1. What do we know about those who are successful at long-term weight loss maintenance? What do we want to know? Jennifer Otten, MS, RD December 7, 2007

2. National Weight Control Registry Registry of >4000 successful weight loss maintainers (initiated in 1994) Registry of >4000 successful weight loss maintainers (initiated in 1994) 18 years and older 18 years and older Entry criteria: Must have lost at least 30 lb. and kept it off at least 1 year Entry criteria: Must have lost at least 30 lb. and kept it off at least 1 year Uses quantitative measures to describe their weight-loss and weight-maintenance strategies Uses quantitative measures to describe their weight-loss and weight-maintenance strategies Cross-sectional and prospective data Cross-sectional and prospective data

3. Why do we care? Very few individuals are able to lose weight and keep it off Very few individuals are able to lose weight and keep it off Individuals in university- and hospital-based weight loss programs typically lose 9 kg (~20 lb.) in 6 months Individuals in university- and hospital-based weight loss programs typically lose 9 kg (~20 lb.) in 6 months Most return to baseline weight within 3-5 years post-treatment Most return to baseline weight within 3-5 years post-treatment Improvements in health measures typically lost on weight regain Improvements in health measures typically lost on weight regain

4. Why do we care? Little is known about successful losers from university- and hospital-based studies Little is known about successful losers from university- and hospital-based studies Generalizability? Generalizability? Studies were small and/or qualitative Studies were small and/or qualitative

5. Definition Successful weight loss maintenance is defined as: Intentionally losing at least 10% of body weight and keeping it off at least one year.

6. Prevalence From limited data, using this definition: About 20% of overweight individuals become successful at long-term weight loss.

7. Description of registry participants Self-selected population Self-selected population Recruited primarily through newspaper and magazine articles Recruited primarily through newspaper and magazine articles Asked to provide “before and after” photographs and names of health care professionals who can verify weight loss Asked to provide “before and after” photographs and names of health care professionals who can verify weight loss Followed annually; no compensation Followed annually; no compensation

8. Demographics 73% women 73% women 82% college educated 82% college educated 95% Caucasian 95% Caucasian 62% married 62% married Average age at entry: 46.8 years Average age at entry: 46.8 years > ½ report being overweight as a child > ½ report being overweight as a child ~75% have 1 or both parents who are obese ~75% have 1 or both parents who are obese

9. Measures Self-report maximum and current weight, height Self-report maximum and current weight, height Studies suggest this is accurate with slight underestimation of actual weight Studies suggest this is accurate with slight underestimation of actual weight Sub-group comparison very accurate Sub-group comparison very accurate Annually complete series of questionnaires Annually complete series of questionnaires Wt characteristics; wt-loss methods and strategies; wt maint. methods and strategies; effect of wt. loss and maint. on QOL; diet; exercise; etc… Wt characteristics; wt-loss methods and strategies; wt maint. methods and strategies; effect of wt. loss and maint. on QOL; diet; exercise; etc…

10. Characteristics of Subjects Lost an average of 33 kg (~73 lb.) and maintained minimum weight loss of 30 lb. for an avg of 5.7 years Lost an average of 33 kg (~73 lb.) and maintained minimum weight loss of 30 lb. for an avg of 5.7 years Losses: 30-300 lb.; Duration: 1-66 yrs. Losses: 30-300 lb.; Duration: 1-66 yrs. 13% have maintained minimum weight loss for >10 years 13% have maintained minimum weight loss for >10 years Reduced BMI from avg of 36.7 kg/m 2 at maximum to 25.1 kg/m 2 currently Reduced BMI from avg of 36.7 kg/m 2 at maximum to 25.1 kg/m 2 currently

11. Method of weight loss? About ½ received some type of help (commercial program, MD, RD) About ½ received some type of help (commercial program, MD, RD) 44.6% reported losing the weight on their own 44.6% reported losing the weight on their own 89% used both diet and PA 89% used both diet and PA Only 10% used diet alone Only 10% used diet alone Only 1% used exercise alone Only 1% used exercise alone Few reported wt. loss meds or surgery Few reported wt. loss meds or surgery

12. Which dietary strategies? 87.6% restrict certain foods 87.6% restrict certain foods 44% limit quantities 44% limit quantities 43% count calories 43% count calories 25% count fat grams 25% count fat grams 20% used liquid formula 20% used liquid formula 22% use exchange system diet 22% use exchange system diet Variable EXCEPT that almost all used a variation of diet + PA

13. Behaviors used to maintain weight loss Strategies used consistently: 1.Consume a low-cal, low-fat diet Report eating ~1400 kcal/d; 24% from fat **** Report eating ~1400 kcal/d; 24% from fat **** (women ~ 1300 kcal/d; men ~ 1685 kcal/d) 2.High levels of PA 90% report on avg. ~1 hr/d of moderate-intensity activity such as brisk walking 90% report on avg. ~1 hr/d of moderate-intensity activity such as brisk walking 76% walk; 20% lift weights; 20% cycle; 18% aerobics 76% walk; 20% lift weights; 20% cycle; 18% aerobics

14. Key Behaviors (con’t) 3.75% weigh at least weekly 44% of these weigh daily 44% of these weigh daily 4.78% eat breakfast daily 4% never eat breakfast (far less than general public: 25% in 1991) 4% never eat breakfast (far less than general public: 25% in 1991) Typical: fruit and cereal Typical: fruit and cereal 5.62% watch < 10 hrs. of TV per week

15. Diet composition over the years

16. Self-reports on success Compared to previous attempts: Subjects used more intensive approaches Subjects used more intensive approaches 81% said they used exercise more 81% said they used exercise more 63% said they used a stricter diet approach 63% said they used a stricter diet approach Had greater reasons (social, health or both) Had greater reasons (social, health or both)

17. Is weight maintenance harder to sustain than weight loss? 42% felt weight maintenance was less difficult than weight loss 42% felt weight maintenance was less difficult than weight loss 33% rated them equally difficult or easy 33% rated them equally difficult or easy 25% found maintenance more difficult 25% found maintenance more difficult

18. Does maintenance become easier over time?

19. Effort vs. Pleasure Subjects with longer duration (3+ years): Subjects with longer duration (3+ years): Reported less effort to diet and maintain weight (p < 0.05) Reported less effort to diet and maintain weight (p < 0.05) Reported less attention required to maintain weight (p < 0.05) Reported less attention required to maintain weight (p < 0.05) INTERESTINGLY, duration found to be assoc. with greater pleasure of WM relative to effort required (p < 0.03) INTERESTINGLY, duration found to be assoc. with greater pleasure of WM relative to effort required (p < 0.03) No effect of duration on pleasure of exercise, LF meal, maintaining weight, sedentary behaviors, or higher-fat eating No effect of duration on pleasure of exercise, LF meal, maintaining weight, sedentary behaviors, or higher-fat eating

20. Duration of maint and 1-yr risk of regain among successful weight losers Duration of wt. loss maintenance OR for gaining >5 lb. vs. maintaining <2 y 1.00 2-4.9 y 0.42 >5 y 0.29

21. Does dieting consistency matter?

23. Consistent dieters (weekly) were 1.5 times more likely to maintain their weight within 5 lbs. over the year (OR = 1.58; 95% CI: 1.2-2.2) Consistent dieters (weekly) were 1.5 times more likely to maintain their weight within 5 lbs. over the year (OR = 1.58; 95% CI: 1.2-2.2) Consistent dieters (yearly) were 1.3 times more likely to maintain their weight within 5 lbs. over the year (OR = 1.33; 95% CI: 1.0-1.8) Consistent dieters (yearly) were 1.3 times more likely to maintain their weight within 5 lbs. over the year (OR = 1.33; 95% CI: 1.0-1.8)

24. What predicts weight regain? More recent weight loss (less than 2 years) More recent weight loss (less than 2 years) Larger weight losses (greater than 30% maximum weight) Larger weight losses (greater than 30% maximum weight) Higher levels of depression, dietary disinhibition, binge eating levels Higher levels of depression, dietary disinhibition, binge eating levels

25. Are there common triggering events? 83% report a trigger 83% report a trigger 23% report medical trigger 23% report medical trigger Associated with less regain over 2 yr follow- up Associated with less regain over 2 yr follow- up 21.3% report “reaching all-time high wt” trigger 21.3% report “reaching all-time high wt” trigger 12.7% report seeing picture or reflection in mirror as trigger 12.7% report seeing picture or reflection in mirror as trigger

26. Can NWCR participants better recover from relapse? Prospective from baseline to year 1 and 2 Only 11% recovered from gains of 1-2 kg Only 11% recovered from gains of 1-2 kg Magnitude of weight regain at yr 1 was the strongest predictor of outcome from year 0 to 2 Magnitude of weight regain at yr 1 was the strongest predictor of outcome from year 0 to 2

27. Does TV viewing play a role? Baseline TV viewing and increases in TV viewing over 1 yr follow-up were significant predictors of 1-yr weight regain. Baseline TV viewing and increases in TV viewing over 1 yr follow-up were significant predictors of 1-yr weight regain. This was independent of PA and dietary behaviors. This was independent of PA and dietary behaviors.

28. Summary Exercise at high levels Exercise at high levels Eat low-cal, low-fat diet Eat low-cal, low-fat diet Eat breakfast Eat breakfast Self-monitor frequently Self-monitor frequently Maintain consistent eating pattern Maintain consistent eating pattern Capitalize on medical triggers Capitalize on medical triggers Preventing large regains appears critical Preventing large regains appears critical

29. What other questions do we want to ask? Attrition rate and why? Do the drop-outs differ? Attrition rate and why? Do the drop-outs differ? Better methods for PA and diet Better methods for PA and diet What else? What else?

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