Literature Review

Successful Weight Loss Maintenance

Article· Literature Review (PDF Available)inAnnual Review of Nutrition 21(1):323-41 · February 2001with 8,854 Reads 
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DOI: 10.1146/annurev.nutr.21.1.323 · Source: PubMed
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Obesity is now recognized as a serious chronic disease, but there is pessimism about how successful treatment can be. A general perception is that almost no one succeeds in long-term maintenance of weight loss. To define long-term weight loss success, we need an accepted definition. We propose defining successful long-term weight loss maintenance as intentionally losing at least 10% of initial body weight and keeping it off for at least 1 year. According to this definition, the picture is much more optimistic, with perhaps greater than 20% of overweight/obese persons able to achieve success. We found that in the National Weight Control Registry, successful long-term weight loss maintainers (average weight loss of 30 kg for an average of 5.5 years) share common behavioral strategies, including eating a diet low in fat, frequent self-monitoring of body weight and food intake, and high levels of regular physical activity. Weight loss maintenance may get easier over time. Once these successful maintainers have maintained a weight loss for 2-5 years, the chances of longer-term success greatly increase.
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April 23, 2001 19:15 Annual Reviews AR133-14
Annu. Rev. Nutr. 2001. 21:323–41
° 2001 by Annual Reviews. All rights reserved
Rena R Wing
and James O Hill
The Miriam Hospital, Brown University, Providence, Rhode Island 02906, and
Center for Human Nutrition, University of Colorado Health Sciences Center, Denver,
Colorado 80262; e-mail:,
Key Words reduced-obese, obesity treatment, diet, exercise, obesity
Abstract Obesity is now recognized as a serious chronic disease, but there is
pessimism about how successful treatment can be. A general perception is that almost
no one succeeds in long-term maintenance of weight loss. To define long-term weight
losssuccess,weneedan accepted definition.Wepropose definingsuccessful long-term
weight loss maintenance as intentionally losing at least 10% of initial body weight and
keeping it off for at least 1 year. According to this definition, the picture is much more
optimistic, with perhaps greater than 20% of overweight/obese persons able to achieve
success. We found that in the National Weight Control Registry, successful long-term
weight loss maintainers (average weight loss of 30 kg for an average of 5.5 years)
share common behavioral strategies, including eating a diet low in fat, frequent self-
monitoring of body weight and food intake, and high levels of regular physical activity.
Weight loss maintenance may get easier over time. Once these successful maintainers
have maintained a weight loss for 2–5 years, thechancesof longer-term success greatly
INTRODUCTION ................................................ 324
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.......... 325
....................... 326
.................. 327
......................................................... 327
Self-Monitoring Weight and Behaviors Related to Weight
.................. 328
Physical Activity
............................................... 329
................................... 330
The Metabolic State of the Reduced-Obese
............................ 330
The Metabolic State of NWCR Subjects
............................... 333
Behavioral Factors in Long-Term Weight Loss Maintenance
................ 333
................................... 334
April 23, 2001 19:15 Annual Reviews AR133-14
324 WING
.................................................... 337
classified as overweight or obese. Many of these individuals are attempting to
lose weight (39). However, the perception of the general public is that long-term
reduction in body weight is difficult to achieve. The goal of this chapter is to
summarize the information available on successful weight loss maintenance. How
many achieve this goal? How do they do it? What are the consequences? In des-
cribing successful weight loss maintainers, we draw heavily on findings from the
National Weight Control Registry (NWCR), a registry of individuals who have
been extremely successful at long-term weight loss maintenance.
Currently, few data are availableon the prevalenceof successful weight lossmain-
tenance. One limit is the lack of a consistent criterion to define “success” and
another is the difficulty of distinguishing intentional from unintentional weight
loss. We therefore propose to define success in weight loss maintenance as achiev-
ingan intentionalweight lossofat least10%ofinitialbody weightandmaintaining
this weight loss for at least one year. We could not find sufficient data, collected in
a systematic fashion, to provide reliable information on predictors of weight loss
for longer periods.
Overall there is a feeling ofpessimism regarding long-term weightloss success
(18).Thispessimismstarted withastudybyStunkard &McLaren-Hume(42),who
followed 100 obese individuals referred to a nutritional weight loss program and
Thisfinding wasinstrumental increatingtheperception, perpetuatedinthe popular
media, that hardly anyone succeeds in long-term maintenance of weight loss.
Recent studies of clinical programs are more positive. Every year for 4 years,
Kramer et al (24) followed up on 114 men and 38 women who had participated
in a behavioral weight loss program. Using a strict criterion of maintaining 100%
of one’s weight loss, they found that only 0.9% of men and 5.3% of women were
consistently successful (i.e. maintaining this criterion all of the 4 years). However,
looking only at year 4, cross-sectional data showed that 2.6% of men and 28.9%
of women had maintained 100% of their weight loss. Several studies have used
5 kg or greater weight loss as a criterion of success. With this criterion, 13% (51)
to 22% (41) of participants are successful 5 years after treatment.
These studies may underestimate the true prevalence of weight loss mainte-
nance because they are based on only one episode of weight loss and may not be
April 23, 2001 19:15 Annual Reviews AR133-14
representative of the general population. Most people who lose weight do so on
their own, without participation in formal programs (5,6); thus, data from clinical
research programs may reflect “hard core” dieters, who may be most resistant
to successful weight loss maintenance. Bartlett et al (4) reviewed eight studies
that examined the prevalence of successful weight loss in community samples;
they were unable to reach conclusions regarding prevalence because these stud-
ies lacked consistent definitions of successful weight loss and many failed to use
nationally representative samples. Moreover, most of the studies assessed weight
loss, not weight loss maintenance.
McGuire et al (27) recently reported results of a random-digit-dial telephone
survey in a nationally representative sample of 500 adults in the United States.
Weight loss maintainers were defined as those who at the time of the survey had
maintained a weight loss of 10% of their maximum weight for at least 1 year.
Of particular interest are those who reported being overweight [body mass index
(BMI) 27 kg/m
] at their maximum weight (N = 228). Of these, 62% indicated
thatat somepointintheir lifetheyhadlost10% oftheirmaximumweight, and38%
reported that they were currently 10% below their maximum weight. Of the 228
reporting having been overweight, 69 (30.3%) had maintained this 10% weight
loss for at least 1 year. These 69 individuals had on average maintained a weight
loss of 42 lb for 7 years.
This survey included a question about whether the weight loss was intentional.
Of the 228 overweight individuals in the survey, 47 (20.6%) reported that they
had intentionally lost weight and had maintained a weight loss of 10% for at least
1 year. Of these individuals, 28 had reduced to normal weight (BMI < 27).
It is important to adopt a consistent definition of successful weight loss main-
tenance. The definition must include criterion for magnitude of weight loss and
duration of maintenance. Weight losses of 5%–10% of initial body weight can lead
to substantial improvement in risk factors for diabetes and heart disease and can
lead to reductions in or discontinuations of medications for these conditions (31).
Thus, if the focus is on overall health, achieving and maintaining a 10% weight
loss should be considered successful, even though for many obese individuals
this weight loss may not return them to a nonobese state. Successful weight loss
maintenance may involve some weight regain. For example, an individual who
lost 20% of initial body weight but regained half of the lost weight would still be
10% below initial body weight, would presumably still have overall improved
health, and thus should be considered “successful.
In defining successful weight loss, it is important that the loss be intentional.
Several recent studies suggest that unintentional weight loss occurs frequently in
the population. Because the causes and consequences of unintentional weight loss
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326 WING
arelikelytodifferfrom thoseassociated withintentional weightloss,itisimportant
to distinguish between the two.
Finally, we propose that 1 year of maintenance be the minimum criterion, in
keeping with the Institute of Medicine (IOM) definition. A 5-year duration might
bea stricter criterion, butwe believe researchwouldbestimulated by first adopting
the 1-year criterion and then studying the factors that help those individuals who
have succeeded for 1 year sustain their success through 5 years.
Thus, we propose that individuals who have intentionally lost at least 10% of
their body weight and have kept it off at least 1 year be considered “success-
ful weight loss maintainers. By this definition, according to our data, 21% of
overweight/obese persons may be successes.
Much of the information about successful weight loss maintenance comes from
the National Weight Control Registry (NWCR), founded in 1994 to study weight
loss and weight maintenance strategies of successful weight loss maintainers. To
beeligible for the NWCR, individualsmusthave maintained atleast a 30-lb weight
loss for at least 1 year. On recruitment, all subjects sign an informed consent form
and then are sent several questionnaires to complete. These questionnaires seek
history, quality of life, and demographic information. All participants are asked to
complete additional follow-up questionnaires on an annual basis.
There are currently over 3000 subjects in the NWCR. They average 45 years of
age and are 80% women, 97% Caucasian, and 67% married. The average weight
loss reported by NWCR participants is 30 kg, and the average duration of weight
maintenanceis5.5 years.Thesesubjectsmaintainabodyweightthatis,onaverage,
10 BMI units lower than their pre–weight loss BMI (from 35–25 kg/m
Abouthalf(46%)ofNWCRsubjects reporthavingbeen overweightaschildren.
Many report a strong family history of obesity, with 46% reporting one parent as
overweight or obese and 27% reporting both parents as overweight or obese.
Almost all NWCR subjects (90%) have experienced previous unsuccessful
attempts at weight loss. No obvious factor or factors distinguish this successful
weight loss from previous failures other than registry participants noting a greater
commitment, stricter dieting, and a greater role of exercise.
Clearly, a negative energy balance is needed to produce weight loss. A neg-
ative energy balance can be achieved by either decreasing intake or increasing
expenditure. Research studies consistently show that successful weight loss main-
tainers change both their intake and their expenditure in order to lose weight and
maintain their losses. In the NWCR, 89% of participants reported modifying both
diet and exercise to achieve their successful weight loss (22). In subjects who re-
portedmodifying food intaketoloseweight,the most commonly reportedmethods
were restricting intake of certain types or classes of foods (88%), limiting quantity
April 23, 2001 19:15 Annual Reviews AR133-14
(44%), and counting calories (44%). However, there was marked variability in
how they made these changes. About half of the registry participants (45%), but
63% of the men, reported losing on their own whereas the remainder of the regis-
trants (55%), and 60% of the women, used a formal (e.g. commercial) weight loss
program (22).
Although most health professionals recommend changes in both diet and phys-
ical activity for weight loss, many popular weight loss plans emphasize diet more
than physical activity. It is worth noting that very few of these successful weight
loss maintainers used diet alone to lose weight.
found much more similarity in the strategies used for maintenance of weight loss.
The three strategies that were common to a largeproportion of NWCR participants
include (a) eating a diet low in fat and high in carbohydrate, (b) frequent self-
monitoring, and (c) regular physical activity.
To determine current dietary intake, registry members were asked on entry into
the registry to complete the Block Food Frequency questionnaire. On average,
participants reported consuming 1381 kcal/day (5778 ± 2200 kJ/day), with 24%
of calories from fat, 19% from protein, and 56% from carbohydrates (22). There
were no differences in the quality of the diet reported by participants who lost
weight on their own compared with those who used weight loss programs (40).
Both groups ate a diet that satisfied the Daily Reference Intakes for calcium,
vitamin C, vitamin A, and vitamin E.
Recently, because some popular diets recommend restricting carbohydrates to
lose weight, data from registry participants were analyzed to determine carbohy-
drateintake(57).Only7.6% of registrymembers reportedeatingfewerthan 90 gof
carbohydrate/day;formany of theseindividuals,totaldailyenergyintakeappeared
unreasonably low. Additional analyses were done to determine the proportion of
subjects eating diets with <24% carbohydrates (1500 calories/90 g of carbo-
hydrate). Less than 1% of registry participants consumed such low-carbohydrate
diets. Compared with registry members who had higher carbohydrate intake, those
ingesting <24% carbohydrates maintained their weight loss for less time and were
less physically active. Thus, the low-fat, high-carbohydrate, low-calorie–eating
pattern appears to be what characterizes the majority of registry participants.
Registry members reported eating on average 4.87 meals or snacks/day, with
few eating less often than twice a day (22). On average, they ate at fast food
restaurants approximately once a week (0.74 times/week) and had 2.5 meals/week
in other types of restaurants. Thus, although the majority of meals were eaten
April 23, 2001 19:15 Annual Reviews AR133-14
328 WING
at home, these individuals maintained their weight loss while enjoying meals at
As part of the random-digit-dialing survey described above, successful weight
loss maintainers (those who intentionally lost 10% of their maximum weight and
maintained it for at least 1 year) were compared with regainers (those who lost at
least10%oftheirbodyweight butgaineditback)and controls(those whoseweight
had never been 10% above their current level and who were weight stable) (29).
These individuals were all asked to complete the Food Habits Questionnaire. This
questionnaire examines strategies used to restrict fat intake and has been shown
to relate to fat intake. Weight loss maintainers reported greater avoidance of fried
foods and more substitution of low-fat for high-fat foods than either regainers or
controls. Again, these findings suggest the importance of low-fat eating in the
maintenance of weight loss.
Other studies have shown that successful weight loss maintenance is associated
with changes in both the quantity and quality of foods consumed. Clinic-based
studies have examined the association between self-reported dietary intake and
weight loss after either 12 or 18 months of treatment. These studies indicate that
intake (19), reduced portion sizes (17), reduced frequency of snacks, and, perhaps
most consistently, reduction in the percentage of calories from fat (11,55).
Several studies have identified decreased consumption of specific foods as be-
ing associated with weight loss maintenance. French et al (8) found that decreased
consumption of french fries, dairy products, sweets, and meat was positively asso-
ciated with weight loss maintenance. Holden et al (15) present data on 118 patients
who were followed for 3 years after ending a very-low-calorie diet. Those who re-
ported that they consumed cheese, butter, high-fat snacks, fried foods, and desserts
less than once a week were more successful at long-term weight control. Eating
“healthy” foods at least once/week was unrelated to weight loss.
Self-Monitoring Weight and Behaviors Related to Weight
Registry members were asked how frequently they monitored their weight. Over
44% reported weighing themselvesat least once a day, and 31% reported weighing
themselves at least once a week (22). Few other studies have examined weighing
as a component of long-term weight loss maintenance. However, monitoring die-
tary intake is frequently associated with weight loss success. Guare et al (10)
completed a 1-year follow-up on 106 participants in behavioral weight loss pro-
grams. Those participants who at 1 year most frequently monitored their intake
maintained a weight loss of 18 kg compared with the approximately 5-kg weight
loss maintained by those who monitored their intake less often. Other studies have
likewise found that consistent self-monitoring is related to weight loss (3). This is
not surprising. Frequent monitoring of weight allows one to detect weight regain
in its early stages and to initiate strategies to reverse the trend and avoid a major
April 23, 2001 19:15 Annual Reviews AR133-14
Self-monitoringmay beviewedasone component ofthemore generalconstruct
of cognitive restraint (i.e. the degree of conscious control one exerts over eating
behaviors). On the Three Factor Eating Scale, registry members report high levels
of dietary restraint (mean = 7.1), similar to the levels reported by patients who
have recently completed treatment for obesity, though not nearly as high as the
levels seen in eating-disordered patients (23). These data suggest that successful
maintainers continue long-term to use behavior-change strategies taught in weight
loss programs. However, why some individuals can persist in conscious control of
intake whereas others revert back to old habits is unclear.
Physical Activity
Regular physical activity has been found in many studies to be associated with
long-term weight loss maintenance (20, 37). Most subjects in the NWCR report
engaging in regular physical activity to lose weight as well as to maintain the
weight loss. Only 9% of registry subjects report maintaining weight loss without
regular physical activity. Using the Paffenbarger Physical Activity Questionnaire
expendingan average of 2545 kcal on physicalactivityper weekand men report an
averageof3293kcal/week.This amountof physicalactivity iscomparabletoabout
1 h of moderate intensity physical activity, such as brisk walking, per day. This is
much higher than physical activity recommendations for the general public. The
Surgeon General recommends that adults engage in 30 min of moderate intensity
physical activity at least 3 days/week (46). Among registry subjects, 52% expend
more than 1000 kcal and 72% more than 2000 kcal on physical activity per week.
Physical activity experts now recommend that rather than only planned ex-
ercise, people increase “lifestyle physical activity, which involves being more
active in daily life (e.g. increase walking, taking stairs, etc) (46). Most registry
subjects report efforts to increase both lifestyle activity and regular planned exer-
cise. As noted above, only 9% report that they do no physical activity for weight
loss maintenance. Among registry members, 49% report using a combination of
walking and another form of regular exercise, 28% report only walking, and 14%
report only another form of regular exercise. Thus, the combination of lifestyle
and programmed exercise is used by almost half the participants, and walking is
an important aspect of the exercise for over 75%.
Table 1 shows the six most frequently reported physical activities of subjects in
the registry (45). It is interesting that a high proportion of subjects report weight
lifting. In the registry, 24% of men and 20% of women regularly engage in weight
lifting. A representative national population, the National Health Interview Sur-
vey, conducted in 1991, reported that 20% of men but only 9% of women regu-
larly engage in weight lifting. Thus, women in the registry engage in weight
lifting to a much greater extent than do women in the general population. The
extent to which this contributes to their success in weight loss maintenance is not
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TABLE 1 The six most common activities reported by
National Weight Control Registry subjects
Activity % Reporting engaging in activity
Walking 76.6
Cycling 20.6
Weight lifting 20.3
Aerobics 17.8
Running 10.5
Stair climbing 9.3
It is not clear to what extent metabolic versus behavioral factors contribute to the
low success rate in long-term weight loss maintenance. It could be that there is
a physiological set-point for weight and that reducing weight below this level
leads to physiological compensation. Alternatively, the difficulty in maintaining a
weight loss could be due to the difficulty in making permanent changes in diet and
physical activity behaviors.
The Metabolic State of the Reduced-Obese
The difficulty in long-term weight maintenance could have metabolic causes. It
is possible that weight loss creates a metabolic state favoring weight regain in
order to return body weight to some optimal or regulated level. This metabolic
state could be due to one or more of the following causes: (a) a resting metabolic
rate lower than expected for the new, lower body weight; (b) a reduced ability to
oxidize fat, thus favoring positive fat balance and fat gain; (c) increased insulin
sensitivity; and/or (d) relatively low leptin levels.
Low Resting Metabolic Rate in the Reduced-Obese State Resting metabolic
rate (RMR) declines with weight loss, but the question is whether this decline
leaves the reduced-obese with aninappropriately low RMR or whether the decline
in RMR is appropriate for the new, lower body mass. During the acute phase of
weight loss, RMR appears to decline because of both food restriction and loss
of body mass (35,50). This is why is it important to measure RMR after a period
of weight stabilization followingweight loss. In the long-term, the decline in RMR
wouldbe expectedto be proportionalto the decline in fat-free mass (FFM) because
fat loss produces only very small declines in RMR (35).
Some reports indicate that RMR declines with weight loss to a much greater
extent than the decline in FFM, whereas other reports indicate that the decline
April 23, 2001 19:15 Annual Reviews AR133-14
in RMR with weight loss is appropriate for the reduction of FFM. In favor of a
greater-than-expected drop in RMR with weight loss, Leibel et al (26) reported a
reductioninrestingmetabolic rateof12.6–16.7kJ/kgof FFMlostinobesesubjects
maintaining a 10% reduction in body weight. Others (9,38,50) have found that
the reduction in RMR with weight loss, over the long-term, is appropriate for
the reduction in body mass. Astrup et al (2) recently published a meta-analysis of
RMR in reduced-obese subjects. They reviewed 12 published studies and obtained
individual data on 124 reduced-obese subjects and 121 control subjects from 15
different published studies. Using traditional meta-analysis, they found that RMR
was about 5% lower in reduced-obese subjects than in control subjects. However,
the more interesting analysis was a comparison of the 124 reduced-obese with
the 121 control subjects. In this comparison, RMR was not significantly lower
in the reduced-obese (P < 0.09). Furthermore, the 3%–5% reduction in RMR
seen in the reduced-obese group was explained entirely by 15% of the reduced-
obese subjects. They suggested that although a low RMR might characterize some
reduced-obese subjects, this is not the norm.
We examined RMR in relation to FFM in 50 NWCR subjects and in 50 matched
control subjects (56). In both groups, RMR was appropriate for body composition
and there was no evidence of a lower-than-expected RMR in NWCR subjects. The
regressionline relating FFM and RMR was not different for the two groups, which
suggests that RMR in our reduced-obese subjects was not inappropriately low.
It is possible that the extremely high levels of physical activity seen in NWCR
subjects may be masking a low RMR. Van Dale et al (48) found that subjects
who engaged in regular exercise during and following weight loss had a “normal”
RMR relative to body mass, whereas those who did not exercise had a lower-than-
predicted RMR relative to body mass. It should be noted, however, that in our
study (56), the matched control subjects were reporting high levels of physical
activity, similar to those reported by NWCR subjects.
The controversy in this area continues. In NWCR subjects, we failed to find
any evidence of a greater “metabolic efficiency” or a “metabolic impairment.
Although increased metabolic efficiency might occur in some subjects, it does not
seem to be an obligatory consequence of weight loss. It is possible that some of
the differences between studies may reflect heterogeneity between reduced-obese
subjects. It is also likely that other methodological issues contribute to different
results. We know little, for example, about how the method of weight reduction
(large versus small deficit,exerciseversus no exercise), the amount of weightloss,
obese individual. Part of the problem has been getting access to enough long-term
successes to study how these factors impact metabolism after weight loss.
Fat Oxidation in the Reduced-Obese State Because achieving body weight
maintenance requires achieving fat balance, an alteration in the ability to use
fat as a fuel could be a factor in predisposing reduced-obese subjects to regain
weight. Given that it is affected by many dietary factors and by physical activity,
April 23, 2001 19:15 Annual Reviews AR133-14
332 WING
assessment of substrate oxidation is not easy. Several investigators have reported
that reduced-obese subjects may have a higher respiratory quotient (RQ), indica-
tive of a lower rate of fat oxidation, than do control subjects. Larson et al (25)
reported a higher adjusted 24-h RQ in formerly obese subjects than in matched
control subjects who had not lost weight. Astrup et al (1) found lower rates of fat
oxidation in formerly obese subjects compared with controls while both groups
were consuming high-fat diets.
In the NWCR we found registry members had a slightly higher (0.807 versus
0.791, P = 0.05) fasting RQ than a control group of nonreduced individuals (56).
However, the usual diet NWCR subjects reported consuming was lower in fat than
that of the control subjects. Because usual fat oxidation is positively correlated
with usual fat intake, it is not clear whether the lower fat oxidation seen in NWCR
subjects reflects an altered metabolic state or simply an altered diet.
Thus, although there are consistent reports of a higher RQ (i.e. lower fat oxida-
tion) in reduced-obese subjects, the question remains as to whether this indicates
an impairment in or a reduced capacity for fat oxidation. It remains a distinct pos-
sibility, however, that a low rate of fat oxidation in reduced-obese subjects could
predispose them to weight gain, especially when they consume high-fat diets.
Insulin Resistance as a Contributor to Weight Regain The role of insulin resis-
tance in weight gain is also controversial. Several studies have shown that within
a population, those who are most insulin sensitive at baseline will gain the most
weight (13,43,47), although this finding is not consistent across all populations
(14).Similarly,thereare inconsistent findings related to whether insulin sensitivity
predictsweight regain.Yost et al (59) reported thatin 10 moderately obese women,
changes in insulin sensitivity (determined using a euglycemic clamp) following a
3-month period of weight loss and a 3-month period of weight maintenance were
positivelycorrelatedwith subsequentweightgain at12and 18months.Theauthors
hypothesized that the increased insulin sensitivity produced a decrease in skeletal
muscle lipid oxidation, directing lipid towardstorage in adipose tissue. In contrast,
Wing (53) examined this relationship in two groups of subjects who participated
in a 3- to 6-month weight loss program. In 125 nondiabetic subjects, changes in
neither fasting insulin nor insulin levels in response to a glucose load were signifi-
cantly related to subsequent weight regain. Similarly, insulin sensitivity measured
using Bergman’s minimal model was not related to subsequent weight regain in
33 diabetic subjects. The inconsistency across studies may relate to differences
in study population, methods of assessing insulin sensitivity, and/or duration of
the weight maintenance phase. Furthermore, all the studies reported changes in
body weight (rather than fat mass), and none reported changes in physical activity
levels, an important determinant of insulin sensitivity. Thus, whether insulin sen-
sitivity plays a role in weight regain following a period of weight loss remains to
be determined. Studies of rats provided with an obesity-producing diet have not,
in general, found insulin sensitivity to predict weight gain (34). Currently we have
no data on insulin sensitivity among NWCR subjects.
April 23, 2001 19:15 Annual Reviews AR133-14
LowLeptinasaFactor in WeightRegain Ithas recently been suggestedthatlow
leptin levels may exist in reduced-obese subjects and may be a factor in propensity
toregainweight(7). In thisstudy, leptin levels werepositively correlatedwithbody
fat mass in a group of eight reduced-obese and eight control subjects. However,
leptin levels were lower in the reduced-obese subjects. Reduced-obese subjects
also had a lower rate of fat oxidation than did the control subjects. Nagy et al
(30), however, found the leptin levels were not related to weight regain over a
4-year period in 14 postmenopausal women. Furthermore, Winget al (55) reported
that leptin levels decreased along with body weight during obesity treatment and
that neither baseline levels nor changes in serum leptin predicted weight regain.
Leptin levels drop with weight loss, and the initial drop may be greater than the
drop in fat mass (36). The important question for weight loss maintenance is
whether the relationship between circulating leptin levels and body fat mass is
altered significantly from baseline after weight loss and weight stabilization. It
is important to point out that the question can only be answered if a period of
weight stabilization precedes measurements. We are currently collecting data on
circulating leptin levels in NWCR subjects.
The Metabolic State of NWCR Subjects
In summary, we have not been able to document a clear metabolic state consistent
with the notionof increased “metabolicefficiency” in reduced-obese subjects. It is
certainly possible that the high levels of physical activity seen in NWCR subjects
may be “masking” this metabolic predisposition to regain weight. Alternatively,
it is possible that NWCR subjects do not exhibit such a metabolic predisposition
and that their success is due to permanent behavior changes of the kind generally
recommended in weight loss programs.
Behavioral Factors in Long-Term Weight Loss Maintenance
Although we have not clearly identified metabolic factors important for long-term
weightloss maintenance, we have identified behavioralfactors that seemto predict
success. These include eating a diet low in fat, self-monitoring body weight and
food intake, and engaging in high levels of physical activity. We believe that
the current population recommendations to reduce dietary fat are consistent with
success in weight loss maintenance. Our subjects report 24% of total energy from
fat, and many recommendations to the public are to reduce dietary fat below 30%.
It is possible that a recommendation of 25% of energy from fat would be a better
recommendation for persons maintaining a weight loss, but insufficient data exist
to support such a public health recommendation. Our data would, however, argue
strongly against any increases in the amount of dietary fat recommended to the
Self-monitoring has been recognized as a useful behavior during weight loss,
during weight maintenance.
April 23, 2001 19:15 Annual Reviews AR133-14
334 WING
Finally, high levels of physical activity seem to be associated with long-term
weight maintenance. Although the exact way in which physical activityhelps with
successful weight loss maintenance is not fully understood, it does seem that a
high degree of regular physical activity is akeyto the success of the subjects in the
registry. Data from the NWCR suggest that the optimal amount of physical activity
to maintain weight loss may be about 1 h/day, or an expenditure of approximately
2500–3000 kcal/week. Others havereported results similar to these. Schoeller et al
(37) found that the relationship between the amount of physical activity and the
prevention of weight regain was not linear. They found that a threshold value of
11 kcal/kg of body weight was necessary to prevent weight regain. This value
roughly translates into the addition of 1.3 h of such moderate activity as brisk
walking per day, or 0.6 h of vigorous activity per day. More recently, Jakicic et al
(16) found that after weight loss, 200 min or more of physical activity per week
was associated with continued weight maintenance, whereas less physical activity
was associated with weight gain in a dose-dependent fashion.
Taken together, this body of literature in obese-reduced subjects suggests that
our physical activity goals for weight management programs may need to be
substantially higher than the physical activity recommendations to the general
population. It is important to realize that the current physical activity guidelines
for the population were developed to optimize cardiovascular health and were not
based on prevention of weight gain. Although we have substantial data to suggest
that regular physical activity protects against weight gain in nonobese individuals
(12), we do not havea good database on which to develop specific physical activity
guidelines to prevent weight gain. Developing such a database should be a high
Concern has been raised that weight loss, and the vigilance required to maintain
weight loss long-term, may be associated with increased risk of eating disor-
ders or depression symptomatology. This concern stems in large part from the
study by Keys et al (21) of semistarvation in normal-weight young men. In their
study, weight losses of approximately 25% of initial weight were achieved in
these normal-weight individuals. Such weight losses were associated with ex-
treme negative psychological reactions and, in a subgroup, short periods of binge
eating. The important question is whether the more-modest weight losses (10%
of body weight) that typically occur in overweight persons produce such negative
effects. This literature was recently reviewed by the National Task Force on the
Prevention and Treatment of Obesity (32). They concluded that participants in
behavioral weight loss programs typically experience improvements in symptoms
of depression or anxiety with weight loss, regardless of whether the weight loss
is produced by moderate diets, very-low-calorie diets, or weight loss medications.
April 23, 2001 19:15 Annual Reviews AR133-14
Before weight loss programs, participants typically report levels of dysphoria in
the nondepressed range; these levels are further reduced with weight loss. Binge
eaters, who enter treatment with higher levels of depressive symptomatology, ex-
perience greater improvements with weight loss. Likewise, both binge eaters and
nonbingeeaterswho participate in weight loss programs that utilize a balanceddiet
with moderate caloric restriction experience reduction in binge eating episodes.
Rather than precipitating binge eating (a common concern), such programs appear
to ameliorate this problem. Three studies (44, 49,58) have evaluated the effect of
very-low-caloriediets andsubsequentrefeedingonbingeeating.Intwoofthe three
(49,58), there was no adverse effect of the very-low-calorie diet on binge eating,
but the third study did suggest a temporary increase in binge eating in those who
were nonbingers at baseline (44). Methodological issues related to the assessment
of binge eating in this study make it difficult to interpret the results.
Likewise, no adverse psychological effects of weight loss have been observed
in the NWCR (23). At entry into the registry, members are asked to complete
the Center for Epidemiologic Studies Depression Scale (CES-D), the Symptom-
Checklist-90-R, and selected questions from the Eating Disorders Examination
related to binge eating and purging. Scores on these assessments were compared
with findings in the literature for relevant comparison groups (including those
withpsychiatricdisorders, obese patients, nondieting control subjects, and random
samples of the US population).
Registry participants reported an average CES-D score of 9.2 (range 0–52);
18% of registry participants scored >16, the cutoff used to distinguish “cases” for
nondepressed individuals. These findings are similar to nondepressed community
control subjects (who have mean CES-D scores of 4.1–10.4, with 21% of indi-
viduals reporting scores >16). In contrast, studies of clinically depressed patients
have mean scores of 13–38 on the CES-D, with over 70% of individuals scoring
>16. Registry participants also appear similar to obese and nonobese community
samples on the Global Symptoms Index of the SCL-90-R.
Rates of binge eating and vomiting were also very lowin registry members; 8%
reported four or more binges/month, and only 1.8% reported any episodes in the
preceding month of vomiting for weight loss purposes. These results are strikingly
lower than what is observed in eating-disordered populations.
In addition, participants in the registry are asked to indicate whether weight
loss has resulted in improvement, worsening, or no change in various aspects of
their life (22). As shown in Table 2, the vast majority of individuals report positive
changes in all aspects. Over 90% of the sample reported improvement in their
overall quality of life, levelof energy, mobility, general mood, and self-confidence.
There are only two areas where any substantial worsening due to weight loss
was noted. Fourteen percent of registry members reported worsening in time spent
thinking about food (49% reported improvement in this regard) and 20% reported
worsening in time spent thinking about their weight (51% reported improvement
in this regard). Thus overall weight loss maintenance appears to produce marked
improvements in quality of life for the majority of individuals.
April 23, 2001 19:15 Annual Reviews AR133-14
336 WING
TABLE 2 Effect of weight loss on other areas of life
Determinant Improved No difference Worse
Quality of life 95.3 4.3 0.4
Level of energy 92.4 6.7 0.9
Mobility 92.3 7.1 0.6
General mood 91.4 6.9 1.6
Self-confidence 90.9 9.0 0.1
Physical health 85.8 12.9 1.3
Interactions with
opposite sex 65.2 32.9 0.9
same sex 50.2 46.8 0.4
strangers 69.5 30.4 0.1
Time spent
interacting with
others 59.1 39.6 1.3
Job performance 54.5 45.0 0.6
Other hobbies 49.1 36.7 0.4
Interactions with
parents 32.8 65.0 2.2
Interactions with
spouse 56.3 37.3 5.9
Time spent
thinking about
food 49.1 36.7 14.2
weight 51.0 28.6 20.4
N = 784. Results indicate percentage.
Registry members are followed over time to try to identify variables related to
continued success (28). Over 1 year of follow-up, 35% of registry participants
regained 5 lbs or more, 59% maintained their weight loss, and 6% lost addi-
tional weight. Baseline characteristics that increased the risk of regain included
more recent weight loss (fewer than 2 years versus more than 2 years), larger
weight losses (>30% of maximum weight versus <30%), and higher levels of
depression, disinhibition, and binge eating at entry into the registry. These find-
ings are of interest, particularly the duration effect. It appears that the first few
years after weight loss are the most vulnerable period for weight regain. Main-
taining ones weight loss for 2–5 years decreased the risk of subsequent regain
by 50%. Thus, individuals who succeed in maintaining their weight loss for
April 23, 2001 19:15 Annual Reviews AR133-14
more than 2 years have a markedly improved chance of continuing to maintain it
over the year of follow-up and distinguished them from maintainers. Gainers in-
creased their fat intake, whereas maintainers kept theirs consistent. Both groups
reported decreases in physical activity, but the regainers had greater decreases:
expending approximately 800 fewer kcal/week compared with 400 kcal/week in
the maintainers. Gainers also reported decreases in their level of dietary restraint
and increases in disinhibition (i.e. loss of control while eating). These findings
confirm the importance of the behavior changes described in earlier sections of
this chapter for the long-term maintenance of weight loss.
It is important that a consensus be reached on a definition for successful weight
lossmaintenance. Our recommendation is that an intentional weight loss of greater
than or equal to 10% of initial body weight that is maintained at least 1 year be
considered success. According to this definition, approximately 20% or more of
individuals who attempt weight loss would be “successful.” Although the NWCR
does not provide information about how many people achieve long-term weight
losssuccess,it does provideinformationabout strategiesusedtoachieveandmain-
tain a weight loss. With regard to weight loss, the most obvious conclusion from
the NWCR is that weight loss should include both changing diet and increasing
achieve theweightlossthatiscommontothesesuccessfulweight loss maintainers.
We believe that strategies for weight loss maintenance may be the key to long-
term weight management success. We find three behaviors in a vast majority of
NWCR subjects. First, these subjects engage in high levels of physical activity.
The amount of physical activitythat facilitates successful weight loss maintenance
may be closer to 1 h/day rather than the 30 min three times per week suggested in
recommendations to the general public. Consequently, we may need to increase
our physical activity goals in obesity treatment programs. Second, these subjects
reporteating a diet lowinfatand high in carbohydrate. Webelieve this is important
information given the oscillating nature of popular diet books regarding optimum
monitoring of weight. Maintaining a substantial weight loss may be a long-term
challenge, and it may be important to have access to information about success.
This may be particularly important in terms of initiating early strategies to stop
weight regain. Currently, the data seem to suggest that differences in behavior
are stronger predictors of weight regain than the differences in physiology or
metabolism.Furtherresearchwithfrequentassessments of behaviorandmetabolic
parameters may be helpful in determining which set of factors is most strongly
related to long-term maintenance of weight loss.
April 23, 2001 19:15 Annual Reviews AR133-14
338 WING
Part of the reasons for developing the NWCR was to counter the belief that
“no one succeeds long-term at weight loss. We believe the subjects in the NWCR
show that you can achieve and maintain substantial amounts of weight loss. Fur-
thermore, we have found that these subjects live “normal” lives after weight loss
and consistently report that life is better after weight loss. Our subjects tell us that
their success requires substantial effort but that it is worth it. Finally, our data sug-
gest that over time, it does get easier to maintain weight loss. It may be a lifelong
struggle, but once you have maintained a weight loss for 2–5 years, the chances
of longer-term success greatly increase.
We express our gratitude to Drs. Mary Lou Klem, Maureen McGuire, Holly Wyatt,
and Helen Seagle for assistance in these studies. The work described here was
supported in part by NIH grants DK42529 (JOH), DK48520 (JOH), and HL41330
Visit the Annual Reviews home page at
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  • ... The treatment of obesity through lifestyle change demonstrates little success on a long term basis with weight often being regained and lifestyle changes not sustained 93 . An alternative strategy is to focus on the prevention of weight gain. ...
    Weight is increasing in the population and holidays, such as Christmas, have been identified as high-risk periods. This thesis presents the development of a behavioural intervention to prevent weight gain over the Christmas period, its evaluation in a Randomised Controlled Trial (The Winter Weight Watch study), and an exploration of participant experiences of the intervention. The possible mechanisms of action of the intervention are also explored. The intervention consisted of encouragement to regularly self-weigh and record weight, physical activity calorie equivalent (PACE) information about commonly consumed festive foods and drinks and weight management tips. The hypothesised main mechanism of action was that each component would promote restraint of energy intake, preventing weight gain over Christmas. The RCT showed the intervention to be effective in preventing weight gain. At follow up the difference in weight between intervention and control groups (adjusting for baseline weight) was -0.49kg. Conscious energy restraint scores increased in the intervention group. The qualitative study showed that participants found the concept of weight gain prevention at Christmas acceptable. Self-weighing and PACE information were key drivers in encouraging restraint of energy intake. PACE information mainly prompted participants to restrain energy intake rather than increase physical activity In conclusion, the developed intervention prevented weight gain during the Christmas period and was acceptable to participants. PACE information and self-weighing were found to be key drivers of self-regulatory behaviours. These findings hold promise for preventing weight gain during high risk periods.
  • ... To avoid overlap between groups, individuals with a weight of 90-95% of their maximum weight were excluded from the study. This decision was based on a) the weight loss maintenance definition by Wing and Hill, suggesting that successful maintainers are those who maintain a loss of at least 10% of their maximum weight for over 12 months (19) , and (ii) ascertaining that regainers were attaining a current body weight below the clinically meaningful weight loss range of 5-10% (20) . Then, eligible participants were asked to report on their current characteristics and habits (those at the time of recruitment). ...
    Weight loss maintenance is crucial for obesity management, yet optimal dietary patterns for this period are not established. We aimed to explore the relationship between adherence to the Mediterranean Diet and weight loss maintenance. Sample includes 565 adults (62% women) of the MedWeight study. Eligible volunteers were those reporting intentional weight loss of ≥10%, starting from a BMI≥25 kg/m ² , over 12 months prior to enrollment. Based on current weight, participants were characterized as maintainers (≤90% max weight), or regainers (>95% max weight). Socio-demographics and weight history were recorded. Dietary intake was assessed by 2 non-consecutive 24-hour recalls within 10 days, and analyzed in energy, macronutrient, and food group intake. Adherence to the Mediterranean Diet was assessed with the MedDietScore (range 0-55, greater scores showing higher adherence). Protein intake was higher in maintainers than regainers (p<0.001). When MedDietScore quartiles were considered, a linear trend for weight loss maintenance was revealed (p<0.05). After adjustment for demographics, being in the 3 rd or 4 th quartile of the MedDietScore (vs. 1 st ) associated with 2.30 (95%CI 1.29-4.09) and 1.88 (95%CI 1.10-3.22) increased odds of maintenance. Regarding individual MedDietScore components, only fruit intake associated with increased odds for maintenance [1.03 (95%CI 1.01-1.06)]. Leave-one-out approach revealed that at least 6 MedDietScore components were essential for the observed relationship. Higher adherence to the Mediterranean Diet was associated with 2-fold increased likelihood of weight loss maintenance. Future studies should replicate these findings in non-Mediterranean populations as well.
  • ... A combination of physical exercise and dietary changes is considered as the most effective non-invasive intervention strategy for obesity. However, weight loss programs have been shown to bring about only an average weight reduction of 10% and despite the weight loss, the majority of patients quickly regain the lost weight (13). This leads to the question of whether weight loss improves the adverse metabolic and inflammatory profile underlying obese conditions. ...
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    Even after successful weight reduction, obese adults tend to quickly regain the lost weight. This raises the question of whether weight loss improves the underlying chronic adipose tissue inflammation characteristic of obesity. In order to improve our understanding of the mechanisms that reshape metabolic organs during weight loss, we investigated the macrophage and T cell function of the liver and adipose tissue on reversing high fat diet (HFD) mice to normal control diet (NCD). Obese mice that were switched to NCD showed an improvement in their metabolic profile that included enhanced glucose and insulin tolerance, decreased cholesterol, triglyceride, serum glutamic-oxaloacetic transaminase (SGOT), and serum glutamic pyruvic transaminase (SGPT) levels that were comparable to NCD controls. However, despite weight loss, increased frequencies, but not total numbers, of IL-17+ and IL-22+ CD4+ T cells, IFN-γ+ and TNF+ CD8+ T cells and IL-17+ and IL-22+ CD8+ T cells were observed in the adipose tissue of mice switched from HFD to NCD compared to NCD and even HFD fed mice. Further, in the liver, IFN-γ+ and TNF+ CD8+ T cell, IL-17+ and IL-22+ CD8+ T cell, macrophage frequencies and their expression of antigen presenting molecules were increased. To determine if macrophages are the major determinants of the sustained inflammation observed during weight loss, we depleted macrophages, which significantly reduced IFN-γ+, TNF+, IL-17+, and IL-22+ CD8+ T cell frequencies in the liver and the adipose tissue. In conclusion, we show that although weight loss improves the metabolic profile, there is an active and ongoing CD8+ T cell inflammation in liver and adipose tissue mediated by macrophages.
  • ... It is likely that a medical condition that caused remarkable weight loss would be identified and diagnosed at this time, if it was not previously diagnosed. Moreover, morbidly obese people who lose weight by natural means lose an average of 8% of their body weight in 3-12 months [30]. Thus, on average, these patients do not achieve massive weight loss and would not be included in our study. ...
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    Study design: Retrospective cohort study. Purpose: To determine the effects of massive weight loss on perioperative complications after lumbar fusion surgery (LFS). Overview of literature: Patients who are obese are more likely to experience low back pain, which would require LFS. Nonetheless, they have a higher risk of perioperative complication development compared with individuals who are not obese. Methods: Patients who underwent LFS at hospitals that participated in the National Surgical Quality Improvement Program database within the United States between 2005 and 2015. Outcomes included 30-day medical complications, surgical complications, and length of stay (LOS). We analyzed a total of 39,742 patients with the use of the International Classification of Disease, ninth revision codes. The patients were categorized in the following two groups: group 1, individuals with a history of massive weight loss within 6 months before LFS, and group 2, individuals without a history of massive weight loss before surgery. Massive weight loss was defined as loss of 10% of total body weight. Patients with a history of malignancy or chronic disease were excluded from the study. Patients in each group were randomly matched based on age, gender, sex, smoking status, and body mass index. Paired two-tailed Student t -tests were used to compare the outcomes. Results: Of the 39,742 patients identified, 129 (0.32%) met the criteria for inclusion in the weight loss group (WL group) and were successfully matched to individuals in the non-weight loss group (non-WL group). Compared with the non-WL group, the WL group had a significantly longer LOS (9.7 vs. 4.0 days, p <0.05), higher surgical site infections (SSIs) (8.0 vs. 3.0, p <0.05), increased number of blood transfusions (40.0 vs. 20.0, p <0.05), and greater deep vein thrombosis (DVTs) (5.0 and 0.00, p <0.05). Conclusions: On a nationwide scale, rapid weight loss before LFS is associated with a higher rate of postoperative complications, including SSI and DVTs, longer average LOS, and more frequent blood transfusions.
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    Bariatric surgery is becoming increasingly popular in the treatment of severely obese patients who failed to lose weight with the help of non-surgical interventions. Such patients are at increased risk for premature death, type 2 diabetes, high blood pressure, gallstones, coronary heart disease, dyslipidemia, some cancers, anxiety, depression, and degenerative joint disorders. Although bariatric surgery appears to be the most effective and durable treatment option for obesity, it is associated with a number of surgical and medical complications. These include a range of conditions, of which dumping syndrome and malnutrition due to malabsorption of vitamins and minerals are the most common. To achieve better surgery outcomes, a number of postsurgical strategies must be considered. The aim of this review was to describe possible complications, ailments, and important moments in the follow-up after bariatric surgery. Adequate lifelong monitoring is crucial for the achievement of long-lasting goals and reduction of post-bariatric complications.
  • Article
    Zusammenfassung Die langfristige Gewichtsabnahme stellt die größte Herausforderung bei der Therapie von Übergewicht und Adipositas dar. Dabei gilt das restriktive Essverhalten, im Sinne individueller Strategien der kognitiven Kontrolle über die Nahrungszufuhr, als ein unabdingbarer Bestandteil von Interventionen zur gesundheitsförderlichen Verhaltensänderung. Die bisherige Ineffektivität dieser Interventionen lässt sich möglicherweise damit erklären, dass die Empfehlungen zum restriktiven Essverhalten sich wahrscheinlich nicht pauschalisieren lassen, sondern sich je nach individueller Situation und im Prozess der langfristigen Gewichtsabnahme verändern müssten. Das Verständnis der Rolle des restriktiven Essverhaltens während der langfristigen Gewichtsabnahme könnte die Wirksamkeit von Interventionen steigern. Aktuell wird der Zusammenhang zwischen restriktivem Essverhalten, Enthemmungsfaktoren und Überessen diskutiert. Die vorliegende Arbeit gibt einen Überblick über den Stand der Forschung zur Bedeutung des restriktiven Essverhaltens im Verlauf der langfristigen Gewichtsabnahme.
  • Article
    This study examined physical discomfort intolerance (DI) as a baseline predictor of weight loss and physical activity outcomes, and assessed whether changes in DI during the initial phase of weight loss prospectively predicted long-term treatment outcomes among adults enrolled in a group-based lifestyle modification program for obesity. DI was measured at baseline and 6 months, and weight and accelerometer-measured physical activity were assessed at baseline, 6 months, and 12 months. Baseline DI was not related to weight loss or physical activity at either timepoint. Change in DI during the first 6 months of treatment was not related to concurrent (i.e., 6-month) weight loss and physical activity, but was significantly predictive of weight loss and physical activity at 12 months. Assessing early changes in DI may help to identify individuals at risk for suboptimal outcomes. Future research should evaluate behavioral weight loss interventions designed to target DI.
  • Article
    Purpose Sports facilities can play a vital role in encouraging physical activity and sport. Also, just the distribution of sports facilities is very important for better access to these facilities. Therefore, the purpose of this study is to evaluate spatial justice in the distribution of built outdoor sports facilities in the city of Isfahan, Iran and provide insight for planning in terms of equitable accessibility. Design/methodology/approach All facilities located in the 15 areas of the city, whether private or public, built for the purpose of physical activity and sports programs were considered in this study (107 cases). To obtain information on the locations of the outdoor sports facilities, Isfahan Atlas data, which has been compiled by Isfahan Municipality was used. Arc geographic information systems environment and its different algorithms were also used to perform different calculations and prepare maps. Findings The results indicated the unfair distribution of built outdoor sports facilities in the city of Isfahan in terms of spatial justice based on the number of built outdoor sports facilities in each area, the population, land area, population density and the spatial pattern of the facilities. Practical implications In this regard, urban authorities and sport managers should make an effort to decrease or obviate inequity in access to outdoor sports facilities for the purpose of promoting participation in physical activity and sport and providing residents with numerous other benefits. Originality/value This paper has concluded that spatial justice in the distribution of built outdoor sports facilities for the improvement of access to these facilities is very important.
  • Article
    Aims The aim of this study was to explore perceptions of barriers, facilitators, strategies and successes in individual vs. group-based weight management programmes. Methods Forty-two, overweight (Body Mass Index ≥ 25-kg.m²) participants (aged 32-63y) volunteered to take part in this study. All participants completed a 3-month weight loss programme, randomised to a group-based (n=21), or self-monitoring only (n=21) approach, respectively. Participants subsequently participated in a semi-structured interview (60±7 mins) to explore individual and collective perceptions of barriers, facilitators, strategies and successes. Results Convergent themes were found for individual and group strategies for facilitators, strategies and successes. Divergent themes were found between groups for barriers, group participants highlighted expense of commercial products, and knowledge of nutrition and dieting, whilst individual participants reported (lack of) social support from peers, (lack of) motivation, and occupation. Conclusion Key stakeholders, facilitators, and individuals must consider these factors prior to the advocation any weight loss strategy.
Literature Review
  • Article
    Risk of first heart attack was found to be related inversely to energy expenditure reported by 16,936 Harvard male alumni, aged 35–74 years, of whom 572 experienced heart attacks in 117,680 person-years of followup. Stairs climbed, blocks walked, strenuous sports played, and a composite physical activity index all opposed risk. Men with index below 2000 kilocalories per week were at 64% higher risk than classmates with higher Index. Adult exercise was independent other influences on heart attack risk, and peak exertion as strenuous sports play enhanced the effect of total energy expenditure. Notably, alumni physical activity supplanted student athleticisn; assessed in college 16–50 years earlier. If it is postulated that varsity athlete status implies selective cardiovascular fitness, such selection alone is insufficient to explain lower heart attack risk in later adult years. Ex-varsity athletes retained lower risk only if they maintained high physical activity Index as alumni.
  • Article
    Full-text available
    The National Weight Control Registry (NWCR) is, to the best of our knowledge, the largest study of individuals successful at long-term maintenance of weight loss. Despite extensive histories of overweight, the 629 women and 155 men in the registry lost an average of 30 kg and maintained a required minimum weight loss of 13.6 kg for 5 y. A little over one-half of the sample lost weight through formal programs; the remainder lost weight on their own. Both groups reported having used both diet and exercise to lose weight and nearly 77% of the sample reported that a triggering event had preceded their successful weight loss. Mean (+/-SD) current consumption reported by registry members was 5778 +/- 2200 kJ/d, with 24 +/- 9% of energy from fat, Members also appear to be highly active: they reported expending approximately 11830 kJ/wk through physical activity. Surprisingly, 42% of the sample reported that maintaining their weight loss was less difficult than losing weight. Nearly all registry members indicated that weight loss led to improvements in their level of energy, physical mobility, general mood, self-confidence, and physical health. In summary, the NWCR identified a large sample of individuals who were highly successful at maintaining weight loss. Future prospective studies will determine variables that predict continued maintenance of weight loss.
  • Article
    We reviewed articles evaluating the relations among dieting, weight loss treatment, weight cycling, eating disorders, and psychological functioning in overweight and obese adults. Moderate caloric (energy) restriction, in combination with behavioral weight loss treatment, does not seem to cause clinically significant binge eating in overweight adults without preexisting binge eating problems and might ameliorate binge eating, at least in the short term, in those reporting recurrent binge eating before treatment. Most studies of behavioral weight loss interventions report improvements in psychological status during weight loss. However, these improvements might return to baseline with weight regain. Weight cycling does not seem to be associated with clinically significant psychopathologic conditions, although results of cross-sectional studies show an association between weight cycling and binge eating, as well as poorer perceived health status. 'Nondieting' approaches seem to lead to improvements in mood and self-esteem; however, weight loss is generally minimal. Concerns that dieting induces eating disorders or other psychological dysfunction in overweight and obese adults are generally not supported by empirical studies. Such concerns should not preclude attempts to reduce caloric intake and increase physical activity to achieve modest weight loss or prevent additional weight gain.
  • Article
    There is growing concern that dieting may adversely affect the metabolic rate and exacerbate efforts to control weight. In this study we measured the resting metabolic rate nine times over 48 weeks in 18 obese women (108.0 ± 3.1 kg) who were randomly assigned to one of two dietary conditions. Nine patients consumed approximately 5021 kJ/d (1200 kcal/d) throughout the 48 weeks, while the other nine consumed a 1757-kJ/d (420-kcal/d) diet for 16 of the first 17 weeks and a conventional reducing diet for the remainder of treatment. All patients increased their physical activity, primarily by walking. During the first 5 weeks, the fall in metabolic rate was more than double the relative reduction in weight. By contrast, at week 48, the metabolic rate of patients in the two conditions was reduced by 9.4% ±4.0% and 8.3% ±2.2%, respectively, while weight was reduced by 16.6% ±2.7% and 19.5%±2.7%, respectively. Thus, neither dietary regimen, combined with modest physical activity, was associated with long-term reductions in resting metabolic rate that exceeded decreases anticipated with the achievement of a lower body weight. (JAMA. 1990;264:707-711)
  • Article
    The current widespread concern with weight reduction rests on at least two assumptions: first, that weight-reduction programs are effective; second, that they are harmless. Recent studies indicate that such programs may be far from harmless.1,2 This report documents their ineffectiveness. The results of treatment, as reported in the medical literature of the past 30 years, are first reviewed. The results of routine treatment of 100 consecutive obese persons in the Nutrition Clinic of the New York Hospital are then reported.Review of the Literature Hundreds of papers on treatment for obesity have been published in the past 30 years. Most, however, do not give figures on the outcome of treatment, and of those that do, most report them in such a way as to obscure the outcome of treatment of individual patients. Some authors, for example, report the total number of patients and the pounds lost without making clear
  • Article
    Full-text available
    Overweight and obesity are increasing in the United States. Changes in diet and physical activity are important for weight control. To examine the prevalence of attempting to lose or to maintain weight and to describe weight control strategies among US adults. The Behavioral Risk Factor Surveillance System, a random-digit telephone survey conducted in 1996 by state health departments. Setting The 49 states (and the District of Columbia) that participated in the survey. Adults aged 18 years and older (N = 107 804). Reported current weights and goal weights, prevalence of weight loss or maintenance attempts, and strategies used to control weight (eating fewer calories, eating less fat, or using physical activity) by population subgroup. The prevalence of attempting to lose and maintain weight was 28.8% and 35.1 % among men and 43.6% and 34.4% among women, respectively. Among those attempting to lose weight, a common strategy was to consume less fat but not fewer calories (34.9% of men and 40.0% of women); only 21.5% of men and 19.4% of women reported using the recommended combination of eating fewer calories and engaging in at least 150 minutes of leisure-time physical activity per week. Among men trying to lose weight, the median weight was 90.4 kg with a goal weight of 81.4 kg. Among women, the median weight was 70.3 kg with a goal weight of 59.0 kg. Weight loss and weight maintenance are common concerns for US men and women. Most persons trying to lose weight are not using the recommended combination of reducing calorie intake and engaging in leisure-time physical activity 150 minutes or more per week.
  • Article
    This report is the first report of the Surgeon General on physical activity and health. For more than a century, the Surgeon General of the Public Health Service has focused the nation's attention on important public health issues. Reports from Surgeons General on the adverse health consequences of smoking triggered nationwide efforts to prevent tobacco use. Reports on nutrition, violence, and HIV/AlDS - to name but a few - have heightened America's awareness of important public health issues and have spawned major public health initiatives. This new report, which is a comprehensive review of the available scientific evidence about the relationship between physical activity and health status, follows in this notable tradition. Scientists and doctors have known for years that substantial benefits can be gained from regular physical activity. The expanding and strengthening evidence on the relationship between physical activity and health necessitates the focus this report brings to this important public health challenge. Although the science of physical activity is a complex and still-developing field, we have today strong evidence to indicate that regular physical activity will provide clear and substantial health gains. In this sense, the report is more than a summary of the science - it is a national call to action.
  • Article
    Objective: A low resting metabolic rate for a given body size and composition, a low rate of fat oxidation, low levels of physical activity, and low plasma leptin concentrations are all risk factors for body weight gain. The aim of the present investigation was to compare resting metabolic rate (RMR), respiratory quotient (RQ), levels of physical activity, and plasma leptin concentrations in eight post-obese adults (2 males and 6 females; 48.9 ± 12.2 years; body mass index [BMI]: 24.5 ± 1.0 kg/m2; body fat 33 ± 5%; mean ± SD) who lost 27.1 ± 21.3 kg (16 to 79 kg) and had maintained this weight loss for ≥2 months (2 to 9 months) to eight age- and BMI-matched control never-obese subjects (1 male and 7 females; 49.1 ± 5.2 years; BMI 24.4 ± 1.0 kg/m2; body fat 33 ± 7%). Research Methods and Procedures: Following 3 days of weight maintenance diet (50% carbohydrate and 30% fat), RMR and RQ were measured after a 10-hour fast using indirect calorimetry and plasma leptin concentrations were measured using radioimmunoassay. Levels of physical activity were estimated using an accelerometer over a 48-hour period in free living conditions. Results: After adjustment for fat mass and fat-free mass, post-obese subjects had, compared with controls, similar levels of physical activity (4185 ± 205 vs. 4295 ± 204 counts) and similar RMR (1383 ± 268 vs. 1430 ± 104 kcal/day) but higher RQ (0.86 ± 0.04 vs. 0.81 ± 0.03, p < 0.05). Leptin concentration correlated positively with percent body fat (r = 0.57, p < 0.05) and, after adjusting for fat mass and fat-free mass, was lower in post-obese than in control subjects (4.5 ± 2.1 vs. 11.6 ± 7.9 ng/mL, p < 0.05). Discussion: The low fat oxidation and low plasma leptin concentrations observed in post-obese individuals may, in part, explain their propensity to relapse.
  • Article
    Obese female subjects entering a combined Very Low Calorie Diet (VLCD) and behavioral weight loss program were identified at baseline as either binge eater or nonbinge eater. The self-reported frequency of binge eating episodes was assessed during treatment and 3 months following treatment termination to determine the effects of the diet program on binge eating. The results suggested that this dieting regime impacted binge eating, with the most dramatic effect occurring once the VLCD ended and subjects were reintroduced to food. Post-VLCD, 30% of subjects identified at baseline as non-binge eaters reported binge eating episodes. At the end of the behavioral weight loss program, 62% of non-binge eaters reported binge eating episodes. However, the effects on binge eating appeared to be limited primarily to the period of dieting, with binge eating episodes decreasing 3 months following the termination of treatment. The results are discussed in terms of the need for increased attention in weight loss programs to the potential effects of dieting on binge eating.