Long Term Control of Obesity

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Studies regarding the ability of patients to first lose weight and then keep it off long-term have been discouraging. A recent study by Heshka et al. highlights this dilemma. A 2-year, multicenter, randomized clinical trial involving 65 men and 358 women compared weight loss between a self-help group and a structured commercial program. At 1 year, weight loss through the structured group was a mean 4.3 kg versus 1.3 kg in the self-help group. However, weight regain occurred in both groups. At the end of 2 years, the structured group had lost 2.9kg and the self-help group 0.2kg [38]. One implication that could be drawn from this study is that if weight regain is inevitable, then why go to the time, expense, and effort to lose it in the first place? Such a position has discouraged many physicians from trying to help obese patients, and insurers from providing financial coverage for treatment.

Breaking the 4-minute mile was considered a physiologic impossibility until 1954 when Roger Bannister ran one mile in under 4 minutes. One month later John Lundy ran a sub-4-minute mile. Since that time world-class milers all complete the one-mile run under 4 minutes. This major victory in running occurred first in the mind of one man. Now the 4-minute mile is simply a benchmark to be passed, not an unrealistic goal.

Today anyone wanting to be a successful miler studies those who run under-4-minute miles, not just anyone who wants to run a 1-mile race. A similar strategy works for long-term weight loss, too. Studying the winners of the race, not just the runners, is a fundamental shift in the approach needed for long-term control of obesity.

There are now scientific data that strongly suggest that as a chronic disease, obesity can be controlled long-term. First, from a non-medical publication, in May 2002 Consumer Reports magazine published data regarding self-reported weight loss. They asked subscribers if they had ever lost weight, kept it off, and how they did it. An amazing 32,213 responses were received. Over 8000 reported at least a 10% weight loss. Over 4000 reported losing 37 lb or more and keeping it off over 5 years [39]. This means about 25% of the population met the National Heart, Lung, and Blood Institute's recommendations of losing 10% as a healthy weight loss goal [17]. Though the majority of respondents were not successful in attaining the recommended weight loss, a significant minority of over 8000 did accomplish that goal.

The limitations of this report are that it was not meant to be a scientific study, and it did not control for self-selection bias. However, the collective experience of those who were successful has something important to say to those who have tried to control their obesity but failed. Such reasoning is exactly what the National Weight Control Registry (NWCR), now with over 4000 registered subjects, followed when it started its database. Therefore, it is worthwhile taking a closer look at the NWCR.

Founded in 1994 by Drs Rena Wing and James Hill, the goal of the NWCR is to collect data from those who have lost at least 30lb and maintained that weight loss for 1 year. Long-term weight loss is defined as the amount of weight still lost after 1 year. The average member of the NWCR has lost 67lb and kept at least 30 lb off for an average of 5.5 years. The NWCR com position is 80% women, 97% white Caucasian, 67% married; the average age is 45 years [40].

The NWCR reports that successful long-term weight loss consists of four basic behaviors. The first behavior is eating a low-fat, high-carbohydrate diet. Less than 1% of the subjects report eating a high-fat diet. The difference in terms of calories in versus calories out balance is that both a gram of carbohydrate and a gram protein contain 4 calories, whereas a gram of fat contains 9 calories. Therefore, gram for gram, caloric density makes a difference in controlling obesity.

The second behavior is regular monitoring of weight and food intake. About three-fourths of the subjects weigh themselves at least weekly, and most monitor the amount of fat they consume. Self-monitoring of weight is the obesity patient's equivalent of the diabetic's glucose monitor and the asthmatic's PFM. Individuals who do not know where they are in terms of their weight cannot make a timely intervention to control the tendency for regaining weight.

The third behavior is eating breakfast most days of the week. Seventy-eight percent eat breakfast every day, and 91% eat breakfast 4 out of 7 days per week. This eating pattern is consistent with keeping the stomach's ghrelin hormone from signaling the brain that the stomach is empty, thus possibly provoking the individual to overeat.

The fourth behavior is physical activity. Ninety-one percent report activity that is comparable to walking 28 miles per week or moderate-intensity exercise for 1 hour per day. These data suggest that regular activity is critical to maintain weight loss [41].

Conversely, 9% of subjects in the NWCR report minimal physical activity. They control their weight almost solely through control of caloric intake. It is important to understand that though less likely to be successful, it is still possible to lose weight and keep it off long-term without a commitment to physical activity. This is encouraging to those obese patients who either cannot exercise due to physical limitations or do not want to be physically active.

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