Five-year follow-up to a behavioral weight-loss program

Long-term treatment of severe obesity: are lifestyle interventions still an option?

Following lifestyle intervention programs based on dietary restriction and habitual physical activity, weight loss, however large, is reported to peak within six months. Despite maintenance protocols, only few cases continue to lose weight thereafter. The majority of cases regain weight and adherence to lifestyle changes are fostered by long-term contact with a supportive team. In general, surgical procedures are reported to produce much larger weight loss and to impact more favorably on long-term weight loss maintenance. Areas covered: We performed a PubMed search on lifestyle modification studies, focusing on the role of behavior programs for the long-term management of obesity in comparison with surgical procedures. Behaviorally-achieved weight loss outcomes can be improved by integrating standard behavior therapy with self-regulation cognitive skills, motivational interviewing and/or phone/internet-based recall systems. Expert commentary: Clinically-important long-term weight loss is achievable by behavior therapy in a small proportion of subjects with obesity, however severe, through personalized programs associating lifestyle modification interventions, with procedures aimed at developing commitment and responsibility skills. A new area of research is the integration of cognitive-behavior therapy with bariatric (metabolic) surgery, either pre- or post-operatively, to exploit long-term adherence to healthy diet and habitual physical activity.

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.

Self-help and long-term behavior therapy for obesity

The Trevose Behavior Modification Program, a self-help group offering continuing care for obesity, has recently been shown to produce large long-term weight losses. The present study aimed to replicate this finding across different settings and participants, assessing the weight losses and attrition rates of 128 participants in three Trevose program satellite groups that used the same treatment procedures and manual as the central Trevose group. The satellite groups' results closely paralleled those of the Central Group. Mean intent-to-treat weight loss, or final losses recorded for all participants regardless of their treatment termination date, was 13.7 +/- 0.7% of initial body weight (1.8 +/- 0.7 kg). At two years, 43.8% of participants remained in treatment, having lost a mean of 19.0 +/- 0.8% of their body weight (16.2 +/- 1.0 kg); at five years, 23.4% remained, having lost 18.4 +/- 1.1% of body weight (15.6 +/- 1.5 kg). These results demonstrate that the Trevose model of weight control, combining self-help and continuing care, can be extended and disseminated to other settings, with potentially significant public health consequences.

Long-term weight-loss maintenance: a meta-analysis of US studies

BACKGROUND

Current perception is that participants of a structured weight-loss program regain all of their weight loss within 5 y.

OBJECTIVE

The objective was to examine the long-term weight-loss maintenance of individuals completing a structured weight-loss program.

DESIGN

Studies were required to 1) have been conducted in the United States, 2) have included participants in a structured weight-loss program, 3) have provided follow-up data with variance estimates for > or =2 y. Primary outcome variables were weight-loss maintenance in kilograms, weight-loss maintenance as a percentage of initial weight loss, and weight loss as a percentage of initial body weight (reduced weight).

RESULTS

Twenty-nine studies met the inclusion criteria. Successful very-low-energy diets (VLEDs) were associated with significantly greater weight-loss maintenance than were successful hypoenergetic balanced diets (HBDs) at all years of follow-up. The percentage of individuals at 4 or 5 y of follow-up for VLEDs and HBDs were 55.4% and 79.7%, respectively. The results for VLEDs and HBDs, respectively, were as follows: weight-loss maintenance, 7.1 kg (95% CI: 6.1, 8.1 kg) and 2.0 (1.5, 2.5) kg; percentage weight-loss maintenance, 29% (25%, 33%) and 17% (13%, 22%); and reduced weight, 6.6% (5.7%, 7.5%) and 2.1% (1.6%, 2.7%). Weight-loss maintenance did not differ significantly between women and men. Six studies reported that groups who exercised more had significantly greater weight-loss maintenance than did those who exercised less.

CONCLUSIONS

Five years after completing structured weight-loss programs, the average individual maintained a weight loss of >3 kg and a reduced weight of >3% of initial body weight. After VLEDs or weight loss of > or =20 kg, individuals maintained significantly more weight loss than after HBDs or weight losses of <10 kg.

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.

Factors differentiating women and men who successfully maintain weight loss from women and men who do not

The current study explored the relative contribution of exercise, coping responses, cognitive attributions, and emotional experiences to successful weight-loss maintenance in men and women. The data were collected via a large community-based survey on dieting and weight loss commissioned by Consumer Union. Men and women who met our criteria for successful (n = 277 men, n = 329 women) and unsuccessful (n = 277 men, n = 329 women) weight-loss maintenance were included in the sample. Successful weight-loss maintainers (Maintainers) reported having lost at least 10% of their highest adult weight and having maintained that weight loss for at least the three years immediately prior to the survey. Unsuccessful weight-loss maintainers (Regainers) reported not ever having been able to maintain a significant weight loss and having lost and regained a minimum of 10 to 19 pounds at least once. In response to a dietary lapse, Maintainers, as compared with Regainers, reported being more likely to use direct coping and less likely to seek help. The results imply that the most useful variables for differentiating between successful and unsuccessful weight-loss maintainers may involve how they respond to a dietary lapse.

Effective long-term treatment of obesity: a continuing care model

BACKGROUND

Despite the well-documented success of behavioral techniques in producing temporary weight loss, treatment is typically followed by weight regain. The maintenance of treatment effects may therefore be the greatest challenge in the long-term management of obesity, and continuous care may be necessary to achieve it.

OBJECTIVE

To describe the design and evaluate the effectiveness of the Trevose Behavior Modification Program, a potentially widely replicable self-help weight loss program offering continuous care.

DESIGN

A description of the course of all subjects (n=171) who entered the Trevose program during 1992 and 1993.

SUBJECTS

One hundred and forty-six women aged 44.1+/-11.7 y with a body mass index (BMI, kg/m2) of 33.2+/-4.4, and 25 men aged 49. 0+/-19.6 with a BMI of 35.1+/-5.2 enrolled in the Trevose program during 1992-1993.

RESULTS

Mean duration of treatment was 27.1 months, with 47.4% of members still in treatment at 2 y and 21.6% at 5 y. Mean intent-to-treat weight loss was 13.7+/-0.5% of initial weight, or 12.8+/-0.5 kg. As long as they remained in treatment, almost all participants lost at least 5% of their initial weight and at least 83% lost more than 10%. Members completing 2 y of treatment lost an average of 19.3% of their initial body weight (17.9 kg); at 5 y the loss was still 17.3% (15.7 kg). After leaving the program, subjects regained weight but remained 4.7% (4.5 kg) below their pretreatment weight.

CONCLUSION

A low-cost program offering treatment of indefinite duration produced large long-term weight losses and may be suitable for widespread replication.

Behavioral strategies of individuals who have maintained long-term weight losses

OBJECTIVE

The purpose of the present study was to compare the behaviors of individuals who have achieved long-term weight loss maintenance with those of regainers and weight-stable controls.

RESEARCH METHODS AND PROCEDURES

Subjects for the present study were participants in a random-digit dial telephone survey that used a representative sample of the U.S. adult population. Eating, exercise, self-weighing, and dietary restraint characteristics were compared among weight-loss maintainers: individuals who had intentionally lost > or =10% of their weight and maintained it for > or = 1 year (n = 69), weight-loss regainers: individuals who intentionally lost > or = 10% of their weight but had not maintained it (n = 56), and weight-stable controls: individuals who had never lost > or = 10% of their maximum weight and had maintained their current weight (+/-10 pounds) within the past 5 years (n = 113).

RESULTS

Weight-loss maintainers had lost an average of 37 pounds and maintained it for over 7 years. These individuals reported that they currently used more behavioral strategies to control dietary fat intake, have higher levels of physical activity (especially strenuous activity), and greater frequency of self-weighing than either the weight-loss regainers or weight-stable controls. Maintainers and regainers did not differ in reported levels of dietary restraint, but both had higher levels of restraint than the weight-stable controls.

DISCUSSION

These results suggest that weight-loss maintainers use more behavioral strategies to control their weight than either regainers or weight-stable controls. It would thus appear that long-term weight maintenance requires ongoing adherence to a low-fat diet and an exercise regimen in addition to continued attention to body weight.

Factors associated with weight change among clients of a residential weight control program indicating binge and nonbinge traits

The long-term effects of a 12- and 26-day residential weight control program on weight change were determined in 187 men and women, 1 to 5 years after treatment. Subjects completed a paper/pencil questionnaire assessing current diet, weight control techniques, exercise behaviors, behavior modification techniques, binge eating, and dieting behavior. General linear modeling was used to investigate the association between behaviors maintained posttreatment and current weight among subjects who demonstrated behaviors indicative of binge traits (BT) and nonbinge traits (NBT). Results indicate that dissimilar variables are predictive of weight change in the BT and NBT groups. Engaging in exercise behaviors and reduced attempts at dieting lead to greater weight loss in NBT individuals. The use of preplaning techniques was found to be indicative of greater weight loss in BT individuals. These findings suggest the importance of identifying individuals who indulge in binge-eating behaviors prior to intervention in order to deliver the appropriate treatment methods.

Identifying predictive variables for long-term weight change after participation in a weight loss program

OBJECTIVE AND DESIGN

To determine if there was an association between weight change and 31 independent variables among obese persons 2 years after a weight loss program. Data were obtained from subjects' records and from questionnaires administered at enrollment and after a 2-year follow-up.

SETTING

The 8-week weight control program was taught by registered dietitians and developed by the staff at the Sid Richardson Institute for Preventive Medicine, Houston, Tex.

SUBJECTS/SAMPLES

Of the 1,460 subjects who attended at least one of eight classes, 509 subjects (123 men and 386 women) responded to the mailed follow-up questionnaire.

MAIN OUTCOME MEASURES

Associations between weight change and the 31 independent variables were assessed. Heights and weights were measured by the dietitians during treatment. Two-year follow-up weights were self-reported.

STATISTICAL ANALYSES PERFORMED

Analysis of variance was used for 16 of the independent variables. For the remaining variables we performed a test of the null hypothesis that the correlation coefficient was 0 based on the test of the regression coefficient between the independent and dependent variable. A stepwise regression process was used to determine the best combination of variables predictive of weight change.

RESULTS

Of the 31 independent variables, 16 were significantly predictive of weight change. The adjusted R2 for the entire group of 16 variables was .379. Thus, 37.9% of the variance was explained by the joint efforts of the 16 variables. Eight variables with an adjusted R2 of .371 (accounting for 37.1% of the variance) were most important: feeling in control of eating habits, percentage over ideal body weight at enrollment, percentage of weight lost during the 8-week treatment, frequency of weight measurement, increase in physical activity, frequency of eating in response to emotions, number of pounds gained before subject resumed diet, and occupation. APPLICATION/CONCLUSION: The predictive variables for weight change may be useful to professionals who treat obese clients and may improve success rates of long-term weight loss.

Identification of correlates of physical activity among Latino adults

127 Latino adults responded to a survey concerning physical activity. Respondents over-represented well educated and middle class Latinos. Subjects reported a mean of 48 minutes/week of walking for exercise. This sample reported less than two episodes per week of vigorous physical activity, again below the recommended 3/wk needed to insure cardiovascular fitness. We expect more representative samples to engage in less physical activity. Stepwise multiple regression analyses were conducted using 24 variables based on Social Learning Theory. A multiple R of 0.66 accounted for over 27% of the variance in walking for exercise (p less than 0.001). Older adults, those with a history of childhood injury, and those who reported friend support were more likely to walk for exercise. Respondents who participated in physical activity during childhood and adolescence (including formal physical education in school) and, paradoxically, those who had models for exercise in childhood were less likely to walk for exercise. A multiple R of 0.75 accounted for 43% of the variance in vigorous physical activity and reached significance (p less than 0.001). Self-efficacy, friends' support, childhood physical activity, and eating a heart healthy diet were positively related to vigorous activity. These results suggest that different correlates influence walking versus vigorous activity, and that correlates of physical activity are different for Latinos compared to Anglos. The findings emphasize the need for larger scale investigations of the determinants of activity within the Latino population.

Identifying correlates of walking for exercise: an epidemiologic prerequisite for physical activity promotion

This study was designed to identify correlates of walking for exercise in adults. Over 2,050 (43.4% response rate) responses to a mailed questionnaire were analyzed. Possible correlates of walking were based on learning theory and previous empirical observations. Respondents averaged less than 1 hr of walking for exercise per week. Women and older adults (greater than or equal to 50 years) reported significantly (P less than 0.05) greater walking than men or younger respondents. Multiple regression analyses were conducted for selected subgroups of respondents. Analyses were conducted on subjects who reported no regular vigorous exercise. Multiple correlation coefficients ranged from 0.32 to 0.48, and most reached significance (P less than 0.05). For the most sedentary subgroups, self-efficacy, family and friend support, and consumption of a heart-healthy diet were repeatedly associated with walking for exercise. It was concluded that an economically secure and well-educated Caucasian sample performs an inadequate amount of walking to ensure benefits such as prevention of cardiovascular disease. Longitudinal analyses are required to confirm the influence of social learning variables. Tentatively, interventions that increase family and friends' support for walking and that enhance perceived self-efficacy should be developed.

Long-term weight loss maintenance: assessment of a behavioral and supplemented fasting regimen

This analysis assessed 18-30-month weight loss maintenance following treatment with both behavior modification and supplemented fasting procedures for 400 patients. Fifty-five per cent of the patients who started treatment discontinued prior to completing the program. Patients who completed treatment lost a mean of 83.9 per cent of their excess weight, but regained an average of 59 per cent to 82 per cent of their initial excess weight by 30 months following start of treatment. The combination of behavior modification and supplemented fasting regimens was a successful means of effecting weight loss. However, there appeared to be limited weight loss maintenance. Behavioral epidemiological studies are needed to identify variables responsible for maintenance of weight loss.

Sex differences in weight loss among adults with type II diabetes mellitus

The treatment of choice for Type II or non-insulin-dependent diabetes mellitus is a behavioral program for the management of weight. However, compliance with this lifelong dietary regimen is often poor. In the current investigation male and female adults with diagnosed Type II diabetes were randomly assigned to either a behavior modification, a cognitive modification, a cognitive-behavior modification, or a control group. Patients were evaluated in terms of weight, percentage of body fat, and glycosylated hemoglobin measures. Men lost significantly more weight than women and subjects in the behavior modification group lost more weight and demonstrated greater decreases in diabetes control than subjects in the cognitive-behavior modification, cognitive, and control groups. A significant interaction indicated that diabetic men may benefit more from behavioral weight reduction programs than diabetic women. Several explanations for these findings are considered.

Shifting gears: self-reported attitudes and behaviors during times of weight loss, maintenance, and gain

One hundred and eleven respondents who had achieved at least a 15-pound (6.80 kg) weight loss in a 20-week cognitive-behavioral treatment program for obesity were asked 6 to 10 years after treatment to describe their current use of cognitive and behavioral activities during periods of weight maintenance, loss, and gain. Eleven scales were constructed to measure the self-reported frequency with which the cognitive and behavioral efforts were extended for Weight Monitoring; Food Record Monitoring; Calorie Counting; Shopping; Food Storage and Preparation; Meal Times; Snack Times; Social Occasions; Taste and Satisfaction; Physical Activity; and Sports/Exercise. A multivariate repeated-analysis of variance indicated that the respondents increased the mean frequencies with which all 11 of the cognitive and behavioral efforts were used during times of weight loss; these mean frequencies decreased during times of maintenance and decreased still further during times of weight gain. The conclusion was drawn that the respondents were able to differentiate among the types of attitudes and behaviors that they used during times of gain, maintenance, and loss.

Experience of loneliness by obese individuals

The present study assessed the relationship between obesity and reported loneliness. The subjects, 68 obese and 64 nonobese individuals, were administered the Revised UCLA Loneliness Scale. Obese subjects had significantly higher loneliness ratings than nonobese subjects. Obese women had significantly higher loneliness scores than nonobese women but no such difference was found between obese men and their thin peers. A significant correlation of .25 was obtained between body weight and loneliness ratings within the total sample and also the obese women ( r = .29). This correlation was nonsignificant within the obese men. Possible explanations for the observed sex differences as well as implications for research and treatment, were discussed.

Patterns of weight change: the interval 6 to 10 years after initial weight loss in a cognitive-behavioral treatment program

29 men and 82 women who had achieved at least a 15-lb. weight loss in a 20-wk. cognitive-behavioral treatment program for obesity were asked 6 to 10 yr. after treatment about their current weights and January 1 weights for the past five years. Four types of weight change indices were then developed to ascertain whether or not the patients had maintained their postprogram weight losses since leaving treatment. Comparisons of pre- and postprogram mean weight differences indicated that the patients had gained an average of 7.15 lb. (3.24 kg) by 1983, but there had not been a mean increase in weight since an earlier follow-up in 1978. Importantly, 32.4% reported 1983 weights below their postprogram weights, and there were no mean differences between the sexes with respect to weight changes for either 1978 or 1983. A weight index based upon percentages of weight gain since leaving treatment indicated that 40.5% had gained back more than 67% of weight that they had lost during treatment. Inspection of 90 patients' weight fluctuations over the past five years above or below their postprogram weights showed 25 distinct patterns. Each of the four weight-change indices gave different perspectives about the patients' abilities to manage their weights over time. The complexity of employing different weight-change indices for evaluating the long-term efficacy of cognitive-behavioral treatment programs for obesity was discussed.

Risk of excess weight gain in university women: a three-year community controlled analysis

A representative sample of university freshman women were compared to same-aged community women for rate of weight change. University women were found to gain a mean of .73 lbs/month, 36 times faster than community women. Analysis of variance showed that university women gained significantly more excess weight than did community women. The incidence of developing "treatable" excess weight was 26% and 9% for university and community women, respectively. University women were 2.6 to 5.2 times as likely as community women to gain 15% or more above ideal weight. Three-year follow-up of university women showed a stabilization and reduction in mean weight for sophomore and junior years. By the junior year, average weight returned to near baseline levels as entering freshman. Mean excess weight loss was associated with a move from mandatory dormitory housing and cafeteria food services. Young adult university women (and men) may be especially important nonclinical study populations for identifying behavioral factors involved in weight gain and self-correcting weight loss, which could be valuable for development of more effective obesity prevention programs.

Effectiveness of hypnosis as an adjunct to behavioral weight management

This study examined the effect of adding hypnosis to a behavioral weight-management program on short- and long-term weight change. One hundred nine subjects, who ranged in age from 17 to 67, completed a behavioral treatment either with or without the addition of hypnosis. At the end of the 9-week program, both interventions resulted in significant weight reduction. However, at the 8-month and 2-year follow-ups, the hypnosis clients showed significant additional weight loss, while those in the behavioral treatment exhibited little further change. More of the subjects who used hypnosis also achieved and maintained their personal weight goals. The utility of employing hypnosis as an adjunct to a behavioral weight-management program is discussed.

Do behavioral treatments of obesity last? A five-year follow-up investigation

Although the long-term maintenance of therapy induced behavior changes and the resulting weight loss represent critical issues in the treatment of obesity, there is a paucity of available data. The present study assessed the durability of treatment induced weight losses 5 years after treatment and the long-term adherence to treatment strategies. Thirty-six of the original 44 subjects who participated in a 10-week behavioral weight control program were interviewed in person (28), by mail (5) or reported their weights by phone (3). Results indicated that most subjects gained back a major portion of the weight they lost during treatment. The average subject had gained 11.94 lb. since treatment termination and was now 1.49 lb. heavier than when he/she entered treatment. Despite the fact that program adherence following the termination of treatment was typically low, both the number of program techniques conscientiously used and the months of conscientious technique use showed significant negative correlations with posttreatment weight gains. Subjects reported that numerous situational, social and emotional factors impacted upon their weight control efforts.