Prevalence and Predictors of Weight-Loss Maintenance in a Biracial Cohort

Results from the Coronary Artery Risk Development in Young Adults Study

      Background

      Few population-based studies have examined the behavioral and psychosocial predictors of long-term weight-loss maintenance.

      Purpose

      The goal of this study was to determine the prevalence and predictors of weight-loss maintenance in a biracial cohort of younger adults.

      Methods

      This study examined a population-based sample of overweight/obese African-American and white men and women who had ≥5% weight loss between 1995 and 2000. Subsequent changes in weight, physical activity, and behavioral and psychosocial factors were examined between 2000 and 2005. Analyses were conducted in 2008–2009.

      Results

      Among the 1869 overweight/obese individuals without major disease in 1995, a total of 536 (29%) lost ≥5% between 1995 and 2000. Among those who lost weight, 34% (n=180) maintained at least 75% of their weight loss between 2000 and 2005, whereas 66% subsequently regained. Higher odds of successful weight-loss maintenance were related to African-American race (OR=1.7, p=0.03); smoking (OR=3.4, p=0.0001); history of diabetes (OR=2.2, p=0.04); increases in moderate physical activity between 2000 and 2005 (OR=1.4, p=0.005); increases in emotional support over the same period (OR=1.6, p=0.01); and less sugar-sweetened soft drink consumption in 2005 (OR=0.8, p=0.006).

      Conclusions

      One third of overweight men and women who lost weight were able to maintain 75% or more of their weight loss over 5 years. Interventions to promote weight-loss maintenance may benefit from targeting increased physical activity and emotional support and decreased sugar-sweetened soft drink consumption.

      Introduction

      Given the importance of obesity as a public health problem, it is surprising how little is known about the prevalence and predictors of long-term weight-loss maintenance. Weight-loss trials have shown that most patients regain weight after treatment termination,
      • Franz M.J.
      • VanWormer J.J.
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      • et al.
      Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up.
      but the average individual who continues to participate in a clinical trial maintains a weight loss of about 3% of initial body weight for up to 5 years after treatment.
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      Analyses
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      Relationship of a large weight loss to long-term weight change among young and middle-aged U.S. women.
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      Dietary practices, dining out behavior, and physical activity correlates of weight loss maintenance.
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      examining predictors of treatment outcomes have identified some behaviors that appear to improve success, including continued consumption of a low-calorie, low-fat diet; increased physical activity; and self-monitoring. Psychosocial correlates of better weight-loss maintenance also have been recognized,
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      Gender differences related to weight history, eating patterns, efficacy expectations, self-esteem, and weight loss among participants in a weight reduction program.
      • McGuire M.T.
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      What predicts weight regain among a group of successful weight losers?.
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      A descriptive study of weight loss maintenance: 6 and 15 year follow-up of initially overweight adults.
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      Mediators of weight loss and weight loss maintenance in middle-aged women.
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      Reductions in internal disinhibition during weight loss predict better weight loss maintenance.
      including lower levels of depressive symptoms, stress, and disinhibition and higher levels of restraint and self-efficacy.
      Much of the clinical trial literature, however, has been limited by short-term follow-up (2 years or less); small sample sizes; high drop-out rates; and lack of intent-to-treat analyses. Moreover, clinical trials have generally evaluated specific short-term treatment approaches in individuals attending weekly weight-loss programs. Individuals who seek assistance for weight loss tend to be heavier,
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      Weight control practices of U.S. adults trying to lose weight.
      have more medical problems,
      • Jeffery R.W.
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      • Forster J.L.
      Prevalence of dieting among working men and women: the Healthy Worker Project.
      • Jeffery R.W.
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      • et al.
      Prevalence of overweight and weight loss behavior in a metropolitan adult population: the Minnesota Heart Survey experience.
      and have higher percentages of binge eating
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      than individuals in the general population. Because the individuals who attend clinical weight-loss treatments may be more difficult to treat, and clinical trials have generally evaluated specific short-term treatment methods (e.g., meal replacements, pharmacotherapy, very low–calorie diets),
      • Franz M.J.
      • VanWormer J.J.
      • Crain A.L.
      • et al.
      Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up.
      the results from such programs may not represent the true prevalence or typical methods for weight-loss maintenance in the general population. Moreover, although cohort studies of larger samples (n>5000) of successful weight losers exist (e.g., the National Weight Control Registry
      • Wing R.R.
      • Phelan S.
      Long-term weight loss maintenance.
      ), these data are based on self-selected samples, and include primarily women, whites, and educated individuals; thus, the findings may not generalize to the population at large.
      Only a few empirical studies have attempted to estimate the prevalence of long-term weight-loss maintenance in the general U.S. population. Prevalence estimates of successful maintenance after weight loss have ranged from 58.9% in the National Health and Nutrition Examination Survey (NHANES, 1999–2002)
      • Weiss E.C.
      • Galuska D.A.
      • Kettel Khan L.
      • Gillespie C.
      • Serdula M.K.
      Weight regain in U.S. adults who experienced substantial weight loss, 1999–2002.
      ; 47% in a random-digit-dial survey
      • McGuire M.T.
      • Wing R.R.
      • Klem M.L.
      • Hill J.O.
      Behavioral strategies of individuals who have maintained long-term weight losses.
      ; and 20% in the Nurses Health Study.
      • Field A.E.
      • Wing R.R.
      • Manson J.E.
      • Spiegelman D.L.
      • Willett W.C.
      Relationship of a large weight loss to long-term weight change among young and middle-aged U.S. women.
      Overall, these studies suggest that sustaining weight loss may be possible for a substantial subset of the general population. However, existing population-based studies have been based on self-reported weights and included a limited array of behavioral and psychosocial measures. Clearly, to better understand the prevalence and predictors of long-term weight control, further research is needed in both men and women that includes more diverse samples, measured weights, multiple follow-ups, and comprehensive assessments.
      The Coronary Artery Risk Development in Young Adults (CARDIA) Study enrolled more than 5000 African-American and white women and men, aged 18–30 years, in 1985–1986 and has followed the cohort for more than 20 years, recording serial measurements of weight and behavioral and psychosocial factors. Prior research in CARDIA has examined predictors of weight loss over 2 years of follow-up.
      • Bild D.E.
      • Sholinksy P.
      • Smith D.E.
      • Lewis C.E.
      • Hardin J.M.
      • Burke G.L.
      Correlates and predictors of weight loss in young adults: the CARDIA study.
      Weight loss generally was associated with greater baseline fatness, lower baseline physical fitness level, self-perception of being overweight, dieting, and previous weight loss and regain. Other CARDIA papers have examined predictors of weight increases over time. In these studies, limited physical activity,
      • Lewis C.
      • Smith D.
      • Wallace D.
      • Williams O.D.
      • Bild D.
      • Jacobs D.R.
      Seven-year trends in body weight and associations with lifestyle and behavioral characteristics in black and white young adults: the CARDIA study.
      • Gordon-Larsen P.
      • Hou N.
      • Sidney S.
      • et al.
      Fifteen-year longitudinal trends in walking patterns and their impact on weight change.
      greater fast-food consumption
      • Pereira M.A.
      • Kartashov A.B.
      • Ebbeline C.B.
      • et al.
      Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis.
      and less dissatisfaction with body size
      • Lynch E.
      • Liu K.
      • Wei G.S.
      • Spring B.
      • Kiefe C.
      • Greenland P.
      The relation between body size perception and change in body mass index over 13 years: the Coronary Artery Risk Development in Young Adults (CARDIA) study.
      were identified as significant predictors of weight gain.
      The purpose of the present study was to determine the prevalence of successful weight loss and maintenance in the CARDIA cohort and to identify the strongest demographic, behavioral, and psychosocial predictors of 5-year weight-loss maintenance. It was hypothesized that among individuals who had lost 5% or more of their body weight, those with higher levels of physical activity; better dietary intake (e.g., fewer sugar-sweetened beverages, less fast-food consumption); and less depressive symptoms would be most likely to maintain at least 75% of their weight loss over 5 years of follow-up.

      Methods

      Sample

      The CARDIA study is a multicenter, longitudinal study of the development and determinants of cardiovascular disease over time among African-American and white adult men and women. The first CARDIA examination took place in 1985–1986 and included 5115 women and men. Sampling was designed to achieve balanced representation among white and African-American men and women; age groups (18–30 years); and education levels. Subsequent to baseline, the cohort was reexamined at Years 2, 5, 7, 10, 15, and 20 (spanning 1987–2005). All examinations were approved by IRBs at each institution. Details of the study design have been published elsewhere.
      • Hughes G.H.
      • Cutter G.
      • Donahue R.
      • et al.
      Recruitment in the Coronary Artery Disease Risk Development in Young Adults (Cardia) study.
      To be included in the current study, participants had to have been overweight or obese (BMI ≥25) and without self-reported major disease in 1995. Of the 3950 participants who were assessed in 1995, a total of 2432 were overweight/obese; of these, 14 were eliminated because of pregnancy between 1995 and 2005 and 549 were eliminated because of a reported illness that potentially could have caused involuntary weight loss over the same time span, including one or more of the following: kidney failure (n=14); cirrhosis (n=1); cancers (n=68); hyperthyroidism (n=32); digestive diseases (n=86); tuberculosis in past year (n=84); HIV (n=11); and/or any reported medical problems interfering with exercise (n=402; predominantly reflecting recent injuries, surgeries, or chronic pain). The remaining 1869 made up the final sample in the current study.
      The weight loss of these 1869 participants was examined between 1995 and 2000 and then weight-loss maintenance between 2000 and 2005 (note that in the current study, calendar years [i.e., 2000, 2005] are used rather than CARDIA assessment years [i.e., Year 15, Year 20] to refer to study time points).
      Overall retention for the 1995, 2000, and 2005 examinations was 78.5%, 74%, and 72% of surviving participants, respectively (approximately 2.5% were deceased as of the 2000 examination and 3.4% in 2005).
      • Pletcher M.J.
      • Bibbins-Domingo K.
      • Lewis C.E.
      • et al.
      Prehypertension during young adulthood and coronary calcium later in life.
      • Pereira M.A.
      • Kartashov A.I.
      • Ebbeling C.B.
      • et al.
      Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis.
      Whites, nonsmokers, more educated participants, and slightly older participants were more likely to return for these exams than African Americans, smokers, those with less education, and younger participants.

      Lewis C. Predictors of weight outcomes, dietary behaviors, and physical activity in coronary artery risk development in young adults (CARDIA). Paper presented at Predictors of Obesity, Weight Gain, Diet and Physical Activity Workshop; 2004; Bethesda MD.

      There was no significant relationship with BMI and exam retention.

      Measures

      As the main purpose of the present study was to examine variables associated with weight-loss maintenance versus regain, assessments occurred after participants' initial weight loss (between 1995 and 2000) at the 2000 and 2005 examinations. Some variables (anger and coping) were assessed in the 2000 exam only, and others (i.e., diet history) in the 2005 examination only, as indicated in the sections that follow.

      Outcome Definitions

      Weight-loss maintainers were defined as participants who were overweight or obese in 1995 (and without pregnancy or major medical illnesses affecting weight); had lost ≥5% by 2000; and had maintained 75% of their weight loss by 2005. A 5% weight-loss criterion was chosen, as this has been shown in numerous studies to be associated with substantial health benefits
      • Leiva D.
      What are the benefits of moderate weight loss?.
      and has been recommended by the IOM as the weight-loss criterion for evaluating success of weight-loss programs
      IOM
      Weighing the options Criteria for evaluating weight-management programs.
      ; this criterion has also been used in other epidemiologic research examining weight-loss maintenance.
      • Field A.E.
      • Wing R.R.
      • Manson J.E.
      • Spiegelman D.L.
      • Willett W.C.
      Relationship of a large weight loss to long-term weight change among young and middle-aged U.S. women.
      Although successful weight control can involve some weight regain, successful weight loss further was defined as maintaining ≥75% of the weight loss for 5 years to identify a relatively weight-stable group of weight-loss maintainers.
      • McGuire M.T.
      • Wing R.R.
      • Klem M.L.
      • Lang W.
      • Hill J.O.
      What predicts weight regain among a group of successful weight losers?.
      • Phelan S.
      • Hill J.O.
      • Lang W.
      • DiBello J.R.
      • Wing R.R.
      Recovery from relapse among successful weight losers.
      Regainers were defined as individuals who were overweight or obese in 1995 (and without pregnancy or major medical illnesses affecting weight); had lost ≥5% by 2000; but had regained >25% of their weight loss by 2005 (Figure 1). Note that the terms weight-loss maintainer and regainer are used to denote these groups, but intentionality of weight changes should not be inferred by the use of these terms.
      Figure thumbnail gr1
      Figure 1Scheme for assessing weight loss maintenance in overweight or obese participants who had lost ≥5% of their body weight between 1995 and 2000, and maintained ≥75% of the weight loss between 2000 and 2005. Weight regain was defined as regaining >25% of weight loss. All participants were without self-reported major disease or pregnancy in 1995.

      Weight, height, demographics

      Weight and height were measured in light clothing and without shoes at the 1995, 2000, and 2005 examinations using calibrated equipment. BMI was calculated using standard formula. Demographic and medical information collected at the 2000 and 2005 examinations were used in analyses. At these time points, all participants were interviewed by trained personnel about their medical history and current use of cigarettes and alcoholic beverages. In 2005, participants also were asked whether they had ever had bariatric surgery. Voluntary versus involuntary weight loss and weight cycling between assessment points was not directly assessed.

      Leisure time physical activity

      The CARDIA physical activity questionnaire
      • Jacobs D.R.
      • Hahn L.P.
      • Haskell W.L.
      • Pirie P.
      • Sidney S.
      Validity and reliability of short physical activity history: CARDIA and the Minnesota Heart Health Program.
      was administered in both 2000 and 2005. Total physical activity was expressed in exercise units as a product of intensity × frequency × 100, to yield a total activity score.

      Dietary intake

      Diet variables were selected based on previous research in weight-loss maintenance
      • Wing R.R.
      • Phelan S.
      Long-term weight loss maintenance.
      • Wing R.R.
      • Papandonatos G.
      • Fava J.L.
      • et al.
      Maintaining large weight losses: the role of behavioral and psychological factors.
      and included calorie intake, percentage of calories from fat, and fast-food and soft drink consumption using a diet history questionnaire administered in 2005.
      • Pereira M.A.
      • Kartashov A.I.
      • Ebbeling C.B.
      • et al.
      Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis.
      • McDonald A.
      • Van Horn L.
      • Slattery M.L.
      The CARDIA dietary history: development, implementation, and evaluation.
      • Liu K.
      • Slattery M.
      • Jacobs D.
      • et al.
      A study of the reliability and comparative validity of the cardia dietary history.
      Fast-food habits were assessed in 2000 and 2005.
      • Pereira M.A.
      • Kartashov A.I.
      • Ebbeling C.B.
      • et al.
      Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis.

      Psychosocial measures

      Depressive symptomatology was assessed in both 2000 and 2005 using the 20-item Center for Epidemiologic Studies depression scale (CES-D).
      • Radloff L.S.
      The CES-D Scale: A self-report depressive scale for research in the general population.
      The shortened version of the SF-36 was used to assess quality of life in the 2000 and 2005 examinations.
      • Ware J.E.
      • Sherbourne C.D.
      The MOS 36-item short-form health survey (SF-36) I: conceptual framework and item selection.
      Social network was measured in 2000 and 2005.
      • Jonsson D.
      • Rosengren A.
      • Doteval A.
      • Lappas G.
      • Wilhelmsen L.
      Job control, job demands and social support at work in relation to cardiovascular risk factors in MONICA 1995, Goteborg.
      Social support was measured also in 2000 and 2005 using eight items drawn from the MacArthur Network.
      • Seeman T.E.
      • Lusignolo T.M.
      • Albert M.
      • Berkman L.
      Social relationships, social support, and patterns of cognitive aging in healthy, high-functioning older adults: MacArthur studies of successful aging.
      Anger was assessed in 2000 only, using the State–Trait Anger Expression Inventory-2.
      • Spielberger C.D.
      State-Trait Anger Expression Inventory–2.
      • Spielberger C.D.
      • Reheiser E.C.
      • Sydeman S.J.
      Measuring the experience, expression, and control of anger In: Kassinove H, ed.
      Coping was assessed in 2000 only, using the Reactive Responding Measure.
      • Taylor S.E.
      • Seeman T.E.
      Psychosocial resources and the SES–health relationship.
      Sleep disturbances were assessed in 2000 and 2005 using questions from the Sleep Heart Health Study
      • Quan S.F.
      • Howard B.V.
      • Iber C.
      • et al.
      The Sleep Heart Health Study: design, rationale, and methods.
      pertaining to excessive daytime sleepiness, trouble falling asleep, and frequent awakening.

      Statistics

      All analyses were performed using SAS version 9.2. Initial univariate t tests and chi-square analyses were conducted to compare groups on demographic and weight-related characteristics. Participants with missing weight data in the final assessment point (2000; n=85) were classified as weight regainers to provide a conservative estimate of the prevalence of successful weight-loss maintenance, but analyses that excluded these 85 individuals revealed similar findings. A three-step process was used to identify the most robust set of predictors of weight-loss maintenance versus weight regain. First, initial multivariate ANOVA for repeated measures was used to examine changes over time (between 2000 and 2005) in each variable and interactions with group (Maintainer versus Regainer), both with and without adjusting for demographic variables affecting weight (race, smoking status, age, gender, marital status, dieting history, 1995 BMI, and percentage weight loss since 1995).
      Second, variables that were found to be significant or approached significance (p<0.15; see Table 2) in these initial adjusted models were entered into a stepwise analysis within predefined categories (i.e., demographic; smoking; physical activity; macronutrient [% of calories from carbohydrate, protein]; dietary components [fast food, diet soft drink, sugar-sweetened soft drinks]; psychosocial; and sleep). Third, variables that were significant (p<0.05) within each predefined category in the stepwise analyses were added individually to a sequential hierarchic model to see whether its inclusion improved the fit of the model using a significant likelihood ratio chi-square. The sequential order in the hierarchic model was based on previous research on variables affecting weight-loss maintenance
      • Wing R.R.
      • Phelan S.
      Long-term weight loss maintenance.
      • Wing R.R.
      • Papandonatos G.
      • Fava J.L.
      • et al.
      Maintaining large weight losses: the role of behavioral and psychological factors.
      and was as follows: (1) demographic and smoking; (2) physical activity; (3) diet (either macronutrient or specific dietary components, such as fast food or soft drinks; each was analyzed in separate models); (4) psychosocial variables; and (5) sleep variables.
      A sensitivity analysis also was conducted using an inverse weighting probability model in which the presence and absence in the final analysis was included as a dependent variable. However, accounting for missingness as an independent variable in the final model did not appreciably influence the findings; thus, only results from the completers' analyses are presented here.

      Results

      Participants were 1869 nonpregnant overweight/obese individuals without major disease in 1995. They were, on average, aged 40.1±3.7 years, with 47% female, 39% white; 48% married; and 69% with a high school education or more. Of these 1869, a total of 536 (29%) lost at least 5% of their body weight between examinations in 1995 and 2000; of these, 180 (33.5%) maintained at least 75% of their weight loss between 2000 and 2005 and were classified as “weight-loss maintainers”; 356 (66.4%) had lost ≥5% but regained more than 25% of their weight loss during 2000–2005 and were classified as “weight regainers.” The maintainers and regainers were compared (below) to identify the characteristics in year 2000 that best distinguished these two groups.

      Baseline (Year 2000) and Changes from 1995 to 2000 As Predictors of Subsequent Regain

      Demographic characteristics and weight changes

      Maintainers and regainers differed on a number of weight-related characteristics (Table 1). Moreover, a significantly greater proportion of weight-loss maintainers than regainers self-reported a history of diabetes (7.5% vs 4.7%, respectively; p=0.001) but no significant differences were observed in reported history of high blood pressure (28% vs 21%, respectively; p=0.19).
      Table 1Comparison of those who maintained their weight loss and those who regained between 2000 and 2005 on demographic and weight-related variables in 2000
      VariableWeight-loss maintainer (n=180)Weight regainer (n=356)p-value
      Demographic
       Age (years)40.1±3.739.7±3.60.18
       Female47.546.00.75
       White36.341.70.22
       African-American63.758.2
       Married47.248.20.84
       High school educated or more67.570.70.44
      Weight/weight-loss information in 1995 and 2000 (M±SD)
       Weight (kg) in 1995103.9±24.2100.4±19.80.08
       BMI in 199535.4±7.834.0±6.20.02
       Weight (kg) at year 200092.3±19.090.6±17.30.29
       BMI at year 200031.5±6.030.7±5.30.10
       Weight loss (1995 wt [kg] – 2000 wt [kg])11.6±9.09.9±6.00.007
       Percentage weight loss ([1995 wt – 2000 wt]/1995 wt)10.6±5.79.6±4.50.04
      Note: Values are percentages unless otherwise mentioned. Weight regain = lost ≥5% between 1995 and 2000 and regained >5% between 2000 and 2005. Weight-loss maintenance = lost ≥5% between 1995 and 2000 and maintained ≥75% of that weight loss between 2000 and 2005. Weight and height in 1995, 2000, and 2005 were based on measured weights using calibrated equipment.

      Behavioral and psychosocial characteristics at year 2000

      In general, the behavioral and psychosocial characteristics measured in the 2000 examination did not differ between those who subsequently gained or maintained their weight 5 years later (Table 2). However, a significantly greater proportion of weight-loss maintainers than regainers reported smoking in the 2000 examination (33% vs 23%, respectively; p=0.0001). Moreover, there was a trend for greater alcohol consumption in maintainers than regainers (7.4 vs 6.6 drinks/week, p=0.09; Table 2). Additionally, there were trends for maintainers to report engaging in slightly less physical activity initially and to report less prevalent awakenings at night (Table 2).
      Table 2Mean behavioral and psychological characteristics at the 2000 and 2005 follow-up examinations
      Characteristic2000 Examination2005 ExaminationSignificance
      MaintainersRegainersp-valueMaintainersRegainersGroupTimeGroup × time
      Current smoker (%)33.223.00.000123.615.80.00050.0060.05
      Physical activity
       Total345.0±22.1382.4±16.70.07344.3±22.4327.9±19.3nsnsns
       High203.2±16.9238.4±12.80.10199.1±17.2205.8±14.8nsnsns
       Moderate141.8±8.4143.9±6.30.14145.2±8.5122.1±7.3nsns0.08
      Sleep (%)
       Daytime sleepiness2524ns3031ns0.04ns
       Trouble falling asleep2319ns2521nsnsns
       Frequent awakenings46530.0748570.02nsns
      Psychosocial
       Quality of life: physical component51.7±0.552.3±0.4ns50.3±0.549.9±0.5ns0.0001ns
       Quality of life: mental component49.8±0.750.1±0.5ns50.9±0.751.1±0.5ns0.05ns
       Chronic burden1.9±0.041.8±0.03ns1.7±0.051.7±0.04ns0.0001ns
       Social support: positive emotional2.1±0.052.1±0.04ns2.0±0.052.1±0.04nsns0.10
       Social support: negative emotional2.0±0.12.1±0.03ns2.0±0.12.1±0.04nsnsns
       Social network7.3±0.27.5±0.1ns5.2±0.25.4±0.20.130.0001ns
       CES-D (Total)10.0±0.610.0±0.4ns9.8±0.610.7±0.5nsnsns
       Anger out1.8±0.031.7±0.02ns0.14
       Reactive responding: emotional2.9±0.062.9±0.04nsns
       Reactive responding: goal3.7±0.063.8±0.04ns0.13
       Reactive responding: vigilance2.8±0.052.8±0.04nsns
      Diet
       Total calories/day2384±110.32580±101.3ns
       % kcal from fat/day36.6±0.7036.0±0.6ns
       % kcal from carbohydrates/day45.1±0.8146.8±0.700.10
       % kcal from protein/day16.1±0.3015.3±0.300.08
       Sugar-sweetened drinks (srv/day)0.93±0.131.2±1.70.02
       Diet beverages (srv/day)1.4±0.200.99±0.180.08
       Water (srv/day)5.7±0.45.8±0.4ns
       Alcohol (srv/week)7.7±0.96.6±0.60.097.2±0.97.2±0.8nsnsns
       Fast food (srv/week)3.4±0.043.3±0.03ns3.5±0.043.4±0.040.070.14ns
      Note: Unadjusted values are presented for ease in interpretation; p-values reflect analyses with adjustment for race, smoking status, age, gender, marital status, dieting history, and initial BMI and weight loss. p-values <0.15 are displayed in the table and denote variables that were entered into subsequent models.
      CES-D, Center for Epidemiologic Studies–Depression scale; ns, nonsignificant (p>0.15); srv, servings

      Change Between the 2000 and 2005 Examinations

      Additional analyses compared changes between the 2000 and 2005 examinations for those who regained weight versus those who maintained their previous weight loss. During this time span, weight-loss maintainers continued to lose weight (4 kg loss) and further reduced their BMI from 31.5±6.0 to 30.4±6.5 whereas regainers increased to above baseline (8.8 kg gain) from a BMI of 30.7±5.3 to 33.6±6.4. In 2005, maintainers were lighter than regainers (88.5±18.7 vs 99.3±20.5 kg, p=0.0001) and were maintaining a weight loss of approximately 15% from 1995 compared with 1% weight regain above baseline for regainers.
      Examining variables assessed in both the 2000 and 2005 examinations, there was a significantly greater reduction in smoking prevalence among regainers than maintainers (p=0.05; Table 2). There was also a trend (p<0.08) for maintainers to slightly increase their physical activity and for regainers to decrease their activity. Group main effects also were found for sleep (Table 2). Examining psychosocial characteristics, several time effects were observed, including substantial declines in physical and mental quality of life scores (Table 2), but the maintainers and regainers had similar changes.
      Table 2 also shows results of the diet history questionnaire administered in 2005. Maintainers consumed significantly (p=0.02) fewer daily servings of sugar-sweetened soft drinks than regainers and slightly more diet soft drinks, fewer calories from protein, and more fast food, but these latter trends were not significant. History of bariatric surgery was also assessed in 2005; four maintainers and no regainers reported ever having had bariatric surgery.

      Multivariable Analyses

      In models containing all variables that were significant or approached significance in univariate analyses, significant predictors of the odds of maintaining weight versus being a regainer included African-American race, history of diabetes, and current smoking at years 2000 and 2005, as well as increases in moderate physical activity between 2000 and 2005, increases in emotional support during the same time span, and less sugar-sweetened soft drink consumption in 2005 (Table 3). In analyses that included macronutrients (instead of foods) as the dietary block, similar findings were observed for changes in moderate activity (OR=1.3, 95% CI=1.1, 1.6, p=0.007) and emotional support (OR=1.6, 95% CI=1.1, 2.3, p=0.01); however, intake of macronutrients was not a significant predictor. Analyses excluding the four participants who reported a history of bariatric surgery revealed near identical findings.
      Table 3Odds of being in the weight-loss maintainers versus regain category
      FactorOR (95% CI)p-value
      African-American1.7 (1.1, 3.0)0.03
      Female0.9 (0.5, 1.4)ns
      Married (Nonmarried = ref)0.9 (0.6, 1.6)ns
      BMI (year 1995)0.9 (0.9, 1.0)ns
      Weight loss between 1995 and 20001.0 (0.9, 1.0)ns
      Smoker in 2000 and 2005 (Never-smokers = ref)3.4 (1.9, 6.2)0.0001
      Dieting history1.0 (0.9, 1.0)ns
      History of diabetes2.2 (1.0, 5.1)0.04
      Increase in units of moderate activity (2000–2005)1.4 (1.1, 1.7)0.005
      Soft drink consumption (servings/day; year 2005)0.8 (0.7, .9)0.006
      Increases in emotional support (2000–2005)1.6 (1.2, 2.7)0.01
      Note: Race, gender, marital status, dieting history, and history of diabetes, measured in 2000. Results based on sequential multiple regression in which demographic variables were entered first, followed by physical activity, dietary, and psychosocial variables.
      ns, nonsignificant (p>0.05)

      Discussion

      To our knowledge, the current study was the first to examine the prevalence of weight loss and maintenance in a diverse population-based cohort using prospectively measured weights. The first principal finding was that 29% (536 of 1869) of the overweight and obese population successfully lost a modest amount of weight (≥5%) over a 5-year time span, with only four of these 536 participants having reported bariatric surgery. In a similarly aged population of women, the Nurses Health Study found that fewer (13%) overweight and obese women had successfully lost 5% or more of their body weight over a 2-year period (determined using self-reported weights). Although encouraging that nearly one third of overweight and obese individuals were successful at weight loss, more effective strategies may be needed to increase the proportion of overweight and obese individuals in the population who lose weight.
      Although it is commonly believed, based on clinical trial outcomes,
      • Stunkard A.J.
      The management of obesity.
      • Mann T.
      • Tomiyama A.J.
      • Westling E.
      • Lew A.M.
      • Samuels B.
      • Chatman J.
      Medicare's search for effective obesity treatments: diets are not the answer.
      that very few individuals succeed at long-term weight-loss maintenance, 34% of the overweight individuals who had successfully lost weight in CARDIA were able to keep the weight off over 5 years. Using similar criteria but self-reported weights, the Nurses Health Study
      • Field A.E.
      • Wing R.R.
      • Manson J.E.
      • Spiegelman D.L.
      • Willett W.C.
      Relationship of a large weight loss to long-term weight change among young and middle-aged U.S. women.
      found that approximately 20% of those who had lost 5% or more kept it off over 2 years. In NHANES (1999–2002), 58.9% of participants reported keeping 10% or more weight loss off (within 5%) for 1 year, also based on self-reported weight. The prevalence of both successful weight loss and maintenance among overweight individuals was 10% in the current study, 15% in the Nurses Health study, and 18% in a random-digit-dial survey.
      • McGuire M.T.
      • Wing R.R.
      • Klem M.L.
      • Hill J.O.
      Behavioral strategies of individuals who have maintained long-term weight losses.
      As CARDIA is the only study that used measured weights, its estimates are potentially the most accurate. However, differences in the definitions used may also explain differences in the estimated prevalence. Nonetheless, these data and other national
      • Kruger J.
      • Blanck H.M.
      • Gillespie C.
      Dietary practices, dining out behavior, and physical activity correlates of weight loss maintenance.
      • Phelan S.
      • Wing R.R.
      Prevalence of successful weight loss.
      and international
      • de Zwaan M.
      • Hilbert A.
      • Herpertz S.
      • et al.
      Weight loss maintenance in a population-based sample of German adults.
      reports similarly suggest that successful weight-loss maintenance, although infrequent, may be more prevalent in the general population than commonly assumed.
      Surprisingly, no significant differences were found in the prevalence of successful weight loss and maintenance across age and gender. In contrast, African Americans had higher odds of long-term weight-loss maintenance than whites. Another population-based study
      • Kruger J.
      • Blanck H.M.
      • Gillespie C.
      Dietary practices, dining out behavior, and physical activity correlates of weight loss maintenance.
      similarly found greater percentages of self-reported successful weight-loss maintenance in African Americans than whites. However, the NHANES study found no significant differences in prevalence between African Americans and whites, and lower prevalence in Mexican Americans.
      • Weiss E.C.
      • Galuska D.A.
      • Kettel Khan L.
      • Gillespie C.
      • Serdula M.K.
      Weight regain in U.S. adults who experienced substantial weight loss, 1999–2002.
      Some clinical weight-loss trials have shown minorities to be somewhat less successful than nonminorities at weight loss
      • Kumanyika S.K.
      • Obarzanek E.
      • Stevens V.J.
      • Hebert P.R.
      • Whelton P.K.
      Weight-loss experience of black and white participants in NHLBI-sponsored clinical trials.
      • Hollis J.F.
      • Gullion C.M.
      • Stevens V.J.
      • et al.
      Weight loss during the intensive intervention phase of the weight-loss maintenance trial.
      but as successful
      • Svetkey L.P.
      • Stevens V.J.
      • Brantley P.J.
      • et al.
      Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial.
      or more successful
      • Wing R.R.
      • Hamman R.F.
      • Bray G.A.
      • et al.
      Achieving weight and activity goals among diabetes prevention program lifestyle participants.
      at weight-loss maintenance. Findings from the current cohort study, which may be more generalizable than clinical trial data, suggest that long-term weight-loss maintenance is similar in men and women and better in African-American than white populations.
      Examining predictors and correlates of weight-loss maintenance, physical activity emerged as a significant variable, a finding that is consistent with findings from both clinical trial
      • Wing R.R.
      Physical activity in the treatment of the adulthood overweight and obesity: current evidence and research issues.
      and epidemiologic
      • Field A.E.
      • Wing R.R.
      • Manson J.E.
      • Spiegelman D.L.
      • Willett W.C.
      Relationship of a large weight loss to long-term weight change among young and middle-aged U.S. women.
      studies. Lower sugar-sweetened soft drink consumption also was related to higher odds of successful weight-loss maintenance. Evidence is mixed on the role of sugar-sweetened beverages in the promotion of weight gain and obesity.
      • Malik V.S.
      • Schulze M.B.
      • Hu F.B.
      Intake of sugar-sweetened beverages and weight gain: a systematic review.
      • Vartanian L.R.
      • Schwartz M.B.
      • Brownell K.D.
      Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis.
      American Institute for Cancer Research, World Cancer Research Fund
      Food, nutrition, physical activity and the prevention of cancer: a global perspective: a project of World Cancer Research Fund International.
      • Pereira M.A.
      The possible role of sugar-sweetened beverages in obesity etiology: a review of the evidence.
      • Bachman C.M.
      • Baranowski T.
      • Nicklas T.A.
      Is there an association between sweetened beverages and adiposity?.
      • Forshee R.A.
      • Anderson P.A.
      • Storey M.L.
      Sugar-sweetened beverages and body mass index in children and adolescents: a meta-analysis.
      • Gibson S.
      Sugar-sweetened soft drinks and obesity: a systematic review of the evidence from observational studies and interventions.
      A recent study that compared successful weight losers and normal-weight controls indicated that weight-loss maintainers consumed little in the way of sugar-sweetened beverages.
      • Phelan S.
      • Lang W.
      • Jordan D.
      • Wing R.R.
      Use of artificial sweeteners and fat-modified foods in weight loss maintainers and always-normal weight individuals.
      The current study's findings are consistent with these latter data and further suggest that limiting intake of sugar-sweetened beverages is characteristic of long-term successful weight losers.
      The study has some limitations. Even though, to be conservative, individuals were excluded who had diseases that could promote unintentional weight loss or inhibit physical activity, intentionality of weight loss was not directly assessed in 2000 and, thus, prevalence estimates of successful weight control could be inflated. Studies that have assessed and excluded unintentional weight losers have reported similar prevalences as those in the current study.
      • Weiss E.C.
      • Galuska D.A.
      • Kettel Khan L.
      • Gillespie C.
      • Serdula M.K.
      Weight regain in U.S. adults who experienced substantial weight loss, 1999–2002.
      • McGuire M.
      • Wing R.
      • Hill J.
      The prevalence of weight loss maintenance among American adults.
      Nonetheless, the extent to which successful weight losers in the current study represent intentional versus unintentional weight losers remains unclear, so these results should be interpreted with caution. This is an observational study, so causality cannot be inferred. Moreover, although population-based, the current study was conducted with participants who have remained in CARDIA through 20 years of follow-up and who may differ in their motivation and/or weight change patterns than the population at large. Finally, the assessments done in the current study, although comprehensive, were not all administered at every examination and not every factor known or thought to be associated with successful weight control was measured (e.g., dietary restraint, disinhibition, self-efficacy, environmental factors). Also, because the measures were collected 5 years apart, the extent to which weight cycled in the interim years was unknown.
      In summary, 29% of overweight and obese men and women successfully lost ≥5% of their body weight over a 5-year time span, and 34% of those who lost weight were able to maintain their weight losses over the next 5 years; African Americans were more likely than whites to be classified as a weight-loss maintainer. Public health interventions to promote weight-loss maintenance may benefit from targeting increased physical activity and emotional support, and decreased soft drink consumption.
      Work on this manuscript was supported (or partially supported) by the following contracts: University of Alabama at Birmingham, Coordinating Center, N01-HC-95095 ; University of Alabama at Birmingham, Field Center, N01-HC-48047 ; University of Minnesota, Field Center and Diet Reading Center (Year 20 Exam), N01-HC-48048 ; Northwestern University , Field Center, N01-HC-48049 ; and Kaiser Foundation Research Institute , N01-HC-48050 , from the National Heart, Lung, and Blood Institute . NHLBI had input into the overall design and conduct of the CARDIA study. The NHLBI co-author, Dr. Loria, was involved in all stages of the current study, including study concept and design, analysis, interpretation, and write-up.
      No other financial disclosures were reported by the authors of this paper.

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