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Trying to Lose Weight, Losing Weight,
and 9-Year Mortality in Overweight U.S.
Adults With Diabetes
EDWARD W. GREGG,
PHD
ROBERT B. GERZOFF,
MS
THEODORE J. THOMPSON,
MS
DAVID F. WILLIAMSON,
PHD
OBJECTIVE — The aim of this study was to examine the relationships between intention to
lose weight, actual weight loss, and all-cause mortality among overweight individuals with
diabetes.
RESEARCH DESIGN AND METHODS — We performed a prospective analysis among
1,401 overweight diabetic adults aged ⱖ35 years sampled in the National Health Interview
Survey. The previous year intention to lose weight and weight change were assessed by self-
report. Nine-year mortality rates were examined according to intent to lose weight and weight
loss, which were adjusted for age, sex, education, ethnicity, smoking, initial body weight, and
diabetes complications.
RESULTS — Individuals trying to lose weight had a 23% lower mortality rate (hazard rate
ratio [HRR] 0.77, 95% CI 0.61–0.99) than those who reported not trying to lose weight. This
association was as strong for those who failed to lose weight (0.72, 0.55–0.96) as for those who
succeeded in losing weight (0.83, 0.63–1.08). Trying to lose weight was beneficial for overweight
(BMI 25–30 kg/m
2
) individuals (0.62, 0.46–0.83) but not for obese (BMI ⬎30) individuals
(1.17, 0.72–1.92). Overall weight loss, without regard to intent, was associated with an increase
of 22% (1.22, 0.99–1.50) in the mortality rate. This increase was largely explained by uninten-
tional weight loss, which was associated with a 58% (1.58, 1.08–2.31) higher mortality rate.
CONCLUSIONS — Overweight diabetic adults trying to lose weight have a reduced risk of
all-cause mortality, independent of whether they lose weight. Actual weight loss is associated
with increased mortality only if the weight loss is unintentional.
Diabetes Care 27:657– 662, 2004
W
eight loss is considered a key
strategy to manage people with
type 2 diabetes because even
modest weight loss is associated with im-
proved blood pressure, lipid concentra-
tions, insulin sensitivity, and glycemic
control (1,2). By reducing these risk fac-
tors, weight loss may reduce the high risk
of vascular complications and death
among individuals with diabetes (3).
However, the physiological benefits of
weight loss have been observed primarily
in short-term studies, and little evidence
exists showing that these benefits trans-
late into increased longevity for people with
type 2 diabetes. Even more troubling, stud-
ies that have examined the association of
weight change with subsequent mortality,
without assessing weight loss intention,
generally find that losing weight is associ-
ated with increased rather than decreased
mortality risk (4–11).
The primary limitation of the obser-
vational literature on weight change and
mortality is the lack of information about
weight loss intention (10,11). The weight-
losing population includes an admixture
of individuals losing weight on purpose
and those who lose weight unintention-
ally. Unintentional weight loss is fre-
quently associated with poor health.
Thus, it is difficult to conclude from most
studies of weight loss whether overweight
adults with diabetes will lower their mor-
tality risk by embarking on weight loss
programs. In the only prospective study
to assess intentional weight loss among
individuals with diabetes, intentionally
losing up to ⬃20 lb was associated with
25% lower all-cause and cardiovascular
disease mortality (12). We recently found
in the general population that intentional
weight loss was associated with reduced
mortality and that attempted weight loss
was associated with reduced mortality in-
dependent of actual weight change (13).
However, three other studies in the gen-
eral population found equivocal associa-
tions between intentional weight loss and
mortality (14–16).
In 1989, a special questionnaire mod-
ule in the National Health Interview Sur-
vey (NHIS) examined weight loss
practices and recent weight change
among a nationally representative sample
of individuals with diabetes (17). Vital
status was followed through 1997 (18),
providing an opportunity to examine the
relationship between weight change and
mortality rates while stratifying by weight
loss intention.
RESEARCH DESIGN AND
METHODS — The NHIS is an ongo-
ing nationwide survey of the health status,
conditions, and behaviors of the U.S.
noninstitutionalized population (17).
The core NHIS uses multistage probabil-
ity sampling to select ⬃45,000 house-
holds and 120,000 individuals annually.
We used data from the 1989 supplement,
in which 2,531 individuals age ⱖ18 years
who reported physician-diagnosed diabe-
●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●
From the Division of Diabetes Translation, the National Center for Chronic Disease Prevention and Health
Promotion Centers for Disease Control and Prevention, Atlanta, Georgia.
Address correspondence and reprint requests to Edward W. Gregg, PhD, Division of Diabetes Translation
Centers for Disease Control and Prevention, 4770 Buford Hwy., N.E. Mailstop K-10, Atlanta, GA 30341.
E-mail: edg7@cdc.gov.
Received for publication 13 August 2003 and accepted in revised form 15 November 2003.
Abbreviations: NHIS, National Health Interview Survey; RCT, randomized controlled trial.
A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion
factors for many substances.
© 2004 by the American Diabetes Association.
Clinical Care/Education/Nutrition
ORIGINAL ARTICLE
DIABETES CARE,VOLUME 27, NUMBER 3, MARCH 2004 657
tes were asked about weight loss and
other behaviors and services related to di-
abetes. The survey’s response rate was
95%. Of the 2,531 respondents, we were
able to link 2,459 to the National Death
Index (18) through December 1997 (9
years). We used an algorithm provided by
the National Center for Health Statistics
to determine which matches should be
classified as deaths.
We excluded 852 individuals whose
BMI before weight loss was ⬍25 kg/m
2
,
because weight loss is not typically indi-
cated for such individuals. We also ex-
cluded 55 individuals aged ⬍35 years
because their mortality was extremely
low. Of the remaining 1,552 individuals,
we excluded 151 with missing data on
weight loss or other covariates, leaving
1,401 for the analysis.
Measurements
Interviewers determined participants’
age, race, sex, education, smoking status,
self-rated health (5-point scale from ex-
cellent to poor), limitations in daily activ-
ity (unable, limited, not limited), and past
year hospitalizations and doctor visits.
Participants were also asked about insulin
use, symptoms of peripheral neuropathy,
history of physician diagnoses of heart
disease, stroke, and diabetic retinopathy,
and years since the diabetes diagnosis.
Self-reported height and weight were
used to compute their BMI before any
weight change. To assess intentional
weight loss, participants were asked,
“Have you tried to lose weight in the past
year?”(yes/no); “Is your weight now
more, less, or about the same as a year
ago?”(more/less/about the same); and “In
the past year, about how much have you
gained/lost?”(number of pounds).
Statistical analyses
To account for age differences across
weight-change groups, we computed age-
adjusted mortality rates using direct ad-
justment to the U.S. 2000 standard
population ⱖ35 years. We used Cox pro-
portional hazards regression to assess the
relationship between weight loss inten-
tion, self-reported weight change, and all-
cause mortality risk while adjusting for
potentially confounding variables. We
considered weight change as continuous
and categorical (lost ⱖ20 lb, lost 1–19 lb,
no change, gained 1–19 lb, gained ⱖ20
lb) variables. We also evaluated weight
change with quadratic terms but did not
find that it improved the fit of the models.
To compare mortality according to
intentional weight loss, we categorized in-
dividuals into four groups with the first
serving as the referent group: 1) not trying
to lose weight and had either stable
weight or weight gain; 2) not trying to lose
weight but lost weight; 3) trying to lose
weight and had either stable weight or
weight gain; and 4) trying to lose weight
and lost weight. We also evaluated mor-
tality risk in which we merged the latter
two groups into one, such that all individ-
uals who were trying to lose weight were
compared with the first group.
Multivariate models controlled for
age, race, sex, education, smoking, “ini-
tial”BMI (BMI before weight change),
measures of health status (self-rated
health, functional limitations, heart dis-
ease, stroke, retinopathy, and neuropa-
thy), measures of health care use (past
year hospitalizations and doctor visits),
insulin use, and years since diabetes diag-
nosis. We tested for interactions between
weight loss and age (35–64 years; ⱖ65
years), sex, BMI (⬍30 or ⱖ30 kg/m
2
), in-
sulin use, diabetes duration, and any vas-
cular disease (cardiovascular disease,
stroke, retinopathy, or neuropathy symp-
toms). Analyses were weighted using
SUDAAN (Research Triangle Institute,
Research Triangle Park, NC) so that study
estimates would statistically represent the
U.S. noninstitutionalized adult over-
weight population with diabetes.
RESULTS —We estimate that 46% of
overweight individuals with diabetes re-
ported no weight change, 45% a weight
loss, and 9% a weight gain (Table 1).
Compared with individuals reporting no
weight change, those with weight loss
were younger, had higher BMI, were more
likely to be women, were more likely to
have been hospitalized in the past year,
had been diagnosed with diabetes more
recently, were less likely to use insulin
(and more likely to take oral medica-
tions), and were more likely to report hy-
pertension and neuropathy (P⬍0.05).
Individuals with weight gain reported
worse health and were more likely to have
functional limitations than those with no
weight change, but these associations
were not statistically significant. Race, ed-
ucation, smoking, number of doctor vis-
its, and stroke were not associated with
weight change.
Sixty-nine percent had tried to lose
weight during the previous year (Table 1).
Those trying to lose weight had a higher
median weight loss (⫺5 lb) than those not
trying to lose weight (0 lb). They were also
more likely to be women, younger, had
higher BMI, and were more likely to be on
oral diabetic medications (and less likely
to take insulin) than those not trying to
lose weight. Additionally, they had been
diagnosed with diabetes more recently
and were more likely to have hyperten-
sion. There were no significant differ-
ences in race, education, smoking, self-
rated health, functional limitations, or in
the frequency of hospitalizations and doc-
tor visits according to weight loss intent.
Similarly, there were no differences in the
prevalence of heart disease, stroke, retinal
disease, or neuropathy symptoms.
Weight change and mortality
Compared with individuals having no
weight change and controlled for age, sex,
race, initial BMI, smoking, and education,
those who lost any weight had a 22%
(hazard rate ratio [HRR] 1.22, 95% CI
0.99–1.50) higher mortality rate and
those losing at least 20 lb had a 40%
higher mortality rate (1.40, 1.05–1.87)
(Table 2). Findings were similar after ad-
ditional control for baseline health status,
health care use, diabetes-related compli-
cations, duration of disease, and insulin
use. When we included weight change as
a continuous variable in the Cox model,
each 10-lb decrease was associated with
an 8% (3–12%) increased mortality rate
(data not shown).
Weight gainers did not have an ap-
preciably higher mortality rate than those
with stable weight (HRR 1.11, 95% CI
0.74–1.66) (Table 2). Mortality rates
were nonsignificantly higher among those
with ⬎20-lb weight gain. Their mortality
was 77% higher than those with stable
weight (1.77, 0.97–3.23). The excess
mortality in this group was attenuated in
fully adjusted analyses (1.48, 0.82–2.68).
Confidence intervals were broad for these
comparisons because of the small number
of deaths.
Weight loss intent and mortality
Compared with those who were not try-
ing to lose weight and who had stable
weight or weight gain, individuals with
unintentional weight loss had a 58%
higher mortality rate (HRR 1.58, 95% CI
1.08–2.31) (Table 3). Among all individ-
Diabetes and weight loss
658 DIABETES CARE,VOLUME 27, NUMBER 3, MARCH 2004
uals not trying to lose weight, each 10 lb
of weight loss was associated with a 22%
increase in mortality rate (data not
shown).
Individuals trying to lose weight had
a 23% lower mortality rate (HRR 0.77,
95% CI 0.61–0.99) than those not trying
to lose weight (with stable weights or
weight gain) (Table 3). However, among
those trying to lose weight, weight change
itself was not associated with mortality. In
other words, the lower mortality rate as-
sociated with trying to lose weight was as
great for those who failed to lose weight
(0.72, 0.55–0.96) as for those who suc-
ceeded in losing weight (0.83, 0.63–
1.08).
When we excluded individuals who
died during the first 2 years of follow-up
(n⫽84), we found similar associations
between weight loss intent and mortality,
although CIs for these analyses were
broader due to the smaller number of
deaths in the analysis. Of note, however,
the association of unintentional weight
loss and mortality was further attenuated
(HRR 1.28, 95% CI 0.84–1.94). Simi-
larly, when we excluded individuals with
particularly large weight loss (⬎20% of
body weight, n⫽68), there was little
change in mortality rates among those try-
ing to lose weight, but the excess mortal-
ity rate associated with unintentional
weight loss was attenuated (1.35, 0.91–
2.00) relative to our primary analysis.
Exclusion of individuals more likely to
have type 1 diabetes, defined as being on
insulin since diagnosis, did not alter our
findings.
Table 1—Demographic and health status characteristics of overweight and obese persons with diabetes
Total
Actual weight change Trying to lose weight
None Loss Gain No Yes
n(%) 1,401 638 (45.6%) 629 (45.5%) 134 (8.9%) 427 (31.0%) 974 (69.0%)
Sex (% women) 57.6 52.5* 60.9 66.2 44.6 63.4†
Mean age (years) 61.2 62.1* 60.1 62.4 64.2 59.9†
Race (% nonwhite) 22.7 22.0 23.4 22.0 21.0 23.4
Current smoker (%) 19.7 17.7 22.5 16.1 23.2 18.2
Education (% ⬍high school) 33.0 33.7 32.5 32.6 35.8 31.8
Mean baseline weight (lb) 196.3 190.9* 203.8 185.8 185.8 201.0†
Baseline BMI (kg/m
2
)31.6 30.5* 33.0 30.4 29.6 32.6†
Median weight change (lb) 0 0 ⫺15 10 0 ⫺5
Self-rated health (% fair or worse) 49.7 47.6 50.6 56.6 51.3 49.0
Any functional limitations (%) 56.3 54.6 56.6 63.4 58.1 55.5
Hospitalized past year (%) 23.8 19.7* 28.8 19.7 25.5 23.0
Doctor visits past year (mean) 9.8 8.3 10.9 10.1 9.6 9.6
Duration of disease (mean years) 10.5 11.5* 9.4 11.0 12.0 9.9†
Insulin use (%) 39.7 42.4* 36.1 44.3 44.0 37.8†
Oral medications (%) 54.0 51.2* 57.9 48.6 47.8 56.8†
Retinal disease (%) 24.5 21.8 27.1 25.2 21.5 25.8
Neuropathy symptoms (%) 39.0 33.7* 42.8 46.8 38.1 39.4
Hypertension (%) 65.6 61.8* 69.9 63.2 56.6 69.7†
Heart disease (%) 32.7 30.4* 36.0 27.2 32.5 32.7
Stroke (%) 8.8 8.7 9.0 8.4 9.9 8.3
All figures except nare weighted to be representative of the U.S. diabetic population in 1989. *Significant difference across weight change groups (P⬍0.05);
†significantly different from those trying to lose weight (P⬍0.05).
Table 2—HRR for all-cause mortality associated with weight change and with degree of weight loss or gain among overweight and obese
persons with diabetes
Weight change
(median)
Prevalence
(%)
Death rate
(%/year)
Primary model*
HRR (95% CI)
Fully adjusted†
HRR (95% CI)
No weight change 0 45.6 3.0 1.0 1.0
Weight loss (lb) ⫺15 45.5 4.0 1.22 (0.99–1.50) 1.19 (0.96–1.47)
1–19 ⫺10 26.4 3.6 1.11 (0.87–1.41) 1.09 (0.85–1.40)
ⱖ20 ⫺30 19.1 4.6 1.40 (1.05–1.87) 1.36 (1.03–1.80)
Weight gain (lb) 10 8.9 3.6 1.11 (0.74–1.66) 1.10 (0.72–1.67)
1–19 8 6.8 3.0 0.97 (0.62–1.53) 1.00 (0.61–1.63)
ⱖ20 25 2.2 5.4 1.77 (0.97–3.23) 1.48 (0.82–2.68)
*Primary model adjusted for age, sex, race, smoking, education, and initial BMI; †fully adjusted model: initial BMI, age, race, sex, education, self-rated health,
smoking, diabetes medications, duration of disease, functional limitations, hypertension, heart disease, stroke, retinal disease, neuropathy symptoms, hospital days,
and doctor visits.
Gregg and Associates
DIABETES CARE,VOLUME 27, NUMBER 3, MARCH 2004 659
We found no significant (P⬎0.05)
interactions of age, sex, obesity status, di-
abetes duration, insulin use, or vascular
disease on the weight loss–mortality asso-
ciations. However, we found that associ-
ations of weight loss and mortality tended
to differ between overweight (BMI 25–29
kg/m
2
) and obese (BMI ⱖ30 kg/m
2
) indi-
viduals (data not shown). Specifically,
compared with the referent group (not
trying to lose weight with stable weight or
weight gain), unintentional weight loss
was associated with a higher relative mor-
tality rate among obese (BMI ⱖ30 kg/m
2
)
individuals (HRR 3.29, 95% CI 1.55–
6.98) than overweight (BMI 25–29 kg/
m
2
) individuals (1.20, 0.80–1.81).
Trying to lose weight was associated with
a lower mortality rate among overweight
individuals (0.62, 0.46–0.83) but was
not associated with mortality among
obese individuals (1.17, 0.72–1.92). The
association between trying to lose weight
and lowered mortality among overweight
individuals existed for those who suc-
ceeded (0.58, 0.43–0.84) as well as those
who failed to lose weight (0.64, 0.42–
0.97).
CONCLUSIONS —Using a national
sample of overweight and obese adults
with diabetes, we found a large difference
in the mortality rate between individuals
with unintentional weight loss (58% in-
crease in mortality rate) and those with
intentional weight loss (a nonsignificant
17% decrease). Our findings suggest that
intentional weight loss is not harmful
among individuals with diabetes, and the
large body of research relating weight loss
to increased mortality (4–11) may be
spuriously influenced by unintentional
weight loss.
An unexpected finding of our study
was that intention to lose weight was as-
sociated with reduced mortality regard-
less of whether weight loss occurred.
Individuals who reported trying to lose
weight had a 23% lower mortality rate
than those not trying to lose weight, and
this benefit was as great for those who
failed to lose weight as for those who suc-
ceeded. There are several possible expla-
nations for this finding. First, trying to
lose weight may be a marker of healthy
behaviors, such as being more physically
active or eating healthier foods, and these
lifestyle behaviors may be more important
determinants of health status than weight
loss per se. Unfortunately, we had little
information on the ways in which people
lose weight in this population, but previ-
ous findings relating physical activity,
lower fat intake, and higher fiber intake to
better health support this idea (19–21).
A second possibility is that people
who report “trying to lose weight”may be
more likely to engage in positive health
behaviors unrelated to weight (e.g., using
seat belts, not smoking) or have more fre-
quent contact with health care providers
and preventive care practices, such as ear-
lier screening and treatment for disease.
Although our analyses controlled for
smoking, health status, and health care
use, as well as for exposure to diabetes
education and nutritional counseling,
there may be other fundamental differ-
ences between people who try to lose
weight that we could not detect.
Our finding that losing weight per se
was not associated with mortality reduc-
tion compared with those who failed to
lose weight may be a reflection of poor
long-term weight loss efficacy. In other
words, weight loss attempts in an obser-
vational, population-based study such as
this are likely to be heterogeneous and
may not reflect what could be achieved
with structured, clinical weight loss pro-
grams. Our study only assessed past year
weight loss at one point in time, and thus,
we were unable to compare people who
succeeded in long-term weight mainte-
nance with those who regained their
weight the following year. Nevertheless,
our finding demonstrates the need to con-
sider weight loss intent and to continue to
explore the possibility that lifestyle
changes may be more important clinical
and public health messages than weight
loss itself.
We found a strong association be-
tween trying to lose weight and lower
mortality rates among overweight (BMI
25–29.9 kg/m
2
) individuals but surpris-
ingly, no association with mortality
among obese (BMI ⱖ30 kg/m
2
) individu-
als. We suspect that because obese adults
have greater levels of risk factors for car-
diovascular or other early mortality than
overweight individuals, typical weight
loss attempts may not be powerful
enough to influence mortality in this
group. Alternatively, obese individuals
may be more likely to receive other types
of medical treatments that outweigh the
effects of lifestyle-based weight loss at-
tempts. We are unaware of data to sup-
port this, however, and recent findings
from the Diabetes Prevention Program
(22) found that the benefits of lifestyle-
induced weight loss for diabetes preven-
tion do not differ by baseline obesity
status. Thus, our findings of differential
effects by weight status should be exam-
ined in other studies.
Few studies have examined the rela-
tionship between intentional weight loss
and mortality. In the first epidemiologic
study of weight loss and mortality among
diabetic individuals undergoing dietary
counseling, Lean et al. (23) found that
greater weight loss was associated with
lower mortality. A subsequent study of
Table 3—HRR for all-cause mortality associated with weight loss intent and weight change among overweight and obese persons with diabetes
Weight change
(median)
Prevalence
(%)
Death rate
(%/year)
Primary model*
HRR (95% CI)
Fully adjusted†
HRR (95% CI)
Excluding first 2 years
of mortality
Not trying to lose weight
Stable weight/weight gain 0 23.0 3.6 1.0 1.0 1.0
Lost weight ⫺15 8.0 6.3 1.73 (1.20–2.48) 1.58 (1.08–2.31) 1.28 (0.84–1.94)
Trying to lose weight overall ⫺5 69.0 3.2 0.80 (0.63–1.01) 0.77 (0.61–0.99) 0.77 (0.58–1.01)
Stable weight/weight gain 0 31.5 2.8 0.74 (0.57–0.98) 0.72 (0.55–0.96) 0.77 (0.57–1.05)
Lost weight ⫺15 37.5 3.4 0.85 (0.66–1.11) 0.83 (0.63–1.08) 0.76 (0.56–1.04)
*Primary model adjusted for age, sex, race, smoking, education and initial BMI; †fully adjusted model: initial BMI, age, race, sex, education, self-rated health,
smoking, diabetes medications, duration of disease, functional limitations, hypertension, heart disease, stroke, retinal disease, neuropathy symptoms, hospital days,
and doctor visits.
Diabetes and weight loss
660 DIABETES CARE,VOLUME 27, NUMBER 3, MARCH 2004
diabetic adults in the Cancer Prevention
Study I associated moderate intentional
weight loss with lower mortality (12).
Similarly, we recently published findings
from the general U.S. population (13) in
which trying to lose weight was also asso-
ciated with lower mortality independent
of weight loss, and mortality rates were
lowest among individuals with modest
weight loss (19 lb). However, several
other studies have found adverse or null
associations of intentional weight loss
(14–16). Previous studies, however, have
not examined the independent associa-
tion of weight loss intention, and it is pos-
sible that by categorizing such individuals
along with individuals who did not try to
lose weight, the benefit of weight loss was
underestimated.
Our study has several limitations.
Both body weight and weight loss were
based on self-report, which is known to
overestimate height, and underestimate
weight (and BMI) compared with physi-
cal measurements. Previous studies, how-
ever, have found self-reports of weight
change and intentional weight loss to be
reliable and accurate (24,25). Addition-
ally, we know of no data indicating that
misclassification of body weight is associ-
ated with weight loss intent. If recall error
were not associated with either weight
loss intent or mortality, this would either
have no effect or bias results toward the
null, possibly leading to an underestimate
of the benefits of intentional weight loss
on mortality.
Observational studies have inherent
limitations. We controlled for health sta-
tus and health care use at baseline and
attempted to account for underlying dis-
ease by excluding individuals who died in
the initial years of follow-up or who had
significant weight losses. However, we
still cannot rule out selection bias or re-
sidual confounding due to improper or
inadequate assessment of underlying
health status. If present, this could lead to
underestimates of both the benefitofin-
tentional weight loss and the mortality
risk associated with unintentional weight
loss. Given that cardiovascular disease is
the most common cause of death among
individuals with diabetes, it is unfortu-
nate that there have been no adequately
controlled randomized controlled trials
(RCTs) to examine the effects of weight
loss on cardiovascular disease outcomes
and mortality. We are reminded by the
recent controversy related to the long-
term effects of hormone replacement
therapy (26,27) that RCTs are important
to confirm the value of broadly used pub-
lic health interventions.
In summary, we found that uninten-
tional weight loss was associated with in-
creased mortality among overweight
diabetic U.S. adults and that trying to lose
weight is associated with decreased mor-
tality independent of actual weight
change. Our study challenges previous
concerns that intentional weight loss
causes increased mortality but still leaves
the relative importance of weight loss per
se unclear. Instead, trying to lose weight
may be beneficial even if such attempts
are not successful. Our study highlights
the importance of independently assess-
ing weight loss intent in observational
studies of weight loss. Further examina-
tion of this question may help determine
whether changes in lifestyle behaviors are
more important determinants of health
status than weight loss itself. A clear an-
swer to this question would have impor-
tant implications for clinical as well as
public health messages.
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