions provide opportunities for peer interaction, normalization of shared experiences, and reduction of social isolation. Reframing obesity as a chronic disease rather than a personal failure may also reduce self-blame and enhance self-efficacy. These mechanisms are consistent with broader evidence linking structured behavioural interventions to improvements in perceived well-being and patient experience [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, the improvement in food-related well-being suggests a qualitative change in participants\u0026rsquo; relationship with eating behaviours. Traditional weight-centred approaches often emphasize restriction, which may reinforce cycles of guilt and perceived failure. In contrast, therapeutic education promotes awareness of hunger cues, emotional regulation, and sustainable behavioural changes. Such approaches may reduce the psychological distress frequently associated with dieting attempts and contribute to improved perceptions of well-being.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eQuality of life beyond anthropometric outcomes\u003c/h2\u003e \u003cp\u003eInterestingly, no association was observed between baseline BMI and baseline quality-of-life score. This observation is consistent with previous research showing that the perceived burden of obesity does not necessarily correlate linearly with anthropometric severity [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Psychological vulnerability, social context, and prior experiences of weight stigma may exert a stronger influence on quality of life than BMI alone.\u003c/p\u003e \u003cp\u003eHistorically, obesity interventions have primarily focused on weight reduction as the main indicator of therapeutic success. However, weight loss alone does not fully capture patient experience or functional improvement [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Increasingly, clinical guidelines emphasize the importance of integrating patient-reported outcomes into obesity management pathways [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Quality of life reflects multiple dimensions, including physical functioning, psychological well-being, social participation, and self-perception, and therefore provides a broader evaluation of therapeutic benefit.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eComparison with existing literature\u003c/h2\u003e \u003cp\u003eThe present findings are consistent with the conceptual framework of therapeutic patient education, which emphasizes the development of self-management skills and psychosocial empowerment beyond biomedical targets. Recent narrative syntheses highlight that the effectiveness of therapeutic patient education in obesity and diabetes should not be assessed solely through biomedical indicators such as weight or glycaemic control, but also through improvements in quality of life and behavioural adaptation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Our results support this multidimensional perspective.\u003c/p\u003e \u003cp\u003ePrevious studies have also shown that multidisciplinary lifestyle interventions combining nutritional counselling, physical activity, and psychological support can improve health-related quality of life in individuals with obesity [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, much of this evidence originates from hospital-based interventions or bariatric surgery contexts, where improvements in HRQoL are often associated with substantial weight loss [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBy contrast, relatively few studies have evaluated structured therapeutic patient education programs delivered in coordinated primary care settings. Furthermore, many investigations rely on generic instruments such as the SF-36 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which may be less sensitive to obesity-specific domains such as body image, eating-related distress, or experiences associated with dietary restriction.\u003c/p\u003e \u003cp\u003eThe present study contributes to the literature by employing a validated obesity-specific instrument (EQVOD) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], allowing domain-level analysis tailored to the sociocultural context of obesity in France. The use of an obesity-specific quality-of-life instrument may provide greater sensitivity to psychosocial and behavioural dimensions affected by excess weight compared with generic HRQoL measures. By evaluating a real-world intervention embedded in community care, this study also supports the growing recognition of multidisciplinary primary care approaches in chronic disease management [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eClinical implications\u003c/h2\u003e \u003cp\u003eThe magnitude of improvement observed in psychosocial and food-related domains suggests that therapeutic education programs may provide benefits extending beyond weight-related outcomes alone. Early improvements in perceived well-being may enhance motivation, support behavioural change, and promote sustained engagement in care.\u003c/p\u003e \u003cp\u003eThese findings support the integration of patient-reported outcome measures into routine obesity management. Assessing quality of life may help clinicians identify priority areas of distress and tailor interventions accordingly. In chronic conditions such as obesity, where long-term management is essential, improvements in perceived well-being may represent an important therapeutic objective alongside traditional clinical outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths. First, it employed a validated obesity-specific questionnaire [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], enabling precise assessment of domains uniquely affected by obesity. Second, it evaluated a structured therapeutic education program implemented within coordinated primary care, thereby enhancing ecological validity. Third, sensitivity analyses addressing missing follow-up data produced consistent results, supporting the robustness of the primary findings.\u003c/p\u003e \u003cp\u003eHowever, several limitations should be considered. The relatively small sample size limits the generalisability of the findings. The before\u0026ndash;after design without a control group also restricts the ability to attribute observed improvements solely to the intervention. Changes in quality of life may partly reflect temporal trends, participant motivation, regression to the mean, or expectancy effects.\u003c/p\u003e \u003cp\u003eIn addition, the short follow-up period does not allow assessment of the long-term sustainability of the observed improvements. Although conservative, the use of LOCF for handling missing follow-up data has recognised methodological limitations. Finally, anthropometric or metabolic outcomes were not assessed alongside quality-of-life measures, preventing evaluation of potential relationships between clinical and patient-reported outcomes.\u003c/p\u003e \u003cp\u003eFuture research should therefore include controlled study designs, larger sample sizes, longer follow-up periods, and the combined assessment of patient-reported and objective clinical outcomes in order to better understand the durability and mechanisms of the observed benefits.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eImplications for primary care\u003c/h2\u003e \u003cp\u003eThese findings suggest that therapeutic patient education programs implemented in primary care may contribute to improving obesity-specific quality of life. Integrating structured educational interventions into coordinated primary care pathways could therefore represent a relevant strategy to support patients living with obesity and to promote more patient-centred evaluation of treatment outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this prospective real-world evaluation, participation in a structured therapeutic patient education program delivered within coordinated primary care was associated with short-term improvement in obesity-specific quality of life. The most substantial gains were observed in psychosocial and food-related domains, highlighting the multidimensional nature of therapeutic benefits beyond anthropometric measures alone.\u003c/p\u003e \u003cp\u003eThese findings support the integration of validated patient-reported outcome measures into routine obesity care pathways. In chronic conditions such as obesity, where psychological and social burden is substantial, quality of life should be considered a key outcome when evaluating therapeutic interventions.\u003c/p\u003e \u003cp\u003eAlthough causal inference cannot be established due to the absence of a control group and the limited sample size, the observed improvements suggest that structured therapeutic patient education programs delivered in primary care may contribute to enhancing patient-perceived well-being.\u003c/p\u003e \u003cp\u003eFurther controlled studies including larger populations, longer follow-up periods, and combined assessment of clinical and patient-reported outcomes are needed to confirm these findings and better understand the mechanisms underlying the observed improvements.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the MR-004 reference methodology of the French Data Protection Authority (CNIL) governing non-interventional research using personal health data. Ethical approval was obtained from CERAPHP Centre prior to study initiation (IRB registration #00011928). Participants received written information regarding the use of their data for research purposes and were informed of their right to object to the use of their data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp;\u003c/h2\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eED conducted the research and drafted the manuscript. AIT supervised the research and contributed to manuscript writing. EL contributed to the study methodology and validated the analytical approach. CR participated in the implementation of the therapeutic education program. SK supervised the overall scientific work and provided methodological guidance. All authors reviewed the manuscript, contributed to the interpretation of the results, and approved the final version of the manuscript.ED \u0026ndash; Elo\u0026iuml;se DeliryAIT \u0026ndash; Anne-Isabelle TropeanoEL \u0026ndash; Emilie LanoyCR \u0026ndash; C\u0026eacute;cile RossSK \u0026ndash; Sandrine Katsahian\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors thank all those who contributed to the implementation of this project. They would like to extend special thanks to the R\u0026eacute;sob\u0026eacute; team, coordinator Brian Ahting and the other members of the CPTS in Paris's 15th arrondissement. The authors would like to acknowledge the ROMDES network (R\u0026eacute;seau Ob\u0026eacute;sit\u0026eacute; de l\u0026rsquo;Adulte en \u0026Icirc;le-de-France) for initiating and developing the therapeutic patient education program evaluated in this study. They also wish to thank the Public Health Department representative of the Regional Health Agency (ARS \u0026Icirc;le-de-France) for their support and commitment to the implementation of this program.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Obesity and overweight. 2024. 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Evolution and effectiveness of therapeutic patient education for obesity and diabetes. Rev Med Suisse. 2022;18(774):512\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.53738/REVMED.2022.18.774.512\u003c/span\u003e\u003cspan address=\"10.53738/REVMED.2022.18.774.512\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Obesity, Primary care, Therapeutic patient education, Quality of life, Patient-reported outcomes, Multidisciplinary care, Lifestyle intervention","lastPublishedDoi":"10.21203/rs.3.rs-9071737/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9071737/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eObesity is a chronic disease associated with substantial physical, psychological, and social burden. Primary care plays a central role in the long-term management of obesity and in coordinating multidisciplinary interventions. Although therapeutic patient education (TPE) is recommended as part of comprehensive obesity care, evidence regarding its impact on obesity-specific quality of life in real-world primary care settings remains limited. This study aimed to evaluate short-term changes in obesity-specific quality of life among adults participating in a structured TPE program delivered within coordinated primary care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a prospective single-arm before\u0026ndash;after study between June 2023 and December 2024 to evaluate the impact of a real-world therapeutic patient education program implemented in a coordinated primary care setting in Paris, France. Adults aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years with body mass index (BMI)\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2; were eligible. Quality of life was assessed at baseline and after completion of the three-month program using the validated French EQVOD questionnaire, an obesity-specific instrument. The primary outcome was the change in global EQVOD score (0\u0026ndash;100 scale). Paired comparisons were performed using non-parametric tests. Domain-specific analyses included adjustment for multiple comparisons. A sensitivity analysis was conducted to assess the impact of missing follow-up data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThirty-one participants were included, of whom 25 completed both baseline and follow-up assessments. Mean BMI was 37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 kg/m\u0026sup2;, and 68% were women. The mean global EQVOD score increased from 57.4 at baseline to 65.0 after the intervention, corresponding to a mean improvement of 7.6 points (95% CI 3.6\u0026ndash;11.7; p\u0026thinsp;=\u0026thinsp;0.002). Statistically significant improvements were observed in psychosocial impact (+\u0026thinsp;9.3 points; p\u0026thinsp;=\u0026thinsp;0.005) and food-related well-being (+\u0026thinsp;7.9 points; p\u0026thinsp;=\u0026thinsp;0.004). Results were consistent in sensitivity analyses. No association was observed between baseline BMI and baseline quality-of-life score.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eParticipation in this structured therapeutic patient education program implemented in primary care was associated with short-term improvement in obesity-specific quality of life, particularly in psychosocial and food-related domains. These findings suggest that therapeutic education programs integrated into primary care may contribute to improving patient-reported outcomes in obesity management. Larger controlled studies with longer follow-up are needed to confirm these results.\u003c/p\u003e","manuscriptTitle":"Changes in obesity-specific quality of life after a therapeutic patient education program in primary care: a prospective before–after study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 17:04:40","doi":"10.21203/rs.3.rs-9071737/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-29T11:40:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177942703990469834406896247348216053959","date":"2026-04-13T20:31:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74560492693287535815447084424911598115","date":"2026-04-13T14:11:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-03T14:32:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-11T04:41:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-10T07:26:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-10T07:26:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2026-03-09T10:32:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3e2fbf25-54f1-4825-afb8-d32fa30ffcf6","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T17:04:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 17:04:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9071737","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9071737","identity":"rs-9071737","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}