Tag Archives: weight regain

Mediterranean Diet Helps With Maintenance of Weight Loss After Ketogenic Diet

Italian seaside tangentially related to this post

Italian seaside tangentially related to this post

Investigators affiliated with universities in Italy and Greece wondered about the effect on obesity of two ketogenic “Mediterranean” diet spells interspersed with a traditional Mediterranean diet over the course of one year. They found significant weight loss, and perhaps more importantly, no regain of lost weight over the year, on average.

This scientific study is right up my alley. I was excited when I found it. Less excited after I read it.

The Set-Up

This was a retrospective review of medical records of patients of a private nutritional service in three fitness and weight control centers in Italy between 2006 and 2010. It’s unclear whether patients were paying for fitness/weight loss services. 327 patient records were examined. Of these, 89 obese participants met the inclusion and exclusion criteria and started the program; 68 completed it and were the ones analyzed. (That’s not at all a bad drop-out rate for a year-long study.)  The completers were 59 males and 12 females (I know, the numbers don’t add up, but that’s what they reported). Ages were between 25 and 65. Average weight was 101 kg (222 lb), average BMI 35.8, average age 49. All were Caucasian. No diabetics.

Here’s the program:

  1. 20 days of a very-low-carb ketogenic diet, then
  2. 20 days of a low-carbohydrate non-ketogenic diet for stabilization, then
  3. 4 months of a normal caloric Mediterranean diet, then
  4. repeat #1 and #2, then
  5. 6 months of a normal caloric Mediterranean diet

In the ketogenic phases, which the authors referred to as KEMEPHY, participants followed a commercially available protocol called TISANOREICA. KEMEPHY is combination of four herbal extracts that is ill-defined (at least in this article), with the idea of ameliorating weakness and tiredness during ketosis. The investigators called this a ketogenic Mediterranean diet, although I saw little “Mediterranean” about it. They ate “beef & veal, poultry, fish, raw and cooked green vegetables without restriction, cold cuts (dried beef, carpaccio and cured ham), eggs and seasoned cheese (e.g., parmesan).” Coffee and tea were allowed. Items to avoid included alcohol, bread, pasta, rice, milk, and yogurt. “In addition to facilitate the adhesion to the nutritional regime, each subject was given a variety of specialty meals constituted principally of protein and fibers. “These meals (TISANOREICA) that are composed of a protein blend obtained from soya, peas, oats (equivalent to 18 g/portion) and virtually zero carbohydrate (but that mimic their taste) were included in the standard ration.” They took a multivitamin every morning. Prescribed carbohydrate was about 30 grams a day, with macronutrient distribution of 12% carb, 36 or 41% protein, and 51 0r 52% fat. It appears that prescribed daily calories averaged 976 (but how can that be prescribed when some food items are “unrestricted”?).

I found little explanation of period #2 mentioned above, the low-carb non-ketogenic diet. Prescribed macronutrients were 25 or 33% carb, 27 0r 31% protein, 41 or 44% fat, and about 91 g carbohydrate. Prescribed daily calories appear to have averaged 1111.

After the first and second active weight loss ketogenic phases, participants ate what sounds like a traditional Mediterranean diet. Average prescribed macronutrient distribution was 57% carbohydrate, 15 % protein, and 27% fat. Wine was allowed. It looks like 1800 calories a day were recommended.

Food consumption was measured via analysis of 3-day diaries, but you have to guess how often that was done because the authors don’t say. The results of the diary analyses are not reported.

What Did They Find?

Most of the weight loss occurred during the two ketogenic phases. Average weight loss in the first ketogenic period was 7.4 kg (16 lb), and another 5.2 kg (11 lb) in the second ketogenic period. Overall average weight loss for the entire year was 16.1 kg (35 lb).

Average systolic blood pressure over the year dropped a statistically significant 8 units over the year, from 125 to 116 mmHg.

Over the 12 months, they found stable and statistically significant drops in total cholesterol, LDL cholesterol (“bad cholesterol”), triglycerides, and blood sugar levels. No change in HDL cholesterol (“good cholesterol”).

Liver and kidney function tests didn’t change.

The authors didn’t give explanations for the drop-outs.

Although the group on average didn’t regain lost weight, eight participants regained most of it. The investigators write that “…the post dietary analysis showed that they were not compliant with nutritional guidelines given for the Mediterranean diet period. These subjects returned tho their previous nutrition habits (“junk” food, high glycaemic index, etc.) with a mean “real” daily intake of 2470 Kcal rather than the prescribed 1800 Kcal.”


A key take-home point for me is that the traditional Mediterranean diet prevented the weight regain that we see with many, if not most, successful diets.

However, most formulas for calculating steady state caloric requirements would suggest these guys would burn more than the 1800 daily calories recommended to them during the “normal calorie” months. How hard did the dieters work to keep calories around 1800? We can only speculate.

Although the researchers describe the long periods of traditional Mediterranean diet as “normal caloric,” they don’t say how that calorie level was determined  and achieved in the real world. Trust me, you can get fat eating the Mediterranean diet if you eat too much.

I’ll be the first to admit a variety of weight loss diets work, at least short-term. The problem is that people go back to their old ways of eating regain much of the lost weight, typically starting six months after starting the program. It was smart for the investigators to place that second ketogenic phase just before the typical regain would have started!

There are so few women in this study that it would be impossible to generalize results to women. Why so few? Furthermore, weight loss and other results weren’t broken down for each sex.

I suspect the results of this study will be used for marketing KEMEPHY and TISANOREICA. For all I know, that’s why the study was done. We’re trusting the investigators to have done a fair job choosing which patient charts to analyze retrospectively. They could have cherry-picked only the good ones. Some of the funding was from universities, some was from Gianluca Mech SpA (what’s that?).

How much of the success of this protocol is due to the herbal extracts and TISANOREICA, I have no idea.

The authors made no mention of the fact the average fasting glucose at baseline was 103 mg/dl (5.7 mmol/l). That’s elevated into the prediabetic range. So probably half of these folks had prediabetes. After the one-year program, average fasting glucose was normal at 95 mg/dl (5.3 mmol/l).

The improved lipids, blood sugars, and lower blood pressure may have simply reflected successful weight loss and therefore could have been achieved  by a variety of diets.

The authors attribute their success to the weight-losing metabolic effects of the ketogenic diet (particularly the relatively high protein content), combined with the traditional Mediterranean diet preventing weight regain.

The authors write:

The Mediterranean diet is associated with a longer life span, lower rates of coronary heart disease, hypercholesterolemia, hypertension, diabetes and obesity. But it is difficult to isolate the “healthy” constituents of the Mediterranean diet, since it is not a single entity and varies between regions and countries. All things considered there is no “one size fits all” dietary recommendation and for this reason we have tried to merge the benefits of these two approaches: the long term “all-life” Mediterranean diet coupled with brief periods of a metabolism enhancing ketogenic diet.

I’ve attempted a similar merger with my Low-Carb Mediterranean Diet. Click here for an outline. Another stab at it was the Spanish Ketogenic Mediterranean Diet. And here’s my version of a Ketogenic Mediterranean Diet.

Steve Parker, M.D.

Reference: Paoli, Antonio, et al. Long Term Successful Weight Loss with a Combination Biphasic Ketogenic Mediterranean Diet and Mediterranean Diet Maintenance Protocol. Nutrients, 5 (2013): 5205-5217. doi: 10.3390/nu5125205

Think Diets Don’t Work? Think Again

Claims that “diets don’t work” are based on the assumption that any weight lost is simply gained back quickly.

The Endocrine Society met in Toronto in June of 2007.  Experts presented data on maintenance of weight loss by overweight people.  What percentage of people who lost 10% of their weight kept the weight off for one year?  About 20%.  Not great, but better than many would expect.  That’s a 200-pounder losing down to 180 and staying at 180 pounds for a year.  This degree of weight loss will improve many cases of high blood pressure, knee arthritis, and type 2 diabetes mellitus.

The U.S. Centers for Disease Control and Prevention reports even better data.  Almost 60% of 1,310  people in the National Health and Nutrition Examination Survey who lost 10% of body weight maintained 95% of the loss for one year.

How do they keep the weight off?  Characteristics of “successful losers” include a low-calorie diet (probably 1,6oo-1,800 on average), weighing at least once per week, and burning about 2,600 calories per week in physical activity.  (A 150-pound person expends 1260 calories a week by walking 3-4 mph for 30 minutes daily.)

Many successful losers cycle through weight loss and gain several times before determining which combination of diet and physical activity ultimately works for them.

So don’t give up!

Steve Parker, M.D,


McGuire, M.T., et al.  International Journal of Obesity, 23[12] (1999): 1,314-1,319.

Weiss, E.C., et al.  American Journal of Preventive Medicine, 33[1] (2007): 34-40.

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.


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.


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

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.