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Patterns of Weight-Loss Maintenance – More Questions Than Answers?



The US National Weight Control Registry (NWCR) is an ongoing registry of individuals successful at maintaining weight loss. Participation is voluntary and individuals have to have maintaine a weight loss of at least 13.6 kg (30 lb) for a minimum of 1 year to qualify.

Registrants are invited annually to respond to a battery of questionnaires in which they self-report various aspects of their lifestyle and health conditions.

In a recent paper in OBESITY, Lorraine Ogden and colleagues from the University of Colorado, present the results of a multivariate latent class cluster analysis in an attempt to identify unique clusters of individuals within the NWCR with regard to their experiences, strategies, and attitudes with respect to weight loss and weight loss maintenance.

Based on the analyses of 2,228 participants enrolled between 1998 and 2002, the researchers found four distinct clusters:

Cluster 1 (50.5%): represents a weight-stable, healthy, exercise conscious group who are very satisfied with their current weight.

Cluster 2 (26.9%): has continuously struggled with weight since childhood; they rely on the greatest number of resources and strategies to lose and maintain weight, and report higher levels of stress and depression.

Cluster 3 (12.7%): represents a group successful at weight reduction on the first attempt; they were least likely to be overweight as children, are maintaining the longest duration of weight loss, and report the least difficulty maintaining weight.

Cluster 4 (9.9%): represents a group less likely to use exercise to control weight; they tend to be older, eat fewer meals, and report more health problems.

So what can we learn from this analysis?

As a clinician, I don’t worry about Cluster 1 too much – these folks are healthy, exercise conscious, and apparently happy – they seem to be at their ‘best weight’ – good for them!

I am also less concerned about Cluster 3 – they apparently had no problem losing weight (which they mostly gained as adults) and don’t seem to have a big problem keeping it off. Unfortunately, they are only about a tenth of the folks in the NWCR, but nevertheless, good for them too! Like those in Cluster 1, they’ve achieved their ‘best weight’.

The people I do worry about, however, are the folks in Clusters 2 and 4. Together, they make up almost 40% of the maintainers, but are clearly struggling, using a lot of support, and have more mental or medical problems – these are the folks who, by definition, are now probably below their ‘best weight’.

But what else can we learn from these findings? Unfortunately, not much.

This is because the study largely tells us ‘what’ people are doing and not ‘why’ they do what they do.

So yes, some people who are healthy, exercise conscious, and generally happy can keep their weight off. But the question really is how or why they become exercise conscious and what exactly makes them happy. Only if I understand the answer to those two questions will I have found a strategy that may work for others – it is probably not simply enough to tell everyone to become exercise conscious and happy (and also, it helps if you happen to be healthy!).

Does it help me to know that even if you don’t exercise and happen to be depressed, you can still keep weight off, but you’ll require a lot of support and may end up quite stressed about it? Perhaps.

Or, if you’re older and have more health problems, your best bet is to simply eat fewer meals? (Now I worry)

While this information may be helpful in a conceptual sort of way, what is really lacking is any insight into the actual biology of what is going on.

Do successful weight maintainers have different genes, less leptin suppression, a less active hedonic system, a lesser starvation response, or simply a more active prefrontal cortex?

What I really want to know is how the biology and/or psychology of ‘maintainers’ differs from that of most people?

Or do they simply have more time on their hands and better support systems and biology doesn’t really matter?

As I’ve said before – studying the ‘whats’ is nice but what we really need to understand are the ‘whys’.

AMS
Edmonton, Alberta

ResearchBlogging.orgOgden LG, Stroebele N, Wyatt HR, Catenacci VA, Peters JC, Stuht J, Wing RR, & Hill JO (2012). Cluster analysis of the National Weight Control Registry to identify distinct subgroups maintaining successful weight loss. Obesity (Silver Spring, Md.) PMID: 22469954

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23 Comments

  1. You know, whether or not I’m a 1 or a 2 depends a lot on the day that my survey shows up in my mailbox. If I’ve had a bad week at work and with my maintenance, I’m going to fill out my survey differently than if I happen to be in a lower stress time.

    I write in the present tense, as you know, because I’m on the registry. This year all I have to report is my weight. Depending upon the year, I may have to fill out long forms (15 pages) short forms (roughly 4 pages, as I recall), or, as is the case this year, just my weight.

    I am not a big fan of the NWCR, though I continue to participate in hopes that they may wise up and start really listening to their participants. For now, however, they continue to oversimply maintenance and advance the cultural mythology that you describe so well as the Nightmare on ELMM (Eat Less Move More) Street. We maintainers do soooo much more than control our portions and TV time, eat breakfast, weigh ourselves and exercise daily, but they ask us NO open-ended questions, and the questions they do ask lead them to the results they want to see.

    Thanks for this post.

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  2. I’m not on the NWCR but I am definitely in category 2 as are most of the women in my family going back a couple of generations and forward to my neice. When someone finds out why, we will be very grateful.

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  3. Debra covered pretty much what i wanted to say…. i’m not on the registry, but i regularly read a blogger who WAS — she dropped out due to frustration, and told her readers about it. there was no way for her to express what she thought was important about her experiences. further, she had lost too much weight at first, then added a few to get up to around 118 pounds — so they consider her a backslider! *shaking head* the registry SEEMS like a good thing, but it’s being managed poorly.

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  4. This article seems hopeful to those of us who struggle to lose weight and maintain the loss among the small group who were normal weight as children and young adults, but are now overweight. I am now wondering if I should try more diligently to lost weight rather than just feel fatalistic that the status quo of being overweight is hopeless to do anything about, because rebound weight gain seems to hard wired in our species. What do you think, Dr. S? Is there enough evidence among this small group?

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  5. I’m on the Registry. I’ve kept my 30 pounds off for ten years and another 80 pounds for about four years. I’m still borderline obese and still trying to lose weight.

    Participation in the Registry is very frustrating because what they advise doing is exactly the advice I followed back in the day (thinking that the experts surely must know what they’re talking about) all the while continuing to gain weight. I only lost weight and managed to maintain what I lost when I went counter to the prevailing advice–low-carb, paleo, intermittent fasting, and low food reward. The questionnaires are clearly designed in a way that inevitably validates the extant dogma. It bothers me to be part of something that is so superficial and that discounts the individuality and complexity of the problem. By participating it feels like I’m endorsing that dogma and discounting those who continue to struggle. I want to scream, “no, I don’t eat breakfast! It’s not a good strategy for me and it might not be for you, either.”

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  6. I have to wonder how many of the people in Cluster 2 also were (sorry to bring it up, but it’s there) abused as kids. That is THERE, and it’s got to be taken into account. Not bringing that up and concentrating almost exclusively on the medical aspects sounds too much to me like, “No no no it’s not what your grandfather did to you at ALL! Just stop thinking about that unpleasant thing in your past that you’re expending so much energy to avoid confronting! Keep avoiding it! It’s your leptin!”

    I mean, I know that we’re talking about a human body, and that a body can malfunction — body parts do that from time to time. But too close a focus on the medical characteristics that are shared by people in Cluster 2 really does allow everyone to cheerfully ignore the other unmedical life experiences that those people may have in common, maybe because they are ugly and hard to deal with, maybe because they seem uncomfortably political, maybe because they are harder to quantify. But they are THERE, and too much talk about leptin and genes allows everyone to stay in denial about it. Commonality of life experience should not be a footnote.

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  7. I neglected to mention the clusters. I have no clue which cluster they’ve chosen for me. I’m not satisfied with my weight nor am I weight stable so I can’t be a 1. What success I have had has derived from multiple, uneven steps over a very long time so I can’t be a 3. I appropriately wore a bikini well into my forties (menopause did me in) so I’m not a 2. I’m older, but not a 4 because I have no other medical problems, exercise extensively, although aimed at mobility and mood rather than weight management, the latter being inefficient and virtually futile, and am oblivious to the notion of consuming food in meal increments. I’ve learned to eat when I’m hungry until I’m no longer hungry, whenever and however often that may be.

    Gotta wonder about the validity and utility of those contrived categories.

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  8. There needs to be more information about their weight history in order to make a judgement, I imagine. I’m betting that maintenance is much, much harder for someone who has a history of dropping weight and then putting it back on. I log my calories on Sparkpeople, where the forums are full of people saying that they have lost tremendous amounts of weight in the past, so they know they can do it again… my understanding is that weight cycling makes it harder and harder each time to keep the weight off, as the body gets better about maintaining its fat stores.

    I also wonder what the starting BMIs were. Again, I imagine it’s much easier for someone who was in the ‘overweight’ category to lose the weight and keep it off, then somebody who was very obese.

    I would also like to know how many people have made a profound change to their life as a result of weight loss. I know that I have become somewhat obsessed with healthy eating and exercise and it seems to me that other people become like this as well. I should add that there is a component of near-obsession involved, rather than just a ‘healthy lifestyle’ change. It makes me believe that losing very big amounts of weight and keeping it off has a big psychological cost. I know that some of my ambition and career drive seems to have turned into exercise and weight maintenance drive, and I’m not sure if that’s a good thing.

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  9. @ Janis above – I would pretty much reject the notion that a struggle to keep weight off is a psychological/abuse issue. The studies about weight regain are too consistent across cultures and different cohorts for it to be reduced down to pop psychology. We are, ultimately, subject to biological rules that our conscious minds can only partially regulate.

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  11. @ Alexie – Janis was referring to Cluster 2. If members of Cluster 2 have higher levels of stress and depression, then it is reasonable to question their experiences as children. “Abuse” need not be narrowly defined as only sexual – I think physical and psychological abuse during childhood also have a profound impact on a person. That impact in turn will affect psychological well-being. It is much harder to lose weight and then maintain the weight loss if one is simultaneously battling demons that are rooted in childhood experiences. That is not “pop psychology” for those members of Cluster 2 who suffer mental illness.

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  12. I was a member of the Registry for five or six years, but didn’t fill in the forms the last time.

    I wonder about the Registry’s methodology and never felt I could answer the questions completely and honestly, partly because they focus on low-fat and processed food. For example, one question is “Do you eat cold cereal?” (Yes) Then later, respondents are given a list of processed cereals and asked to nominate which ones they eat. I couldn’t answer that question because I eat only home-made, sugar-free muesli or granola. Am I that unusual?

    That’s just one trivial example, but the questionnaires always left me feeling frustrated. Rating your feelings on an 8-point scale doesn’t work for me.

    I agree with Alexie’s comment: I know that I have become somewhat obsessed with healthy eating and exercise and it seems to me that other people become like this as well. I should add that there is a component of near-obsession involved, rather than just a ‘healthy lifestyle’ change. It makes me believe that losing very big amounts of weight and keeping it off has a big psychological cost. I know that some of my ambition and career drive seems to have turned into exercise and weight maintenance drive, and I’m not sure if that’s a good thing.

    For the record, I have lost 40 kg from a starting weight of 100 kg, have maintained my weight loss steadily for about 8.5 years, and would fit into Cluster 1. I had a weight problem since early childhood, and didn’t yo-yo diet.

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  13. Just adding that my starting BMI was 39.9.

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  14. But mental illness is not solely (or even most often) the result of trauma. Rates of mental illness and trauma are no higher among fat people than among the general population. There is simply no evidence that mental illness or trauma causes obesity.

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  15. I have simply seen too many women (especially women) who have struggled their whole lives with their weight who were abused in some way as kids, including friends of mine. And stories on various blogs are just too numerous to deny. There are absolutely connections in people’s minds with “If I am too small, I can be more easily abused,” and those connections must be addressed. And since ALL of the people I’ve known and encountered who have that buried belief would fall smack in the middle of Cluster 2, it seems to me that denying that is flat-out dangerous. It’s also cruel.

    No, they aren’t the only big people in the world, and yes there are slim people battling demons. But one of the commonalities of people who struggle the hardest with any addiction — Cluster 2 folks, whatever their drug of choice is — is that they survived abuse and it started young. I’ve known a lot of people over time, and more online. Every single one of them who is seriously overweight, like over 300 lbs, and has struggled against it their whole lives have been through serious crap as kids. Every single one. I do not want to just sweep their experiences under the rug because it makes people queasy, nor do I think there’s value is telling them, “Go ahead and keep avoiding thinking about what was done to you, here’s a pill.” These are friends of mine — and they’re right in the center of Cluster 2.

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  16. BTW, these are not women who are “mentally ill.” They are women who have been through some serious shit as kids. There is a difference. That alone indicates to me that there may be more going on with Cluster 2 than out-of-whack DNA, and that it needs to be investigated.

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  17. @Janis, The plural of ‘anecdote’ is not ‘data’. I certainly home the people you know with a history of childhood trauma get the help they need to heal those wounds.

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  18. Bobbini, at some point, the plural of anecdote does become data. It requires study.

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  19. Bobbini even on this site Dr. Sharma has occasionally mentioned this — the definite correlation between substance abuse (in this case, food) and having tolerated abuse as a kid. There most certainly are indicators that this requires and deserves study.

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  20. Here’s the link to one of the studies that you claim don’t exist:

    http://www.drsharma.ca/obesity-interpersonal-violence-in-childhood-as-a-risk-factor-for-obesity.html

    Sweeping this under the rug will not help people for whom this is a problem. No “healing of wounds” for those affected by this will occur as long as people hide their eyes about it and refuse to acknowledge that this is a rick factor because they fear being associated with abuse victims. What you’re saying is, “I hope they heal their wounds, over there, as far from me as possible.”

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  21. Janis, has it occurred to you that fat kids often get physically and mentally abused because they’re fat? Any study of the phenomenon you talk about would have to take that into consideration. I mean, you can’t blame body size on abuse when the abuse was at least partly because of body size.

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  22. I am in no way advocating sweeping abuse under the rug. I am arguing that we should not start with the assumption that someone who is fat has been abused.

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  23. Holy mother of dreamers – what is so obvious in all of this, is the amount of speculation that is going on here. The first thing that comes to mind is “I wonder what Einstein’s blog would have looked like?” And if he would have had a blog, I wonder if it would have impeded his progress. He would have just been “Dr, Albert” at the time. Would the comments have spurred him to greater progress or slowed him down? Who’s job was it to discover the theory of relativity anyway? Still, I really am grateful for all of his efforts. Just speculating about speculating.

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