obesity reviews

doi: 10.1111/j.1467-789X.2008.00516.x

Long-term weight loss and weight-loss maintenance strategies

S. Rssner, M. Hammarstrand, E. Hemmingsson, M. Neovius and K. Johansson

Obesity Unit, Department of Medicine, Karolinska Institutet (HS), Stockholm, Sweden Received 28 February 2008; revised 9 July 2008; accepted 11 July 2008 Address for correspondence: Kari Johansson, Department of Medicine, Karolinska Institutet (HS), SE-141 86 Stockholm, Sweden. E-mail: kari.johansson@ki.se

Summary
It has been suggested that about 20% of subjects undergoing weight-loss programmes can achieve a certain degree of long-term success. At present, surgery remains the only method resulting in long-term sustained weight loss, but access remains restricted. Hence it is important to analyse, in addition to pharmacotherapy, the methods to improve the effects of diet, exercise and behavioural modication. Since these techniques are less spectacular than others, there is a risk that their potential will be overlooked, in spite of the fact that they remain the main alternative for most subjects undergoing weight-loss therapy. This review summarizes realistic treatment alternatives and also provides data from a day care treatment, a strategy not much reported in the literature. This is a standard treatment modality for diabetes but less common in obesity treatment. Keywords: Behaviour maintenance. modication, day care, weight loss, weight-loss

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Introduction
Despite the success of gastric bypass surgery (1), there is still agreement that diet, exercise and behaviour modication constitute the cornerstones of modern long-term obesity treatment. It is simply not feasible to surgically remove the obesity epidemic; in Sweden, approximately 1600 bariatric procedures are conducted annually, while the number of patients qualifying for such an intervention (body mass index 35) is in the order of magnitude of 150200 000. Weight-loss drugs are available, but in spite of the enormous efforts to develop such drugs, few can actually be prescribed. Their effect is moderate and the costs are high, especially since these drugs are often not reimbursed. Bariatric surgery is arguably a welcome solution to a difcult problem for our national health services and the most effective method available. In the media, considerable attention was given to the outcome of the Swedish obese subjects (SOS) study, demonstrating that 10 years after surgery, the mean maintained weight loss, depending on surgical procedure, ranged from 20% to 32%, resulting in a decreased mortality of 29% (1). This has resulted in the misunderstanding that bariatric surgery
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is the only way to treat severe obesity. For numerous reasons, such as cost and lack of trained surgeons, surgery will remain an unrealistic option for almost all severely obese patients. The nding that maintained weight loss has benets as regards both reduced mortality and morbidity on the other hand increases the need to critically evaluate the non-surgical alternatives and improve them (2).

What is success?
In the past, obesity treatment success was generally described in terms of absolute weight loss (3). When the understanding of the complexities of weight-loss programmes became more apparent, a second dimension was introduced in describing the qualities of a weight-loss programme: the problems associated with dropout rate. After all it is the combination of the weight-loss programme as such and the extent to which individuals can adhere to the programme that will determine the total amount of fat that is lost in a given programme (4). The next step was the understanding that weight loss as such is certainly important, not least from a cosmetic point of view, but that the reduction in associated medical risk factors may be even

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more important from the medical perspective. For the obese patient losing weight, it was easy to understand that such weight loss would improve appearance and reduce mechanical problems, whereas the individual patient had no way of understanding that such weight lost also had benecial effects on several hormonal and metabolic risk factors. A surprising further nding related to the fact that several aspects of psychosocial problems were benecially affected, also by modest weight loss (5). Finally, it was realized that acceptance even of moderate but sustained weight loss of about 510% of baseline body weight represented a denite degree of success (6). In perusing the literature, it becomes obvious that the behavioural modication part of treatment programmes is often described in general and not very specic terms (710). It also appears as if the diet and exercise part used in both the placebo and drug groups in clinical trials of weight-loss drugs differ markedly. Rimonabant trials have had a median weight loss of 1.6 kg in the placebo arms, while sibutramine studies have had lower weight reductions (1.4 kg) and orlistat higher weight reductions (3.8 kg) (10). The principles of diet, exercise and behavioural modication are well-established, but the actual and precise settings in which these components are integrated and exposed to the obese patient under treatment are often less detailed. The competence of the supervising staff may vary considerably from moderately trained lay groups to highly skilled health professionals (11,12). Furthermore, to evaluate behaviour change programmes, it is necessary to have some understanding about the patient characteristics. It is obvious that many weight-loss programmes will appeal to individuals with modest problems of psychological or medical nature. Like with alcoholism and other types of abuse, there is a certain degree of success in self-treatment, which is rarely reported or scientically evaluated (13). In a review of long-term weight-loss studies in obese adults, irrespective of treatment modality, Douketis et al. addressed long-term treatment of obese adults. Of the potentially relevant 986 studies, only 44 remained in the nal meta-analysis. The most common reason for rejection was that the studies were not proper clinical trials (n = 674), had inadequate duration of follow-up (n = 163), were small in size (n = 54), or used non-approved treatment (n = 41) (14). In reporting the weight-loss results from all treatment options, they concluded that there are numerous limitations, which restrict the applicability in clinical practice. Often the treatment is described in such vague terms that it is difcult to reconstruct in detail how the programme was conducted. The present review attempts to discuss principles of long-term behavioural modication programmes at a practical level and to evaluate their potential role in the treatment armamentarium. Below we describe the spa,

starvation, long-term treatment strategies and the day care treatment.

The spa
A negative caloric balance will result in weight loss. This was the fundamental concept on which obesity treatment programmes were developed already a century ago. In the beginning of the 20th century, the Kelloggs brothers (who later developed cornakes) had set up huge health spas in upstate New York, where the rich and famous were treated as in-patients with diet and exercise, although the behaviour modication component was not that prominent (15). In Central Europe, there has always been a tradition for in-patient spa treatment for a couple of weeks per year (16), but without-follow-up weight-loss maintenance is minimal. This then explains the success of these spas, who happily welcome the same patients from year to year being comfortable that the weight loss achieved during a few weeks is certainly not going to prevail until it is time for the next treatment programme 1 year later.

Starvation
Total starvation was a treatment modality during the last century up to the 1960s (17,18), before it was realized that weight-loss maintenance rather than weight loss only was the crucial issue. With ketonaemia developing possibly curbing hunger, it was not very difcult for patients to lose weight in specialized units, being supplied only with uids, electrolytes, minerals, vitamins and other essential trace elements. With time lean body mass was also broken down and in fact placed the patient undergoing starvation in a less favourable position, since with loss of lean body mass the basal metabolic rate would drop, making it more difcult to maintain weight at the lower level (1922). Very-low-calorie diets (VLCD) were introduced as an option to drastically reduce energy intake but maintain the essential elements. The early VLCD contained only about 330 kcal d-1 (Cambridge) but later it was realized that to increased safety and tolerability, the energy intake could be increased up to 9001000 kcal d-1 (low-calorie diets) maintaining the same effects on weight loss (23,24).

Long-term treatment strategies

Our 1985 study looking at 4-year follow-up of patients with severe obesity was probably one of the rst attempts to draw attention to the fact that obesity is a chronic condition, which made us develop an early programme with long-lasting effects (25). In our follow-up, 72% of those for whom we reported 4-year data could be restudied 1012 years later. The mean weight loss after 4 years was 10.6 16.7 kg. At the late follow-up, there was no

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signicant change in the mean weight loss achieved after 4 years for either sex (26). Recently the Diabetes Prevention Project showed similar success (27). Furthermore, the Finnish study on weight-loss maintenance in diabetic patients also demonstrated in a similar way that effects achieved after a 4-year period were in fact maintained 3 years later (28). The initial programme acted as a kind of vaccination, providing the individuals with tools for future weight control. However, several years earlier Hellenius had described that this could be achieved with even simpler tools (29,30). Studying men who had survived a myocardial infarction, she could demonstrate that a very modest short-term early intervention had measurable effects 16 months later. This prevention programme included low intensive preventive efforts, advice on diet, exercise or in a randomized controlled trial. Interestingly, advice on weight loss, diet and exercise on only one occasion given by a physician signicantly reduced body weight, waist circumference, blood pressure and cholesterol levels (30) as well as insulin levels during an oral-glucose-tolerance test (OGTT) (29) after 6 months. At a long-term follow-up after 18 months (31), reductions in several important risk factors were maintained. There was a certain concern that such programmes would affect the quality of life among the patients, but a follow-up study demonstrated that life was not negatively affected by the changes imposed by these intervention programmes (32). Most conventional obesity treatment programmes would typically last for a few months with group sessions and classes based on educational material developed at the local and national level. Follow-up is then generally the crucial study component, and numerous studies demonstrate that the dropout rate increases as weight-loss plateaus (14). It is surprising that in spite of the diversity in therapeutical approaches, in most treatment programmes, maximal initial weight loss, whether by diet, exercise, behavioural modication, pharmacotherapy, will generally have happened during the rst 6 months, after which there is only modest, if any further weight loss observed (7,9). It has generally been assumed that weight loss achieved at a slower pace is better preserved than weight loss, which takes place more rapidly. However, as described in one of our reviews (33), the literature demonstrates that rapid rather than slow initial weight loss is positively and not negatively related to long-term weight maintenance. This observation based on the study of the literature was further analysed in a recent conceptual review of factors associated with weight-loss maintenance and weight regain (5). In this analysis, we dened weight maintenance as intentional weight loss that has subsequently been maintained for at least 6 months and identied in addition to the previous observation about early pronounced weight loss a number

of other factors which were positively related to long-term weight-loss maintenance. Among these were a number of psychological factors, such as reaching a self-determined goal weight, having control of over-eating as well as selfmonitoring of behaviours, internal motivation to lose weight, social support and better coping strategies. In a general sense, the review summarized that obese individuals who do the right thing as regards all standard psychological components of a weight-loss programme do signicantly better than those who cannot adjust their life to a new situation. Among other factors associated with successful long-term outcome, a physically active lifestyle and a regular meal rhythm, not surprisingly, came out as signicant predictors of long-term success (13).

Weight-loss camps
Weight-loss camps are a relatively new approach in treating obese subjects. Such weight-loss camps are more common in children than adults (3440). The majority of the studies concluded that weight-loss camps were effective in assisting children to lose weight and improve a range of health outcomes. Long-term evaluation is, however, scare. In adults only one weight-loss camp study was identied (35), where in addition weight-loss maintenance after 24 years was investigated. The programme resulted in a 15% weight loss; however, after 4 years only 28% had maintained a weight loss above 10%.

Day care treatment

Whereas in-patient care for obesity within a national healthcare system for resource reasons is practically obsolete today, an intermediate form of treatment, the day care unit, might merit further interest. A systematic search of Medline until 2 February 2008 was performed using the following search strings: obesity AND (day care OR day-care) AND treatment or obesity AND (ambulatory treatment) or obesity AND (treatment principles) or obesity OR (outpatient treatment). Figure 1 summarizes the results of the systematic search. However, only one article by Westlake et al. from 1974 (41) with a small sample size (n = 14) investigated the effect of day care treatment in adults. In addition, an analysis of current standard textbooks of obesity treatment rarely mentions the day care treatment modality for obesity as an alternative, with the exception for an association with diabetes (4244). Further, in the publications of international congresses on obesity since 1976, there is no direct mentioning of day care treatment for obesity. Since we have used this approach for many years, we were interested to analyse the pros and cons of this option to treat patients (12). One reason would be that in a specialized obesity unit only patients would generally be admitted who have failed

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Citations from search (until February 2008; n = 858) Citations excluded (n = 800) RCTs retrieved for more detailed evaluation (n = 58) RCTs excluded (n = 57): Irrelevant (n = 43) Day care treatment in children (n = 12) Prevalence of obesity in a day hospital (n = 1) Day care in diabetes (n = 1) Potentially appropriate included in systematic review (n = 1)
Figure 1 Summary of article screening and selection process for day care treatment of obesity. RCT, randomized controlled trial.

elsewhere. Thus already from the beginning we will anticipate that the patient group will be more resistant to behavioural modication than a group that has not previously undergone repeated attempts to lose weight but failed. The day care programme was developed in response to the need for some patients, for whom weekly sessions were insufcient to maintain motivation for profound lifestyle changes. During a certain period, the day care unit constituted the major long-term weight-loss programme at the obesity unit, where patients were admitted in groups of 810 individuals. Attempts were made to make groups reasonably homogenous as regards age, underlying metabolic complications, personality problems, etc. Occasionally, groups consisting mainly of patients with more homogenous complication patterns were formed, such as polycystic ovary disease, sleep apnoea or eating disorders. As always, most applicants to the programme were women, but attempts were made to over-recruit men, who in general had much more severe risk patterns than the women. The benets of having only one gender at a time in a group were discussed in-depth, but generally there was agreement that mixed groups were more natural, resulted in fruitful discussions between the sexes and also developed a correct social behaviour in the patients to shape up and adhere to the protocol. The patients invited to the day care programme would typically have access to physicians, nurses, dieticians, physiotherapists, health educators and also some access to a psychologist. The same day of the week patients would typically come to the unit for a full day starting with a healthy breakfast and a morning lecture. This would be a presentation by one of the team members about pertinent problems related to the ongoing programme, such as hunger and appetite, food selection, changes in physical activity capacity, stigmatization, outside frustration, etc., and would be based on the manual developed at the unit by Melin (45). Every week, patients would go home with a

task to carry out for the next week involving a behavioural change that the patients considered they could manage until the next visit. Diabetic patients generally could easily adjust their insulin and other pharmacotherapy with selfmonitoring. Medication for hypertension and hyperlipidaemia was generally adjusted at a later stage when patients would visit their general practitioner for followup. Patients were asked to tell their general practitioner that they were part of a weight-loss programme in our attempt to inform indirectly about the existence of the programme and of the success that it actually achieved. The benets of a 12-week day care programme can be summarized as follows: the patient is continuously reminded of the programme, spending 1 d per week with therapists and other fellow patients. A full day makes it possible to build a comprehensive programme including an educational breakfast, lectures, food preparation, physical activity programmes, group interaction and behavioural modication exercise around certain themes. Questions and problem unresolved after 1-d treatment can be addressed the following week to enhance motivation. Weekly feedback provides the participant with an increased understanding of the consequences of behavioural change for weight development overtime. The access to a multidisciplinary team during one whole day gives every group participant a chance to discuss and penetrate the individual problems underlying their particular obesity situation. Physical activity while patients spend a whole day in the treatment unit makes it possible not only to provide an opportunity for exercise but also to follow up discussing side effects of the activity, analysis of strengths and weaknesses of various forms of physical activity, change of programme content, etc. Most Swedish patients can integrate into their working conditions and family life 1 d of absence for a period of a few months and receive compensatory reimbursement from the social insurance system. When patients were invited to the day care programme, we assumed that with their severe obesity problems and often long waiting times they would be highly motivated. The programme was conducted at a group level. We have realized that in spite of the interest expressed some patients may actually not have been motivated enough. Tests to show motivation have been developed but are generally considered to have limited value. In an optimal setting the motivation should have been individually assessed and the programme tailored to perceived needs an approach for which we did not have sufcient resources. The 12-week programme has then been followed up by monthly group sessions, and half a year later and onwards by booster sessions where patients have been invited again for one full day to reinforce key messages, address new upcoming problems and enhance compliance (46). The salient results of such a program are summarized in Table 1 and Fig. 2. In our interim analysis of the outcome of the

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Weight reduction (mean, 95% CI) 12 months kg % 24 months kg %

Table 1 Weight changes after 12 and 24 months (ITT population) compared with baseline of day care obesity treatment stratied by sex, BMI and age

Gender Male Female P value BMI (kg m-2) <35 3539.9 4044.9 45 P value Age (year) <30 3039 4049 50 P value

124 261

6.4 (4.7, 8.2) 6.0 (5.0, 7.0) 0.660* 2.9 (1.0, 4.9 (3.4, 7.4 (5.7, 7.6 (5.7, 0.004 5.9 (3.3, 6.1 (4.0, 5.9 (4.2, 6.4 (5.1, 0.965 4.8) 6.4) 9.1) 9.4)

4.7 (3.5, 3.9) 5.1 (4.2, 6.0) 0.569* 2.7 (0.8, 4.4 (3.0, 6.0 (4.7, 5.5 (4.2, 0.036 4.7 (2.6, 5.0 (3.4, 4.7 (3.3, 5.3 (4.2, 0.916 4.7) 5.7) 7.3) 6.7)

5.3 (3.4, 7.1) 4.5 (3.4, 5.6) 0.921* 1.7 (0.5, 3.6 (2.2, 5.5 (3.6, 6.7 (4.6, 0.010 6.1 (3.0, 5.0 (2.9, 4.1 (2.2, 4.5 (3.2, 0.625 3.9) 5.0) 7.3) 8.8)

3.8 (2.5, 5.2) 3.8 (2.8, 4.7) 0.461* 1.7 (-0.6, 3.9) 3.2 (1.9, 4.4) 4.4 (3.0, 5.7) 4.9 (3.3, 6.4) 0.066 4.9 (2.4, 4.2 (2.5, 3.2 (1.7, 3.6 (2.5, 0.552 7.4) 5.8) 4.7) 4.7)

47 114 131 93

58 88 100 141

8.4) 8.1) 7.7) 7.8)

6.8) 6.5) 6.1) 6.4)

9.2) 7.0) 6.1) 5.8)

*Independent t-test. One-way ANOVA. ITT, intention to treat; BMI, body mass index; CI, condence intervals.

60%

40%

20%

0%
Males Females T2DM Males Females Males Females Males Females Hypertension Hypertriglyceridaemia Metabolic Syndrome

Baseline

12 months

24 months

T2DM (type 2 diabetes) defined as fasting blood glucose 6.1 mmol L1 Hypertension defined as 130/85 mmHg Hypertriglyceredemia defined as triglycerides 1.7 mmol L1 Metabolic syndrome existed if three criteria of the NCEP/ATPIII (waist circumference male > 102 cm, female > 88 cm; HDL male < 1.0 mmol L1 , female 1.3 mmol L1 , blood glucose 6.1 mmol L1 , blood pressure 130/85 mmHg; triglycerides 1.7mmol L1 ) were present.
Figure 2 Day care unit patient data: prevalence of obesity-related diseases at baseline, 12 months and 24 months.

day care unit 385 subjects were included. About 60% of them completed the scheduled 2-year follow-up (Fig. 3). The results were in all respects similar for men and women although as usual more women took part in the pro-

gramme. This attrition is similar to what has been observed in the placebo group in randomized controlled trials of weight-loss drugs for 1 year (Neovius M, Johansson K, Neovius K, DeSantis S, Rssner S, unpublished). As indi-

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300

261 (100%) 200 (77%) 157 (60%) 100 (81%) 71 (57%)

0

Summary
The optimal treatment strategy for weight-loss maintenance is still a matter of debate. Most although not all experts argue that long-term treatment is essential in stabilizing new behavioural modication changes. In the literature treatment of obesity is often described in rather vague terms, making a precise replication difcult. This review draws attention to a treatment form which has been widely used in diabetes care but received surprisingly little attention in the treatment of obese patients, namely the day care principle. A search of the literature revealed that very few attempts have been made to use this treatment approach and we demonstrate that for patients with severe obesity and related comorbidities this approach might be worthwhile to consider.

200

124 (100%)
100

Baseline

12 months Male Female

24 months

Figure 3 Data showing completing participants (n) in a day care unit at baseline, after 12 and 24 months.

cated these patients were severely obese and also with a considerable metabolic risk as evidenced by the fact that about 70% of the men and 50% of the women fullled the National Cholesterol Education Program/Adult Treatment Panel III criteria for a metabolic syndrome1 at entry (47). After 2 years the prevalence of the metabolic syndrome had decreased to about 59% and 42% for men and women respectively (Fig. 2). For subjects who have reported good results from lay group programmes, such as Weight Watchers, Jenny Craig, etc., it is possible, although not proven, that the success in treatment may reect the fact that these individuals have been in a state where they are receptive to modest intervention and motivated with acceptable weight loss, weight-loss maintenance and high compliance (13). On the other hand it is reasonable to assume that to specialize units many individuals will be referred, who have failed in such and other treatment programmes. Just in the way cancer deaths will be expected in a unit specializing in such treatment because of the recruitment criteria, it is reasonable to assume that those who are referred to a specialized obesity unit or themselves seek support from there represent a group for whom many other programmes have failed. The day care programme described here was developed by specialists in an academic obesity unit. However, it is possible that the components of this programme could be adapted in a lay group setting. Just as other lay groups have organized group sessions it would be interesting to see whether it is technically, nancially and practically feasible to run day care units in other settings. Obviously there is no country, in which the primary healthcare system has been able to adequately cope with the obesity problem and hence all efforts should be combined.
1

Conict of Interest Statement

No conict of interest was declared.

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2008 The Authors Journal compilation 2008 International Association for the Study of Obesity. obesity reviews 9, 624630