Practices Associated with Weight Loss Versus
Weight-Loss Maintenance
Results of a National Survey
Christopher N. Sciamanna, MD, MPH, Michaela Kiernan, PhD, Barbara J. Rolls, PhD,
Jarol Boan, MD, Heather Stuckey, DEd, Donna Kephart, PhD, Carla K. Miller, PhD,
Gordon Jensen, MD, PhD, Terry J. Hartmann, PhD, Eric Loken, PhD,
Kevin O. Hwang, MD, MPH, Ronald J. Williams, MD, Melissa A. Clark, PhD,
Jane R. Schubart, PhD, Arthur M. Nezu, PhD, Erik Lehman, MS, Cheryl Dellasega, PhD
Background: Few studies have examined the weight-control practices that promote weight loss and
weight-loss maintenance in the same sample.
Purpose: To examine whether the weight control practices associated with weight loss differ from
those associated with weight-loss maintenance.
Methods: Cross-sectional survey of a random sample of 1165 U.S. adults. The adjusted associations
of the use of 36 weight-control practices in the past week with success in weight loss (ⱖ10% lost in the
past year) and success in weight-loss maintenance (ⱖ10% lost and maintained for ⱖ1 year) were
examined.
Results: Of the 36 practices, only 8 (22%) were associated with both weight loss and weight-loss
maintenance. Overall, there was poor agreement (kappa⫽0.22) between the practices associated with
weight loss and/or weight-loss maintenance. For example, those who reported more often following
a consistent exercise routine or eating plenty of low-fat sources of protein were 1.97 (95% CI⫽1.33,
2.94) and 1.76 (95% CI⫽1.25, 2.50) times more likely, respectively, to report weight-loss maintenance but not weight loss. Alternatively, those who reported more often doing different kinds of
exercises or planning meals ahead of time were 2.56 (95% CI⫽1.44, 4.55) and 1.68 (95% CI⫽1.03,
2.74) times more likely, respectively, to report weight loss but not weight-loss maintenance.
Conclusions: Successful weight loss and weight-loss maintenance may require two different sets of
practices. Designing interventions with this premise may inform the design of more effective
weight-loss maintenance interventions.
(Am J Prev Med 2011;41(2):159 –166) © 2011 American Journal of Preventive Medicine
Introduction
O
ver the past 20 years, the percentage of overweight and obese Americans, as well as the prevalence of weight-related comorbidities, has
grown tremendously.1 Approximately 20% of U.S. adults
are able to lose and maintain at least 10% of their body
From the Department of Medicine (Sciamanna, Boan, Stuckey, Williams),
Department of Pediatrics (Williams), and Department of Surgery (Schubart), Penn State Hershey Medical Center; the Department of Nutrition
Sciences (Rolls, Jensen, Hartmann), Department of Human Development
and Family Studies (Loken), Department of Public Health Sciences
(Kephart, Lehman), and Department of Humanities (Dellasega), Penn
State University, Hershey; the Department of Psychology, Drexel University (Nezu), Philadelphia, Pennsylvania; Stanford Center for Research in
Disease Prevention, Stanford University (Kiernan), Stanford, California;
Department of Human Nutrition, Ohio State University (Miller), Colum-
weight for at least 1 year, but each weight-loss attempt is
relatively unsuccessful.2,3 Approximately one third of
weight lost is regained within 1 year, and the remainder is
typically regained within 3 to 5 years.4 Although the elements of formal weight-loss programs (e.g., self-monitoring,
stimulus control), which consistently lead to average
weight losses of approximately 10% of body weight at
bus, Ohio; Department of Medicine, University of Texas Medical School at
Houston (Hwang), Houston, Texas; and Department of Community
Health, Brown University (Clark), Providence, Rhode Island
Address correspondence to: Christopher N. Sciamanna, MD, MPH,
Penn State Hershey Medical Center, Department of Medicine, Division of
General Internal Medicine Mail Code H034, 500 University Drive, Hershey
PA 17033. E-mail: [email protected].
0749-3797/$17.00
doi: 10.1016/j.amepre.2011.04.009
© 2011 American Journal of Preventive Medicine • Published by Elsevier Inc.
Am J Prev Med 2011;41(2):159 –166 159
160
Sciamanna et al / Am J Prev Med 2011;41(2):159 –166
21 weeks, are well understood, the elements of formal
weight-maintenance programs remain to be identifıed.
One possible reason for the low rates of weight-loss
maintenance may be that the practices that lead to weight
loss differ from the practices that support weight-loss
maintenance. One of the most commonly used measures
of weight-control practices that lead to weight loss is the
Eating Behavior Inventory (EBI).5–7 Changes in the EBI
score, among individuals in weight-loss programs, correlate closely with the amount of weight lost.8,9 For weightloss maintenance, much of what is known is based on the
National Weight Control Registry (NWCR), a long-term
study of more than 6000 adults who have maintained a
weight loss of at least 30 pounds (13.6 kg) for at least 1
year. Studies from the NWCR, for example, have observed that a number of practices are associated with
weight-loss maintenance, including consistent dieting,10
decreased food group variety,11 and less TV watching.12
Despite isolated fındings from past research about key
practices during loss or maintenance, no study has examined the same set of practices for both phases. Traditional
weight-loss programs typically include multiple components from multiple theoretic approaches (e.g., cognitive–behavioral therapy, self-regulation theory).13–15 Weightmaintenance interventions typically have focused on the
long-term use of the same set of practices, by encouraging
problem solving to overcome barriers to their long-term
use.16 –19 However, behavioral maintenance may require
different actions, rather than “action sustained over
time.”20 –22 Conceivably, the reason for the high rates of
success in weight loss and the low rates of success in
weight-loss maintenance may be that the practices that
lead to weight loss are different from the practices that
help one maintain weight loss. In the present study, the
question of whether the practices associated with weight
loss differed from those associated with weight-loss
maintenance was examined. It was of particular interest
as to whether there may be specifıc practices that are
associated with weight-loss maintenance but not in initial
weight loss. If so, it would help to inform the development
of interventions specifıc to weight-loss maintenance.
Methods
A survey of weight-control practices was created, based on principles of Positive Deviance.23 Positive Deviance is related to the
framework of problem solving and is based on the notion that
individuals who are unusually successful have different practices
than those who are not successful. These practices can be identifıed
and disseminated to inform the problem-solving process.24
In the present study, in-depth interviews were conducted fırst to
identify the weight-control practices used by successful individuals, which was followed by a survey. For the in-depth interviews,
1165 adults were recruited who were successful at weight-loss
maintenance, via newspaper and online advertisements. Long-
term success was defıned as losing at least 30 pounds (13.6 kg) and
keeping it off for at least 1 year, consistent with the NWCR criterion.25 The interview script identifıed practices used to maintain
weight loss with open-ended questions and probes about behaviors
and cognitions, including What habits do you use regularly now to
maintain a healthy weight? Trained staff of the Penn State Survey
Research Center conducted the phone interviews. Two research
assistants coded transcripts, ten of which were coded by both
assistants (interrater agreement⫽94%). Only practices mentioned
by at least 10% of participants were included, leaving a fınal list of
36 practices. Additional details of interviews are available in a
published manuscript describing the survey development.26
A survey was then created to measure the use of each practice in
the past week, on a 5-point scale, which was recategorized into high
(often, very often) and low (never, sometimes, seldom) use. The
survey was conducted during February 2008 among a nationwide
panel of adults aged ⱖ21 years (Knowledge Networks, Inc.) living
in the U.S. Additional details about the panel’s sampling and recruitment are available elsewhere.27 The IRB at Pennsylvania State
University approved the study. Weight history (e.g., weight 1 year
ago) and physical activity were assessed using items from the National Health and Nutrition Examination Survey (NHANES)
Weight History Questionnaire and the Behavioral Risk Factor Surveillance System (BRFSS).28 Past medical history and demographic
variables (e.g., age, gender) were assessed using standard measures.
Weight-control success was categorized in two ways. First, the
amount of weight lost in the current weight-loss attempt was determined by subtracting the weight at the beginning of the weightloss attempt from the current weight, and categorized based on the
amount of weight lost (at least 10% of initial weight versus less than
10%). Second, individuals whose weight 1 year ago and current
weight were both at least 10% less than their maximum weight were
considered successful at long-term weight loss.29 This variable was
limited to those who were overweight or obese (BMIⱖ25.0) at their
maximum weight. Although different time points to defıning the
weight-loss and weight-maintenance phases were considered, as
there is no sharp demarcation between the weight-loss and weightloss maintenance phases, standard defınitions from the NWCR
(25) were used, consistent with a meta-analysis showing that most
weight regain occurs in the fırst year.30
Results
Demographic, weight history, and medical history variables
for the sample can be seen in Table 1. Forty-seven individuals (3.7%) were excluded subsequently for either having one
of the three missing weight variables, being pregnant, or
having a BMI of less than 18.5 (considered underweight
according to the NIH Guidelines).29 More than one third
were overweight, consistent with other nationally representative surveys.31 As the primary objective was to compare
the weight-control practices of those with successful weight
loss versus successful weight-loss maintenance, 2% (n⫽19)
adults who reported both successful weight loss and successful weight-loss maintenance were excluded. Among the 926
remaining individuals whose maximum weight corresponded to a BMI ⬎25, 10.6% (n⫽98) lost 10% of their body
www.ajpmonline.org
Sciamanna et al / Am J Prev Med 2011;41(2):159 –166
Table 1. Demographics and weight-loss history among
participants, %
Overall
(n⫽1165)
161
Table 1. (continued)
Overall
(n⫽1165)
BMI ever ⱖ25.0
(n⫽926)
Excellent
13.3
10.0
Very good
33.1
31.7
Good
37.0
40.1
Fair
13.0
14.2
Poor
3.6
4.0
No
74.6
70.8
Yes
24.5
29.2
No
90.1
88.1
Yes
9.1
11.9
No
71.1
67.1
Yes
28.9
32.9
BMI ever ⱖ25.0
(n⫽926)
Health status
Age (years)
18–34
25.3
22.1
35–44
20.5
21.2
45–64
39.3
41.2
ⱖ65
14.9
15.6
Male
49.0
51.1
Female
51.0
48.9
White, nonHispanic
70.8
70.1
Black, nonHispanic
10.3
11.2
6.8
6.1
12.0
12.6
Less than high
school
12.2
12.4
High school
32.1
33.2
Some college
26.6
26.5
College graduate
29.2
27.9
⬍25,000
21.4
21.7
25,000–49,999
30.2
30.2
⬎50,000
48.4
48.2
18.5–25
30.3
14.4
⬎25–30
34.4
41.9
⬎30–35
19.4
24.0
⬎35–40
8.8
10.9
⬎40
7.2
8.9
No
54.2
39.1
Yes
45.8
60.9
⬍150/week
50.2
50.1
ⱖ150/week
49.8
49.1
Gender
High cholesterol
Race and ethnicity
Hispanic
Other nonHispanic
Diabetes
Hypertension
Education
Income ($)
Current BMI category
Trying to lose weight
Activity minutes
(continued)
August 2011
weight in the past year and 20.7% (n⫽192) maintained a
weight loss of at least 10% for at least 1 year.
The percentage of individuals using each practice often
or very often and the adjusted association between the use
of each practice and both initial weight loss and weightloss maintenance are reported in Table 2. Four of the
practices were associated with weight-loss maintenance
but not initial weight loss. For example, those who reported following a consistent exercise routine more often
and those who reported eating more often plenty of lowfat sources of protein were 1.97 (95% CI⫽1.33, 2.94) and
1.76 (95% CI⫽1.25, 2.50) times, respectively, more likely
to report successful weight-loss maintenance but were
not more likely to report successful initial weight loss.
Of the 18 practices associated with successful weight
loss, ten were also associated with weight-loss maintenance and eight were not. For example, those who reported limiting more often the amount of carbohydrates
or “carbs” eaten were 2.76 (95% CI⫽1.69, 4.51) times
more likely to report successful initial weight loss and
1.62 (95% CI⫽1.10, 2.38) times more likely to report
successful weight-loss maintenance, compared to those
who reported using these practices less often. Alternatively, those who reported more often doing different
kinds of exercises or planning what was eaten ahead of
time were 2.56 (95% CI⫽1.44, 4.55) and 1.68 (95%
CI⫽1.03, 2.74) times more likely, respectively, to report
successful initial weight loss but not weight-loss
maintenance.
Sciamanna et al / Am J Prev Med 2011;41(2):159 –166
162
Table 2. Association between using specific weight-control practices often and very often in the past 7 days and
weight-control outcomes
Successful
weight-loss
maintenance
(20.7%)c
Successful weight
loss (10.6%)a
Overall (%)
(n⫽1165)
Yes
(n⫽98)
No
(n⫽828)
ORb (CI)
3.0
10.2
3.0
Look for information about
weight loss, nutrition,
or exercised
13.0
20.8
Replace high-calorie foods
or drinks
41.5
Eat plenty of fruits or
vegetables
p-value
Yes
(192)
No
(734)
OR (CI)
3.17 (1.20, 8.33)
0.019
4.0
3.7
1.43 (0.59, 3.47)
0.434
13.7
1.72 (0.96, 3.11)
0.007
14.4
14.4
1.25 (0.76, 2.03)
0.377
51.1
40.4
1.30 (0.81, 2.07)
0.273
38.8
42.2
0.89 (0.63, 1.27)
0.535
51.6
63.3
46.7
2.50 (1.51, 4.13)
⬍0.001
54.9
46.6
1.54 (1.08, 2.19)
0.017
Eat healthy snacksd
35.5
52.1
31.1
2.55 (1.59, 4.11)
⬍0.001
36.8
32.4
1.31 (0.91, 1.88)
0.152
Eat plenty of low-fat
sources of proteind
50.3
45.3
48.3
0.91 (0.57, 1.45)
0.698
55.8
45.8
1.76 (1.25, 2.50)
0.001
Limit the amount of
carbohydrates or
“carbs” you eat
25.0
41.7
23.0
2.76 (1.69, 4.51)
⬍0.001
31.4
23.2
1.62 (1.10, 2.38)
0.014
Eat about the same thing
every day
40.9
39.7
39.9
1.09 (0.67, 1.77)
0.718
38.5
40.2
0.95 (0.67, 1.36)
0.789
Limit the amount of sugar
you eat or drinkd
45.9
61.4
44.5
1.96 (1.22, 3.16)
0.006
50.9
45.0
1.33 (0.94, 1.89)
0.111
Limit the amount of
unhealthy food in your
home
44.4
51.5
41.0
1.60 (1.00, 2.56)
0.051
42.0
42.0
1.10 (0.78, 1.56)
0.584
Drink plenty of water
59.3
63.4
59.3
1.28 (0.79, 2.08)
0.325
55.5
60.8
0.81 (0.57, 1.14)
0.229
Avoid eating or drinking
too much while eating
out
60.4
67.2
58.3
1.59 (0.98, 2.57)
0.061
65.1
57.6
1.31 (0.92, 1.86)
0.139
Control your portions
35.8
50.2
32.0
2.18 (1.36, 3.49)
0.001
39.4
32.4
1.62 (1.12, 2.32)
0.01
Plan what you’ll buy
before you get to the
grocery store
52.8
61.8
49.5
1.69 (1.06, 2.69)
0.029
57.2
49.0
1.55 (1.10, 2.19)
0.012
Plan what you’ll eat ahead
of timed
30.7
43.0
28.5
1.68 (1.03, 2.74)
0.04
30.6
29.7
1.21 (0.83, 1.76)
0.323
Allow yourself to eat a
small amount of some
unhealthy foods
22.6
14.3
20.8
0.45 (0.23, 0.89)
0.021
20.9
19.9
1.06 (0.70, 1.61)
0.78
Read nutrition labels
38.3
53.4
34.0
1.98 (1.21, 3.26)
0.007
42.1
34.4
1.71 (1.18, 2.45)
0.004
Avoid skipping a meal,
including breakfastd
36.2
45.2
31.9
1.78 (1.10, 2.86)
0.018
37.6
32.1
1.30 (0.90, 1.87)
0.161
Follow a consistent
exercise routined
27.6
23.6
25.9
1.41 (0.81, 2.46)
0.223
32.4
23.8
1.97 (1.33, 2.94)
⬍0.001
Do different kinds of
exercisesd
14.6
21.5
13.1
2.56 (1.44, 4.55)
0.001
15.6
13.5
1.38 (0.86, 2.21)
0.18
p-value
Diet practices
Participate in a weightloss programd
Physical activity practices
(continued on next page)
www.ajpmonline.org
Sciamanna et al / Am J Prev Med 2011;41(2):159 –166
163
Table 2. (continued)
Successful
weight-loss
maintenance
(20.7%)c
Successful weight
loss (10.6%)a
Overall (%)
(n⫽1165)
Yes
(n⫽98)
No
(n⫽828)
ORb (CI)
Try to fit exercise into your
lifestyle
28.4
23.3
27.1
Walk for exercise
37.2
39.7
Do exercises that you
enjoyd
32.6
Exercise with other people
p-value
Yes
(192)
No
(734)
OR (CI)
0.83 (0.47, 1.48)
0.532
29.1
26.1
1.33 (0.89, 1.97)
0.163
36.4
1.48 (0.91, 2.40)
0.115
39.7
35.9
1.37 (0.96, 1.95)
0.085
34.6
30.8
1.73 (1.04, 2.89)
0.035
32.6
30.8
1.21 (0.83, 1.76)
0.332
14.3
14.2
15.3
1.11 (0.59, 2.10)
0.742
13.1
15.7
0.91 (0.56, 1.48)
0.699
5.9
10.0
5.5
1.98 (0.89, 4.41)
0.095
9.5
5.1
2.05 (1.11, 3.81)
0.022
Think about how much
better you feel when
you are thinnerd
37.9
53.4
38.1
1.80 (1.13, 2.87)
0.014
45.2
38.4
1.41 (1.00, 2.00)
0.052
Remind yourself why you
need to control your
weightd
39.2
53.8
40.5
1.57 (0.98, 2.52)
0.059
50.2
39.6
1.76 (1.24, 2.51)
0.001
Think about how much
progress you’ve made
18.3
38.6
17.9
2.78 (1.71, 4.53)
⬍0.001
31.7
17.0
2.43 (1.65, 3.57)
⬍0.001
Look at older pictures of
yourself to motivate
you
7.7
9.7
7.8
1.09 (0.51, 2.32)
0.828
10.9
7.2
1.72 (0.98, 3.04)
0.06
Think about the clothes
you would like to fit
into
24.0
31.4
26.5
1.23 (0.74, 2.05)
0.418
27.0
27.0
1.06 (0.72, 1.57)
0.768
Think about not overeating
while you were eating a
meal
24.0
36.9
24.5
1.63 (1.00, 2.64)
0.051
23.3
26.4
0.83 (0.56, 1.23)
0.36
Notice how many people
are overweight
49.3
49.7
47.4
0.95 (0.61, 1.50)
0.838
52.8
46.3
1.32 (0.94, 1.84)
0.111
Think about your goal for
a healthy weight
35.3
51.9
35.5
1.76 (1.10, 2.82)
0.019
44.1
35.3
1.70 (1.19, 2.43)
0.004
24.5
36.7
22.3
1.70 (1.03, 2.81)
0.039
31.1
21.8
1.76 (1.20, 2.57)
0.004
Write down what you eat
and drink each dayd
4.7
8.7
5.8
1.30 (0.57, 2.96)
0.535
7.9
5.6
1.39 (0.72, 2.66)
0.324
Write down how much you
exercise each day
5.6
43.0
28.5
1.68 (1.03, 2.74)
0.04
30.6
29.7
1.21 (0.83, 1.76)
0.323
p-value
Cognitive practices
Reward yourself for
sticking to your diet or
exercise pland
Tracking practices
Weigh yourself
a
Defined as current weight at least 10% less than weight 1 year ago, among those who were overweight at their maximum weight (n⫽926).
OR, adjusted for age, gender, race, health status, education level, and medical conditions
c
Defined as having a current weight and a weight 1 year ago at least 10% less than the maximum weight, among those who were overweight at their maximum weight
(n⫽926).
d
Practices were discordantly associated with either weight loss or weight-loss maintenance, but not both.
Note: Bolded text signifies an adjusted p-value ⬍0.5.
b
Overall, the use of 14 of the 36 (see Table 2, footnote d)
practices was discordantly associated with either weight
loss or weight-loss maintenance but not both. The percentage agreement, therefore, was 61% (22 of 36 pracAugust 2011
tices). This agreement is only slightly higher than by
chance alone (18 of 36 practices or 50% agreement). The
Cohen’s kappa was not signifıcant (kappa⫽0.22,
p⫽0.16), suggesting poor agreement.
164
Sciamanna et al / Am J Prev Med 2011;41(2):159 –166
Discussion
In this sample, 14 practices were associated with either
weight loss or weight-loss maintenance, but not both. The
percentage agreement between practices associated with
weight loss and/or weight-loss maintenance (61%) was
not much higher than chance, consistent with a kappa
value (0.22) that was not signifıcant.
Most (75%) of the practices that were associated with
weight-loss maintenance represented a subset of those
that were associated with weight loss. Four practices (Eat
plenty of low-fat sources of protein, Follow a consistent
exercise routine, Reward yourself for sticking to your diet
or exercise plan, Remind yourself why you need to control your weight), however, were associated with weightloss maintenance but not initial weight loss. The main
conclusion that these data support is that the set of practices that support weight loss may be different from the
set of practices that support weight-loss maintenance. A
prevailing notion of weight-loss maintenance is that it
represents “action sustained over time.”20 –22 If this were
to be true, a high degree of agreement should have been
observed between the practices associated with weight
loss and those associated with weight-loss maintenance.
The agreement, however, was poor.
Most of the practices measured (e.g., self-weighing,
portion control) are not novel, yet the present study is
novel in that it is the fırst nationally representative study
to examine whether the weight-control practices associated with weight loss differ from those associated with
weight-loss maintenance. Positive deviance uses qualitative methods to increase the odds that all possibly effective practices are identifıed, regardless of their association
with a theory (e.g., cognitive– behavioral theory).23 Although qualitative methods were used to identify the
practices, the consistency of a number of observations
with other studies increases the confıdence in these methods. For example, self-weighing was associated with initial weight loss and weight-loss maintenance, consistent
with fındings observed in the NWCR and by other investigators.32,33 In addition, planning meals was associated
with weight loss, consistent with earlier fındings.34 As
behavioral weight control is the sum total of a great number of practices that each influence caloric intake and/or
caloric expenditure, positive deviance is closely related to
the framework of problem solving, where alternative
practices are explored, identifıed, selected, implemented,
and evaluated.16,18,35–37
A number of the observed relationships are hypothesized to be consistent with the underlying process of
problem solving. Weight control, however, is a somewhat
unique problem as many alternative solutions (e.g., portion control) typically are implemented at the same time
rather than sequentially, which makes it challenging to
measure the impact of each and thereby discard ineffective practices. This may explain why a number of practices that were used consistently (e.g., drink plenty of
water) were not associated with success; if you cannot
show a practice to be unhelpful it is harder to decide to
stop using it. Given the great number of potential weightcontrol practices, each of which may be helpful, the principles of problem solving also may explain why a number
of practices that were associated with success (e.g., reward
yourself for sticking to your diet or exercise plan), were
used by only a minority of adults; as individuals typically
stop making changes once they achieve success, there
simply may be too many potential weight-control practices to presume that each would be used by each successful individual.36
Problem-solving interventions have proven effective
in weight control, and improvements in problem-solving
skills, as observed by Murawski et al.,38 have been associated with successful weight outcomes.16,18, 39 A key activity of problem solving is identifying alternative solutions
that may help.40 This may explain the observation that
those who reported doing different kinds of exercises
more often were more likely to report success in initial
weight loss but not in weight-loss maintenance. Early on
in the problem-solving process, it may be important to
experiment with different exercises, to identify ones that
have the qualities that the user likes and has confıdence in
doing.
Once these activities have been identifıed, Rothman
and colleagues41 suggest that future success may be dependent on having an effective routine for making these
activities habitual. This is consistent with the observation
in the current study that those who reported more often
following an exercise routine were more likely to report
successful weight-loss maintenance but not more likely to
report successful initial weight loss (Table 2). This also
may explain why eating plenty of low-fat sources of protein was associated with weight-loss maintenance and not
weight loss. During the weight-loss phase, a focus is on
limiting calories, but later one must adopt behaviors that
satisfy the dual long-term goals of limiting calories and
meeting nutritional needs; eating plenty of low-fat
sources of protein is hypothesized to be one of those
behaviors.
During the process of problem solving, individuals
implement potential solutions and verify whether they
help or not.35 Solutions that help should be continued,
which may explain why most (75%, 8 of 12) of the practices that were associated with weight-loss maintenance
were associated also with initial weight loss. In addition, a
positive problem-solving orientation has been observed
to increase motivation to actively engage in problem solvwww.ajpmonline.org
Sciamanna et al / Am J Prev Med 2011;41(2):159 –166
39
ing. Although individuals are highly motivated at the
beginning of a weight-control program, this motivation
decreases over time.42 This may explain why two practices (reward yourself for sticking to your diet or exercise
plan and remind yourself why you need to control your
weight) were associated with weight-loss maintenance
but not with weight loss. These two practices may elicit
personal motivations to actively persist in the weightcontrol process over the long term, which West et al.42
observed was an effective intervention for improving
weight-loss maintenance.
The current study had several limitations. First, given
the cross-sectional design, future research will need to
determine whether changes in practices produce changes
in weight outcomes. Given the high degree of correlation
(0.34 – 0.74) between changes in the use of practices and
outcomes using the EBI,8,34,43 it is anticipated that these
practices will be shown to be associated with changes in
weight. Second, the measure has not been validated
against gold standard measures of diet and activity. Several of the items asked about the intake of specifıc types of
foods (e.g., high carbohydrate), which may not have been
reported accurately, as adults commonly have diffıculty
categorizing foods. For example, the Health and Diet
Survey44 observed that only 3% of U.S. adults could correctly identify whether or not a list of six foods (e.g.,
oatmeal) were made from whole grains. Although examples taken from the interviews were provided in the survey questions that were asked in order to increase the
accuracy of reporting,26 future validation studies will be
needed for the measure of weight-control practices.
Third, the current study relied on self-reported
weights, which have been shown to underestimate actual
weights by approximately 1.98 kg for men and 1.86 kg for
women,45 despite high observed correlations between reported and measured weights; 0.98 for current weight and
0.94 for weight 4 years ago.46 If present, however, these
inaccuracies should have biased some of the associations
toward the null. Fourth, methods such as cognitive-based
testing, think-aloud and focused-probing interviews,
commonly used to ensure the accuracy of survey questions,47,48 were not used and should be considered in
future studies. Fifth, the interviews performed to identify
the practices were done only with individuals who maintained weight loss, so they may underrepresent the practices used by individuals successful in initial weight loss.
Although the components of weight-loss interventions
that lead to weight loss are fairly well understood,15,49 the
components of weight-maintenance interventions are
much less so. Three large weight-loss maintenance studies,16,19,50 for example, all employed a different set of
methods and practices, yet they all showed an impact,
preventing regains of between 1.6 kg and 2.5 kg at 12
August 2011
165
months. The main conclusion in the current study, that
the practices that are associated with weight loss are different from those that are associated with weight-loss
maintenance, is potentially quite important. Few studies,
for example, have identifıed practices that are associated
with weight-loss maintenance but not initial weight loss.
In the present study, it was observed that those who used
four practices (eat plenty of low-fat sources of protein,
follow a consistent exercise routine, reward yourself for
sticking to your diet or exercise plan, and remind yourself
why you need to control your weight) more often were
more likely to be successful in weight-loss maintenance
but not in initial weight loss.
Although these fındings are preliminary and will need
to be replicated, they are consistent with previous work
suggesting that the process of behavior initiation (e.g.,
weight loss) is different from the process of behavior
maintenance.20 –22 Given the waning motivation to engage in the weight-control process over time,42 designing
interventions that focus on encouraging different practices at different times may enable the creation of more
effective weight-loss maintenance interventions.
The study was funded by a grant jointly provided by Pennsylvania State University and Highmark Blue Cross Blue Shield
(Pittsburgh PA).
No fınancial disclosures were reported by the authors of this
paper.
References
1. Cowie CC, Rust KF, Byrd-Holt DD, et al. Prevalence of diabetes and
impaired fasting glucose in adults in the U.S. population: National
Health and Nutrition Examination Survey 1999 –2002. Diabetes Care
2006;29(6):1263– 8.
2. McGuire MT, Wing RR, Hill JO. The prevalence of weight loss maintenance among American adults. Int J Obes Relat Metab Disord
1999;23(12):1314 –9.
3. Kraschnewski JL, Boan J, Esposito J, et al. Long-term weight loss
maintenance in the U.S. Int J Obes (Lond) 2010;34(11):1644 –54.
4. Wadden TA, Phelan S. Behavioral assessment of the obese patient. In:
Wadden TA, Stunkard AJ, eds. Handbook of obesity treatment. New
York: Guilford Press, 2002:186 –226.
5. O’Neil PM, Currey HS, Hirsch AA, et al. Development and validation
of the Eating Behavior Inventory. J Behav Assess 1979;1(2):123–32.
6. Nothwehr F, Dennis L, Wu H. Measurement of behavioral objectives
for weight management. Health Educ Behav 2007;34(5):793– 809.
7. French SA, Jeffery RW, Murray D. Is dieting good for you? Prevalence,
duration and associated weight and behaviour changes for specifıc
weight loss strategies over four years in U.S. adults. Int J Obes Relat
Metab Disord 1999;23(3):320 –7.
8. O’Neil PM, Rieder S. Utility and validity of the Eating Behavior Inventory in clinical obesity research: a review of the literature. Obes Rev
2005;6(3):209 –16.
9. Gold BC, Burke S, Pintauro S, Buzzell P, Harvey-Berino J. Weight loss
on the web: a pilot study comparing a structured behavioral interven-
166
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
Sciamanna et al / Am J Prev Med 2011;41(2):159 –166
tion to a commercial program. Obesity (Silver Spring) 2007;
15(1):155– 64.
Gorin AA, Phelan S, Wing RR, Hill JO. Promoting long-term weight
control: does dieting consistency matter? Int J Obes Relat Metab Disord
2004;28(2):278 – 81.
Raynor HA, Jeffery RW, Phelan S, Hill JO, Wing RR. Amount of food
group variety consumed in the diet and long-term weight loss maintenance. Obes Res 2005;13(5):883–90.
Raynor DA, Phelan S, Hill JO, Wing RR. Television viewing and longterm weight maintenance: results from the National Weight Control
Registry. Obesity (Silver Spring) 2006;14(10):1816 –24.
Brownell KD. The LEARN Program for weight control. Dallas TX:
American Health, 1997.
The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care 2002;25(12):2165–71.
Foster GD, Makris AP, Bailer BA. Behavioral treatment of obesity.
Am J Clin Nutr 2005;82(1S):230S–5S.
Perri MG, Limacher MC, Durning PE, et al. Extended-care programs
for weight management in rural communities: the Treatment of Obesity in Underserved Rural Settings (TOURS) randomized trial. Arch
Intern Med 2008;168(21):2347–54.
Perri M, Nezu AM, Viegener BJ. Improving the long-term management of obesity: theory, research and clinical guidelines. New York:
Wiley, 1992.
Perri MG, Nezu AM, McKelvey WF, Shermer RL, Renjilian DA,
Viegener BJ. Relapse prevention training and problem-solving therapy
in the long-term management of obesity. J Consult Clin Psychol
2001;69(4):722– 6.
Svetkey LP, Stevens VJ, Brantley PJ, et al. Comparison of strategies for
sustaining weight loss: the weight loss maintenance randomized controlled trial. JAMA 2008;299(10):1139 – 48.
Rothman AJ, Gillespie AH, Johnson-Askew WL. Decision making in
eating behavior: interacting perspectives from the individual, family,
and environment: an introduction. Ann Behav Med 2009;38(S1):S1–3.
Rothman AJ. Toward a theory-based analysis of behavioral maintenance. Health Psychol 2000;19(1S):64 –9.
Kiernan M, Perri MG, Moore S, King AC, Taylor CB, Kraemer HC.
Promoting healthy weight with “Stability First”: Study design and
theoretical considerations. International Society of Behavioral Nutrition and Physical Activity; June; Lisbon, Portugal 2009.
Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The
power of positive deviance. BMJ 2004;329(7475):1177–9.
Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the doorto-balloon time in acute myocardial infarction. N Engl J Med 2006;
355(22):2308 –20.
Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. A descriptive
study of individuals successful at long-term maintenance of substantial
weight loss. Am J Clin Nutr 1997;66(2):239 – 46.
Stuckey HL, Boan J, Miller-Day M, Lehman E, Sciamanna CN. Using
positive deviance for determining successful weight control practices.
Qual Health Res 2011;21(4):563–79.
Barry CL, Brescoll VL, Brownell KD, Schlesinger M. Obesity metaphors: how beliefs about the causes of obesity affect support for public
policy. Milbank Q 2009;87(1):7– 47.
Weiss EC, Galuska DA, Kettel Khan L, Gillespie C, Serdula MK. Weight
regain in U.S. adults who experienced substantial weight loss, 1999 –
2002. Am J Prev Med 2007;33(1):34 – 40.
Clinical guidelines on the identifıcation, evaluation and treatment of
overweight and obesity in adults. Bethesda MD: National Heart, Lung,
and Blood Institute, 2000.
30. Franz MJ, VanWormer JJ, Crain AL, et al. Weight-loss outcomes: a
systematic review and meta-analysis of weight-loss clinical trials with a
minimum 1-year follow-up. J Am Diet Assoc 2007;107(10):1755– 67.
31. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends
in obesity among U.S. adults, 1999 –2008. JAMA 2010;303(3):235– 41.
32. Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature. J Am Diet Assoc 2011;111(1):92–102.
33. Butryn ML, Phelan S, Hill JO, Wing RR. Consistent self-monitoring of
weight: a key component of successful weight loss maintenance. Obesity (Silver Spring) 2007;15(12):3091– 6.
34. Qi BB, Dennis KE. The adoption of eating behaviors conducive to
weight loss. Eat Behav 2000;1(1):23–31.
35. Nezu AM. Problem solving and behavior therapy revisited. Behav Ther
2004;35:1–33.
36. Nezu AM, Nezu CM, D’Zurilla TJ. Solving life’s problems: a 5 step
guide to enhanced well-being. 3rd ed. New York: Springer, 2007.
37. Nezu AM, Nezu CM, Felgoise SH, McClure KS, Houts PS. Project
Genesis: assessing the effıcacy of problem-solving therapy for distressed adult cancer patients. J Consult Clin Psychol 2003;
71(6):1036 – 48.
38. Murawski ME, Milsom VA, Ross KM, et al. Problem solving, treatment
adherence, and weight-loss outcome among women participating in
lifestyle treatment for obesity. Eat Behav 2009;10(3):146 –51.
39. Nezu AM, Nezu CM, Perri M. Problem solving to promote treatment
adherence. In: Levensky WTODER, ed. Promoting treatment adherence: a practical handbook for health care providers. New York: Sage,
2006.
40. Nezu AM, Nezu CM, Jain D. Social problem solving as a mediator of
the stress–pain relationship among individuals with noncardiac chest
pain. Health Psychol 2008;27(6):829 –32.
41. Rothman AJ, Sheeran P, Wood W. Reflective and automatic processes
in the initiation and maintenance of dietary change. Ann Behav Med
2009;38(1S):S4 –17.
42. West DS, Gorin AA, Subak LL, et al. A motivation-focused weight loss
maintenance program is an effective alternative to a skill-based approach. Int J Obes (Lond) 2011;35(2):259 – 69.
43. Befort CA, Stewart EE, Smith BK, Gibson CA, Sullivan DK, Donnelly
JE. Weight maintenance, behaviors and barriers among previous participants of a university-based weight control program. Int J Obes
(Lond) 2008;32(3):519 –26.
44. Health and Diet Survey: Dietary guidelines supplement—report of
fındings (2004 and 2005): DHHS, Offıce of Disease Prevention and
Health Promotion, 2008 January.
45. Casey VA, Dwyer JT, Berkey CS, Coleman KA, Gardner J, Valadian I.
Long-term memory of body weight and past weight satisfaction: a
longitudinal follow-up study. Am J Clin Nutr 1991;53(6):1493– 8.
46. Stevens J, Keil JE, Waid LR, Gazes PC. Accuracy of current, 4-year, and
28-year self-reported body weight in an elderly population. Am J Epidemiol 1990;132(6):1156 – 63.
47. Willis GB, Royston P, Bercini D. The use of verbal report methods in
the development and testing of survey questionnaires. Appl Cogn
Psycho 1991;5(3):251– 67.
48. Blair J, Conrad F, Castellano Ackermann A, Claxton G, eds. The effect
of sample size on cognitive interview fındings. Alexandria VA: American Statistical Association, 2006.
49. Wadden TA, Crerand CE, Brock J. Behavioral treatment of obesity.
Psychiatr Clin North Am 2005;28(1):151–70., ix.
50. Wing RR, Tate DF, Gorin AA, Raynor HA, Fava JL. A self-regulation
program for maintenance of weight loss. N Engl J Med 2006;
355(15):1563–71.
www.ajpmonline.org