Category Archives: Weight Regain

Is Exercise Important for Maintenance of Weight Loss In Women?

This news is a bit stale, but I wanted my readers to be sure to see it.

An article in the July 28, 2008, issue of Archives of Internal Medicine teaches us the role of regular physical activity in keeping lost weight from returning to once-overweight women.

Methodology

201 overweight women (body mass index 27-40) aged 21 to 45 wanted to lose excess weight.  They were sedentary at baseline, exercising fewer than three days a week for under 20 minutes.  Sound familiar?  Depending on baseline weight, the participants were assigned to eat either 1200 or 1500 calories per day, and to exercise according to one of four different exercise programs.  Exercise recommendations were to burn a certain number of calories per week (1000 or 2000 calories) at either moderate or vigorous intensity.  There were weekly group meetings for discussion of eating and exercise for the first six months, twice monthly meetings during the next 6 months, and monthly for the next six months.  There was telephone contact for between months  19 to 24.  This is pretty intense contact.  Each participant was given a treadmill to use at home, but my impression is that other forms of exercise were permitted and discussed.

Ten subjects were excluded from follow-up analysis, mostly because they got pregnant.  Nineteen others lost interest and dropped out.

Participants self-reported their physical activity levels.

At 24 months into the study, 170 of the original 201 participants were able to provide objective weight loss data.

Findings

Of the 170 subjects available for full analysis at 24 months, 54 either gained weight or lost none.  Thirty-three lost 0 to 4.9% of initial body weight, 36 lost 5 to 9.9% initial body weight, and 47 (24.6%) lost 10% or more of initial body weight.  [Who says diets don’t work?]

People who lost 10% or more of initial body weight at 24 months reported performing more physical activity – 275 minutes a week – compared with those who lost less than 10% of initial body weight.  This amount of exercise equates to 55 minutes of exercise on five days per week above the baseline level of activity, which was sedentary as you recall.  Whether they were assigned to “moderate” or “vigorous” exercise intensity didn’t seem to matter.  Whether they actually performed at the assigned level is unclear.

These women who sustained a weight loss of 10% or more of initial body weight at 24 months were burning 1835 calories a week in physical activity.

Women who lost less than 10% of initial body weight, or lost no weight, exercised an average of 34 minutes a day on five days a week.

By 24 months, participants on average had regained about half of the weight they had lost during the first six months  [which is typical].

Take-Home Points

After six months of dieting, many people start to regain half of what they lost.  We saw this phenomenon in the Israeli study of low-fat vs low-carb vs Mediterranean diet (DIRECT trial).

If you have a lot of excess fat to lose, you have to wonder if it would make sense to start a different diet program every six months, until you reach your weight goal.  Maybe there’s something about the novelty and excitement of a new diet program that keeps you motivated and disciplined for six months.

The authors note there are few similar long-term studies examining the amount and intensity of physical activity needed to improve weight loss success.  So this is important information.

In using exercise to help prevent weight regain, it may not matter whether the exercise is moderate or intense.

The authors write:

…the inability to sustain weight loss appears to mirror the inability to sustain physical activity.

Long-term sustained weight loss is possible for a significant portion of overweight women.  Although most women won’t do it, success is enhanced by exercising for 55 minutes on five days a week.  Most men won’t exercise that much either.  Which camp do you fall into?

[For physical activity instruction and information, visit Shape Up America!, Physical Activity for Everyone, or Growing Stronger: Strength Training for Older Adults.]

Steve Parker, M.D.

Reference:  Jakicic, John M., et al.  Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women.  Archives of Internal Medicine, 168 (2008): 1,550-1,559.  

The Role of Exercise in Maintenance of Weight Loss In Women

A 2008 article in Archives of Internal Medicine teaches us the role of regular physical activity in keeping lost weight from returning to once-overweight women.

Methodology

201 overweight women (body mass index 27-40) aged 21 to 45 wanted to lose excess weight. They were sedentary at baseline, exercising fewer than three days a week for under 20 minutes. Sound familiar? Depending on baseline weight, the participants were assigned to eat either 1200 or 1500 calories per day, and to exercise according to one of four different exercise programs. Exercise recommendations were to burn a certain number of calories per week (1000 or 2000 calories) at either moderate or vigorous intensity. There were weekly group meetings for discussion of eating and exercise for the first six months, twice monthly meetings during the next 6 months, and monthly for the next six months. There was telephone contact for between months 19 to 24. This is pretty intense contact. Each participant was given a treadmill to use at home, but my impression is that other forms of exercise were permitted and discussed.

Ten subjects were excluded from follow-up analysis, mostly because they got pregnant. Nineteen others lost interest and dropped out.

Participants self-reported their physical activity levels.

At 24 months into the study, 170 of the original 201 participants were able to provide objective weight loss data.

Findings

Of the 170 subjects available for full analysis at 24 months, 54 either gained weight or lost none. Thirty-three lost 0 to 4.9% of initial body weight, 36 lost 5 to 9.9% initial body weight, and 47 (24.6%) lost 10% or more of initial body weight. (Who says diets don’t work?)

People who lost 10% or more of initial body weight at 24 months reported performing more physical activity – 275 minutes a week – compared with those who lost less than 10% of initial body weight. This amount of exercise equates to 55 minutes of exercise on five days per week above the baseline level of activity, which was sedentary as you recall. Whether they were assigned to “moderate” or “vigorous” exercise intensity didn’t seem to matter. Whether they actually performed at the assigned level is unclear.

These women who sustained a weight loss of 10% or more of initial body weight at 24 months were burning 1835 calories a week in physical activity.

Women who lost less than 10% of initial body weight, or lost no weight, exercised an average of 34 minutes a day on five days a week.

By 24 months, participants on average had regained about half of the weight they had lost during the first six months [which is typical].

Take-Home Points

After six months of dieting, many people start to regain half of what they lost. We saw this phenomenon recently in the Israeli study of low-fat vs low-carb vs Mediterranean diet.

If you have a lot of excess fat to lose, you have to wonder if it would make sense to start a different diet program every six months, until you reach your weight goal. Maybe there’s something about the novelty and excitement of a new diet program that keeps you motivated and disciplined for six months.  For someone with lots of weight to lose, I wonder if they’d do better switching to a new diet every six months.

The authors note there are few similar long-term studies examining the amount and intensity of physical activity needed to improve weight loss success. So this is important new information.

In using exercise to help prevent weight regain, it may not matter whether the exercise is moderate or intense.

The authors write:

…the inability to sustain weight loss appears to mirror the inability to sustain physical activity.

Long-term sustained weight loss is possible for a significant portion of overweight women. Although most women won’t do it, success is enhanced by exercising for 55 minutes on five days a week. Most men won’t exercise that much either. Which camp do you fall into?

For physical activity instruction and information, visit Shape Up America!, Physical Activity for Everyone, or Growing Stronger: Strength Training for Older Adults.

Steve Parker, M.D.

Reference: Jakicic, John M., et al. Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women. Archives of Internal Medicine, 168 (2008): 1,550-1,559.

Prevention of Weight Regain

Clinical Diabetes recently published a review article, “Weight Regain Prevention,” summarizing effective strategies for prevention of weight regain after a successful weight-loss program. The article is not specifically for or about people with diabetes. You are probably aware that regain of lost weight is a huge problem.

“One more rep then I’m outa here!”

The authors start with a review of various weight-loss strategies, including low-calorie diets, very low-calorie diets, commercial programs such as Weight Watchers, behavior modification therapy, meal replacements, weight-loss drugs, etc. I recall no mention of bariatric surgery.

To its credit, Weight Watchers is the only commercial program to report data from randomized controlled trials, the gold standard in clinical scientific studies of effectiveness. [Weight Watchers lost more weight than the self-help control group.]

By way of review, here is the typical pattern of a weight loss effort. Maximal weight loss occurs in the first six months, at least for people who are compliant and don’t drop out of the program after the first few weeks. After the initial six months, weight regain starts. By one or two years after start of the effort, most people – but not all – have regained all the lost weight, if not more.

The authors’ recommendations for prevention of weight regain are mostly based on well-designed, published, peer-reviewed, scientific studies. They identified characteristics of successful weight loss maintainers – what I call “successful losers.” The idea is that a person will enhance her odds of keeping the lost weight off by incorporating these habits into her lifestyle:

  • Maintain high levels of physical activity. Consider at least 60 minutes daily of moderate activity. Ouch!
  • Limit television to less that a few hours a day.
  • Eat a diet low in fat and calories. [I disagree with the accross-the-board low-fat recommendation.]
  • Maintain a consistent eating pattern throughout the week and year. Successful losers often report less variety, compared to other people, in all food groups except for fruits.
  • Eat breakfast routinely.
  • Control emotional eating.
  • Weigh frequently, whether daily or weekly.
  • Catch and address weight regain early, before it gets out of hand.
  • Consider sequential medications. E.g., sibutramine for months, then orlistat for months.
  • Individual and/or group follow-up support. Even follow-up by phone works.
  • Have realistic expectations. Most dieters only lose about half the weight they expected in the first place. The resulting sense of disappointment sabotages efforts to keep the weight off. Anticipate the universal tendency to regain lost weight.
  • Helpful diet patterns: eat more than five servings a day of fruits and vegetables, watch portion sizes, self-record food intake, plan meals, limit fast food.
  • “Exercise is central to weight loss maintenance.” And finally . . .
  • “Exercise is central to weight loss maintenance.”

Steve Parker, M.D.

Reference: Ulen, Christina, et al. Weight Regain Prevention. Clinical Diabetes, 26 (2008): 100-113. DOI: 10.2337/diaclin.26.3.100

Yo-Yo Dieting In Women Has No Effect On Death Rates

Yo-yo dieting isn’t so bad after all.

Fifteen years ago there was lots of hand-wringing in the medical community about the potential dire physical consequences of “weight cycling” – also known as yo-yo dieting. You know, lose a bunch of weight, gain it back, lose it again, gain it back, etc.

After a while, yo-yo dieting as a medical issue dropped off the radar screen. 

A 2009 study in the Archives of Internal Medicine reported on the cardiovascular and mortality effects of yo-yo dieting in women in the massive Nurses’ Health Study. One in four of these women could be classified as weight cyclers. The worst ones were defined as those who lost at least 9.1 kg ( 20 pounds) at least three times.

It turns out the weight cyclers had the same rates of death from cardiovascular disease or any cause as the women who didn’t cycle. They did eventually gain more overall weight as they aged, compared to the non-cyclers.

Note that this study investigated death rates only. So there may have been effects on rates of high blood pressure, diabetes, gout, stroke, etc, that we wouldn’t know about.

Steve Parker, M.D.

Field, Alison, et al. Weight cycling and mortality among middle-aged or older women. Archives of Internal Medicine, 169 (2009): 881-886.

How to Prevent Weight Regain

Losing excess weight is easier than keeping it off.

Neither is exactly a walk in the park.

Prevention of weight regain is the most problematic area in the field of weight management. You may have heard that “diets don’t work,” but they do. Many different weight loss programs work short-term, if “work” is defined as loss of five, 10, or more pounds while you adhere to the program for several weeks or months. The problem is that the lost pounds usually return.

Why? You get bored with the diet, or your willpower flags, or the diet simply stops working, or the transition from weight loss to maintenance is unclear, or you just feel too bad to go on, or you lose your commitment, or you take a job as a taste tester for Baskin-Robbins Ice Cream, or whatever.

Most diets ultimately fail in the long run because people go back to their old habits.

Read on for the secret to prevention of weight regain. They apply to a majority of weight-loss methods, although many programs ignore this problem because the cure is a hard pill to swallow.

Moving Ahead

For purposes of further discussion, I will assume that you have already lost excess weight down to your goal and now we must focus on staying thereabouts from here on out. Finally down to your goal! A grand accomplishment! You’ve got a new wardrobe, or the old clothes fit again. You have more energy and feel younger. Maybe you cured or improved some health problems. Perhaps you’re getting more attention from the opposite sex.

Our species’ scientific name is Homo sapiens. It is from the Latin sapere, which means “to be wise.” Wisdom is the ability to make correct judgments and decisions. Undoubtedly, your success at weight loss required correct judgments and decisions. You are not done yet. You will need sustained wisdom to avoid weight regain.

Be wise about this especially: you can never again eat all you want, whenever you want, over sustained periods of time.

Now that you have reached your goal weight, you must restrain yourself on a daily basis. Think about it. You became overweight because you didn’t watch what you ate and didn’t exercise enough. You can’t go back to your old ways. Reject this advice, and you have a 100 percent chance of regaining your lost weight.

Have you heard of the Energy Balance Equation?

Calorie Intake minus Calories Burned

= Change in Body Fat

You have been able to lose fat weight because you ate less energy (calories) than your body required for metabolism and physical activity. Your body remedied the energy deficit by converting fat into energy. A pound of fat contains 3,500 calories of energy. If you lost a pound per week, your body on average converted 500 calories of fat daily into energy (7 days x 500 calories = 3,500 calories = 1 pound of fat).

Now that you are at your goal weight and want to stay there, you need to add 500 calories per day back into the equation. Add the calories by eating more food, exercising less, or a combination of the two. But if you add back more than 500, you will regain weight.

The true measure of a successful weight management program is not simply how much weight is lost, but whether the lost weight stays lost over the long run. What distinguishes weight losers who keep the weight off from those who gain it back? Two factors, mostly:

1. Restrained eating

2. Regular physical activity.

“Successful losers” apply self-restraint on an almost daily basis, avoiding food that they know will lead to weight regain. They limit how much they eat. They consciously choose not to return to their old eating habits, despite urges to the contrary. The other glaring difference is that, compared to regainers, the successful losers remain physically active. They exercised while losing weight, and continue to exercise in the maintenance phase of their program. This is true in at least eight out of 10 cases. It’s clear that regular exercise is not always needed, but it dramatically increases your chances of long-term success.

In a nutshell, my maintenance phase prescription for you is: Keep exercising, and eat a little more. Keep exercising, and eat a little more.

Go out of your way to be physically active for 30 to 45 minutes on at least four days per week, if not all days. Walking is fine. The more you exercise, the more you can eat without getting fat again.

At the end of your weight-loss phase and the beginning of the maintenance phase, it is surprisingly easy to start overeating. Forewarned is forearmed. Avoid this landmine any way you can. It helps to continue monitoring food consumption and exercise on your food diary while eating an additional 200–500 calories per day. Continue weighing daily. Keep exercising. After a month or two of this regimen, you’ll have an intuitive sense of what and how much you should be eating without regaining weight. Then stop the daily log routine.

Another option for transition to the maintenance phase: if you have been exercising regularly but loathe it, you could stop exercising and stay on your current calorie level diet. In other words, don’t start eating more. See what happens with your weight. Perhaps you could later eat an extra 100 to 200 daily calories without gaining weight. Continue recording your daily intake and weight for a couple months.

Weigh yourself daily during the first two months of your maintenance-of-weight-loss phase. After that, weigh weekly. Daily weights will remind you how hard you worked to achieve your goal. When you look now at a brownie, candy bar, or piece of pie, you ask yourself, “Do I really want to walk an extra hour or jog an extra three miles today to burn off those calories?” If so, enjoy. Otherwise, forego the unneeded calories.

Be aware that you might regain five or 10 pounds of fat now and then. You probably will. It’s not the end of the world. It’s human nature. You’re not a failure; you’re human.

But draw the line and get back on your old weight-loss program for one or two months. Analyze and learn from the episode. Why did it happen? Slipping back into your old ways? Slacking off on exercise? Too many special occasion feasts? Allowing junk food back into the house? Learn which food item is your nemesis—the food that consistently torpedoes your resolve to eat right. For example, I have two—candy, and sweet baked goods such as cookies and muffins. If I just look at them I add a pound. Remember an old ad campaign for a potato chip: “Betcha can’t eat just one!”? Well, I can’t eat just one cookie. So I don’t get started. I might eat one if it’s the last one available. Or I satisfy my sweet craving with fresh fruit or a diet soda. Just as a recovering alcoholic can’t drink any alcohol, perhaps you should totally abstain from…? You know your own personal gastronomic Achilles heel. Or heels. Experiment with various strategies for vanquishing your nemesis.

It’s OK to overindulge in food infrequently (10–12 times per year), on special occasions such as birthdays, wedding anniversaries, holidays. But you must counteract the extra calories by cutting down intake or by exercising more, either before or after the feast. No big deal.

Click to read additional ideas on prevention of weight regain.

Steve Parker, M.D.

Anti-Aging and Other Metabolic Benefits of Exercise

At my Diabetic Mediterranean Diet blog, I recently noted that regular physical activity prevented or postponed death. Onward now to other benefits.

Waist Management

Where does the fat go when you lose weight dieting? Chemical reactions convert it to energy, water, and carbon dioxide, which weigh less than the fat. Most of your energy supply is used to fuel basic life-maintaining physiologic processes at rest, referred to as resting or basal metabolism. Basal metabolic rate (BMR) is expressed as calories per kilogram of body weight per hour.

The major determinants of BMR are age, sex, and the body’s relative proportions of muscle and fat. Heredity plays a lesser role. Energy not used for basal metabolism is either stored as fat or converted by the muscles to physical activity. Most of us use about 70 percent of our energy supply for basal metabolism and 30 percent for physical activity. Those who exercise regularly and vigorously may expend 40–60 percent of their calorie intake doing physical activity. Excess energy not used in resting metabolism or physical activity is stored as fat.

Insulin, remember, is the main hormone converting that excess energy into fat; and carbohydrates are the major cause of insulin release by the pancreas.

To some extent, overweight and obesity result from an imbalance between energy intake (food) and expenditure (exercise and basal metabolism). Excessive carbohydrate consumption in particular drives the imbalance towards overweight, via insulin’s fat-storing properties.

In terms of losing weight, the most important metabolic effect of exercise is that it turns fat into weightless energy. We see that weekly on TV’s “Biggest Loser” show; participants exercise a huge amount. Please be aware that conditions set up for the show are totally unrealistic for the vast majority of people.

Physical activity alone as a weight-loss method isn’t very effective. But there are several other reasons to recommend exercise to those wishing to lose weight. Exercise counteracts the decrease in basal metabolic rate seen with calorie-restricted diets. In some folks, exercise temporarily reduces appetite (but others note the opposite effect). While caloric restriction during dieting can diminish your sense of energy and vitality, exercise typically does the opposite. Many dieters, especially those on low-calorie poorly designed diets, lose lean tissue (such as muscle and water) in addition to fat. This isn’t desirable over the long run. Exercise counteracts the tendency to lose muscle mass while nevertheless modestly facilitating fat loss.

How much does exercise contribute to most successful weight-loss efforts? Only about 10 percent on average. The other 90 percent is from food restriction.

Fountain of Youth

Regular exercise is a demonstrable “fountain of youth.” Peak aerobic power (or fitness) naturally diminishes by 50 percent between young adulthood and age 65. In other words, as age advances even a light physical task becomes fatiguing if it is sustained over time. By the age of 75 or 80, many of us depend on others for help with the ordinary tasks of daily living, such as housecleaning and grocery shopping. Regular exercise increases fitness (aerobic power) by 15–20 percent in middle-aged and older men and women, the equivalent of a 10–20 year reduction in biological age! This prolongation of self-sufficiency improves quality of life.

Heart Health

Exercise helps control multiple cardiac (heart attack) risk factors: obesity, high cholesterol, elevated blood pressure, high triglycerides, and diabetes. Regular aerobic activity tends to lower LDL cholesterol, the “bad cholesterol.” Jogging 10 or 12 miles per week, or the equivalent amount of other exercise, increases HDL cholesterol (“good cholesterol”) substantially. Exercise increases heart muscle efficiency and blood flow to the heart. For the person who has already had a heart attack, regular physical activity decreases the incidence of fatal recurrence by 20–30 percent and adds an extra two or three years of life, on average.

Effect on Diabetes

Eighty-five percent of type 2 diabetics are overweight or obese. It’s not just a random association. Obesity contributes heavily to most cases of type 2 diabetes, particularly in those predisposed by heredity. Insulin is the key that allows bloodstream sugar (glucose) into cells for utilization as energy, thus keeping blood sugar from reaching dangerously high levels. Overweight bodies produce plenty of insulin, often more than average. The problem in overweight diabetics is that the cells are no longer sensitive to insulin’s effect. Weight loss and exercise independently return insulin sensitivity towards normal. Many diabetics can improve their condition through sensible exercise and weight management.

Miscellaneous Benefits

In case you need more reasons to start or keep exercising, consider the following additional benefits: 1) enhanced immune function, 2) stronger bones, 3) preservation and improvement of flexibility, 4) lower blood pressure by 8–10 points, 5) diminished premenstrual bloating, breast tenderness, and mood changes, 6) reduced incidence of dementia, 7) less trouble with constipation, 7) better ability to handle stress, 8) less trouble with insomnia, 9) improved self-esteem, 10) enhanced sense of well-being, with less anxiety and depression, 11) higher perceived level of energy, and 12) prevention of weight regain.

People who lose fat weight but regain it cite lack of exercise as one explanation. One scientific study by S. Kayman and associates looked at people who dropped 20 percent or more of their total weight, and the role of exercise in maintaining that loss. Two years after the initial weight loss, 90 percent of the successful loss-maintainers reported exercising regularly. Of those who regained their weight, only 34 percent were exercising.

Steve Parker, M.D.