A descriptive analysis of men and women who have lost significant weight and are highly successful at maintaining the loss

Differences in weight loss outcomes for males and females on a low-carbohydrate diet: A systematic review

It has been widely demonstrated that there are a broad range of individual responses to all weight management regimens, often masked by reports of the mean. Identifying features of responders and non-responders to weight loss regimens enables a more tailored approach to the provision of weight management advice. Low-carbohydrate diets are currently popular, and anecdote suggests that males are more successful at losing weight using this approach. This is feasible given the physiological and socio-psychological differences between the genders. We analysed the extent and variation in weight change for males and females separately through a systematic search for all low-carbohydrate diet trials published since 1985. Very few studies compared weight loss outcomes by gender and, of those that did, most lacked supporting data. The majority of studies reported no gender difference but when a gender difference was found, males were more frequently reported as losing more weight than females on a low-carbohydrate diet. The lack of gender stratification in weight loss trials is concerning, as there are a range of gender-based factors that affect weight loss outcomes. This study highlights the importance of examining weight change for males and females separately, since as failure to do so may mask any potential differences, which, if detected, could assist with better weight loss outcomes.

Underreporting of energy intake in weight loss maintainers

BACKGROUND

Individuals with overweight or obesity commonly underreport energy intake (EI), but it is unknown if the tendency to underreport persists in formerly obese individuals who lose significant weight and maintain their weight loss over long periods of time.

OBJECTIVE

Assess the accuracy of self-reported EI in successful weight loss maintainers (WLM) compared with controls of normal body weight (NC) and controls with overweight/obesity (OC).

METHODS

Participants for this case-controlled study were recruited in 3 groups: WLM [n = 26, BMI (in kg/m2) 24.1 ± 2.3; maintaining ≥13.6 kg weight loss for ≥1 y], NC (n = 33, BMI 22.7 ± 1.9; similar to current BMI of WLM), and OC (n = 32, BMI 34.0 ± 4.6; similar to pre-weight loss BMI of WLM). Total daily energy expenditure (TDEE) was measured over 7 d using the doubly labeled water (DLW) method, and self-reported EI was concurrently measured from 3-d diet diaries. DLW TDEE and self-reported EI were compared to determine accuracy of self-reported EI.

RESULTS

WLM underreported EI (median, interquartile range) (-605, -915 to -314 kcal/d) to a greater degree than NC (-308, -471 to -68 kcal/d; P < 0.01) but not more than OC (-310, -970 to 18 kcal/d; P = 0.21). WLM also showed a greater degree of relative underreporting (-25.3%, -32.9% to -12.5%) compared with NC (-14.3%, -19.6% to -3.1%; P = 0.02) but not OC (-11.2%, -34.1% to -0.7%; P = 0.16). A greater proportion of WLM was classified as underreporters (30.8%) than NC (9.1%; P = 0.05) but not OC (28.1%; P = 1.00).

CONCLUSIONS

WLM underreported EI in both absolute and relative terms to a greater extent than NC but not OC. These findings call into question the accuracy of self-reported EI in WLM published in previous studies and align with recent data suggesting that WLM rely less on chronic EI restriction and more on high levels of physical activity to maintain weight loss. This trial was registered at clinicaltrials.gov as NCT03422380.

Effects of nutrition education on weight gain prevention: a randomized controlled trial

Background

Body weight (BW) reduction through energy restriction is ineffective at impacting the obesity epidemic. Shifting from an obesity treatment to weight gain prevention focus may be more effective in decreasing the burden of adult obesity.

Methods

This was a 1-year randomized controlled trial of weight gain prevention in healthy premenopausal women, aged 18–45 y, with a body mass index (BMI) of >18.5 kg/m². Eighty-seven women were randomized to a weight gain prevention intervention delivered by a registered dietitian (RDG) or counselor (CSG), or to a control (CON) group. Eighty-one women (mean ± SD, age: 31.4 ± 8.1 y; BW: 76.1 ± 19.0 kg; BMI: 27.9 ± 6.8 kg/m²) completed baseline testing and were included in intention-to-treat analyses; anthropometric, blood pressure, dietary intake and physical activity measurements and biochemical markers of health were measured every three months. Data were analyzed using repeated measures ANCOVA, with significance at P < 0.01.

Results

Sixty-two percent of women met the weight gain prevention criteria (BW change within ±3 %) after one year; this did not differ by group assignment. Body fat % was lower in the RDG versus CSG and CON groups at all intervals (P < 0.001). Systolic blood pressure increased from month 6 to 9 and decreased from month 6 to 12 in the CON group (P < 0.001), with a significant group x time interaction (P < 0.01). Estimated carbohydrate intake (%) was higher in the RDG vs. CON group at month 9 (P < 0.01); fat intake (%) was lower in the RDG vs. CON group and CSG vs. CON group at months 3 and 9, respectively (P < 0.01). Estimated fruit intake (svgs/d) was higher in the RDG vs. CON group at months 3, 6, 9 and 12 (P < 0.01), and non-meat protein sources (svgs/d) was higher in the RDG vs. CSG and CON groups at month 3 (P < 0.001). Estimated energy, macronutrient and food group intakes did not change over time.

Conclusions

A majority of all participants maintained BW over one year and were able to do so regardless of whether they received nutrition education. Additional studies that include a variety of clinical outcomes are needed to evaluate further aspects of nutrition education on weight gain prevention and health status over the long term.

Changes of dietary patterns during participation in a web-based weight-reduction programme

Objective

To examine the weight-loss success associated with distinct dietary patterns and to determine changes of these dietary patterns during participation in a web-based weight-reduction programme.

Design

Factor analysis was used to identify the dietary patterns of twenty-two food groups that were administered in 14 d dietary protocols at baseline and after 3 months. Successful weight loss (≥5 % of initial weight) and BMI were calculated. Logistic regression analyses were used to assess the rates of weight-loss success from each dietary pattern and changing or remaining in the initial dietary pattern. A generalised linear mixed model was used to estimate the effects of changing or staying in a dietary pattern on change in BMI.

Subjects

Adults (n 1635) aged 18–81 years.

Setting

Users of a web-based weight-reduction programme (2006–2012).

Results

Participants who aligned to a healthful dietary pattern at baseline (OR=1·8; 95 % CI 1·5, 2·3) and after 3 months (OR=1·5; 95 % CI 1·2, 1·9) had a greater chance of successfully losing weight. After adjusting for age, sex, initial dietary pattern and BMI, participants who started with or changed to the healthful dietary pattern had a greater chance of being successful (OR=1·4; 95 % CI 1·1, 1·7) and a higher BMI reduction of 0·30 (95 % CI 0·2, 0·5) kg/m2 compared with those who started with or changed to the energy-dense or high-carbohydrate dietary pattern.

Conclusions

A favourable healthful dietary pattern at the beginning and after 3 months was positively associated with anthropometry. However, successful weight loss was feasible in each dietary pattern.

The monster in the mirror: reasons for wanting to change appearance

PURPOSE

Many adults are dissatisfied with their body, regardless of their weight, and weight loss is commonly perceived as an effective solution to this dissatisfaction. The main purpose of this study was to examine the reasons for wanting to modify one's bodily appearance (shape and weight), and to compare these reasons by sex, age, and weight group.

METHODS

The sample consisted of 796 French-speaking Canadian adults (100 men, 696 women; M age = 27.00 years, SD = 7.88, range 18-64; M body mass index = 24.99 kg/m(2), SD = 6.37, range 12.6-66.5 kg/m(2)) who were asked online whether or not they wanted to change their appearance and if so, why. Answers were subjected to a content analysis wherein recurrent themes were grouped and labeled.

RESULTS

Most participants (83.2%) wanted to change their appearance. Women, participants with a higher BMI, and older participants were significantly more likely to report this desire. The three most frequently evoked reasons were body dissatisfaction, well-being, and health/shape.

CONCLUSIONS

The results suggest that body dissatisfaction constitutes the primary motive for change for both men and women of all ages, especially for those who are of healthy weight or underweight. Women and younger adults seem to be under the impression that in changing their appearance they will be more comfortable in their own skin. Men, older adults, and overweight adults, on the other hand, are more preoccupied by their health/shape and seldom relate their appearance to their psychological balance.

Knowledge, attitudes, and practices of public sector primary health care physicians of rural north karnataka towards obesity management

Introduction:

Obesity is a risk factor for cardiovascular disease (CVD), diabetes mellitus (DM), and hypertension (HTN). In an era of rapidly growing prevalence of obesity, it is important to explore the current knowledge, attitude, and practices of primary care physicians.

Materials and Methods:

Study participants were medical officers (MOs) of primary health centers in three districts of North Karnataka. The questionnaire was developed by a review of literature in the field and validated with five participants for scope, length, and clarity.

Results/Discussion:

Of the 102 participants, only 15% were aware about the burden of obesity in India. HTN, DM, and CVD were indicated as comorbidities by 73, 78, and 60 participants, respectively. Only 25 and 12 participants indicated appropriate body mass index (BMI) cut-off values for overweight and obesity diagnosis. Of the 102 participants, 54 were not aware of the guidelines for obesity management. Practices and attitudes of the participants were encouraging. Nearly all of them felt that the adults with BMI within the healthy range should be encouraged to maintain their weight and, three-fourth of them agreed that most overweight persons should be treated for weight loss and small weight loss can achieve major medical benefit. However, nearly half of the participants’ responses were stereotypical as they felt only obese and overweight with comorbidities should be treated for weight loss. Two-thirds of them use BMI to diagnose overweight/obese and nearly all of them advice their patients to increase physical activity and restrict fat. Most of the participants were advising their patients to restrict sugar intake, increase fruits and vegetable consumption, reduce red meat, and avoid alcohol consumption.

Conclusion:

Present study exposed the lack of knowledge regarding obesity. However, practices and attitudes of the participants were promising. There is a need of in-service training to MOs to further improve their knowledge and practices towards management of obesity.

Impact of a brief dietary self-monitoring intervention on weight change and CPAP adherence in patients with obstructive sleep apnea

OBJECTIVE

Weight loss can decrease the severity of obstructive sleep apnea (OSA) in many obese individuals; however, very few studies have investigated the effects of behavioral weight loss interventions for patients with OSA. The aims of this pilot study were to determine the feasibility and initial effects on weight and continuous positive airway pressure (CPAP) use of a brief minimal-contact self-monitoring-based weight loss intervention (SM). An additional aim was to investigate the association between weight loss and CPAP adherence.

METHODS

Forty obese men and women diagnosed with mild or moderate OSA were randomized to either the SM or an attention-control (AC) condition. SM participants completed daily dietary logs for 6 weeks. Participants were weighed at baseline, post-treatment (6 weeks), and at a 6-week follow up.

RESULTS

Recruitment and retention were good in this study and attrition rates did not differ significantly by group. Intent to treat repeated measures ANOVA indicated a main effect of time (but not group), such that both groups lost weight over time. Pearson r correlations between weight change and CPAP adherence indicated that among SM participants, 6-week weight loss was correlated with CPAP adherence at post-treatment and follow-up, such that SM participants with greater weight loss at 6 weeks had greater CPAP adherence at 6 and 12 weeks.

CONCLUSION

This study provides initial support for the beneficial effects of a minimal-contact weight loss intervention for patients with obstructive sleep apnea and highlights a possible association between weight loss and CPAP adherence.

Physical Activity and Long-Term Maintenance of Weight Loss

To examine the effect of exercise on the long-term maintenance of weight loss, two types of literature were reviewed--correlational studies of predictors of long-term weight loss, and randomized trials comparing diet, exercise, and the combination of diet plus exercise. Both literatures were striking in the consistency with which activity emerged as a determinant of long-term maintenance of weight loss. The benefits of exercise for long-term weight maintenance were observed with different types of populations, diets, and exercise interventions. Several possible explanations for these positive effects of diet plus exercise are presented, and suggestions made for future research on ways to maximize the benefit of this approach to weight control. Since adherence to exercise may ultimately prove to be the cornerstone for long-term weight maintenance, studying ways to improve exercise adherence is recommended.

Using positive deviance for determining successful weight-control practices

Based on positive deviance (examining the practices of successful individuals), we identified five primary themes from 36 strategies that help to maintain long-term weight loss (weight control) in 61 people. We conducted in-depth interviews to determine what successful individuals did and/or thought about regularly to control their weight. The themes included weight-control practices related to (a) nutrition: increase water, fruit, and vegetable intake, and consistent meal timing and content; (b) physical activity: follow and track an exercise routine at least 3x/week; (c) restraint: practice restraint by limiting and/or avoiding unhealthy foods; (d) self-monitor: plan meals, and track calories/weight progress; and (e) motivation: participate in motivational programs and cognitive processes that affect weight-control behavior. Using the extensive data involving both the practices and practice implementation, we used positive deviance to create a comprehensive list of practices to develop interventions for individuals to control their weight.

Weight loss interventions in young people (18 to 25 year olds): a systematic review

This systematic review assesses weight loss interventions in young adults (18-25 years), who are vulnerable to weight gain. This age group experience critical life course points (leaving home for higher studies or job, pregnancy, cohabitation) and develop/establish lifestyle and behavioural patterns making this an opportune intervention period. Medline, Embase, Cinahl, PsychINFO and Cochrane Library were searched (1980 to March 2008). All trials and cohort studies with control groups that assessed weight loss interventions in this specific age group were included finally identifying 14 studies. Before and after comparison of behavioural/motivational interventions (-2.40 kg; 95% CI -5.4 to 0.6) and combination interventions (-2.96; 95% CI -4.4 to -1.5) consistently showed weight loss. Behavioural/motivational interventions increased self-efficacy, the desire to control weight, boosted self-esteem, and increased satisfaction with body areas and appearance. Interventions also showed improvements in HDL cholesterol, insulin, glucose and maximum oxygen uptake. However, recruitment to participation in interventions was a barrier for this age group with small sample sizes and short-term interventions. There may be gender differences in preference to participation in certain type of interventions. Further research to understand attitudes towards healthy lifestyle and preferences of interventions is needed to develop suitable interventions for this vulnerable age group.

Exercise and obesity

Obesity and overweight are linked to a wide range of medical conditions, such as hypertension, diabetes mellitus, osteoarthritis, obstructive sleep apnea, and coronary artery disease. Overweight and obese patients who are unable to lose weight with diet alone can benefit from well-structured exercise. Potentially, an individual exercise prescription can become one of the most important components of an obesity treatment program, along with an appropriate diet. Short-term (<6 months of duration) interventions consisting of exercise combined with appropriate diet and counseling can produce a significant weight loss. No consensus exists on the amount of physical activity necessary to maintain the weight loss achieved during a short-term intervention. Long-term intervention is frequently influenced by weight regain related to complex interactions between physiologic and psychosocial factors.

Metabolic and behavioral compensatory responses to exercise interventions: barriers to weight loss

An activity-induced increase in energy expenditure theoretically disturbs energy balance (EB) by creating an acute energy deficit. Compensatory responses could influence the weight loss associated with the energy deficit. Individual variability in compensation for perturbations in EB could partly explain why some individuals fail to lose weight with exercise. It is accepted that the regulatory system will readily defend impositions that promote a negative EB. Therefore, a criticism of exercise interventions is that they will be ineffective and futile methods of weight control because the acute energy deficit is counteracted. Compensation for exercise-induced energy deficits can be categorized into behavioral or metabolic responses and automatic or volitional. An automatic compensatory response is a biological inevitability and considered to be obligatory. An automatic compensatory response is typically a metabolic consequence (e.g., reduced resting metabolic rate) of a negative EB. In contrast, a volitional compensatory response tends to be deliberate and behavioral, which the individual intentionally performs (e.g., increased snack intake). The purpose of this review is to highlight the various metabolic and behavioral compensatory responses that could reduce the effectiveness of exercise and explain why some individuals experience a lower than expected weight loss. We propose that the extent and degree of compensation will vary between individuals. That is, some individuals will be predisposed to compensatory responses that render them resistant to the weight loss benefits theoretically associated with an exercise-induced increase in energy expenditure. Therefore, given the inter-individual variability in behavioral and metabolic compensatory responses, exercise prescriptions might be more effective if tailored to suit individuals.

Evaluation of a brief pilot nutrition and exercise intervention for the prevention of weight gain in general practice patients

Objective

To pilot-test a brief written prescription recommending lifestyle changes delivered by general practitioners (GPs) to their patients.

Design

The Active Nutrition Script (ANS) included five nutrition messages and personalised exercise advice for a healthy lifestyle and/or the prevention of weight gain. GPs were asked to administer 10 scripts over 4 weeks to 10 adult patients with a body mass index (BMI) of between 23 and 30 kg m− 2. Information recorded on the script consisted of patients' weight, height, waist circumference, gender and date of birth, type and frequency of physical activity prescribed, and the selected nutrition messages. GPs also recorded reasons for administering the script. Interviews recorded GPs views on using the script.

Setting

General practices located across greater Melbourne.

Subjects and results

Nineteen GPs (63% female) provided a median of nine scripts over 4 weeks. Scripts were administered to 145 patients (mean age: 54 ± 13.2 years, mean BMI: 31.7 ± 6.3 kg m− 2; 57% female), 52% of whom were classified as obese (BMI >30 kg m− 2). GPs cited ‘weight reduction’ as a reason for writing the script for 78% of patients. All interviewed GPs (90%,n = 17) indicated that the messages were clear and simple to deliver.

Conclusions

GPs found the ANS provided clear nutrition messages that were simple to deliver. However, GPs administered the script to obese patients for weight loss rather than to prevent weight gain among the target group. This has important implications for future health promotion interventions designed for general practice.

The obesity epidemic in the United States: role of cardiac rehabilitation

Obesity is an independent risk factor for the development of coronary heart disease. The vast majority of individuals entering into cardiac rehabilitation are overweight. Weight loss has been shown to be helpful in modifying multiple coronary risk factors. Cardiac rehabilitation programs, as secondary prevention centers, need to develop programs to assist participants with meaningful and permanent weight loss.

Weight loss expectations in obese patients and treatment attrition: an observational multicenter study

OBJECTIVE

To investigate the influence of weight loss expectations (expected 1-year BMI loss, dream and maximum acceptable BMI) on attrition in obese patients seeking treatment.

RESEARCH METHODS AND PROCEDURES

Obese subjects (1,785; 1,393 women; median age, 46 years; median BMI, 36.7 kg/m(2)) seeking treatment in 23 medical Italian centers were evaluated. Baseline diet and weight history, weight loss expectations, and primary motivation for seeking treatment (health or improving appearance) were systematically recorded. Psychiatric distress, binge eating, and body image dissatisfaction were tested at baseline by self-administered questionnaires (Symptom Check List-90, Binge Eating Scale, and Body Uneasiness Test). Attrition and BMI change at 12 months were prospectively recorded.

RESULTS

At 12 months, 923 of 1,785 patients (51.7%) had discontinued treatment. Compared with continuers, drop-outs had a significantly lower age, a lower age at first dieting, lower dream BMI, a higher expected 1-year BMI loss, and a higher weight phobia. At logistic regression analysis, the strongest predictors of attrition at 12 months were lower age and higher expected 1-year BMI loss. The risk of drop-out increased systematically for unit increase in expected BMI loss at 12 months (hazard ratio, 1.12; 95% confidence interval, 1.04 to 1.20; p = 0.0018). The risk was particularly elevated in the first 6 months.

DISCUSSION

Baseline weight loss expectations are independent cognitive predictors of attrition in obese patients entering a weight-losing program; the higher the expectations, the higher attrition at 12 months. Unrealistic weight goals should be tackled at the very beginning of treatment.

Weight loss expectations in obese patients seeking treatment at medical centers

OBJECTIVE

To investigate weight loss expectations (expected 1-year BMI loss, dream BMI, and maximum acceptable BMI) in obese patients seeking treatment and to examine whether expectations differ by sex, weight, diet and weight history, age, psychological factors, and primary motivations for weight loss.

RESEARCH METHODS AND PROCEDURES

1891 obese patients seeking treatment in 25 Italian medical centers (1473 women; age, 44.7 +/- 11.0 years; BMI, 38.2 +/- 6.5 kg/m2) were evaluated. Diet and weight history, weight loss expectations, and primary motivation for seeking treatment (health or improving appearance) were systematically recorded. Psychiatric distress, binge eating, and body image dissatisfaction were tested by self-administered questionnaires (Symptom CheckList-90, Binge Eating Scale, and Body Uneasiness Test).

RESULTS

In 1011 cases (53.4%), 1-year expected BMI loss was > or = 9 kg/m2, dream BMI was 26.0 +/- 3.4 kg/m2 (corresponding to a 32% loss), and maximum acceptable BMI was 29.3 +/- 4.4 kg/m2 (-23%). BMI and age were the strongest predictors of weight goals. Weight loss necessary to reach the desired targets was largely in excess of weight loss observed during previous dieting. Psychiatric distress, body dissatisfaction, and binge eating did not predict weight loss expectations. The primary motivation for weight loss was concern for future or present health; women seeking treatment to improve appearance had a lower grade of obesity, were younger, and had first attempted weight loss at a younger age.

DISCUSSION

Obese Italian patients had unrealistic weight loss expectations. There were significant disparities between patients' perceptions and physicians' weight loss recommendations of desirable treatment outcome.

Psychological predictors of weight regain in obesity

It is a consistent finding that, among obese patients, the weight lost as a result of the most widely available treatments for obesity is almost always regained. This relapse appears to be attributable to the individual's inability to persist with the behavioural strategies needed to maintain the new lower weight. Little research has investigated the psychological mechanisms that might account for this phenomenon. This study aimed to identify psychological factors that predict weight regain. Fifty-four women with obesity who had lost weight by attending community slimming clubs were interviewed immediately after losing 10% of their initial body weight, and then followed-up every 2 months for a period of 1 year by means of telephone interviews. The results identified two prospective predictors of weight regain: one cognitive factor (dichotomous thinking) and one historical variable (maximum lifetime weight). The finding that a specific cognitive style is a significant predictor of relapse has implications for the treatment of obesity.

Attitudes and reported practice for obesity management in Korea after introduction of anti-obesity agents

This study aimed to evaluate current clinical assessments and management of obesity in the primary care setting in Korea since anti-obesity agents have become available. A questionnaire was sent to eligible primary care physicians selected from a national probability sample in two specialties: family physicians and internists. Of 939 randomly selected physicians, 452 (48.1%) replied. We found that 51.8% of physicians were aware of the definition of obesity, and 33.8% were aware of the definition of abdominal obesity proposed by Asia-Pacific guideline. When evaluating apparently obese patients, 50.0% of respondents measured body mass index (BMI) and 20.4% measured waist circumference. Fewer than 50% of physicians measured blood glucose or lipid profiles, both of which are risk factors for obesity. About 47.3% of physicians prescribed an anti-obesity medication without allowing sufficient time for nonpharmacologic therapy to take effect, and 68.8% of physicians prescribed anti-obesity medications to patients that requested them regardless of obesity status. The majority of respondents did not appropriately evaluate obesity and its risk factors, and were readily susceptible to prescribing anti-obesity medications. Our findings suggest that primary care physicians in Korea need additional education on obesity and its management.

Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain

Weight loss is difficult to achieve and maintaining the weight loss is an even greater challenge. The identification of factors associated with weight loss maintenance can enhance our understanding for the behaviours and prerequisites that are crucial in sustaining a lowered body weight. In this paper we have reviewed the literature on factors associated with weight loss maintenance and weight regain. We have used a definition of weight maintenance implying intentional weight loss that has subsequently been maintained for at least 6 months. According to our review, successful weight maintenance is associated with more initial weight loss, reaching a self-determined goal weight, having a physically active lifestyle, a regular meal rhythm including breakfast and healthier eating, control of over-eating and self-monitoring of behaviours. Weight maintenance is further associated with an internal motivation to lose weight, social support, better coping strategies and ability to handle life stress, self-efficacy, autonomy, assuming responsibility in life, and overall more psychological strength and stability. Factors that may pose a risk for weight regain include a history of weight cycling, disinhibited eating, binge eating, more hunger, eating in response to negative emotions and stress, and more passive reactions to problems.

Feeding behaviors and weight loss outcomes over 64 months

Maintenance of reduced body weight following intentional weight loss is often unsuccessful. Identification of behaviors associated with sustained reductions should aid in dietary weight management. This survey assessed associations between an array of appetitive indices and weight loss outcomes in a sample of 80 adults participating in an open-labeled, unsupervised weight management program over a 64-month period. Participants were divided into maintainers (weight loss >5 kg at Year 1, sustained reduction >75% at Month 64), rebounders (weight loss >5 kg at Year 1, <75% reduction at Month 64), and nonresponders (weight loss <5 kg at Year 1). Nonresponders spent significantly more time shopping for food weekly, tended to have the highest total exposure time to food and to eat with fewer people than the other groups. Maintainers reported higher mean hunger over the course of a day, tended to spend more time preparing food and consumed less energy from fat and foods that they rated as predominantly bitter. Rebounders had significantly lower dietary restraint scores and tended to have less control over the purchase and preparation of foods in their diet. Individuals with different long-term weight loss outcomes possess distinct feeding-related attributes that may provide a basis for improved intervention strategies.

Pilot study: access to fitness facility and exercise levels in olanzapine-treated patients

BACKGROUND

Increasingly alarmed by the health risks (that is, weight gain, elevated lipids, and poor glucose tolerance) posed by novel antipsychotic medications, clinicians who treat schizophrenia are attempting to help patients improve lifestyle factors. Unfortunately, schizophrenia research has neglected exercise as a legitimate adjunctive treatment for schizophrenia.

OBJECTIVE

To assess the extent to which stable patients with schizophrenia would adhere to an exercise program if offered access to a fitness facility.

METHODS

Ten of 20 stable patients with schizophrenia or schizoaffective disorder who were treated with olanzapine for at least 4 weeks had the opportunity to receive access to a Young Men's Christian Association (YMCA) fitness facility, based on random allocation. The intervention included a free membership to the YMCA for 6 months, with access to all the fitness amenities and equipment. The mean dosage of olanzapine was 11.5 mg daily for the YMCA group.

RESULTS

Of the 10 subjects, 2 did not attend at all. One subject met criteria for full attendance for each of the 6 months and lost 15 Kg. Dropout rates were as follows: 90% at 6 months, 70% at 5 months, and 40% at 4 months. The main reason they gave for poor attendance was lack of motivation. The mean weight gain was 2 kg in the YMCA group.

CONCLUSION

Most subjects did not regularly exercise or attend. They cited poor motivation as the main reason. The subject who exercised regularly lost a significant amount of weight.

Weight maintenance and relapse in obesity: a qualitative study

OBJECTIVE

To investigate, among women with obesity who have lost weight, the psychological factors associated with successfully maintaining the new lower weight, as opposed to weight regain.

DESIGN

Qualitative research methods (in-depth individual interviews and group interviews) were used to assess the characteristics of successful weight maintainers, as compared with weight regainers and healthy-weight women.

SUBJECTS

In all, 76 females were recruited from the community, comprising 28 formerly obese women who had lost weight and maintained their new lower weight for at least 1 y; 28 obese women who had lost weight but regained the weight that they had lost; and 20 women with a stable weight in the healthy range.

RESULTS

Certain psychological factors were identified which characterised the regainers but not the maintainers. These factors were: failure to achieve weight goals and dissatisfaction with the weight achieved; the tendency to evaluate self-worth in terms of weight and shape; a lack of vigilance with regard to weight control; a dichotomous (black-and-white) thinking style; and the tendency to use eating to regulate mood.

CONCLUSION

The results suggest that psychological factors may provide some explanation as to why many people with obesity regain weight following successful weight loss. The factors identified in this study need to be examined further using prospective designs.

Reduction in obesity and coronary risk factors after high caloric exercise training in overweight coronary patients

BACKGROUND

The majority of patients with coronary heart disease (CHD) are overweight. However, little weight loss occurs with participation in a standard cardiac rehabilitation (CR) program.

METHODS

Fifteen overweight patients (average body mass index of 31.0 kg/m2) with CHD completed a 4-month exercise training program in a CR program. The exercise program consisted primarily of walking long duration (60-90 minutes per session) 5 to 7 days per week at a relatively low intensity of 50% to 60% of peak VO2. Measures of body composition by dual-energy x-ray absorptiometry, body fat distribution by computed tomography, plasma lipid-lipoprotein, glucose and insulin concentrations, and peak VO2 were obtained before and after the exercise intervention. Patients maintained an isocaloric diet throughout the study.

RESULTS

Patients had reductions in total body weight (-4.6 kg), fat mass (-3.6 kg), percent body fat (-2.9%), and waist circumference (-5.6 cm) (all P <.001) while maintaining fat-free mass. Subcutaneous adipose tissue was reduced by 12% (P <.001) and visceral adipose tissue was lowered by 14% (P <.001). There were favorable changes in the lipid-metabolic profile with reductions in triglyceride levels (-23.7%), total cholesterol/HDL-C ratio (-14.3%), and fasting insulin levels (-22.3%) (all P <.05). Peak VO2 increased by 21.2% (P <.001).

CONCLUSIONS

The present pilot study results suggest that a high caloric training exercise training program in the CR setting may be effective in promoting weight loss and improving coronary risk factors in overweight coronary patients. Although additional research with randomized control patients is needed, this alternative to traditional CR may be considered to maximize weight loss as part of a secondary prevention program.

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.

Managing obesity: a survey of attitudes and practices among Israeli primary care physicians

OBJECTIVES

To document and assess Israeli family physicians' (FPs) knowledge, attitudes and practices regarding the management of overweight and obesity.

METHODS

Anonymous questionnaires were completed by 510 family physicians (82% compliance rate). The questionnaires were distributed in various continuous medical education sites of FPs in Israel. The measures included attitudes to and resources of knowledge on weight management, views regarding the prescription of drugs, approaches to and strategies recommended for weight loss.

RESULTS

In all, 73% of FPs viewed weight management as important and reported that they often treated cases of overweight and obesity, including for patients without concomitant risk factors. The medical advice most frequently offered is: increase physical activity, decrease number of total calories (eat less) and consultation with a dietitian (95, 81 and 58% respectively). However, most responders (72%) believed that they had limited efficacy in treating obesity and considered themselves not well prepared by medical school to treat overweight patients. Some 60% reported feeling that they have insufficient knowledge regarding nutritional issues. Regarding pharmacotherapy for treating obesity, only 66% knew the drugs' prescription indications. However, the vast majority (87%) knew about the gradual increase of weight after stopping drug treatment.

CONCLUSIONS

Knowledge gaps and ambivalent attitudes toward obesity management were found. More education focusing on obesity, from medical school to post-graduate learning, seems warranted based on these findings.

Medical management of obesity

Obesity has become a major health problem in many countries because of its high prevalence and causal relationship with serious medical complications. Many of the medical complications associated with obesity improve with intentional weight in a dose-dependent fashion, and even a modest weight loss of 50% of initial weight has beneficial effects. This article reviews the nonsurgical approaches for achieving weight loss in obese persons.

Self-help in the long-term treatment of obesity

Despite the short-term success of professional behavioural techniques for obesity, weight losses are typically regained following treatment. The long-term maintenance of treatment effects will probably require ongoing, continuing care. Continuing care may be economically feasible when administered through self-help treatment modalities. Self-help confers a number of psychological benefits, such as self-reliance and an increased sense of empowerment. The effectiveness and cost-effectiveness of various modalities of self-help are reviewed, including purely self-prompted help, self-administered manuals, computer-assisted therapy, professionally assisted correspondence courses, and non-profit and commercial self-help groups. Stepped-care models suggest using a combination of these approaches when appropriate. However, logistical difficulties present themselves in stepped-care approaches with obesity, such as the complicating effects of severity and comorbidity on stepped-care status. Self-help groups are a promising venue for the provision of continuing care and as an adjunct to more intensive, specialty therapies.

A new cognitive behavioural approach to the treatment of obesity

While behavioural approaches to the management of obesity are often successful in achieving clinically significant weight loss, the weight lost is generally regained. The great majority of patients return to their pre-treatment weight within 3 years. There have been attempts to improve the long-term effectiveness of behavioural treatment but the results have been disappointing. In this paper we suggest that, among other factors, this is because of the neglect of the contribution of cognitive factors to weight regain, and because there is often ambiguity over the goals of treatment. We present a cognitive behavioural analysis of the processes involved in weight regain, and we describe a new cognitive behavioural treatment derived from it. This treatment is designed to minimise the problem of weight regain by addressing psychological obstacles to the acquisition of, and long-term adherence to, effective weight-control behaviour.

Obesity management: Australian general practitioners' attitudes and practices

OBJECTIVES

To document general practitioners' (GPs) attitudes and practices regarding the prevention and management of overweight and obesity.

RESEARCH METHODS AND PROCEDURES

A cross-sectional survey of a randomly selected sample of 1500 Australian GPs was conducted, of which 752 questionnaires were returned. The measures included views on weight management, definitions of success, views regarding the usefulness of drugs, approaches to and strategies recommended for weight management, and problems and frustrations in managing overweight and obesity.

RESULTS

GPs view weight management as important and feel they have an important role to play. Although they consider themselves to be well prepared to treat overweight patients, they believe that they have limited efficacy in weight management and find it professionally unrewarding. GPs view the assessment of a patient's dietary and physical activity habits and the provision of dietary and physical activity advice as very important. The approaches least likely to be considered important and/or least likely to be practiced were those that would support the patient in achieving and maintaining lifestyle change.

DISCUSSION

There remains considerable opportunity to improve the practice of GPs in their management of overweight and obesity. Although education is fundamental, it is important to acknowledge the constraints of the GPs' existing working environment.

The correlates of long-term weight loss: a group comparison study of obesity

OBJECTIVE

Although the majority of weight loss attempts are unsuccessful, a small minority succeed in both weight loss and maintenance. The present study aimed to explore the correlates of this success.

METHOD

A group comparison design was used to examine differences between women who were classified as either weight loss maintainers (had been obese (body mass index, BMI=30+ kg/m2) and had lost weight to be considered non-obese (BMI<30 kg/m2) and maintained this weight loss for a minimum of 3 y; n=44), stable obese (maintained an obese weight (BMI=30+ kg/m2) for longer than 3 y; n=58), and weight loss regainers (been obese (BMI=30+ kg/m2), lost sufficient weight to be considered non-obese (BMI<30 kg/m2) and regained it (BMI=30+ kg/m2), n=40). In particular, the study examined differences in profile characteristics, historical factors, help-seeking behaviours and psychological factors.

RESULTS

The results showed that in terms of profile and historical factors, the weight loss maintainers had been lighter, were currently older and had dieted for longer than the other groups but were matched in terms of age, class and ethnic group. In terms of help-seeking behaviours, the weight loss maintainers reported having tried healthy eating more frequently but were comparable to the other subjects in terms of professionals contacted. Finally, for psychological factors the weight loss maintainers reported less endorsement for medical causes of obesity, greater endorsement for psychological consequences and indicated that they had been motivated to lose weight for psychological reasons.

CONCLUSIONS

Weight loss and maintenance is particularly correlated with a psychological model of obesity. This has implications for improving the effectiveness of interventions and the potential impact of current interest in medical approaches to obesity.

A descriptive study of weight loss maintenance: 6 and 15 year follow-up of initially overweight adults

OBJECTIVE

To describe factors associated with long-term maintenance of weight loss.

DESIGN AND SUBJECTS

We identified initially overweight individuals (body mass index >27 kg/m2, n=911) from the nationwide Finnish Twin Cohort and studied those who lost at least 5% of their body weight between 1975 and 1981. Subjects who had maintained weight loss until 1990 (38 men, 17 women) were compared to both regainers (28 men, 26 women) and the other overweight subjects in the cohort.

MEASUREMENTS

Self-report data on weight, height, health behaviours and perceived well-being; self-report and register-based data on health status and use of medication.

RESULTS

Only 6% of all overweight individuals lost and maintained at least 5% weight loss. In men weight loss maintenance was associated with a low level of stress and health-promoting behaviours but also with medical problems. Failure to maintain weight loss seemed to be associated with stressful life and past high alcohol intake. In women weight loss maintenance was associated with low initial well-being and health-compromising behaviours that improved after weight loss.

CONCLUSION

Long-term weight loss maintenance is rare. Predictors of weight loss maintenance are different between women and men. International Journal of Obesity (2000)24, 116-125

Persons successful at long-term weight loss and maintenance continue to consume a low-energy, low-fat diet

OBJECTIVES

To describe the dietary intakes of persons who successfully maintained weight loss and to determine if differences exist between those who lost weight on their own vs those who received assistance with weight loss (eg, participated in a commercial or self-help program or were seen individually by a dietitian). Intakes of selected nutrients were also compared with data from the third National Health and Nutrition Examination Survey (NHANES III) and the 1989 Recommended Dietary Allowances (RDAs).

SUBJECTS

Subjects were 355 women and 83 men, aged 18 years or older, primarily white, who had maintained a weight loss of at least 13.6 kg for at least 1 year, and were the initial enrollees in the ongoing National Weight Control Registry. On average, the participants had lost 30 kg and maintained the weight loss for 5.1 years.

METHODS

A cross-sectional study in which subjects in the registry completed demographic and weight history questionnaires as well as the Health Habits and History Questionnaire developed by Block et al. Subjects' dietary intake data were compared with that of similarly aged men and women in the NHANES III cohort and to the RDAs. Adequacy of the diet was assessed by comparing the intake of selected nutrients (iron; calcium; and vitamins C, A, and E) in subjects who lost weight on their own or with assistance.

RESULTS

Successful maintainers of weight loss reported continued consumption of a low-energy and low-fat diet. Women in the registry reported eating an average of 1,306 kcal/day (24.3% of energy from fat); men reported consuming 1,685 kcal (23.5% of energy from fat). Subjects in the registry reported consuming less energy and a lower percentage of energy from fat than NHANES III subjects did. Subjects who lost weight on their own did not differ from those who lost weight with assistance in regards to energy intake, percent of energy from fat, or intake of selected nutrients (iron; calcium; and vitamins C, A, and E). In addition, subjects who lost weight on their own and those who lost weight with assistance met the RDAs for calcium and vitamins C, A, and E for persons aged 25 years or older.

APPLICATIONS

Because continued consumption of a low-fat, low-energy diet may be necessary for long-term weight control, persons who have successfully lost weight should be encouraged to maintain such a diet.

The decision to lose weight

The purpose of this article is to describe the reasons people give for deciding to lose weight compared by weight history and gender. The sample consisted of 162 Caucasian community volunteers. Data were obtained from an extensive open-ended interview that was analyzed using content analysis. Respondents were categorized into five groups, according to their success at weight loss: Successful, Always Normal Weight, Underweight, Clinically Successful, and Always Obese. The Clinically Successful and Always Obese were included in the category Unsuccessful Dieter. Reasons given for entering a weight-loss regime included attractiveness or appearance, health, fear, self-esteem issues, age, and competition. For the Successful Dieter, attractiveness and health were the two major motivations. Men and women were similar in their reasons for entering a weight-loss program. The issue of what makes a decision of sufficient importance to maintain weight loss remains unexplained. "Centrality" is offered as a possible explanation.

Current dieting, weight loss history, and weight suppression: behavioral correlates of three dimensions of dieting

The present study investigated three dimensions of dieting (current dieting, history of dieting, weight suppression) and behaviors related to energy balance in a community sample of 999 women. The three dimensions, current dieting status, history of dieting, and weight suppression, were examined in relation to dietary intake, eating behaviors, physical activity, and weight concerns. Twenty-two percent of the women were current weight loss dieters, 8.3% were currently dieting for weight maintenance, and 69.3% were not currently dieting. Twenty-eight percent of the women were weight suppressers. Current dieting for weight loss or weight maintenance was associated with lower percent of kilocalories from fat (33% vs. 35% among nondieters), less frequent consumption of sweet foods, more frequent consumption of vegetables and fruits, more frequent self-weighing, and lower tolerance for weight gain prior to taking action (10 lb vs. 14 lb among nondieters). Current dieters and those with an extensive history of dieting self-reported a greater number of healthy and unhealthy weight loss practices during the past year, and they scored higher on measures of low-fat eating behaviors and restrained eating. Weight suppression was associated with higher physical activity levels and low-fat eating behaviors. Distinguishing weight suppression from current dieting status may provide insight into the behaviors related to successful weight loss maintenance, whereas measures of dieting history might be useful in clinical contexts.

Assessing Impact of Weight on Quality of Life

This paper is a preliminary report on the development of a new instrument, the Impact of Weight on Quality of Life (IWQOL) questionnaire, that assesses the effects of weight on various areas of life. We conducted two studies utilizing subjects in treatment for obesity at Duke University Diet and Fitness Center. The first study describes item development, assesses reliability, and compares pre- and post-treatment scores on the IWQOL. In the second study we examined the effects of body mass index (BMI), gender, and age on subjects' perceptions of impact of weight on quality of life. Results indicate adequate psychometric properties with test-retest reliabilities averaging .75 for single items, and .89 for scales. Scale internal consistency averaged .87. Post-treatment scores differed significantly from pre-treatment scores on all scales, indicating that treatment produced positive changes in impact of weight on quality of life. The results of the second study indicate that the impact of weight generally worsened as the patients' size increased. However for women there was no association between BMI and impact of weight on Self-Esteem and Sexual Life. Even at the lowest BMI tertile studied, women reported that weight had a substantial impact in these areas. There were also significant gender differences, with women showing greater impact of weight on Self-Esteem and Sexual Life compared with men. The impact of age was a bit surprising, with some areas showing positive changes and others showing no change.

A biomedical and feminist perspective on women's experiences with weight management

Weight concerns and dieting have become so normative for U.S. women that weight is the lens through which experience is viewed. The obsession with weight and dieting among women is considered by feminists to be one result of the oppression by women resulting from questionable weight standards and weight control programs that foster a view of overweight as a sign of addiction and lack of control. Feminist critique is used to deconstruct both the literature related to weight standards and health and the research on weight loss/weight management. Feminist and ethnographic methods are used to describe successful and unsuccessful experiences with weight management of 20 Euro-American women who had participated in a 1985 weight study and agreed to be reinterviewed. Success at weight management was examined from a biomedical perspective using Body Mass Index (BMI) norms and from a feminist perspective using participants' subjective definitions of success. Based upon BMI, only 8 members of the study group were defined as successful, whereas based upon the women's perspectives, 11 members were successful. Participants' definitions of successful weight management were divergent from biomedical definitions and could be categorized into three perspectives: biomedical, reframed normal weight, and holistic. Women who ascribed to the biomedical definition of success embodied the cultural ideal of thinness by adhering to an underweight weight norm. Participants using the reframed normal weight definition of success rejected biomedical weight norms and created their own weight norms. The holistic perspective on success involved the use of a broader, health-focused definition of successful weight management and offers some directions for revising current health promotion care relative to weight.

Physical activity and obesity

Obesity is a major public health problem. Secular increases in the prevalence of obesity appear to be paralleled by decreases in physical activity. Although physical activity and weight are associated, the exact nature of the relationship remains uncertain. Research strongly suggests that exercise is a critical component of any program for weight control and health improvement. Potential mechanisms linking exercise and weight are discussed. For some persons, the health improvement derived from increased activity may not depend on weight loss. Modest levels of activity may be sufficient to achieve both the weight and health benefits of exercise.

Toward a definition of a successful dieter

The purpose of the research was to examine the characteristics of successful weight losers and to compare the findings with a control group of unsuccessful weight losers. The project was designed around a definition of successful dieters, based on the Metropolitan Life Insurance weight tables. The definition, in fact, was not particularly useful. This article describes the difficulties associated with using the original definition as the inclusion criteria for sample selection, the reanalysis of data using the Body Mass Index (BMI), and finally, the creation of a new definition developed from the construction of weight history based on changes in the BMI as an adult. This article presents the final outcome of what a definition of a successful dieter should consist in future research.

Obesity, weight loss, and health

Obesity is a multifactorial, complicated condition or group of conditions that afflicts a growing number of people in the United States. Precise etiologies are not well understood, and both commercial and medical treatment programs are characterized by high rates of recidivism. A cultural preoccupation with slimness has created a huge industry serving millions of people who are attempting continually to reduce weight. Contradictory messages from professionals have led to confusion concerning the health implications of obesity and the potential risks of repeated dieting. This review summarizes the major areas of consensus and controversy concerning the health implications of obesity and weight loss and suggests directions for treatment that take into account the complex causes and consequences of obesity.

Challenging commonly held beliefs about obesity

The task of nurses is to diagnose and treat human responses to illness and the threats of illness. The challenge is in finding the correct diagnosis and selecting the appropriate treatment. To do this appropriately, nurses need to separate health and illness from life-style; to discover whether or not life-style changes are really called for in treating illness or threats of illness or if nurses are uncomfortable with life-styles that are different from their own and expect all people to have a life-style similar to theirs. To intervene appropriately, nurses need to know whether they are working to help others return to their life-style preference or are forcing patients to chose the nurses' life-style preference. The case of the obese and the search for the successful dieter exemplifies the health care system's need to have individuals follow an exercise and eating program to lead them to thinness (a cultural value) whether or not they value thinness. Are health professionals forcing patients to conform to the professionals' life-style rather than assisting them to a healthier state within their own?

Long term health implications of fitness and physical activity patterns

Northern Ireland has the highest incidence of coronary heart disease (CHD) in the world. The physical fitness, activity patterns, health knowledge, attitudes, and dietary habits of a random, stratified sample of 3211 Northern Irish children, comprising 1540 boys and 1671 girls, age range 11-18 years were examined. At all ages boys were significantly more active than girls. The most important finding was an appreciable decline in physical activity levels after the age of 14 years reaching extremely low levels in older girls. While 75% of exercise taken was not related to school, physical education classes constituted the only exercise taken by one third of pupils. Girls had healthier nutritional habits and were more inclined to employ weight control measures than boys. There was a preponderance of children with a higher body mass index indicating a tendency to obesity in the child population. Over 20% of school leavers of both sexes regularly smoked cigarettes and 20% regularly drank alcohol. The postulated relationship between childhood inactivity, adult sedentary lifestyle, and increased risk of CHD raises serious cause for concern regarding the future cardiovascular health of many children.

The role of exercise in weight regulation in nonathletes

Obesity is an extremely prevalent condition that is associated with a range of deleterious health effects. While traditionally considered a disorder primarily of energy intake, accumulating evidence underscores the importance of energy expenditure in the development and treatment of obesity. As the most variable component of energy expenditure, physical activity can influence the development of obesity as well as success in achieving both initial and long term weight loss. Among the types of exercise-related physiological and behavioural factors most likely to be involved in the development of obesity are reductions in the amount of physical activity actually performed, differences in the effect of physical activity on diet-induced thermogenesis, and modeling of deleterious dietary and exercise patterns on the part of the family and other facets of the environment. In contrast, there is relatively little evidence supporting the common belief that obese individuals have a significantly greater energy intake than nonobese individuals. With respect to weight reduction in the already obese, while increased physical activity levels often augment caloric restriction programmes in aiding initial weight loss, evidence suggests that physical activity may be particularly important in helping to sustain initial losses through increased total energy output, preservation of lean body mass, and changes in substrate utilisation. The psychological benefits received from regular participation in a physical activity programme may serve as an additional impetus for engaging in such activities over the long run. Developing programmes to aid in long term adherence to physical activity regimens remains the most critical challenge. Recent results suggest the utility of regular, brief contacts in aiding sustained physical activity participation in individuals attempting to control their weight.