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ABSTRACT

There is a general perception that almost no one succeeds in long-term maintenance of weight loss. However, research has shown that 20% of overweight individuals are successful at long-term weight loss when defined as losing at least 10% of initial body weight and maintaining the loss for at least 1 y. The National Weight Control Registry provides information about the strategies used by successful weight loss maintainers to achieve and maintain long-term weight loss. National Weight Control Registry members have lost an average of 33 kg and maintained the loss for more than 5 y. To maintain their weight loss, members report engaging in high levels of physical activity (1 h/d), eating a low-calorie, low-fat diet, eating breakfast regularly, self-monitoring weight, and maintaining a consistent eating pattern across weekdays and weekends. Moreover, weight loss maintenance may get easier over time; after individuals have successfully maintained their weight loss for 25 y, the chance of longer-term success greatly increases. Continued adherence to diet and exercise strategies, low levels of depression and disinhibition, and medical triggers for weight loss are also associated with long-term success. National Weight Control Registry members provide evidence that long-term weight loss maintenance is possible and help identify the specific approaches associated with long-term success.

The perception of the general public is that no one ever succeeds at long-term weight loss. This belief stems from Stunkard and McLaren-Humes 1959 study of 100 obese individuals, which indicated that, 2 y after treatment, only 2% maintained a weight loss of 9.1 kg (20 lb) or more (1). More recently, a New England Journal of Medicine editorial titled Losing Weight: An Ill-Fated New Years Resolution (2) echoed the same pessimistic message.

The purpose of this paper is to review the data on the prevalence of successful weight loss maintenance and then present some of the major findings from the National Weight Control Registry (NWCR), a database of more than 4000 individuals who have indeed been successful at long-term weight loss maintenance.

Wing and Hill (3) proposed that successful weight loss maintainers be defined as individuals who have intentionally lost at least 10% of their body weight and kept it off at least one year. Several aspects of this definition should be noted. First, the definition requires that the weight loss be intentional. Several recent studies indicate that unintentional weight loss occurs quite frequently and may have different causes and consequences than intentional weight loss (4,5). Thus, it is important to include intentionality in the definition. The 10% criterion was suggested because weight losses of this magnitude can produce substantial improvements in risk factors for diabetes and heart disease. Although a 10% weight loss may not return an obese to a non-obese state, the health impact of a 10% weight loss is well documented (6). Finally, the 1-y duration criterion was proposed in keeping with the Institute of Medicine criteria (7). Clearly, the most successful individuals have maintained their weight loss longer than 1 y, but selecting this criterion may stimulate research on the factors that enable individuals who have maintained their weight loss for 1 y to maintain it through longer intervals.

There are very few studies that have used this definition to estimate the prevalence of successful weight loss maintenance. McGuire et al (8) reported results of a random digit dialing survey of 500 adults, 228 of whom were overweight or obese [body mass index (BMI) 27 kg/m2] at their maximum nonpregnant weight. Of these 228, 47 (20.6%) met the criteria for successful weight loss maintenance: they had intentionally lost at least 10% of their body weight and maintained it for at least 1 y. On average, these 47 individuals had lost 20.7 14.4 kg (45.5 lb; 19.5 10.6% from maximum weight) and kept it off for 7.2 8.5 y; 28 of the 47 had reduced to normal weight (BMI <27 kg/m2).

Survey data such as these have the perspective of a persons entire lifetime and thus may include many weight loss attempts, some which were successful and some unsuccessful. It is more typical to assess success during one specific weight loss bout. In standard behavioral weight loss programs, participants lose an average of 710% (710 kg) of their body weight at the end of the initial 6-mo treatment program and then maintain a weight loss of 56 kg (56%) at 1-y follow-up. Only a few studies have followed participants for longer intervals; in these studies, 1320% maintain a weight loss of 5 kg or more at 5 y. In the Diabetes Prevention Program (9), 1000 overweight individuals with impaired glucose tolerance were randomly assigned to an intensive lifestyle intervention. The average weight loss of these participants was 7 kg (7%) at 6 mo; after 1 y, participants maintained a weight loss of 6 kg (6%), and, at 3 y, they maintained a weight loss of 4 kg (4%). At the end of the study (follow-up ranging from 1.8 to 4.6 y; mean, 2.8 y), 37% maintained a weight loss of 7% or more.

Thus, although the data are limited and the definitions varied across studies, it appears that 20% of overweight individuals are successful weight losers.

Although it is often stated that no one ever succeeds in weight loss, we all know some people who have achieved this feat. In an effort to learn more about those individuals who have been successful at long-term weight loss, Wing and Hill (10) established the National Weight Control Registry in 1994. This registry is a self-selected population of more than 4000 individuals who are age 18 or older and have lost at least 13.6 kg (30 lb) and kept it off at least 1 y. Registry members are recruited primarily through newspaper and magazine articles. When individuals enroll in the registry, they are asked to complete a battery of questionnaires detailing how they originally lost the weight and how they now maintain this weight loss. They are subsequently followed annually to determine changes in their weight and their weight-related behaviors.

The demographic characteristics of registry members are as follows: 77% are women, 82% are college educated, 95% are Caucasian, and 64% are married. The average age at entry to the registry is 46.8 y. About one-half of registry members report having been overweight as a child, and almost 75% have one or two parents who are obese.

Participants self-report their current weight and their maximum weight. Previous studies suggest that such self-reported weights are fairly accurate (slightly underestimating actual weight) (11,12). In the NWCR, participants are asked to identify a physician or weight loss counselor who can provide verification of the weight data. When, in a subgroup of participants, the information provided by participants was compared with that given by the professional, the self-report information was found to be very accurate.

Participants in the registry report having lost an average of 33 kg and have maintained the minimum weight loss (13.6 kg) for an average of 5.7 y. Thirteen percent have maintained this minimum weight loss for more than 10 y. The participants have reduced from a BMI of 36.7 kg/m2 at their maximum to 25.1 kg/m2 currently. Thus, by any criterion, these individuals are clearly extremely successful.

Previously, we reported information about the way in which registry participants lost their weight (10); interestingly, about one-half (55.4%) reported receiving some type of help with weight loss (commercial program, physician, nutritionist), whereas the others (44.6%) reported losing the weight entirely on their own. Eighty-nine percent reported using both diet and physical activity for weight loss; only 10% reported using diet only, and 1% reported using exercise only for their weight loss. The most common dietary strategies for weight loss were to restrict certain foods (87.6%), limit quantities (44%), and count calories (43%). Approximately 25% counted fat grams, 20% used liquid formula, and 22% used an exchange system diet. Thus, there is variability in how the weight loss was achieved (except that it is almost always by diet plus physical activity).

The earliest publication regarding the registry documented the behaviors that the members (n = 784) were using to maintain their weight loss (10). Three strategies were reported very consistently: consuming a low-calorie, low-fat diet, doing high levels of physical activity, and weighing themselves frequently. Recently, a fourth behavior was identified: consuming breakfast daily (13). Each of these behaviors is described below. Registry members reported eating 1381 kcal/d, with 24% of calories from fat. In interpreting their data, it is important to recognize that 55% of registry members report that they are still trying to lose weight and to consider that dietary intake is typically underestimated by 2030%. Thus, registry members are probably eating closer to 1800 kcal/d. However, even with this adjustment, it is apparent that registry members maintain their weight loss by continuing to eat a low-calorie, low-fat diet.

More recently, we have examined other aspects of their diet. Of particular interest is the fact that 78% of registry members report eating breakfast every day of the week (13). Only 4% report never eating breakfast. The typical breakfast is cereal and fruit. Registry members also report consuming 2.5 meals/wk in restaurants and 0.74 meals/wk in fast food establishments.

Another characteristic of NWCR members is high levels of physical activity. Women in the registry reported expending an average of 2545 kcal/wk in physical activity, and men report an average of 3293 kcal/wk (10). These levels of activity would represent 1 h/d of moderate-intensity activity, such as brisk walking. The most common activity is walking, reported by 76% of the participants. Approximately 20% report weight lifting, 20% report cycling, and 18% report aerobics.

Registry members also reported frequent monitoring of their weight (10). More than 44% report weighing themselves at least once a day, and 31% report weighing themselves at least once a week. This frequent monitoring of weight would allow these individuals to catch small weight gains and hopefully initiate corrective behavior changes.

The vigilance regarding body weight can be seen as one aspect of the more general construct of cognitive restraint (ie, the degree of conscious control exerted over eating behaviors). Registry members are asked to complete the Three Factor Eating Inventory (14), which includes a measure of cognitive restraint. Registry members scored high on this measure (mean of 7.1), with levels similar to those seen in patients who have recently completed a treatment program for obesity, although not as high as eating-disordered patients. These findings suggest that successful weight loss maintainers continue to act like recently successful weight losers for many years after their weight loss.

Registry participants are followed over time to identify variables related to continued success at weight loss and maintenance. Findings from the initial follow-up study (15) indicated that, after 1 y, 35% gained 2.3 kg (5 lbs) or more (7 kg on average), 59% continued to maintain their body weight, and 6% continued to lose weight.

Participants who regained weight (>2.3 kg) were compared with those who continued to maintain their body weight to examine whether there were any baseline characteristics that could distinguish the two groups. The single best predictor of risk of regain was how long participants had successfully maintained their weight loss (Table 1). Individuals who had kept their weight off for 2 y or more had markedly increased odds of continuing to maintain their weight over the following year. This finding is encouraging because it suggests that, if individuals can succeed at maintaining their weight loss for 2 y, they can reduce their risk of subsequent regain by nearly 50%.

TABLE 1

Duration of weight loss maintenance and 1-y risk of weight regain among successful weight losers1

TABLE 1

Duration of weight loss maintenance and 1-y risk of weight regain among successful weight losers1

Another predictor of successful weight loss maintenance was a lower level of dietary disinhibition, which is a measure of periodic loss of control of eating. Participants who had fewer problems with disinhibition [ie, scores <6 on the Eating Inventory subscale (14)] were 60% more likely to maintain their weight over 1 y. Similar findings were found for depression, with lower levels of depression related to greater odds of success. These findings point to the importance of both emotional regulation skills and control over eating in long-term successful weight loss.

Several key behavior changes that occurred over the year of follow-up also distinguished maintainers from regainers. Not surprisingly, those who regained weight reported significant decreases in their physical activity, increases in their percentage of calories from fat, and decreases in their dietary restraint. Thus, a large part of weight regain may be attributable to an inability to maintain healthy eating and exercise behaviors over time. The findings also underscore the importance of maintaining behavior changes in the long-term maintenance of weight loss.

Another variable that has been examined in the registry is the presence of a triggering event leading to participant successful weight loss. Most registry participants reported a trigger for their weight loss (83%). Medical triggers were the most common (23%), followed by reaching an all time high in weight (21.3%), and seeing a picture or reflection of themselves in the mirror (12.7%).

Because medical triggers have been shown to promote long-term behavior change in other areas of behavioral medicine (16), we examined whether individuals who reported medical triggers were more successful than those who reported nonmedical triggers or no triggers. A medical trigger was defined broadly and included, for example, a doctor telling the participant to lose weight and/or a family member having a heart attack. Findings indicated that people who had medical reasons for weight loss also had better initial weight losses and maintenance (17). Specifically, those who said they had a medical trigger lost 36 kg, whereas those who had no trigger (17.1%) or a nonmedical trigger (59.9%) lost 32 kg. Medical triggers were also associated with less regain over 2 y of follow-up. Those with medical triggers gained 4 kg (2 kg/y), whereas those with other or no medical triggers gained at a significantly faster rate, averaging 6 kg in both groups.

These findings are intriguing because they suggest that the period following a medical trigger may be an opportune time to initiate weight loss to optimize both initial and long-term weight loss outcomes.

The topic of dieting consistency was also recently examined in the registry. Participants were asked whether they maintained the same diet regimen across the week and year, or if they tended to diet more strictly on weekdays and/or nonholidays (18). Few people said they dieted more strictly on the weekend compared with the rest of the week (2%) or during holidays compared with the rest of the year (3%). Most participants reported that their eating was the same on weekends and weekdays (59%) and on holidays/vacations and the rest of the year (45%). The remaining groups reported that they were stricter during the week than on weekends (39%) and during nonholiday times compared with holidays (52%).

We evaluated whether maintaining a consistent diet was related to subsequent weight regain after 2 y. Interestingly, results indicated that participants who reported a consistent diet across the week were 1.5 times more likely to maintain their weight within 5 lb over the subsequent year than participants who dieted more strictly on weekdays. A similar relationship emerged between dieting consistency across the year and subsequent weight regain; individuals who allowed themselves more flexibility on holidays had greater risk of weight regain. Allowing for flexibility in the diet may increase exposure to high-risk situations, creating more opportunity for loss of control. In contrast, individuals who maintain a consistent diet regimen across the week and year appear more likely to maintain their weight loss over time.

We also examined different patterns of weight change among registry participants followed over time. We were particularly interested in evaluating whether participants who gained weight between baseline and year 1 were able to recover over the subsequent year. We found that few people (11%) recovered from even minor lapses of 12 kg. Similarly, magnitude of weight regain at year 1 was the strongest predictor of outcome from year 0 to 2. Participants who gained the most weight at year 1 were the least likely to re-lose weight the following year, both when recovery was defined as a return to baseline weight or as re-losing at least 50% of the year 1 gain.

Although participants gained weight and recovery was uncommon, the regains were modest (average of 4 kg at 2 y), and the vast majority of participants (96%) remained >10% below their maximum lifetime weight, which is considered successful by current obesity treatment standards.

These findings, nonetheless, suggest that reversing weight regain appears most likely among individuals who have gained the least amount of weight. Preventing small regains from turning into larger relapses appears critical to recovery among successful weight losers.

Results of random digit dial surveys indicate that 20% of people in the general population are successful at long-term weight loss maintenance. These data, along with findings from the National Weight Control Registry, underscore the fact that it is possible to achieve and maintain significant amounts of weight loss.

Findings from the registry suggest six key strategies for long-term success at weight loss: 1) engaging in high levels of physical activity; 2) eating a diet that is low in calories and fat; 3) eating breakfast; 4) self-monitoring weight on a regular basis; 5) maintaining a consistent eating pattern; and 6) catching slips before they turn into larger regains. Initiating weight loss after a medical event may also help facilitate long-term weight control.

Additional studies are needed to determine the factors responsible for registry participant apparent ability to adhere to these strategies for a long period of time in the context of a toxic environment that strongly encourages passive overeating and sedentary lifestyles.

RRW is the cofounder of the National Weight Control Registry (with James O Hill). RRW coauthored the manuscript with SP, who is a coinvestigator of the National Weight Control Registry. RRW and SP have no financial or personal interest in the organizations sponsoring this research.

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Long-term weight loss maintenance | The American Journal of Clinical Nutrition | Oxford Academic

ContextPopular diets, particularly those low in carbohydrates, have challenged current recommendations advising a low-fat, high-carbohydrate diet for weight loss. Potential benefits and risks have not been tested adequately.

ObjectiveTo compare 4 weight-loss diets representing a spectrum of low to high carbohydrate intake for effects on weight loss and related metabolic variables.

Design, Setting, and ParticipantsTwelve-month randomized trial conducted in the United States from February 2003 to October 2005 among 311 free-living, overweight/obese (body mass index, 27-40) nondiabetic, premenopausal women.

InterventionParticipants were randomly assigned to follow the Atkins (n=77), Zone (n=79), LEARN (n=79), or Ornish (n=76) diets and received weekly instruction for 2 months, then an additional 10-month follow-up.

Main Outcome MeasuresWeight loss at 12 months was the primary outcome. Secondary outcomes included lipid profile (low-density lipoprotein, high-density lipoprotein, and nonhigh-density lipoprotein cholesterol, and triglyceride levels), percentage of body fat, waist-hip ratio, fasting insulin and glucose levels, and blood pressure. Outcomes were assessed at months 0, 2, 6, and 12. The Tukey studentized range test was used to adjust for multiple testing.

ResultsWeight loss was greater for women in the Atkins diet group compared with the other diet groups at 12 months, and mean 12-month weight loss was significantly different between the Atkins and Zone diets (P<.05). Mean 12-month weight loss was as follows: Atkins, 4.7 kg (95% confidence interval [CI], 6.3 to 3.1 kg), Zone, 1.6 kg (95% CI, 2.8 to 0.4 kg), LEARN, 2.6 kg (3.8 to 1.3 kg), and Ornish, 2.2 kg (3.6 to 0.8 kg). Weight loss was not statistically different among the Zone, LEARN, and Ornish groups. At 12 months, secondary outcomes for the Atkins group were comparable with or more favorable than the other diet groups.

ConclusionsIn this study, premenopausal overweight and obese women assigned to follow the Atkins diet, which had the lowest carbohydrate intake, lost more weight and experienced more favorable overall metabolic effects at 12 months than women assigned to follow the Zone, Ornish, or LEARN diets. While questions remain about long-term effects and mechanisms, a low-carbohydrate, high-protein, high-fat diet may be considered a feasible alternative recommendation for weight loss.

Trial Registrationclinicaltrials.gov Identifier: NCT00079573

The ongoing obesity epidemic,1 along with its health costs and consequences2 and the health benefits of weight loss,3-6 have been well established. National dietary weight loss guidelines (ie, energy-restricted, low in fat, high in carbohydrate)7 have been challenged, particularly by proponents of low-carbohydrate diets.8,9 However, limited evidence has been available to effectively evaluate other diets.10,11

Several recent trials compared low-carbohydrate vs traditional low-fat, high-carbohydrate weight-loss diets.12-16 A meta-analysis that pooled the results of these early trials concluded that low-carbohydrate, nonenergy-restricted diets were at least as effective as low-fat, high-carbohydrate diets in inducing weight loss for up to 1 year.17 However, most of these trials were limited by combinations of small sample sizes, high rates of attrition, short durations, or limited diet assessment.

For the A TO Z (Atkins, Traditional, Ornish, Zone) Weight Loss Study, we selected 4 diets3 popular and substantially different diets and 1 diet based on national guidelinesrepresenting a spectrum of carbohydrate intake: Atkins8 (very low in carbohydrate), Zone9 (low in carbohydrate), LEARN18 (Lifestyle, Exercise, Attitudes, Relationships, and Nutrition; low in fat, high in carbohydrate, based on national guidelines), and Ornish19 (very high in carbohydrate). The primary study objective was to examine the effects of diets and gradations of carbohydrate intake on weight loss and related metabolic variables in overweight and obese premenopausal women.

Participants were recruited from the local community, primarily through media advertisements. Premenopausal women aged 25 to 50 years were invited to enroll if their body mass index (calculated as weight in kilograms divided by height in meters squared) was 27 to 40, body weight was stable over the previous 2 months, and medications were stable for at least 3 months. Women were excluded if they self-reported hypertension (except for those whose blood pressure was stable using antihypertension medications); type 1 or 2 diabetes mellitus; heart, renal, or liver disease; cancer or active neoplasms; hyperthyroidism unless treated and under control; any medication use known to affect weight/energy expenditure; alcohol intake of at least 3 drinks/d; or pregnancy, lactation, no menstrual period in the previous 12 months, or plans to become pregnant within the next year. Race/ethnicity data were collected by self-report to be used for descriptive purposes and possible ancillary analyses of subgroups. All study participants provided written informed consent. The study was approved annually by the Stanford University Human Subjects Committee.

Participants were enrolled in 4 cohorts, with the first cohort starting in February 2003 and the last cohort starting in September 2004. Randomization was conducted in blocks of 24 (6 per treatment group) and occurred by having a blinded research technician select folded pieces of paper with group assignments from an opaque envelope. Participants were assigned 1 of 4 diet books: Dr Atkins' New Diet Revolution,8Enter the Zone,9The LEARN Manual for Weight Management,18 or Eat More, Weigh Less by Ornish.19

Each diet group attended 1-hour classes led by a registered dietitian once per week for 8 weeks and covered approximately one eighth of their respective books per class. The same dietitian taught all classes to all groups in all 4 cohorts and was rated by participants at the end of the 8-week sessions for enthusiasm and knowledge of the material (rating scale of 1-5, from strongly disagree to strongly agree, respectively). The LEARN program is intended to be a 16-week program and, therefore, the 8 weeks of guidance through this book reflected an accelerated time frame, which was necessary to match the time frame given for the other 3 diet groups. Efforts to maximize retention in the study included e-mail and telephone reminders for appointments, e-mail or telephone contact from staff between the 2- and 6-month and between the 6- and 12-month data collection points, and incentive payments of $25, $50, and $75 for completing the 2-, 6-, and 12-month data collection, respectively.

Each group received specific target goals according to the emphasis of the assigned diet. The Atkins group aimed for 20 g/d or less of carbohydrate for induction (usually 2-3 months) and 50 g/d or less of carbohydrate for the subsequent ongoing weight loss phase. The Zone group's primary emphasis was a 40%-30%-30% distribution of carbohydrate, protein, and fat, respectively. The LEARN group was instructed to follow a prudent diet that included 55% to 60% energy from carbohydrate and less than 10% energy from saturated fat, caloric restriction, increased exercise, and behavior modification strategies. The primary emphasis for the Ornish group was no more than 10% of energy from fat. Additional recommendations given for physical activity, nutritional supplements, and behavioral strategies were consistent with those presented in each diet book.8,9,18,19 The guidelines for the Zone and LEARN diets incorporated specific goals for energy restriction, while for the Atkins and Ornish diets, there were no specific energy restriction goals.

A range of behavior modification techniques were discussed during the 2-month classes. The Ornish and Zone books suggest some stimulus-control strategies but on the whole do not emphasize behavior modification, whereas both the Atkins and LEARN books suggest multiple strategies, such as relapse preparation and planning strategies and goal setting. Overall, the LEARN manual has the greatest emphasis on behavior modification strategies.

Process and Outcome Measures

All data were collected at baseline, 2, 6, and 12 months.

Diet and Physical Activity Data. Dietary intake data were collected by telephone-administered, 3-day, unannounced, 24-hour dietary recalls using Nutrition Data System for Research software, versions 4.05.33, 4.06.34, and 5.0.35 (Nutrition Coordinating Center, University of Minnesota, Minneapolis). Data collectors were trained and certified by the Nutrition Coordinating Center. The recalls occurred on 2 weekdays and 1 weekend day per time point, on nonconsecutive days whenever possible. Local foods not found in the comprehensive database were added to the database manually. A food amounts booklet was used to assist participants with portion size estimation. Energy expenditure was assessed using the well-established Stanford 7-day physical activity recall.20

Anthropometric Data. Height was measured to the nearest millimeter using a standard wall-mounted stadiometer. Body weight was measured to the nearest 0.1 kg on a calibrated clinical scale. Waist and hip circumference were measured to the nearest millimeter by standard procedures using a 150-cm anthropometric measuring tape.21 Whole-body fat (percentage of body mass) was determined by dual-energy x-ray absorptiometry using pencil-beam mode on the Hologic QDR-2000 (first 3 cohorts) and, later, the array mode on a Hologic QDR 4500 densitometer (last cohort) (Hologic Inc, Waltham, Mass).

Metabolic Measures. Blood samples were collected after a 10-hour or longer fast. Plasma total cholesterol and triglycerides (free glycerol blank subtracted) were measured enzymatically using Stanford Clinical Chemistry Laboratoryestablished methods.22,23 High-density lipoprotein cholesterol (HDL-C) was measured by liquid selective detergent followed by enzymatic determination of cholesterol.24 Low-density lipoprotein cholesterol (LDL-C) was calculated according to the methods described by Friedewald et al.25 Lipid assays were monitored by the Lipid Standardization Program of the Centers for Disease Control and Prevention and were consistently within specified limits (monthly coefficients of variation were all 3.1%). The nonHDL-C measure was defined as total cholesterol value minus HDL-C value.26 Total plasma insulin in serum was measured by radioimmunoassay.27 Blood glucose was measured using a modification of the glucose oxidase/peroxidase method.28,29

Resting blood pressure was measured 3 times at 2-minute intervals as described elsewhere30; the initial reading was discarded and the last 2 readings were averaged. Clinic and laboratory staff members were blinded to treatment assignment.

The primary objective was to test whether any of the 4 diets, representing a spectrum of carbohydrate intake, was more effective than any other in 12-month weight loss. The selected minimal clinically significant between-group difference in weight change was 2.7 kg (6 lb, approximately 3% for a 180-lb individual). Based on previous trials, we projected a 6.3-kg SD of weight change.31,32 The primary analysis was conducted applying intention-to-treat methods with baseline values carried forward for missing values. Thus, with 4 treatment groups and a projected 75 participants per group, the study was designed to have 80% power to detect a 2.7-kg difference for 12-month weight change between groups.

Dietary composition data (energy intake; percentage carbohydrate, fat, and protein; and grams of saturated fat and fiber) were analyzed using raw, unadjusted means (SDs) (ie, no imputation for missing data). Between-group differences in dietary intake at each time point were tested by analysis of variance (ANOVA). For weight and for all secondary outcome measures, analyses were conducted using all time points and all diets and were tested for diet grouptime (log time +1) interactions in a mixed model using autoregressive covariance structure (SAS version 9.1.3 with Service Pack 3, SAS Institute Inc, Cary, NC). Triglyceride data were log-transformed to attain normal distributions for testing; for ease of interpretation, values presented in the text and figures are untransformed.

Differences among diets for 12-month changes from baseline were tested by ANOVA. For statistically significant ANOVAs, all pairwise comparisons among the 4 diets were tested using the Tukey studentized range adjustment. Statistical testing of changes from baseline to 2 months and to 6 months using pairwise comparisons are presented for descriptive purposes.

For exploratory purposes, ancillary analyses were conducted to determine the effect of diet group assignment on secondary outcomes at 12 months after adjusting for changes in weight loss using linear regression. Also for exploratory purposes, all analyses of weight and secondary outcome measures were tested using only available data, without using baseline values carried forward for missing data or other imputation methods. There were no substantive differences in any of these findings compared with the analyses with baseline values carried forward and, therefore, only the primary analyses are presented. Multiple regression was used to examine potential interactions between race/ethnicity and diet group for effects on weight loss; there were no significant interactions. All statistical tests were 2-tailed using a significance level of .05.

Participant enrollment began in February 2003, and the study ended in October 2005. Figure 1 shows participant flow; Table 1 shows baseline characteristics.

In all 4 diet groups, 85% to 89% of participants attended at least 75% of their assigned classes (6 of 8). Attendance was not different by diet group (P=.68). Retention at 12 months was 88%, 77%, 76%, and 78% for the Atkins, Zone, LEARN, and Ornish groups, respectively, and was not significantly different among groups (P=.30). Participant ratings for class instructor enthusiasm and knowledge of material were very high for both among all diet groups and were not significantly different among groups; average scores ranged from 4.4 to 4.7 on a scale of 1 to 5, with 5 as the highest rating.

Dietary Intake and Energy Expenditure

Total energy intake was not different among diet groups at baseline or any subsequent time point (P>.40 for all) (Table 2). However, relative to baseline, there was a significant mean decrease in reported energy intake at all postrandomization time points (P<.001): 497 (SD, 496), 387 (SD, 498), and 351 (SD, 576) kcal/d at 2, 6, and 12 months, respectively, for all groups combined.

There were no significant group differences at baseline in percentage of energy from carbohydrate, fat, or protein or in grams of saturated fat or fiber, except for a borderline significant difference in percentage of energy from fat between Atkins and LEARN (P=.05) (Table 2). At subsequent time points the diets were statistically different in carbohydrate content, progressing from low to high across the Atkins, Zone, LEARN, and Ornish groups. This same pattern was observed for fiber intake. The reverse pattern, higher to lower intakes, was statistically significant for protein, fat, and saturated fat at all time points. Between-group differences in patterns of nutrient intake were largest at 2 months. At 12 months, the patterns of nutrient differences between groups were still present, but the magnitude of differences was diminished.

Total energy expenditure was slightly higher for the Ornish group vs the other 3 groups at baseline but was not significantly different among groups at any subsequent time point (Table 1). Relative to baseline, there was a modest and significant mean increase (P<.05) in energy expenditure at all time points for all groups combined: +0.5 (SD, 2.8), +0.4 (SD, 2.7), and +1.0 (SD, 3.0) kcal/kg per day at 2, 6, and 12 months, respectively.

Weight and Anthropometric Outcomes

Mean 12-month weight change was 4.7 kg (95% confidence interval [CI], 6.3 to 3.1 kg) for Atkins, 1.6 kg (95% CI, 2.8 to 0.4 kg) for Zone, 2.2 kg (95% CI, 3.6 to 0.8 kg) for LEARN, and 2.6 kg (95% CI, 3.8 to 1.3 kg) for Ornish and was significantly different for Atkins vs Zone (Figure 2). At the 2- and 6-month intermediate time points, the weight change for the Atkins group was significantly greater than for all other groups (P<.05). Weight change among the Zone, LEARN, and Ornish groups did not differ significantly at any time point. The pattern of changes in body mass index, percentage of body fat, and waist-hip ratio among groups paralleled the changes in weight, although the between-group differences at 12 months did not achieve statistical significance for percentage of body fat (P=.07) or waist-hip ratio (P=.10) (Table 3).

Results generated by 84% of the study population (n=262) with baseline blood samples (Atkins, n=70; Zone, n=65; LEARN, n=63; and Ornish, n=64) were available for testing. Four of the LDL-C values could not be calculated because of triglyceride concentrations greater than 400 mg/dL (4.52 mmol/L) and were treated as missing data. At all time points, the statistically significant findings for HDL-C and triglycerides concentrations favored the Atkins group (Table 3). Changes in LDL-C concentrations at 2 months favored the LEARN and Ornish diets over the Atkins diet; however, these differences diminished and were no longer significant at 6 and 12 months. Non-HDL-C differences among groups were not significant at any time point.

Insulin, Glucose, and Blood Pressure Outcomes

Insulin and glucose measurements were obtained from the same aforementioned 84% of the total sample for lipids. Neither the overall trajectory (ie, across all time points) nor the 12-month differences were significantly different among groups for either fasting insulin or fasting glucose concentrations (Table 3).

Parallel to the group changes in weight, the decrease in mean blood pressure levels was largest in the Atkins group at all time points. At 12 months, the decrease in systolic blood pressure was significantly greater for the Atkins group than for any other group. For diastolic pressure, the only significant pairwise difference at 12 months favored the Atkins over the Ornish group.

Ancillary Analyses of Diet Group Effects Independent of Changes in Weight

For the 249 participants who completed the full 12-month protocol, we examined the independent effect of diet group on secondary outcomes after adjusting for 12-month changes in weight using linear regression. Each of the statistically significant 12-month differences between diet groups (ie, triglycerides, HDL-C, and systolic and diastolic blood pressure; Table 3) remained statistically significant after including weight loss in the model; however, the level of significance was diminished.

Compared with women who were assigned to follow diets having higher carbohydrate content, women assigned to the diet with the lowest carbohydrate content had more weight loss and more favorable changes in related metabolic risk factors at 2 and 6 months. The finding of greater weight loss for the Atkins diet continued through 12 months, reaching statistical significance in comparison with the Zone diet. There were no significant differences in weight loss at any time point among the Zone, LEARN, and Ornish diets. Although the weight loss in the Atkins group was greater than that of other groups, the magnitude of weight loss was modest, with a mean 12-month weight loss of only 4.7 kg.

Many concerns have been expressed that low-carbohydrate weight-loss diets, high in total and saturated fat, will adversely affect blood lipid levels and cardiovascular risk.34-36 These concerns have not been substantiated in recent weight-loss diet trials. The recent trials, like the current study, have consistently reported that triglycerides, HDL-C, blood pressure, and measures of insulin resistance either were not significantly different or were more favorable for the very-low-carbohydrate groups.12-16

The exception to this pattern has been LDL-C concentrations. Two of the most consistent findings in recent trials of low-carbohydrate vs low-fat diets have been higher LDL-C concentrations and lower triglyceride concentrations in the low-carbohydrate diets.17 Although a higher LDL-C concentration would appear to be an adverse effect, this may not be the case under these study conditions. The triglyceride-lowering effect of a low-carbohydrate diet leads to an increase in LDL particle size, which is known to decrease LDL atherogenicity.37-39 In the current study, at 2 months, mean LDL-C concentrations increased by 2% and mean triglyceride concentrations decreased by 30% in the Atkins group. These findings are consistent with a beneficial increase in LDL particle size, although LDL particle size was not assessed in our study. In addition, we examined nonHDL-C concentrations as an alternate indicator of atherogenic lipoproteinsa variable not substantially influenced by changes in triglyceride concentrations26and observed no significant differences among groups at any time point.

Therefore, we interpret these findings to suggest that there were no adverse effects on the lipid variables for women following the Atkins diet compared with the other diets and, furthermore, no adverse effects were observed on any weight-related variable measured in this study at any time point for the Atkins group. Further examination of the dietary effects on lipid variables would benefit from analyses of lipoprotein particle subfractions and follow-up of longer than 12 months.

Our study and the study by Dansinger et al16 were similar in several design features, including similar number and types of treatment groups and the same duration. Despite the similarities in design, several conclusions differed between the trials. Dansinger et al reported that weight loss at 12 months did not differ by diet group but only by level of adherence, regardless of diet type. In addition, Dansinger et al reported improvements within groups over 12 months for cardiac risk factors but did not report any significant differences between groups. In contrast, we observed statistically significant differences among diet groups for both weight loss and risk factors at 12 months.

These differences are likely attributable to at least 2 factors. One factor concerns the different study populations: our study was restricted to women aged 20 to 50 years who did not have diabetes and were not taking medications for cardiac risk factors, whereas the population in the study by Dansinger et al was much broader in its inclusion criteria. A second likely factor was differences in statistical power; in the study by Dansinger et al, 93 of 160 enrolled participants completed the trial (42% attrition at 12 months; ie, n=21-26 per treatment group); in the current study, 248 of 311 women completed the trial (20% attrition; ie, n=58-68 per treatment group).

The current study examined whether risk factor responses to diets were independent of weight loss. After statistically adjusting for weight loss differentials among groups, the secondary outcome differences among groups at 12 months that were significant in the unadjusted model remained significant in the adjusted model, although the level of significance was diminished. This supports a combined effect of benefit for the very-low-carbohydrate Atkins diet attributable to both increased weight loss and dietary composition. However, our study was not designed to specifically address this ancillary question. Krauss et al38 recently addressed this issue directly in a study testing diets that ranged from low to high carbohydrate intake under conditions of weight stability followed by conditions of weight loss. Improvements in lipids and lipoproteins were greater for participants in the very-low-carbohydrate diet during the weight-stable phase but were greater for those in the high-carbohydrate diet after weight loss and restabilization; overall the low-carbohydrate and weight-loss effects were reported to be equivalent but not additive under the tightly controlled conditions of this study.

The 4 study diets used in our study differed significantly in composition beyond carbohydrate content. Protein, fat, and saturated fat followed a continuum across diets, inverse to carbohydrate content. In a series of recent weight-loss trials that substituted either protein for fat while holding carbohydrate constant40,41 or protein for carbohydrate while holding fat constant,38,42,43 the higher-protein diets led to improvements in weight loss, triglycerides, and HDL-C and increased satiety. In the OmniHeart study, under weight-stable conditions, blood pressurelowering benefits were observed for a high-protein relative to a high-carbohydrate diet.44 Therefore, the reported effects of the current study should be interpreted as resulting from the combination of macronutrient changes that occur when following low- vs high-carbohydrate diets, not just changes in carbohydrates alone. For example, greater satiety from the higher protein content of the Atkins diet may have contributed to the benefits observed for that group, although satiety was not assessed.

The amount of weight loss at 12 months relative to baseline among all groups was modest at 2% to 5%. However, even modest reductions in excess weight have clinically significant effects on risk factors such as triglycerides and blood pressure and, therefore, can have an important public health impact at the population level.4-6,45,46 Greater success with long-term weight loss is likely dependent on a number of factors beyond macronutrient composition, including improved behavioral strategies, longer-term structured guidance, greater emphasis on increasing energy expenditure (ie, regular physical activity), and addressing societal and environmental factors, such as portion sizes of restaurant meals.45,47-49

Strengths of the current study relative to previous trials include a larger sample size, a 12-month duration, lower attrition rates, the contrast of 4 rather than 2 diets differing in carbohydrate content, and the significant differences in macronutrient intake achieved by the diet groups. Although adherence to the 4 sets of dietary guidelines varied within each treatment group and waned over time, especially for the Atkins and Ornish diets, we believe that the adherence levels obtained are a fair representation of studying the diets and variations in macronutrient intake under realistic conditions and, therefore, increase the external validity of the findings. Other strengths include the extensive dietary assessment and the comprehensive health and risk factor data collected. The restriction of our study to premenopausal women allowed us to avoid possible interactions of effects with sex and menopausal status, but because of our focus on this population, generalizations of findings to other populations should be made with caution.

This study also has several limitations. Menstrual cycle timing was not taken into consideration for blood sampling for lipid analyses, which likely increased within-person variability and diminished the ability to detect between-group differences. Moreover, weight-loss trajectories for each group had not stabilized at 12 months; the trajectories of weight change between 6 and 12 months suggest that longer follow-up would likely have resulted in progressively diminished group differences. Other limitations included the lack of a valid and comparable assessment of individual adherence to the 4 different diets, the lack of data on whether participants had familiarity using any of the specific study diets prior to enrolling in the trial, and the lack of assessment of satiety.

In this study of overweight and obese premenopausal women, those assigned to follow the Atkins diet had more weight loss and more favorable outcomes for metabolic effects at 1 year than women assigned to the Zone, Ornish, or LEARN diets. Concerns about adverse metabolic effects of the Atkins diet were not substantiated within the 12-month study period. It could not be determined whether the benefits were attributable specifically to the low carbohydrate intake vs other aspects of the diet (eg, high protein intake).

While questions remain about long-term effects and mechanisms, these findings have important implications for clinical practice and health care policy. Physicians whose patients initiate a low-carbohydrate diet can be reassured that weight loss is likely to be at least as large as for any other dietary pattern and that the lipid effects are unlikely to be of immediate concern. As with any diet, physicians should caution patients that long-term success requires permanent alterations in energy intake and energy expenditure, regardless of macronutrient content.

Corresponding Author: Christopher D. Gardner, PhD, Hoover Pavilion, N229, 211 Quarry Rd, Stanford, CA 94305-5705 (cgardner@stanford.edu).

Author Contributions: Drs Gardner and Balise had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Gardner, Kraemer, King.

Acquisition of data: Gardner.

Analysis and interpretation of data: Gardner, Kiazand, Alhassan, Kim, Stafford, Balise, Kraemer, King.

Drafting of the manuscript: Gardner, Kiazand, Balise, Kraemer, King.

Critical revision of the manuscript for important intellectual content: Gardner, Kiazand, Alhassan, Kim, Stafford, Kraemer, King.

Statistical analysis: Gardner, Alhassan, Stafford, Balise, Kraemer.

Obtained funding: Gardner, King.

Administrative, technical, or material support: Kiazand.

Study supervision: Gardner.

Financial Disclosures: None reported.

Funding/Support: This investigation was supported by National Institutes of Health grant R21AT1098, by a grant from the Community Foundation of Southeastern Michigan, and by Human Health Service grant M01-RR00070, General Clinical Research Centers, National Center for Research Resources, National Institutes of Health.

Role of the Sponsor: None of the funding agencies played any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the manuscript.

Acknowledgment: We gratefully acknowledge the work of the study staff who worked with participants in recruitment, intervention, and data collection, including Rise Cherin, MS, RD, Kathryn Newell, MS, Suzanne Olson, MS, Jennifer Morris, PhD, Jane Borchers, MS, RD, Laurie Ausserer, MS, Ellen DiNucci, MA, Kelly Boyington, Jana Stone, Andrea Vaccarella, RD, Noel Segali, RD, and Gretchen George, MS, RD, all of Stanford University, as well as the staff of the Stanford University Hospital General Clinical Research Center.

AtkinsR.Dr Atkins' New Diet Revolution.New York, NY: Harper Collins; 2002

SearsB, LawrenW.Enter the Zone.New York, NY: Harper Collins; 1995

BrownellKD.The LEARN Manual for Weight Management.Dallas, Tex: American Health Publishing Co; 2000

OrnishD.Eat More, Weigh Less.New York, NY: Harper Collins; 2001

American College of Sports Medicine.Physical Fitness Testing and Interpretation.Philadelphia, Pa: Williams & Wilkins; 2000

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Journals - JAMA

At the heart of our program is a multidisciplinary approach to help our patients achieve successful long-term weight loss. Our team of endocrinologists, dietitians, social workers, psychologists, psychiatrists, nurses and surgeons work alongside patients to create a personal weight loss plan. This collaboration helps patients maintain weight-loss results and achieve long-term improvements for metabolic disorders.

The program is led by world-renowned surgeons who have published more than 350 papers and book chapters. Our team focuses on the evaluation and treatment of severe morbid obesity and the complications associated with conditions such as Type 2 diabetes, hypertension, degenerative disc disease, sleep apnea and hyperlipidemia.

The reputation of our program has earned us numerous accolades, including being named a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Accredited Comprehensive Center and receiving the Center of Excellence distinction from Blue Cross-Blue Shield, Cigna, Aetna and Health Net, among others. Ours is one of the few programs in Southern California to have received the highest ratings from national independent health-care rating organizations based on quality and outcomes.

As an academic medical center, we take care to be clear with our patients about the costs for our services. Our patient navigators work with patients to help them fully understand their financial options and the requirements of their insurance carriers.

Unlike other bariatric surgery offerings that charge patients a program fee in addition to surgical fees to cover the nutritional, medical, and psychiatric care required for successful long-term weight loss, there is no additional or hidden cost for the support of our multidisciplinary team.

Successful weight loss surgery involves far more than the surgeons exceptional skill. It requires changes in diet and lifestyle and even changes in the way patients think about themselves, who they can be, and what they can achieve.

One of the reasons Keck Medicine of USCs metabolic and bariatric surgery program has achieved recognition as a Center of Excellence is the emphasis the entire team places on patient education, support and empowerment. USC Bariatric Surgery Program patients can see Keck Medicine surgeons at both Keck Hospital of USC in Los Angeles and USC Verdugo Hills Hospital in La Caada.

The program starts out well before any surgical consultation by ensuring that every potential patient has the information he or she needs to make the best possible decisions. All prospective patients must attend a free seminar hosted by USC physicians to make sure they fully understand their surgical and non-surgical weight loss options. Attendees are able to ask questions and hear directly about the experiences of successful patients from the challenges to the triumphs.

These free seminars are held in two locations for the convenience of the prospective patients, at the Pasadena Hilton and at Keck Hospital. A full schedule can be viewed here.

Bariatric surgery patients face more than the physical challenges of getting back into action after a procedure. There are the emotional challenges of establishing and committing to new habits and the social challenges of friends or family members reacting in surprising ways to new achievements. Our surgeons, nurses, social workers and dietitians create a unique health plan for each patient. Keck Medicine also offers a monthly support group so patients can talk about their concerns and triumphs with people who understand exactly what theyre going through.

We have performed several thousand procedures with best outcomes and no mortalities following laparoscopic gastric bypass procedures.

Patient I: Before and After

Recent published data in the New England Journal of Medicine (1,2) has shown that weight-loss surgeries, in particular laparoscopic gastric bypass and sleeve procedures, are more effective than medical therapies in the treatment of Type 2 diabetes in the morbidly obese patient. In certain cases where the diabetes has been recently diagnosed, it is possible to discontinue all medications after successful surgery.

Ref: 1-N Engl J Med 2012; 366:1577-15852-N Engl J Med 2012; 366:1567-1576

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USC Bariatric Surgery/Weight Loss Management Center | A ...

Lifestyle changes can help people with obesity lose weight. These interventions result in only 5-10% weight loss after six months. Also, about one-third of individuals will not respond to lifestyle changes. Many people regain the weight that was once lost. Weight-loss drugs can be an interesting strategy for obese people having difficulty losing weight.

Phentermine is a weight-loss drug that suppresses the appetite. The United States Food and Drug Administration (FDA) approved phentermine as a weight-loss drug almost 60 years ago. Most studies on phentermine for weight-loss have limited treatment durations to less than 12 weeks. Concerns regarding the safety of long-term phentermine treatment have limited the use of this weight-loss drug to only a few weeks.

Researchers from the Department of Epidemiology and Prevention at the Wake Forest School of Medicine in North Carolina designed a study to compare short-term and long-term use of phentermine. The primary focus of the study was the difference in weight loss and cardiovascular disease and death rates in the short-term and long-term treatment groups. The results of the study were published in Obesity.

Researchers formed four groups of patients. The first two groups included people taking phentermine continuously. The short-term use group used phentermine continuously for 16 weeks or less. The long-term group took phentermine for more than 365 consecutive days.

Two other groups of patients were created to capture data from people taking phentermine intermittently. One group included individuals with two or more episodes of phentermine therapy in which neither episode lasted more than 16 weeks. This was the short-term intermittent group. The last group included individuals with two or more episodes of taking phentermine, but at least one episode was longer than 16 weeks. The last group was named medium-term intermittent.

The results of this study demonstrate that long-term treatment with phentermine was associated with greater weight loss. At six, 12, and 24 months after starting phentermine weight loss was greater in the long-term, short-term intermittent, and medium-term intermittent groups compared with the FDA approved short-term therapy group.

The amount of weight loss in each group varied at each follow-up time. At six months, the short-term intermittent group lost more weight than the short-term continuous group. However, the medium-term intermittent group lost more weight than all other groups at the 6-month and 12-month follow-up time. After two years from starting the weight-loss drug, the long-term continuous group experienced the greatest weight loss among the other groups.

The safety of taking this drug for longer treatment periods was also evaluated. The most significant concern about using phentermine for more than three months was the risk of cardiovascular side effects and death.

A slight increase in heart rate was observed among phentermine users, but heart rates went back to normal after stopping the weight-loss drug. Systolic blood pressure was actually lower in individuals using phentermine for long-term treatment. This might be explained by the effect of losing weight on blood pressure and not the weight-loss drug itself. The researchers also did not notice any increase in cardiovascular disease risk or any increase in death rates among long-term phentermine users.

Several limitations of this study require consideration. First of all, the researchers did not note any other health care provider interventions for weight loss. There is no way for the researchers to know if long-term users of phentermine were also involved in other programs that could contribute to weight loss. Also, the group of long-term continuous phentermine users was small compared with the other groups. Further studies are required to test the safety and efficacy of phentermine in a larger group of people and for longer treatment times.

Many people are searching for a safe weight-loss drug that results in permanent weight loss. Despite the obvious limitations in this study, phentermine seems to be safe and effective when used for treatment times that surpass three months. Over the longer follow-up time, there was greater weight loss without increases in cardiovascular disease risk or death. Although further studies are required to confirm these long-term results, phentermine seems to be a reasonable option for people with low cardiovascular disease risk.

Written by Jessica Caporuscio, PharmD

References:

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Long-term use of weight-loss drug may be safe and ...

I have always loved FOOD! The sweeter it is, the more I like it! Over the years, I have tried to lose weight by tying things here and there; working out as much as I could as well. The final straw came just before the Christmas holiday. I looked like a big, fat mess!

Every week that I would walk in to the Peabody office, I felt like a celebrity! I was always greeted by smiles from everybody! It began to be my favorite part of the week. They were all so profession, and yet, so friendly. Every week they had wisdom on how to get through week by week. I couldnt have done what I have done without each of them.

The diet itself is not all that difficult. For me, I started feeling better and having more energy after week 2. With the help of that new energy feeling, that made each week easier and easier to get through. At one time, I thought exercise was the only way to lose poundage. NOT TRUE FOLKS! It is all about nutrition!

On my first weigh-in, I came in at a disgusting 231lbs. Today, my final weigh-in, I was 190. I have lost 41lbs in 10 weeks! Folks, if I can do this, anybody can!!! I mean that from the bottom of my heart! You will feel better, certainly look better and I love all the compliments from my family and peers! Thank You Awaken 180 and Kathryn, Catherin, Elazabeth and Ramon for changing my life around. I look forward to seeing you guys in the Maintenance section of your sensational program. Even though I have not met you; but Thanks to Awaken 180 creator, Paige, for creating this wonderful diet plan that REALLY works!

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Massachusetts' Weight Loss Program

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Soma Spray For Long Term Weight Loss | HGH.com

Exercise is insurance for long term weight lossI cant even begin to tell you how many times I tell this to my clients. So many people seek my advice for exercise and weight loss and although exercise in and of itself may not facilitate significant weight loss, it is paramount to long term weight loss and weight management. I remember speaking at a weight loss surgery retreat this past year and before I began I went around the room and had each participant introduce themselves, explain where they were at with their weight loss journey, and tell me their current exercise habits. This was a small group of about nine weight loss surgery patients, but as they revealed their storiesevery single person who had not adopted a consistent exercise program had regained a substantial amount of their weight and every patient that was exercising regularly kept their weight off. No real surprise to me and when I pointed out that fact to the group; well, lets just say it proved my point. What a great way to start a talk about exercise and weight lossup front confirmation that this exercise stuff really works!

Ive witnessed both the weight regain and weight loss in thousands of clients over the years and every time, the regularity of exercise literally weighs in on which direction a client will landweight loss, weight management, or weight gain. And this is why I just completed my second book about exercise and weight loss. My newest book, Bariatric Fitness For Your New Life, gives you a functional approach with easy to follow instructions and step-by-step photos that will inform, educate, and outline functional exercise programs. It is a post-surgery program of mental coaching, mobility work, strength training, and fat-burning cardio routines. Bariatric surgery is a highly effective way to take control of your weight, but its only one part of the solution. A sound exercise program combined with healthy nutrition that is individualized for your current health and fitness level are key components to long term success. Bariatric Fitness For Your New Life will give you the tools you need for success! My first book, Rx Fitness for Weight Loss The Medically Sound Solution to Get Fit and Save Your Life, is geared to inform, educate and provide medically sound exercise guidance and motivation for the overweight and obese client who has always struggled with fitness specific to weight loss. Both of my books will encourage and instruct every person no matter what fitness level to thoroughly understand how to exercise, injury free, in order to maximize long-term weight loss and improved overall health. They also include real client testimonials and realistic fitness models that will encourage and motivate you to continue down your path of success.

Julias books can be ordered here:Bariatric Fitness for Your New LifeRx Fitness for Weight Loss

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Exercise & Long Term Weight Loss Walk from Obesity

Weight loss: 6 strategies for success

Follow these proven strategies to reduce your weight and boost your health.

Hundreds of fad diets, weight-loss programs and outright scams promise quick and easy weight loss. However, the foundation of successful weight loss remains a healthy, calorie-controlled diet combined with increased physical activity. For successful, long-term weight loss, you must make permanent changes in your lifestyle and health habits.

How do you make those permanent changes? Consider following these six strategies for weight-loss success.

Long-term weight loss takes time and effort and a long-term commitment. Make sure that you're ready to make permanent changes and that you do so for the right reasons.

To stay committed to your weight loss, you need to be focused. It takes a lot of mental and physical energy to change your habits.

So as you're planning new weight-loss-related lifestyle changes, make a plan to address other stresses in your life first, such as financial problems or relationship conflicts. While these stresses may never go away completely, managing them better should improve your ability to focus on achieving a healthier lifestyle. Once you're ready to launch your weight-loss plan, set a start date and then start.

No one else can make you lose weight. You must undertake diet and exercise changes to please yourself. What's going to give you the burning drive to stick to your weight-loss plan?

Make a list of what's important to you to help stay motivated and focused, whether it's an upcoming beach vacation or better overall health. Then find a way to make sure that you can call on your motivational factors during moments of temptation. Perhaps you want to post an encouraging note to yourself on the pantry door, for instance.

While you have to take responsibility for your own behavior for successful weight loss, it helps to have support of the right kind. Pick people to support you who will encourage you in positive ways, without shame, embarrassment or sabotage.

Ideally, find people who will listen to your concerns and feelings, spend time exercising with you or creating healthy menus, and who will share the priority you've placed on developing a healthier lifestyle. Your support group can also offer accountability, which can be a strong motivation to stick to your weight-loss goals.

If you prefer to keep your weight-loss plans private, be accountable to yourself by having regular weigh-ins, recording your diet and exercise progress in a journal, or tracking your progress using digital tools.

It may seem obvious to set realistic weight-loss goals. But do you really know what's realistic? Over the long term, it's best to aim for losing 1 to 2 pounds (0.5 to 1 kilogram) a week. Generally to lose 1 to 2 pounds a week, you need to burn 500 to 1,000 calories more than you consume each day, through a lower calorie diet and regular physical activity.

Depending on your weight, 5 percent of your current weight may be a realistic goal. Even this level of weight loss can help lower your risk for chronic health problems, such as heart disease and type 2 diabetes. If you're 180 pounds (82 kilograms), that's 9 pounds (4 kilograms).

When you're setting goals, think about both process and outcome goals. "Walk every day for 30 minutes" is an example of a process goal. "Lose 10 pounds" is an example of an outcome goal. It isn't essential that you have an outcome goal, but you should set process goals because changing your habits is a key to weight loss.

Adopting a new eating style that promotes weight loss must include lowering your total calorie intake. But decreasing calories need not mean giving up taste, satisfaction or even ease of meal preparation.

One way you can lower your calorie intake is by eating more plant-based foods fruits, vegetables and whole grains. Strive for variety to help you achieve your goals without giving up taste or nutrition.

Get your weight loss started with these tips:

While you can lose weight without exercise, regular physical activity plus calorie restriction can help give you the weight-loss edge. Exercise can help burn off the excess calories you can't cut through diet alone.

Exercise also offers numerous health benefits, including boosting your mood, strengthening your cardiovascular system and reducing your blood pressure. Exercise can also help in maintaining weight loss. Studies show that people who maintain their weight loss over the long term get regular physical activity.

How many calories you burn depends on the frequency, duration and intensity of your activities. One of the best ways to lose body fat is through steady aerobic exercise such as brisk walking for at least 30 minutes most days of the week. Some people may require more physical activity than this to lose weight and maintain that weight loss.

Any extra movement helps burn calories. Think about ways you can increase your physical activity throughout the day if you can't fit in formal exercise on a given day. For example, make several trips up and down stairs instead of using the elevator, or park at the far end of the lot when shopping.

It's not enough to eat healthy foods and exercise for only a few weeks or even months if you want long-term, successful weight loss. These habits must become a way of life. Lifestyle changes start with taking an honest look at your eating patterns and daily routine.

After assessing your personal challenges to weight loss, try working out a strategy to gradually change habits and attitudes that have sabotaged your past efforts. And you have to move beyond simply recognizing your challenges you have to plan for how you'll deal with them if you're going to succeed in losing weight once and for all.

You likely will have an occasional setback. But instead of giving up entirely after a setback, simply start fresh the next day. Remember that you're planning to change your life. It won't happen all at once. Stick to your healthy lifestyle and the results will be worth it.

.

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Weight loss: 6 strategies for success - Mayo Clinic

Name: Tami MarinoAge: 51Height: 54 (163 cm)Highest weight: 305 lbs (139 kg)Current weight: 144 lbs (65 kg)Lowest weight: 133 lbs (61 kg)

How do you maintain a weight loss long-term on a keto low-carb diet? Tami Marino has a no excuses approach, which clearly works extremely well for her.

Indeed, this attitude helped her lose 170 pounds (77 kg) during perimenopause a period of hormonal fluctuation that often involves weight gain.

However, for decades her life was consumed by yo-yo dieting, food addiction, and bingeing.

I first became overweight during puberty and got up to 250 pounds (114 kg) in my teens. It was a really tough time, Tami remembers. My mom was always overweight and really concerned about my weight. Shed buy certain foods for my sister, who never had a weight problem, but they were off limits for me. I definitely felt a lot of pressure to lose weight. My grandparents would always say, If you would just lose weight, Ill take you shopping or Ill get you whatever you want if you just lose weight. And that made things very uncomfortable, and its probably what led me to start eating in secret.

She struggled with her weight throughout her teens and into adulthood. Although shed lose weight by following Weight Watchers or starvation diets, she always gained it back.

Although she didnt develop gestational diabetes with any of her three pregnancies, when she was 40, Tami was diagnosed with type 2 diabetes. At the time her HbA1c was 9.4%, which reflects an estimated average blood sugar level of 223 mg/dL (12.4 mmol/L).

Her A1c continued to climb over the next several years, despite doing everything she was told to do, which included taking larger dosages of diabetes medications and following low-fat dietary recommendations. In addition, she developed fatty liver, high blood pressure, and severe depression.

Then in May of 2014, everything changed following a visit to her doctors office.

Id been on metformin and glipizide for a while, and Id also started taking Victoza injections a couple of times within the past month. I was really scared about taking that last medication because of some things Id read about it. I remember my doctor telling me not to test my blood sugar at home, but I would test anyway. And even with all those meds, my blood sugar was still in the 300s mg/dl (16.7 mmol/L) and even in the 400s mg/dl (22.2 mmol/L) sometimes, she recalls.

Then I heard the doctor say, Along with the meds youre already taking, youre going to need to take insulin. And that absolutely petrified me, remembers Tami.

Unwilling to accept that she was destined to take multiple medications and insulin for the rest of her life, she began doing her own research online. She found a Facebook group called Type 2 Rebels and began to realize there might be a way to improve her blood sugar control and potentially even reverse her disease. It was in this group that she learned about the work of Dr. Richard K. Bernstein, a doctor with type 1 diabetes who follows and recommends a very low-carb diet for all types of diabetes.

I read his book Diabetes Solution, and although it made a lot of sense, I didnt start following it immediately, Tami admits. It was just completely different than what Id heard from my doctor and what Id been told for years about nutrition, which was to eat low fat, lots of whole grains, and things like that.

Although it took her about a month to fully embrace the concept of a very low-carb lifestyle, once she did, the results were dramatic and life changing.

I felt so much better, was less hungry, less depressed. It was amazing.

Whats more, she achieved her lowest weight of 133 pounds (61 kg) in May of 2016 and has maintained that loss within 11 pounds for the past 17 months.

Although exercise has become an integral part of her life in maintenance, Tami didnt do much physical activity during her weight loss journey.

I really didnt exercise while I was losing weight, but I became more mobile. I had more energy and could move around a lot more easily, she says.

The powerful changes in her blood sugar, weight and overall health help motivate her to remain low carb at all times. However, she has had several challenges over the past several months.

Im now in menopause, which has been more of a struggle than I ever expected, says Tami. The hormone changes often lead to hunger and trigger binge-eating behaviors. I still eat only low-carb foods, but I sometimes eat too much. Im not perfect, but I do the best I can.

Additionally, a few financial setbacks have led to more limited food choices.

I try to focus on less expensive low-carb options like eggs, canned fish, and chicken. I really cant afford to have some of the foods I love very often, like steak and bacon. Those are like treats for me. But I wont ever eat high-carb foods like rice or pasta, no matter how cheap they are. Staying low carb is my priority,she states, confidently.

No matter what is going on in her life, Tami maintains her characteristic no excuses attitude. In fact, its a hashtag she uses on social media on a regular basis.

Years ago, I would have given up and gone back to where I started. But now I just wont do that. No excuses allowed.

Although she rarely tracks her food intake, Tami believes she stays below 20 grams of net carb per day as a rule. Except when I eat almond butter, she laughs. Thats a tough food for me to consume in moderation, so I try to stay away from it most of the time.

Breakfast (8:00 am):Black coffee

Lunch (2:00-3:00 pm):Hard-boiled eggs, avocado, flaxseed, pickles, salad

Dinner (6:00 pm):Chicken or bunless burgers, vegetables or salad with olive oil or bleu cheese dressing

Snack (8:00-9:00 pm):Sardines, salad, nuts

I actually dont add much fat to my meals, she says. I cook veggies in a little olive oil or coconut oil, and I like bleu cheese dressing on a bacon cheeseburger sometimes.

Treats are few and far between. Ill sometimes have almond butter or other nut butters when theyre on sale. I also like Quest bars because they dont spike my blood sugar and theyre portion controlled, which really helps, says Tami. And once in a great while Ill make a low-carb treat to bring to a holiday party. But overall, I try to keep things as simple as possible and really not focus on food too much because of my food addiction, she says.

In addition, she maintains the same no excuses attitude about exercise, which she finds extremely beneficial for mental, physical and emotional health.

I work out 5-6 times a week, aiming for 6 whenever possible, she says. I prefer to do it first thing in the morning after having coffee. I walk on the treadmill for about an hour on the highest incline. Sometimes Ill do a core class that has some cardio. Ive tried yoga and Zumba, but I dont like classes too much. Ive figured out that I really like doing things at my own pace.

And her favorite form of exercise?

Oh, I absolutely love resistance training, Tami says, enthusiastically. I do at least an hour and lately often closer to two hours because I recently increased my reps. I cant do free weights because I have a hernia, but I do leg presses, incline presses. I also have a good support system at the gym as far as the people who work there and friends I see there. On days I cant get to the gym, Ill do planks on the floor at home or get out and walk as much as I can. No matter what, I get some kind of physical activity in every day.

Here are Tamis tips for maintaining a no excuses attitude:

You can follow Tami on her Instagram account, @tamislowcarblife.

Franziska Spritzler, RD

For more tips on losing weight long term, have a look at one of these guides:

Top 10 tips to lose weight on low carb for women 40+

How to lose weight

Sign up for the free 2-week keto low-carb challenge!

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