I was looking for something else when I came across an article entitled “Long-term weight loss maintenance” that I had somehow previously overlooked in the supplement to the July 2005 issue of the American Journal of Clinical Nutrition.
The article begins by quoting a couple of older articles in other journals discussing the futility of expecting any long term weight-loss maintenance because recidivism is so high among those who have lost significant amounts of weight. The figures most quoted are that of those people who lose substantial amounts of weight (20 lbs. or more) only 2-5% manage to keep it off for at least two years. Given these statistics, a diagnosis of pancreatic cancer or some particularly malignant type of leukemia would have a better prognosis in terms of percentage of cures.
The authors of the paper discuss a number of studies in which researchers surveyed people randomly via telephone (a highly suspect way to gather reliable data, if you ask me) to find those who had lost weight and maintained their weight loss for at least a year. After crunching the data for these studies and a few others, the authors state that “it appears the ~20% of overweight individuals are successful weight losers.”
Based on my experience with many thousands of weight loss patients I would say that the figure for weight maintenance is somewhere between the 5% worst case and the 20% best case. If I had to pick a percentage I would say somewhere in the 12-15% range. More about “successful” maintenance later.
The authors set as their goal:

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 , a database of more than 4000 individuals who have indeed been successful at long-term weight loss maintenance.

Now all I have to hear is the name National Weight Control Registry (NWCR) and my antennae are up because this is the outfit started and monitored by one James O. Hill, PhD from the University of Colorado. Who is James O. Hill? James O. Hill is a researcher who publishes frequently and has somehow become the go-to guy for the media on issues of obesity and weight loss. He is no friend of the low-carbohydrate diet; in fact, I would say that he is a low-fat fanatic. I have heard him speak at numerous conferences, and he fairly drips with animosity and superciliousness toward anything low-carb. MD and I were once in the audience of an academic obesity conference at which Hill threw up a slide of an article that had appeared on the front page of the New York Times not long before about us, Protein Power, and the idea that maybe the low-fat diet had not been the panacea everyone had expected. He flashed the slide up on the screen, gave the audience time to read the gist of it, then turned to the crowd with a sort of David Letterman look of puzzlement, as if to say, I’m not making this up—these people really are this stupid.
It’s not just that Hill chose to attack us personally in a large forum (and I’m sure he and his buddy Robert Eckels, also from the University of Colorado, still do) that puts me off of him, I just think he’s totally on the wrong track. And has sold out, as well. Sold out? To whom? To the sugar lobby for one.
Several years back I was looking for some sugar statistics, so I went to the website for the sugar lobby. While navigating around there, I made my way into the scientific section where I found a White Paper basically extolling the virtues of carbohydrate and sugar written by James O. Hill and paid for by the sugar lobby.
I just went back to the sugar lobby website, and, lo and behold, there is no longer a paper there by James O. Hill. All the new data coming out showing that refined carbohydrates, sugar in particular, are not particularly healthful I’m sure gave ol’ Jim second thoughts about having his shameless defense of sugar out there where God and everybody could see it and associate it with him. But, ol’ Mike was still hot on the trail.
I went on Google and googled James O. Hill white paper sugar and found a link right at the top. But when I went to that link I got a page telling me that:

The page you are looking for might have been removed, had its name changed, or is temporarily unavailable.

Not to be deterred, I noticed that the Google link had a little highlighted link that said: Cached. I clicked, and there in all its glory was ol’ Jim’s White Paper. Read it and you will discover the essence of the philosophy of James O. Hill, PhD, major spokesperson for weight-loss academia.
The authors tell what the NWCR is:

In an effort to learn more about those individuals who have been successful at long-term weight loss, [Rena R.] Wing and [James O.] Hill 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). 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.
The study registrants, who are entirely self selected and recruited by Hill et al, have used a number of methods to lose their weight, with about half losing weight using the help of a physician or other structured commercial program and the other half doing it on their own. The vast majority (89%) reported using both diet and exercise to achieve their goals.

Here’s where it starts to get interesting:

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).

If you analyze these figures something interesting comes to light. 87.6% of successful maintainers (the NWCR database) lost their weight by restricting certain foods, i.e., fat, carbohydrate or protein. No one really restricts protein; it’s always fat or carbohydrate. According to the above data, 25% of the people lost their weight by counting fat grams) a low-fat diet), so subtracting this from the 87.6% means that 62.6% of them must have counted carbs, which, I’m sure, was a bitter pill for ol’ Jim to swallow. And is no doubt why it’s reported as it is, i.e., in such a way that it has to be dug out instead of presented directly.
The authors of the study go on to list a number of things that registry members have done to maintain their weight loss.
1. Consuming a low-calorie, low-fat diet
2. Performing high levels of exercise
3. Weighing themselves frequently
4. Eating breakfast daily
5. Eating infrequently at restaurants
I find it difficult to believe that if most of the people in the registry lost their weight following a low-carb diet (62.6%) that they would adopt a low-fat diet for maintenance. I can believe that many of them exercise frequently as that is a phenomenon of having lost weight. We never particularly encouraged our own patients to undertake a strenuous exercise regimen because we knew from experience that they would increase their activity levels as they lost weight and started feeling better. The idea that frequent weighing has a role in helping people maintain their weight loss seems a bit absurd to me, but maybe constant monitoring helps prevent the weight from creeping back up. I would think a regular waist measurement would be more accurate since people who exercise more often gain some muscle mass that translates into weight gain on the scales. Gaining muscle mass won’t make the abdominal circumference larger, however. Finally, I firmly believe that avoiding restaurants as much as possible goes a long way toward helping people keep thin. In fact, probably the single best thing you can do for your health is to spend more time in your own kitchen.
I looked at a few statistics on the dining out habits of Americans over the time period that obesity has been skyrocketing. Searching through the US Department of Agriculture files and MarketResearch.com data it is apparent that the rise of eating somewhere other than home has tracked pretty well with the rise in obesity. In 1977 Americans consumed 83% of their meals at home; it had dropped to 78% by 1995; and now only 60% of meals are eaten at home. That makes it 40% that are eaten at restaurants.
When people cook at home they never use high-fructose corn syrup, if they are at all enlightened, they don’t cook with trans fats, they don’t use rancid oils, they aren’t tempted by the dessert tray, they don’t drink as much water (drinking water with meals makes you chew less, swallow more often, and eat more), and they don’t pick at the bread basket until it’s empty.
When people eat at restaurants, they do all the above. Restaurants fry a lot of food in oils that are trans fat going in the fryer and become overheated and rancid in pretty short order. I remember a weight-loss patient I took care of once who owned a popular restaurant that was famous for its deep fried biscuits. I had eaten them there (it was almost impossible not to–see what I mean?), knew how good they were, and asked her how she could keep from eating them all day long. Her response was an eye-opener. She said, “Oh, I like them a lot when the oil is fresh.” Having worked in a restaurant I can tell you that the oil ain’t fresh for long. And having never sampled her deep fried biscuits when the oil was fresh, I couldn’t tell the difference.
Restaurants often advertise that their stuff is cooked in olive oil, but what they don’t tell you is that whatever it is they’re cooking comes to them frozen in oil containing a lot of trans fat. Sometimes stuff is precooked in trans fat, then reheated.
How many times have you been to a restaurant, been full, then the dessert tray comes by? It’s often hard to resist. How about the bread basket? Have you ever waited for the food to arrive and eaten one piece of bread or one dinner roll after another? I know I have.
It bears repeating that the best thing you can do for your health is spend more time in your own kitchen. If you cook it, you know what’s in it. You control what’s in it.
My main argument with this paper (other than the fact that I believe anything that Jim Hill touches is suspect) is that I really don’t believe that the majority of people who lost weight on a low-carb diet would switch to a low-fat diet to maintain. I think the biggest problem that people have maintaining on any diet—even low-carb diets—is that they look at the weight-loss part of the experience as a sort of boot camp that once they get through with will allow them to forget about dieting and go back to their old eating habits. Then when they regain their weight, they say, That diet didn’t work. Sure, I lost weight, but then I gained it all right back. I’ve heard it a thousand times.
I can tell you that if you have gained weight, you are eating too much of the wrong kinds of foods. If you lose all your excess weight and then go back to eating too much of the wrong kinds of foods, you will gain all your lost weight back and then some. That I’ll give you a 100% guarantee on.
People need to think of maintenance in terms of medications. Let’s say you have high blood pressure, for example, and your doctor prescribes medication for it. Your blood pressure drops and stays down. If you stop the medicine and your blood pressure goes back up, you wouldn’t blame the medicine. You wouldn’t say, That medicine didn’t work. Sure, it got my blood pressure down, but as soon as I went off of it, my blood pressure came right back up. Ridiculous as that sounds, that’s exactly what many people do with diet.

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