Weight regain following sustained weight reduction is predicted by relative insulin sensitivity

Twice-Weekly 36-Hour Intermittent Fasting Practice Attenuates Hunger, Quadruples ß-Hydroxybutyrate, and Maintains Weight Loss: A Case Report

Intermittent fasting (IF) approach to weight loss obviates the inconvenience of calorie counting required in daily caloric restriction (DCR). A metabolic defense mechanism (MDM) obstructs weight loss and facilitates weight regain possibly by increasing hunger and efficiency of exercise energy expenditure (EEf), and by reducing resting metabolic rate (RMR) and energy expenditure (EE) including physical activity (PA). IF may test whether its paradigm can better counteract MDM than DCR. A knowledge gap exists about whether the duration of weekly uninterrupted fasts (UFs), when the IF protocols are isocaloric, affects the MDM. The aim and objective of this 82-week study were to determine whether 36 hours of near-absolute twice-weekly UF will exacerbate MDM but generate similar rates of weight and fat losses compared to four IF studies featuring 20 hours of weekly UF with both IF protocols matched for weekly hours of fast (108) and free access to food (60), a fasting-to-eating (F/E) ratio of 1.8. This case report presents results of twice-weekly fasting on non-consecutive days (5:2-NC) and compares them to results from a 4:3-NC protocol with a 20-hour UF caused by a modification of providing a 500-600 kcal meal on three fasting days (M4:3-NC). Because the large meal raises insulin concentration for four hours at the start of the fasting day, the 20-hour UF consists of the remaining eight hours on the fasting day, followed by 12 additional nocturnal hours of fasting. The hypotheses were that (1) because of their matched F/E ratio, the rates of weight and fat losses will be similar in both protocols, and (2) because of its longer UF period, hunger will be higher and RMR and EE will be lower, in 5:2-NC than in M4:3-NC protocol. The main findings were that the 5:2-NC protocol produced (1) slower rates of weight and fat losses, (2) modest reduction in the sensation of hunger and substantial decline in fullness, (3) no change in RMR and EE, and (4) fourfold post-fast increase in the circulating concentration of the ketone body ß-hydroxybutyrate (BHB), 2.5 greater than in the M4:3-NC protocol. The absence of increased hunger and changes in EE, the variability of the rate of weight loss in the 5:2-NC protocol, plus increased EEf in one M4:3-NC study, suggest that IF does not mitigate MDM, but that shortened UF period in M4:3-NC reduces the rise in BHB. Thus, the addition of a large meal on fasting days is unnecessary for the prevention of hunger and is counterproductive for increases in BHB and its potential health benefits. Continuous practice of the 5:2-NC protocol allows sustained weight loss and maintenance of lost weight with diminished hunger for as long as it is implemented.

Effects of duration of uninterrupted fast in weekly intermittent fasting: Comparison of an 82-week 5:2 case report to an isocaloric modified 4:3 protocol

Intermittent fasting (IF) approach for weight loss obviates the inconvenience of calorie counting of daily caloric restriction (DCR). It tests IF ability to better counteract a metabolic defense mechanism (MDM) than DCR. MDM obstructs weight loss and facilitates weight regain possibly by increasing hunger and efficiency of exercise energy expenditure (EEf), and by reducing resting metabolic rate (RMR) and physical activity (PA). A knowledge gap exists about whether the duration of weekly uninterrupted fasts (UFs), where the IF protocols are isocaloric, mitigate the MDM. This study compares two IF protocols that have the same weekly number of hours of fast (108) and free access to food (60), but which differ in the duration of UF. An 82-week case report was conducted with twice-weekly near-absolute 36-hour fasts on non-consecutive days (5:2-NC) and compared to ten studies with a 20-hour UF on three non-consecutive days (4:3-NC) modified through provision of a 500-600 kcal meal on fasting days. The large meal raised insulin concentration for 4 hours and reduced the UF to 8 hours followed by 12 nocturnal hours of fasting. The hypotheses were that (1) because of their matched F/E ratio, the rates of weight and fat losses will be similar in both protocols, and (2) because of its longer UF period, hunger will be higher and RMR and voluntary physical activity lower, in 5:8-NC than in M4:3-NC protocol,. The main differences between the two protocols were, (1) slower rates of weight and fat losses, (2) lower sensation of hunger and substantial decline in fullness, no change in RMR and physical activity, and 2.5 times higher post-fast concentration of the ketone body beta-hydroxybutyrate (BHB) in 8:2-NC compared to M4:3-NC protocol. Absence of increased hunger and the variability of the rate of weight loss in 5:2-NC protocol, plus increased EEf in one M4:3-NC study suggest that IF does not curtail MDM, but shortened UF period in M4:3-NC reduces elicitation of BHB. Thus, the addition of a large meal on fasting days is unnecessary for prevention of hunger and is counterproductive for increases in BHB and its potential health benefits.

Plasma Levels of Triglycerides and IL-6 Are Associated With Weight Regain and Fat Mass Expansion

CONTEXT

Long-term weight loss (WL) maintenance is the biggest challenge for overweight and obesity because of the almost unavoidable phenomenon of partial or even total weight regain (WR) after WL.

OBJECTIVE

In the present study we investigated the relations of (the changes of) adipocyte size and other risk biomarkers with WR during the follow-up of the Yoyo dietary intervention.

METHODS

In this randomized controlled study, 48 overweight/obese participants underwent a very-low-calorie diet to lose weight, followed by a weight-stable period of 4 weeks and a follow-up period of 9 months. Anthropometric measurements, adipocyte volume of abdominal subcutaneous adipose tissue, and plasma metabolic parameters (free fatty acids [FFAs], triglycerides [TGs], total cholesterol, glucose, insulin, homeostasis model assessment of insulin resistance [HOMA-IR], interleukin 6 [IL-6], angiotensin-converting enzyme [ACE] activity, retinol binding protein 4 [RBP4]) at the beginning and the end of follow-up were analyzed.

RESULTS

Our results show that changes of TGs, IL-6, HOMA-IR, and ACE are significantly positively correlated with WR. Multiple linear regression analysis shows that only TG and IL-6 changes remained significantly correlated with WR and increased body fat mass. Moreover, the change in HOMA-IR was tightly correlated with the change in TGs. Surprisingly, change in adipocyte volume during follow-up was not correlated with WR nor with other factors, but positive correlations between adipocyte volume and HOMA-IR were found at the beginning and end of the follow-up.

CONCLUSION

These results suggest that TGs and IL-6 are independently linked to WR via separate mechanisms, and that HOMA-IR and adipocyte volume may indirectly link to WR through the change of plasma TGs.

Revisiting the Compensatory Theory as an explanatory model for relapse in obesity management

Weight regain remains the main challenge in obesity management, and its etiology remains elusive. The aim of the present review was to revise the available evidence regarding the "Compensatory Theory," which is an explanatory model of relapse in obesity treatment, and to propose alternative mechanisms that can contribute to weight regain. It has been proposed, and generally accepted as true, that when a person loses weight the body fights back, with physiological adaptations on both sides of the energy balance equation that try to bring body weight back to its original state: this is the Compensatory Theory. This theory proposes that the increased orexigenic drive to eat and the reduced energy expenditure that follow weight loss are the main drivers of relapse. However, evidence showing a link between these physiological adaptations to weight loss and weight regain is lacking. Here, we propose that the physiological adaptations to weight loss, both at the level of the homeostatic appetite control system and energy expenditure, are in fact a normalization to a lower body weight and not drivers of weight regain. In light of this we explore other potential mechanisms, both physiological and behavioral, that can contribute to the high incidence of relapse in obesity management. More research is needed to clearly ascertain whether the changes in energy expenditure and homeostatic appetite markers seen in reduced-obese individuals are a compensatory mechanism that drives relapse or a normalization towards a lower body weight, and to explore alternative hypotheses that explain relapse in obesity management.

Obesity in African-Americans: The role of physiology

The disproportionate obesity in African American (AA) women has a physiologic basis and can be explained by the interactive effects of insulin secretion, insulin clearance, insulin sensitivity and the glycaemic load of the diet. This review will present data supporting a physiologic basis for obesity propensity in obesity-prone AA women that resides in their unique metabolic/endocrine phenotype: high beta-cell responsiveness, low hepatic insulin extraction and relatively high insulin sensitivity, which together result in a high exposure of tissues and organs to insulin. When combined with a high-glycaemic (HG) diet (that stimulates insulin secretion), this underlying propensity to obesity becomes manifest, as ingested calories are diverted from energy production to storage. Our data indicate that both weight loss and weight loss maintenance are optimized with low-glycaemic (LG) vs HG diet in AA. Whether greater obesity in AA is mechanistically related to their greater prevalence of type 2 diabetes is debatable. This review provides data indicating that obesity is not strongly related to insulin resistance in AA. Rather, insulin resistance in AA is associated with relatively low adipose tissue in the leg, consistent with a genetic predisposition to impaired lipid storage. Greater bioenergetic efficiency has been reported in AA and, via resultant oxidative damage, could plausibly contribute to insulin resistance. In summary, it is proposed here that a subset of AA women are predisposed to obesity due to a specific metabolic/endocrine phenotype. However, greater diabetes risk in AA has an independent aetiology based on impaired lipid storage and mitochondrial efficiency/oxidative stress.

The sliding set-point: how insulin and diet interact to explain the obesity epidemic (and how to fix it)

PURPOSE OF REVIEW

The current approach to weight loss (intentional energy deficit) is difficult to implement and sustain, and rarely leads to successful long-term weight loss maintenance. The aim of this article is to review recent literature on the role of insulin in obesity propensity, and by extension, the effectiveness of carbohydrate restriction in facilitating weight loss, with particular attention to individual variability in patient response.

RECENT FINDINGS

A genetic signature for insulin secretion predisposes to elevated BMI. A genetic signature for insulin resistance is a marker for impaired fat storage, is associated with relative leanness, and predisposes to cardiometabolic disease. The largest randomized weight-loss trial ever conducted to examine insulin/diet interactions revealed no interactive effect of insulin phenotype with diet composition on body weight in the context of energy restriction. However, smaller studies revealed unique effects of carbohydrate restriction on energy partitioning that are not reflected in body weight; that is, preferential loss of total and ectopic adipose tissue. Carbohydrate-restricted diets are associated with greater adherence, and with greater total and resting energy expenditure.

SUMMARY

For patients with a predisposition to high insulin secretion, carbohydrate restriction may facilitate long-term reductions in body fat, perhaps by reducing hunger, maintaining energy expenditure, and promoting adherence.

HNF1A variant, energy-reduced diets and insulin resistance improvement during weight loss: The POUNDS Lost trial and DIRECT

AIM

To determine whether weight-loss diets varying in macronutrients modulate the genetic effect of hepatocyte nuclear factor 1α (HNF1A) rs7957197 on weight loss and improvement of insulin resistance.

MATERIALS AND METHODS

We analysed the interaction between HNF1A rs7957197 and weight-loss diets with regard to weight loss and insulin resistance improvement among 722 overweight/obese adults from a 2-year randomized weight-loss trial, the POUNDS Lost trial. The findings were replicated in another independent 2-year weight-loss trial, the Dietary Intervention Randomized Controlled Trial (DIRECT), in 280 overweight/obese adults.

RESULTS

In the POUNDS Lost trial, we found that a high-fat diet significantly modified the genetic effect of HNF1A on weight loss and reduction in waist circumference (P for interaction = .006 and .005, respectively). Borderline significant interactions for fasting insulin and insulin resistance (P for interaction = .07 and .06, respectively) were observed. We replicated the results in DIRECT. Pooled results showed similar significant interactions with weight loss, waist circumference reduction, and improvement in fasting insulin and insulin resistance (P values for interaction = .001, .005, .02 and .03, respectively). Greater decreases in weight, waist circumference, fasting insulin level and insulin resistance were observed in participants with the T allele compared to those without the T allele in the high-fat diet group (P = .04, .03 and .01, respectively).

CONCLUSIONS

Our replicable findings provide strong evidence that individuals with the HNF1A rs7957197 T allele might obtain more benefits in weight loss and improvement of insulin resistance by choosing a hypocaloric and high-fat diet.

Metabolic Benefits of Prior Weight Loss with and without Exercise on Subsequent 6-Month Weight Regain

OBJECTIVE

To determine the 6-month follow-up effects after intentional 6-month weight loss alone (WL) and after weight loss with aerobic exercise (AEX + WL) on body composition, glucose metabolism, and cardiovascular disease risk factors in older postmenopausal women and to identify the mechanisms for weight regain.

METHODS

Women (n = 65, BMI > 25 kg/m² ) underwent maximal oxygen consumption testing, dual-energy x-ray absorptiometry, computed tomography scans, and oral glucose tolerance tests before and after 6 months of AEX + WL or WL and at 12 months ad libitum follow-up. Insulin sensitivity (M) (hyperinsulinemic-euglycemic clamp) was measured at baseline and 6 months. Thirty WL and thirty-five AEX + WL women completed a follow-up at 12 months.

RESULTS

Similar weight loss was observed (-8%) in both groups from 0 to 6 months. Total fat mass, fat-free mass, visceral fat area, subcutaneous abdominal and midthigh fat areas, fasting glucose, insulin levels, homeostatic model assessment of insulin resistance (HOMA-IR), insulin areas under the curve, and triglyceride levels decreased similarly after WL and AEX + WL and remained lower at 12 months than at baseline, despite weight regain at 12 months. Initial M was associated with weight regain (r = -0.40, P < 0.01). Weight regain was related to independent changes in leptin and HOMA-IR from 6 to 12 months in a multiple regression model (r = 0.77, P < 0.0001).

CONCLUSIONS

Reductions in body fat and improvements in insulin sensitivity after AEX + WL and WL were maintained at 12 months despite modest weight regain. Baseline insulin resistance partially predicted the magnitude of weight regain in postmenopausal women.

Weight loss-induced cellular stress in subcutaneous adipose tissue and the risk for weight regain in overweight and obese adults

BACKGROUND/OBJECTIVE

Weight loss is often followed by weight regain after the dietary intervention (DI). Cellular stress is increased in adipose tissue of obese individuals. However, the relation between cellular stress and weight regain is unclear. Previously, we observed increased adipose tissue cellular stress of participants regaining weight compared with participants maintaining weight loss. In the current study, we further investigated the relation between weight regain and changes in the expression of stress-related genes and stress protein levels to determine possible predictors of weight regain.

PARTICIPANTS/METHODS

In this randomized controlled trial, sixty-one healthy overweight/obese participants followed a DI of either a 5-week very-low-calorie diet (500 kcal per day) or a 12-week low-calorie diet (1250 kcal per day; WL period) with a subsequent 4-week weight stable diet (WS period), and a 9-month follow-up. The WL and WS period taken together was named the DI. Abdominal subcutaneous adipose tissue biopsies were collected in 53 participants for microarray and liquid chromatography-mass spectrometry analysis. RNA and protein levels for a broad set of stress-related genes were correlated to the weight regain percentage.

RESULTS

Different gene sets correlated to weight regain percentage during WS and DI. Bioinformatics clustering suggests that during the WS phase-defined genes for actin filament dynamics, glucose handling and nutrient sensing are related to weight regain. HIF-1 (hypoxia-inducible factor-1) is indicated as an important regulator. With regard to DI, clustering of correlated genes indicate that LGALS1, ENO1 and ATF2 are important nodes for conferring risk for weight regain.

CONCLUSIONS

Our present findings indicate that the risk for weight regain is related to expression changes of distinct sets of stress-related genes during the first 4 weeks after returning to energy balance, and during the DI. Further research is required to investigate the mechanistic significance of these findings and find targets for preventing weight regain.

Impact of dietary glycemic challenge on fuel partitioning

The 'carbohydrate-insulin theory of obesity' is used to justify popular health claims stating that carbohydrates make you fat or a high glycemic load and consumption of sugar-sweetened beverages (SSBs) and breakfast skipping increase fat gain. According to this theory, the elevated postprandial insulin secretion to a high glycemic challenge is blamed as a causal mechanism by directing nutrients away from oxidation in muscle towards storage in adipose tissue. Scientific evidence is however largely disagreeing with an adverse effect of postprandial hyperinsulinemia on fuel partitioning. Possible reasons for this disagreement are differences in insulin sensitivity and energy balance. Diet-induced hyperinsulinemia may lead to a higher fat storage only at a positive energy balance. A shift in fuel partitioning towards fat storage requires improved or maintained insulin sensitivity in adipose tissue when compared with skeletal muscle. This may be the case during refeeding (after weight loss), physical inactivity or in metabolically healthy obese subjects (relative to insulin-resistant subjects). The adverse effect of a high-glycemic diet, SSBs consumption or breakfast skipping on body weight is likely due to increased energy consumption rather than to increased fat storage.

Weight loss-induced stress in subcutaneous adipose tissue is related to weight regain

Initial successful weight loss is often followed by weight regain after the dietary intervention. Compared with lean people, cellular stress in adipose tissue is increased in obese subjects. However, the relation between cellular stress and the risk for weight regain after weight loss is unclear. Therefore, we determined the expression levels of stress proteins during weight loss and weight maintenance in relation to weight regain. In vivo findings were compared with results from in vitro cultured human Simpson-Golabi-Behmel syndrome (SGBS) adipocytes. In total, eighteen healthy subjects underwent an 8-week diet programme with a 10-month follow-up. Participants were categorised as weight maintainers or weight regainers (WR) depending on their weight changes during the intervention. Abdominal subcutaneous adipose tissue biopsies were obtained before and after the diet and after the follow-up. In vitro differentiated SGBS adipocytes were starved for 96 h with low (0·55 mm) glucose. Levels of stress proteins were determined by Western blotting. WR showed increased expressions of β-actin, calnexin, heat shock protein (HSP) 27, HSP60 and HSP70. Changes of β-actin, HSP27 and HSP70 are linked to HSP60, a proposed key factor in weight regain after weight loss. SGBS adipocytes showed increased levels of β-actin and HSP60 after 96 h of glucose restriction. The increased level of cellular stress proteins in the adipose tissue of WR probably resides in the adipocytes as shown by in vitro experiments. Cellular stress accumulated in adipose tissue during weight loss may be a risk factor for weight regain.

Edmonton Obesity Staging System Prevalence and Association with Weight Loss in a Publicly Funded Referral-Based Obesity Clinic

OBJECTIVES

To determine the distribution of EOSS stages and differences in weight loss achieved according to EOSS stage, in patients attending a referral-based publically funded multisite weight management clinic.

SUBJECTS/METHODS

5,787 obese patients were categorized using EOSS staging using metabolic risk factors, medication use, and severity of doctor diagnosis of obesity-related physiological, functional, and psychological comorbidities from electronic patient files.

RESULTS

The prevalence of EOSS stages 0 (no risk factors or comorbidities), 1 (mild conditions), 2 (moderate conditions), and 3 (severe conditions) was 1.7%, 10.4%, 84.0%, and 3.9%, respectively. Prehypertension (63%), hypertension (76%), and knee replacement (33%) were the most common obesity-related comorbidities for stages 1, 2, and 3, respectively. In the models including age, sex, initial BMI, EOSS stage, and treatment time, lower EOSS stage and longer treatment times were independently associated with greater absolute (kg) and percentage of weight loss relative to initial body weight (P < 0.05).

CONCLUSIONS

Patients attending this publicly funded, referral-based weight management clinic were more likely to be classified in the higher stages of EOSS. Patients in higher EOSS stages required longer treatment times to achieve similar weight outcomes as those in lower EOSS stages.

Biological mechanisms that promote weight regain following weight loss in obese humans

Weight loss dieting remains the treatment of choice for the vast majority of obese individuals, despite the limited long-term success of behavioral weight loss interventions. The reasons for the near universal unsustainability of behavioral weight loss in [formerly] obese individuals have not been fully elucidated, relegating researchers to making educated guesses about how to improve obesity treatment, as opposed to developing interventions targeting the causes of weight regain. This article discusses research on several factors that may contribute to weight regain following weight loss achieved through behavioral interventions, including adipose cellularity, endocrine function, energy metabolism, neural responsivity, and addiction-like neural mechanisms. All of these mechanisms are engaged prior to weight loss, suggesting that these so called "anti-starvation" mechanisms are activated via reductions in energy intake, rather than depletion of energy stores. Evidence suggests that these mechanisms are not necessarily part of a homeostatic feedback system designed to regulate body weight, or even anti-starvation mechanisms per se. Although they may have evolved to prevent starvation, they appear to be more accurately described as anti-weight loss mechanisms, engaged with caloric restriction irrespective of the adequacy of energy stores. It is hypothesized that these factors may combine to create a biological disposition that fosters the maintenance of an elevated body weight and works to restore the highest sustained body weight, thus precluding the long-term success of behavioral weight loss. It may be necessary to develop interventions that attenuate these biological mechanisms in order to achieve long-term weight reduction in obese individuals.

Adaptations of leptin, ghrelin or insulin during weight loss as predictors of weight regain: a review of current literature

Numerous laboratory studies involving both animal and human models indicate that weight loss induces changes in leptin, ghrelin and insulin sensitivity, which work to promote weight regain. It is unclear, however, whether these biological changes serve as a biomarker for predicting weight regain in free-living humans in which biological, behavioral and environmental factors are likely at play. We identified 12 studies published between January 1995 and December 2011 that reported changes in leptin, ghrelin or insulin during intentional weight loss with a follow-up period to assess regain. Two of the nine studies examining leptin suggested that larger decreases were associated with greater regain, three studies found the opposite (smaller decreases were associated with greater regain), whereas four studies found no significant relationship; none of the studies supported the hypothesis that increases in ghrelin during weight loss were associated with regain. One study suggested that improvements in insulin resistance were associated with weight gain, but five subsequent studies reported no association. Changes in leptin, ghrelin or insulin sensitivity, taken alone, are not sufficient to predict weight regain following weight loss in free-living humans. In future studies, it is important to include a combination of physiological, behavioral and environmental variables in order to identify subgroups at greatest risk of weight regain.

Ethnic differences in the relationship between insulin sensitivity and insulin response: a systematic review and meta-analysis

OBJECTIVE

Human blood glucose levels have likely evolved toward their current point of stability over hundreds of thousands of years. The robust population stability of this trait is called canalization. It has been represented by a hyperbolic function of two variables: insulin sensitivity and insulin response. Environmental changes due to global migration may have pushed some human subpopulations to different points of stability. We hypothesized that there may be ethnic differences in the optimal states in the relationship between insulin sensitivity and insulin response.

RESEARCH DESIGN AND METHODS

We identified studies that measured the insulin sensitivity index (SI) and acute insulin response to glucose (AIRg) in three major ethnic groups: Africans, Caucasians, and East Asians. We identified 74 study cohorts comprising 3,813 individuals (19 African cohorts, 31 Caucasian, and 24 East Asian). We calculated the hyperbolic relationship using the mean values of SI and AIRg in the healthy cohorts with normal glucose tolerance.

RESULTS

We found that Caucasian subpopulations were located around the middle point of the hyperbola, while African and East Asian subpopulations are located around unstable extreme points, where a small change in one variable is associated with a large nonlinear change in the other variable.

CONCLUSIONS

Our findings suggest that the genetic background of Africans and East Asians makes them more and differentially susceptible to diabetes than Caucasians. This ethnic stratification could be implicated in the different natural courses of diabetes onset.

Misconceptions in body weight regulation: implications for the obesity pandemic

Energy is a concept of universal importance. In applying it to body weight regulation, the focus has been on energy balance and how this balance is affected by intakes and expenditures. However, energy is an abstract concept without biological equivalent and applying it to explain body weight regulation has led to various misconceptions and created intellectual obstacles in understanding the obesity problem. When nutrient and substrate interactions are considered, instead, a number of important issues pertaining to body weight regulation and to the obesity epidemic can be much more pertinently addressed.

Insulin sensitivity affects propensity to obesity in an ethnic-specific manner: results from two controlled weight loss intervention studies

Background

Risk for obesity differs with ethnicity/race and is associated with insulin sensitivity (S_I), insulin responsiveness, and dietary glycemic load (GL). The objective of this study was to test the hypotheses that, 1) obesity-prone, normal weight, African-American (AA) women would be more insulin sensitive than BMI-matched, never overweight AA women; 2) increased adiposity over time would be associated with greater baseline S_I and higher dietary GL in AA but not European-American (EA) women; and 3) increased adiposity over time would be predicted by S_I in women with high but not low acute insulin response to glucose (AIRg).

Methods

Two controlled weight loss interventions were conducted involving overweight (BMI 25.0-29.9 kg/m²) premenopausal AA and EA women. The first included matching with normal-weight (BMI <25.0 kg/m²) controls following weight loss, and then comparing S_I. The second included a 1-year follow-up of weight-reduced participants to identify predictors of change in %body fat. Main outcome measure in the first study was insulin sensitivity (S_I) as assessed with intravenous glucose tolerance test (IVGTT), and in the second study was change in %fat, as assessed with DXA, over one year. AIRg was assessed during IVGTT, and free-living diet was determined by food record.

Results

In the first study, formerly overweight AA women were 43% more insulin sensitive than BMI-matched never overweight AA (P < 0.05). In the second study, S_I was positively associated with change in %fat over 1 year only in AA women (P < 0.05) and women with high AIRg (P < 0.05). In addition, AA who were insulin sensitive and who consumed a higher GL diet tended to gain greater %fat (P = 0.086 for diet x S_I interaction). In both studies, AA women had higher AIRg (P < 0.001) than EA women.

Conclusions

Formerly overweight (obesity-prone) AA women were more insulin sensitive than never overweight AA women, a quality that may predispose to adiposity, particularly when combined with a high GL diet. This ethnicity/race-specific effect may be due to high insulin responsiveness among AA.

Caloric restriction induces changes in insulin and body weight measurements that are inversely associated with subsequent weight regain

BACKGROUND

Successful weight maintenance following weight loss is challenging for many people. Identifying predictors of longer-term success will help target clinical resources more effectively. To date, focus has been predominantly on the identification of predictors of weight loss. The goal of the current study was to determine if changes in anthropometric and clinical parameters during acute weight loss are associated with subsequent weight regain.

METHODOLOGY

The study consisted of an 8-week low calorie diet (LCD) followed by a 6-month weight maintenance phase. Anthropometric and clinical parameters were analyzed before and after the LCD in the 285 participants (112 men, 173 women) who regained weight during the weight maintenance phase. Mixed model ANOVA, Spearman correlation, and linear regression were used to study the relationships between clinical measurements and weight regain.

PRINCIPAL FINDINGS

Gender differences were observed for body weight and several clinical parameters at both baseline and during the LCD-induced weight loss phase. LCD-induced changes in BMI (Spearman's ρ = 0.22, p = 0.0002) were inversely associated with weight regain in both men and women. LCD-induced changes in fasting insulin (ρ = 0.18, p = 0.0043) and HOMA-IR (ρ = 0.19, p = 0.0023) were also associated independently with weight regain in both genders. The aforementioned associations remained statistically significant in regression models taking account of variables known to independently influence body weight.

CONCLUSIONS/SIGNIFICANCE

LCD-induced changes in BMI, fasting insulin, and HOMA-IR are inversely associated with weight regain in the 6-month period following weight loss.

Tissue-specific responses of lipoprotein lipase to dietary macronutrient composition as a predictor of weight gain over 4 years

This study evaluated if the effect of dietary macronutrient composition on adipose tissue lipoprotein lipase (ATLPL) and skeletal muscle lipoprotein lipase (SMLPL) predicted the long-term (over 4 years) changes in body weight and composition in free-living adults. Using a crossover design, 39 healthy subjects (n = 24 normal weight, n = 7 overweight, n = 8 obese) each followed a 2-week isocaloric high-carbohydrate (HC; 55% CHO:25% fat) and high-fat (HF; 30% CHO:50% fat) diet. On day 15 of each diet, biopsies were performed in the fasted state and 6 h after a meal. Body weight and composition were measured annually over 4 years. The outcomes for body weight, fat mass and % body fat were assessed using a linear two-stage mixed model. The mean (±SEM) increase in body weight and fat mass over 4 years was 0.29 ± 0.15 kg/year (P = 0.063) and 0.31 ± 0.15 kg/year (P = 0.051), respectively. The most consistent predictors of future body weight and fat changes were the ΔATLPL and ΔSMLPL responses (0-6 h) to a HC diet/meal. For the HC diet/meal, the subjects who had an increase in ATLPL activity/cell gained more % body fat over 4 years (P = 0.006) whereas subjects who had a decrease in SMLPL activity/g also had an increase in fat mass (P = 0.021). No significant relationships were observed between fasting ATLPL and SMLPL or enzyme responses to meals and any of the outcomes following the HF diet. In free-living adults the variability in tissue-specific lipoprotein lipase (LPL) responsiveness to a HC diet/meal predicts longitudinal changes in body composition.

Predictive factors of excess body weight loss 1 year after laparoscopic bariatric surgery

BACKGROUND

Bariatric surgery (BS) is widely accepted for the treatment of patients with morbid obesity (MO). We aimed to determine presurgical predictors of and surgical technique-related differences in excess weight loss (EWL) 1 year after BS.

METHODS

This retrospective study included 407 subjects (F/M 3:1, median age = 44 years) who underwent laparoscopic Roux-en-Y gastric bypass (RYGB, n = 307) or sleeve gastrectomy (SG, n = 100) at our University Hospital and were evaluated 1 year after surgery.

RESULTS

Baseline median (min-max) body mass index (BMI) was 47 kg/m(2) (range = 36-71). BMI was higher in the SG than in the RYGB group (53 vs. 46 kg/m(2), p < 0.0001). Simple correlation analysis showed negative associations between EWL and age, BMI, waist circumference (WC), fasting glucose, HbA1c, triglycerides (TG), blood pressure, and total cholesterol (all p < 0.01). EWL (mean ± SD) did not differ by gender (p = 0.2), was lower in diabetic than in nondiabetic subjects (71 ± 17% vs. 79 ± 17%, p < 0.0001), and higher in the RYGB vs. SG group (76 ± 18% vs. 68 ± 15%, p < 0.0001). However, SG vs. RYGB differences in EWL disappeared (p = 0.4) after taking into account baseline BMI. Multiple regression and logistic analysis showed that younger individuals with lower BMI but higher WC, and lower HbA1c and TG, had higher EWL and a higher rate of successful (EWL ≥ 60%) weight loss.

CONCLUSIONS

Our data indicate that some of the characteristics that would have subjects referred early for BS were associated with higher weight loss. Therefore, the timing of laparoscopic BS might be an important factor for MO individuals in which medical weight loss intervention has failed.

Biology's response to dieting: the impetus for weight regain

Dieting is the most common approach to losing weight for the majority of obese and overweight individuals. Restricting intake leads to weight loss in the short term, but, by itself, dieting has a relatively poor success rate for long-term weight reduction. Most obese people eventually regain the weight they have worked so hard to lose. Weight regain has emerged as one of the most significant obstacles for obesity therapeutics, undoubtedly perpetuating the epidemic of excess weight that now affects more than 60% of U.S. adults. In this review, we summarize the evidence of biology's role in the problem of weight regain. Biology's impact is first placed in context with other pressures known to affect body weight. Then, the biological adaptations to an energy-restricted, low-fat diet that are known to occur in the overweight and obese are reviewed, and an integrative picture of energy homeostasis after long-term weight reduction and during weight regain is presented. Finally, a novel model is proposed to explain the persistence of the "energy depletion" signal during the dynamic metabolic state of weight regain, when traditional adiposity signals no longer reflect stored energy in the periphery. The preponderance of evidence would suggest that the biological response to weight loss involves comprehensive, persistent, and redundant adaptations in energy homeostasis and that these adaptations underlie the high recidivism rate in obesity therapeutics. To be successful in the long term, our strategies for preventing weight regain may need to be just as comprehensive, persistent, and redundant, as the biological adaptations they are attempting to counter.

Body weight, not insulin sensitivity or secretion, may predict spontaneous weight changes in nondiabetic and prediabetic subjects: the RISC study

OBJECTIVE

Previous studies have found that high insulin sensitivity predicts weight gain; this association has not been confirmed. Our aim was to systematically analyze metabolic predictors of spontaneous weight changes.

RESEARCH DESIGN AND METHODS

In 561 women and 467 men from the Relationship Between Insulin Sensitivity and Cardiovascular Disease (RISC) cohort (mean age 44 years, BMI range 19-44 kg/m(2), 9% impaired glucose tolerance) followed up for 3 years, we measured insulin sensitivity (by a euglycemic clamp) and β-cell function (by modeling of the C-peptide response to oral glucose and by acute insulin response to intravenous glucose).

RESULTS

Insulin sensitivity was similar in weight gainers (top 20% of the distribution of BMI changes), weight losers (bottom 20%), and weight stable subjects across quartiles of baseline BMI. By multiple logistic or linear regression analyses controlling for center, age, sex, and baseline BMI, neither insulin sensitivity nor any β-cell function parameter showed an independent association with weight gain; this was true in normal glucose tolerance, impaired glucose tolerance, and whether subjects progressed to dysglycemia or not. Baseline BMI was significantly higher in gainers (26.1 ± 4.1 kg/m(2)) and losers (26.6 ± 3.7 kg/m(2)) than in weight stable subjects (24.8 ± 3.8 kg/m(2), P<0.0001 for both gainers and losers). Baseline waist circumference (or equivalently, BMI or weight) was a positive, independent predictor of both weight gain and weight loss (odds ratio 1.48 [95% CI 1.12-1.97]) in men and (1.67 [1.28-2.12]) in women. In men only, better insulin sensitivity was an additional independent predictor of weight loss.

CONCLUSIONS

Neither insulin sensitivity nor insulin secretion predicts spontaneous weight gain. Individuals who have attained a higher weight are prone to either gaining or losing weight regardless of their glucose tolerance.

Weight science: evaluating the evidence for a paradigm shift

Current guidelines recommend that "overweight" and "obese" individuals lose weight through engaging in lifestyle modification involving diet, exercise and other behavior change. This approach reliably induces short term weight loss, but the majority of individuals are unable to maintain weight loss over the long term and do not achieve the putative benefits of improved morbidity and mortality. Concern has arisen that this weight focus is not only ineffective at producing thinner, healthier bodies, but may also have unintended consequences, contributing to food and body preoccupation, repeated cycles of weight loss and regain, distraction from other personal health goals and wider health determinants, reduced self-esteem, eating disorders, other health decrement, and weight stigmatization and discrimination. This concern has drawn increased attention to the ethical implications of recommending treatment that may be ineffective or damaging. A growing trans-disciplinary movement called Health at Every Size (HAES) challenges the value of promoting weight loss and dieting behavior and argues for a shift in focus to weight-neutral outcomes. Randomized controlled clinical trials indicate that a HAES approach is associated with statistically and clinically relevant improvements in physiological measures (e.g., blood pressure, blood lipids), health behaviors (e.g., eating and activity habits, dietary quality), and psychosocial outcomes (such as self-esteem and body image), and that HAES achieves these health outcomes more successfully than weight loss treatment and without the contraindications associated with a weight focus. This paper evaluates the evidence and rationale that justifies shifting the health care paradigm from a conventional weight focus to HAES.

Glucose metabolism and diet predict changes in adiposity and fat distribution in weight-reduced women

Among obesity-prone individuals, metabolic state may interact with diet in determining body composition. We tested the hypotheses that, among 103 weight-reduced women over 1 year, (i) insulin sensitivity would be positively associated with change in %fat; (ii) this association would be modulated by dietary glycemic load (GL); and (iii) changes in fat distribution would be related to indexes of glucose metabolism. Insulin sensitivity, glucose effectiveness, fasting and postchallenge insulin and glucose, and glucose tolerance were assessed during intravenous glucose tolerance test (IVGTT). Changes in %fat and fat distribution were examined using dual-energy X-ray absorptiometry and computed tomography. Dietary GL was assessed on 67 women using food records. On average, women showed a +5.3 +/- 3.0% change in %fat over 1 year, with the magnitude of this change being greater in relatively insulin sensitive women (+6.0 +/- 0.4%, mean +/- s.e.m.) than in relatively insulin resistant women (+4.4 +/- 0.4 kg; P < 0.05). Women who were relatively insulin sensitive and who consumed a higher GL diet showed a +6.8 +/- 0.7% change in %fat, which was greater than those who were less insulin sensitive, regardless of diet (P < 0.05), but did not differ from women who were relatively insulin sensitive and who consumed a lower GL diet (P = 0.105). Changes in intra-abdominal and deep subcutaneous abdominal fat were inversely associated with the postchallenge decline in serum glucose. In conclusion, greater insulin sensitivity may predispose to adiposity among weight reduced women, an effect that may be ameliorated by a lower GL diet. The potential association between indexes of glucose disposal and changes in fat distribution warrants further study.

Weight regain after sustained weight reduction is accompanied by suppressed oxidation of dietary fat and adipocyte hyperplasia

A dual-tracer approach (dietary14C-palmitate and intraperitoneal3H-H2O) was used to assess the trafficking of dietary fat and net retention of carbon in triglyceride depots during the first 24 h of weight regain. Obesity-prone male Wistar rats were allowed to mature under obesogenic conditions for 16 wk. One group was switched to ad libitum feeding of a low-fat diet for 10 wk (Obese group). The remaining rats were switched to an energy-restricted, low-fat diet for 10 wk that reduced body weight by 14% and were then assessed in energy balance (Reduced group), with free access to the low-fat diet (Relapse-Day1 group), or with a provision that induced a minor imbalance (+10 kcal) equivalent to that observed in obese rats (Gap-Matched group). Fat oxidation remained at a high, steady rate throughout the day in Obese rats, but was suppressed in Reduced, Gap-Matched, and Relapse-Day1 rats though 9, 18, and 24 h, respectively. The same caloric excess in Obese and Gap-Matched rats led to less fat oxidation over the day and greater trafficking of dietary fat to visceral depots in the latter. In addition to trafficking nutrients to storage, Relapse-Day1 rats had more small, presumably new, adipocytes at the end of 24 h. Dietary fat oxidation at 24 h was related to the phosphorylation of skeletal muscle acetyl-CoA carboxylase and fatty acid availability. These observations provide evidence of adaptations in the oxidation and trafficking of dietary fat that extend beyond the energy imbalance, which facilitate rapid, efficient regain during the relapse to obesity.

A novel interaction between dietary composition and insulin secretion: effects on weight gain in the Quebec Family Study

BACKGROUND

Clinical trials of low-fat diets characteristically produce small mean long-term weight loss but a large interindividual variation in response. This variation has been attributed to psychological and behavioral factors, although biological differences may also play a role.

OBJECTIVE

The objective was to determine whether physiologic differences in insulin secretion explain differences in weight gain among individuals consuming low- and high-fat diets.

DESIGN

Of 276 individuals followed in the Quebec Family Study for a mean of 6 y, we compared those in the lowest with those in the highest dietary fat tertiles. We performed oral-glucose-tolerance tests at baseline and examined the insulin concentration at 30 min (insulin-30) as a proxy measure of insulin secretion. Six-year changes in body weight and waist circumference were the primary endpoints. We determined the associations between insulin-30 and the primary endpoints by linear regression analysis, with adjustment for potentially confounding factors.

RESULTS

Mean changes in body weight and waist circumference did not differ significantly between the lowest- and highest-fat diet groups. However, these endpoints were strongly associated with insulin-30, especially among individuals consuming the lowest-fat diet. Insulin-30 at baseline was significantly associated with 6-y weight gain (r = 0.51, P < 0.0001) and change in waist circumference (r = 0.55, P < 0.0001) in the lowest diet fat, group [corrected], but not in the highest diet fat group (r = 0.18, P = 0.086 and r = 0.20, P = 0.058, respectively) [corrected] Individuals in the highest insulin-30 and lowest dietary fat group gained 1.8 kg more than did those in the highest insulin-30 and highest dietary fat group (51%; P = 0.034); they gained 4.5 kg more than did those in the lowest insulin-30 and lowest dietary fat group (6.5-fold; P = 0.0026).

CONCLUSION

A proxy measure of insulin secretion strongly predicts changes in body weight and waist circumference over 6 y in adults, especially among those consuming lower-fat diets, which demonstrates the existence of a novel diet-phenotype interaction.

Glucose homeostasis predicts weight gain: prospective and clinical evidence

BACKGROUND

The potential long-term impact of low glycaemia on body fat accumulation has not been verified. Therefore, we examined the effects of low glucose concentrations on long-term energy balance and weight gain in humans.

METHODS

Two sets of analyses were realized in order to verify this objective. First, Study 1 consisted of 259 participants between 20 and 65 years of age selected from Phase 2 of the Quebec Family Study (QFS). The association between glucose concentrations at the end of an oral glucose tolerance test (OGTT) and changes in body mass was analysed prospectively (mean follow-up of 6 years). In addition, Study 2 consisted of 44 obese participants (20 men and 24 women) randomly assigned to a 15-week weight loss program in either a drug therapy group (fenfluramine) or a placebo group coupled with energy intake restriction. The focus of this study was the relationship between glycaemic control at the end of the treatment and post-treatment weight regain.

RESULTS

In Study 1, the glucose concentrations at 120 min of the OGTT were negatively correlated with weight gain over 6 years (r=-0.42, p<0.01). In Study 2, the weight loss program induced a mean reduction in body weight of 10 kg in the fenfluramine and placebo groups. In participants who returned for a follow-up visit (mean=81 weeks after the intervention), the glucose area below fasting values (GABF) at the end of the OGTT increased with weight loss (p<0.01) and was correlated with weight regain (r=0.74, p<0.01).

CONCLUSIONS

Lower glucose concentrations at the end of an OGTT are correlated with weight gain over time. Large amounts of weight loss are associated with low glycaemia at the end of an OGTT. These low glucose concentrations are strong predictors of the amount of weight regained after weight loss.

The 24-h carbohydrate oxidation rate in a human respiratory chamber predicts ad libitum food intake

BACKGROUND

The 24-h respiratory quotient (24-h RQ) and 24-h carbohydrate balance (24-h CHO-Bal) are predictors of weight change. Whether these relations are mediated by the effects of substrate oxidation and balance on food intake is not known.

OBJECTIVE

We tested whether substrate oxidation and balance predict future ad libitum food intake.

DESIGN

Substrate oxidation and balance were measured in a respiratory chamber in 112 normoglycemic subjects (83 Pima Indians and 29 whites; 67 men and 45 women) in energy balance for 3 d before tests were performed. The subjects then self-selected their food ad libitum for the following 3 d.

RESULTS

The 24-h RQ, 24-h carbohydrate oxidation (24-h CHO-Ox), and 24-h CHO-Bal in the respiratory chamber predicted subsequent ad libitum food intake over 3 d (as a percentage of weight maintenance energy needs; %EN-WM). The 24-h CHO-Ox explained 15% of the variance in %EN-WM. The weight change over the 3-d ad libitum period was associated positively with 24-h CHO-Ox and negatively with 24-h CHO-Bal in the chamber; these associations were no longer significant after adjustment for %EN-WM.

CONCLUSION

Carbohydrate oxidation and balance predict subsequent ad libitum food intake and can influence short-term weight changes, which indicates that carbohydrate balance is a contributing metabolic factor affecting food intake.

Carbohydrate balance predicts weight and fat gain in adults

BACKGROUND

The prevention and treatment of obesity is a public health challenge.

OBJECTIVE

We investigated the effects of dietary composition, insulin sensitivity (S(I)), and energy balance on predicted changes in body composition.

DESIGN

In a randomized crossover design study, 39 normal-weight (n = 23), overweight (n = 8), and obese (n = 8) men and women (aged 25-36 y) each followed a 15-d isocaloric high-fat (HF; 50% fat) and high-carbohydrate [HC; 55% carbohydrate (CHO)] diet with a 4-6-wk washout period during the first year. During each treatment, energy balance was measured while the subjects were inactive by using indirect calorimetry on day 15, and S(I) was measured by using a euglycemic clamp study (40 mU . m(-2) . min(-1)) on day 16. Weight and body composition were then measured annually for 4 y. The outcomes for fat mass, percentage body fat, and weight were measured by using a linear 2-stage mixed model.

RESULTS

CHO balance (day 15) and S(I) (day 16) on the HC diet were highly and significantly correlated (r = 0.55, P < 0.001). On the HC diet, the subjects who had a higher positive CHO balance (day 15) gained less fat mass (P < 0.001), percentage body fat (P = 0.006), and weight (P = 0.024) over time. When adjusted for S(I), CHO balance remained a significant predictor of changes in fat mass (P = 0.021) and percentage body fat (P = 0.025).

CONCLUSIONS

On a HC diet, the subjects who had a higher positive CHO balance on day 15 while they were inactive gained less fat mass during 4 y, a predictive effect independent of S(I). As suggested in rodents, the capacity to expand the glycogen pool might reduce energy intake and protect against fat and weight gain.

Leptin secretion after a high-fat meal in normal-weight rats: strong predictor of long-term body fat accrual on a high-fat diet

The objective of this study was to investigate meal-related endocrine changes that permit one to identify Sprague-Dawley rats at normal weight that are prone (OP) vs. resistant (OR) to obesity. In blood collected via chronic cardiac catheters, a 2-h high-fat meal (HFM, 50% fat, 40 kcal) at dark onset caused a significant increase in leptin, insulin, and triglycerides compared with premeal levels. Similar to patterns in already obese compared with lean rats on a high-fat diet, these meal-induced endocrine changes in normal-weight rats on lab chow were almost twofold larger in OP rats that, compared with OR rats, subsequently accumulated 100% more fat mass on a chronic high-fat diet. These exaggerated endocrine changes were similarly observed in blood collected using a simpler tail vein puncture procedure. In three separate experiments, the HFM-induced rise in leptin was found to be the strongest, positive correlate (r = +0.58, +0.62 and +0.64) of long-term body fat accrual. The lowest (2-5 ng/ml) vs. highest (6-9 ng/ml) scores for this post-HFM leptin measurement identified distinct OR and OP subgroups, respectively, when they were similar in body weight (340-350 g), premeal leptin (2.6-3.4 ng/ml), and meal size (40 kcal). Subsequent tests in these normal-weight OP rats revealed a distinct characteristic compared with OR rats, namely, exaggerated HFM-induced rise in expression of the orexigenic peptide galanin in the paraventricular nucleus. Thus, with this HFM-induced leptin measurement, OP rats can be identified while still at normal weight and then investigated for mechanisms that contribute to their excessive body fat accrual on a high-fat diet.

Psychological aspects of weight maintenance and relapse in obesity

Studies have shown that, among formerly obese individuals, the continued practice of the behavioural strategies adopted during weight loss is associated with the successful maintenance of a new lower weight. Much less attention has been focused on the psychological factors that motivate the continued use or abandonment of these critical weight maintenance behaviours. This paper reviews studies that have attempted to identify psychological characteristics that may be associated with weight maintenance and relapse in obesity. This is important because a better understanding of these factors may lead to the development of improved psychological treatments for obesity. The results of the studies suggest that a number psychological factors, such as having unrealistic weight goals, poor coping or problem-solving skills and low self-efficacy, may have an important effect on the behaviours involved in weight maintenance and relapse in obesity, and further research in this area is warranted.

Successful weight loss maintenance

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.

Polycystic ovarian syndrome (PCOS) and insulin resistance

OBJECTIVES

Polycystic ovary syndrome (PCOS) presents a high risk of developing type 2 diabetes mellitus. We studied a group of women with PCOS and evaluated this defect in insulin action.

METHODS

The study population consisted of nine PCOS women, six obese type 2 diabetic patients, and five controls whose body mass index (BMI) was similar to that of the nine PCOS women. The 75-g oral glucose tolerance test (OGTT) and the hyperinsulinemic euglycemic glucose clamp test were performed. Clinical characteristics and the metabolic profiles, including the insulin sensitivity index (ISI), were compared.

RESULTS

PCOS women showed significantly elevated insulin responses during OGTT, but their blood glucose levels were comparable with the controls. The subjects with PCOS had more insulin resistance than the other groups. There was no difference among the groups in terms of clinical characteristics and metabolic profiles, except age, luteinzing hormone (LH), testosterone, and sex hormone binding globulin (SHBG).

CONCLUSION

We conclude that PCOS women have significant insulin resistance which is independent of adiposity.

Exercise in weight management of obesity

Obesity is a chronic metabolic disorder associated with CVD and increased morbidity and mortality. When the BMI is > or = 30 kg/m2, mortality rates from all causes, and especially CVD, are increased by 50% to 100%. There is strong evidence that weight loss in overweight and obese individuals improves risk factors for diabetes and CVD. Additional evidence indicates that weight loss and the associated diuresis reduce blood pressure in both overweight hypertensive and nonhypertensive individuals, reduce serum TG levels, increase high-density lipoprotein cholesterol levels, and may produce some reduction in low-density lipoprotein cholesterol concentrations. Of interest, even if weight loss is minimal, obese individuals showing a good level of cardiorespiratory fitness are at reduced risk for cardiovascular mortality than lean but poorly fit subjects. Insulin and catecholamines have pronounced metabolic effects on human adipose tissue metabolism. Insulin stimulates LPL and inhibits HSL; the opposite is true for catecholamines. There is regional variation in adipocyte TG turnover favoring lipid mobilization in the visceral fat depots and lipid storage in the peripheral subcutaneous sites. The hormonal regulation of adipocyte TG turnover is altered in obesity and is most marked in central obesity. There is resistance to insulin stimulation of LPL; however, LPL activity in fasted obese subjects is increased and remains so following weight reduction. Catecholamine-induced lipolysis is enhanced in visceral fat but decreased in subcutaneous fat. Numerous adaptive responses take place with physical training. These adaptations result in a more efficient system for oxygen transfer to muscle, which is now able to better utilize the unlimited lipid stores instead of the limited carbohydrate reserves available. In addition, the reduced adipose tissue mass represents an important mechanical advantage, allowing better long-term work. Gender differences have been reported in the adaptation of adipose tissue metabolism to aerobic exercise training. Physical training helps counteract the permissive and affluent environment that predisposes reduced-obese subjects to regain weight. An exercise program using weight resistance modalities may also be included safely, and it improved program retention in a multidisciplinary weight management program that was designed for obese children. Thirty to 45 minutes of physical activity of moderate intensity, performed 3 to 5 days a week, should be encouraged. All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all days. Public health interventions promoting walking are likely to be the most successful. Indeed, walking is unique because of its safety, accessibility, and popularity. It is noteworthy that there is a clear dissociation between the adaptation of cardiorespiratory fitness and the improvements in the metabolic risk profile that can be induced by endurance training programs. It appears that as long as the increase in energy expenditure is sufficient, low-intensity endurance exercise is likely to generate beneficial metabolic effects that would be essentially similar to those produced by high-intensity exercise. The clinician should therefore focus on the improvement of the metabolic profile rather than on weight loss alone. Realistic goals should be set between the clinician and the patient, with a weight loss of approximately of 0.5 to 1 pound per week. It should be kept in mind that since it generally takes years to become overweight or obese, a weight loss pattern of 0.5 or 1 pound per week will require time and perseverance to reach the proposed target. However, the use of physical activity as a method to lose weight seems inversely related to patients' age and BMI and directly related to the level of education. Thus, public health interventions helping these groups to become physically active remain a challenge and further emphasize the importance of the one-on-one interaction between the clinician/health care professional with the obese individual "at risk" of CVD. This notion is critical, as it has been shown that less than half of obese adults have reported being advised to lose weight under the guidance of health care professionals.

The origins of western obesity: a role for animal protein?

A reduced propensity to oxidize fat, as indicated by a relatively high fasting respiratory quotient, is a major risk factor for weight gain. Increased insulin secretion works in various ways to impede fat oxidation and promote fat storage. The substantial 'spontaneous' weight loss often seen with very-low-fat dietary regimens may reflect not only a reduced rate of fat ingestion, but also an improved insulin sensitivity of skeletal muscle that down-regulates insulin secretion. Reduction of diurnal insulin secretion may also play a role in the fat loss often achieved with exercise training, low-glycemic-index diets, supplementation with soluble fiber or chromium, low-carbohydrate regimens, and biguanide therapy. The exceptional leanness of vegan cultures may reflect an additional factor - the absence of animal protein. Although dietary protein by itself provokes relatively little insulin release, it can markedly potentiate the insulin response to co-ingested carbohydrate; Western meals typically unite starchy foods with an animal protein-based main course. Thus, postprandial insulin secretion may be reduced by either avoiding animal protein, or segregating it in low-carbohydrate meals; the latter practice is a feature of fad diets stressing 'food combining'. Vegan diets tend to be relatively low in protein, legume protein may be slowly absorbed, and, as compared to animal protein, isolated soy protein provokes a greater release of glucagon, an enhancer of fat oxidation. The low insulin response to rice may mirror its low protein content. Minimizing diurnal insulin secretion in the context of a low fat intake may represent an effective strategy for achieving and maintaining leanness.

Insulin sensitivity as a predictor of weight regain

A recent study found that increases in insulin sensitivity following weight loss and stabilization were strongly related to subsequent weight regain. The present paper analyzed this relationship in two behavioral weight-loss programs. In the first study, 125 nondiabetic subjects were followed over 30 months; weight losses averaged 10 kg at six months, and subjects had regained 8 kg of their weight loss by their 30-month follow-up. Neither fasting insulin levels at six months nor changes in fasting insulin from zero to six months were related to subsequent weight regain. Similarly, insulin levels measured two hours after a 75 g glucose load were unrelated to subsequent weight regain. The second study followed 33 individuals with Type II diabetes, treated with behavior modification, and either a low calorie diet or a very low calorie diet. Weight losses averaged 18 kg at six months, and subjects had regained 10 kg by their 24-month follow-up. The Bergman minimal model was used to assess insulin sensitivity at 6-month intervals. Initial analyses suggested that changes in insulin sensitivity from zero to six months were related to subsequent weight regain, but this effect was strongly influenced by an outlier. After removing this individual, there were no significant relationships between the changes in insulin sensitivity that accompanied weight loss and future weight regain. Likewise, insulin sensitivity at 12 months did not predict weight regain from 12 to 24 months. These data do not support the hypothesis that increases in insulin sensitivity with weight loss are associated with subsequent weight regain.