American Journal of Epidemiology
Copyright O 1999 by The Johns HopWns University School of Hygiene and PubBc Health
An rights reserved
Vol. 149, No. 6
Printed In U.SA.
French et al. Respond to Dr. Kuller
Simone A. French,1 Aaron R. Folsom,1 Robert W. Jeffery,1 and David F. Williamson2
Dieting for weight loss is widespread in the United
States. More than 40 percent of adult women are currently trying to lose weight, and rates are even higher
among overweight women (1, 2). Some researchers
have raised concerns about the health effects of dieting
after several observational studies showed associations
between weight loss and increased mortality (3-6).
Some have argued that intentional weight loss is not
only emotionally stressful and damaging to self-esteem,
but that it is also hazardous to physical health (1, 7).
A major limitation in interpreting the epidemiologic
findings on weight loss has been the absence of information on whether dieting or ill health is the cause of
the weight losses linked to higher mortality risk. The
present studies (8-11) are among the first to address
this important issue. It is reassuring that they provide
evidence that seem intuitively obvious to Dr. Kuller—
that unintentional weight loss is most associated with
higher mortality risk.
There is still much to be learned about the consequences of intentional weight loss, who is successful,
and the methods most effective for long-term maintenance (12-17). We agree with Dr. Kuller that clinical
trials using behavioral methods are the preferred scientific design with which to examine whether weight
loss reduces mortality risk. The absence of effective
methods to maintain long-term weight loss has made
such trials challenging to implement and emphasizes
the importance of further research on the identification
and development of successful weight maintenance
methods. Case-control and prospective observational
studies specifically designed to examine processes of
successful weight loss maintenance among overweight
people and weight gain prevention among normalweight people can still provide valuable data on the
health effects of dieting and weight loss (16, 18).
These studies also provide needed information to
develop more-effective interventions for primary prevention of weight gain that might address the current
epidemic of obesity in the United States (19).
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2. Horm J, Anderson K. Who in America is trying to lose weight?
Ann Intern Med 1993;119 (Part 2, Suppl.):672-6.
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4. Pamuk ER, Williamson DF, Madans J, et al. Weight loss and
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and advisable to lose weight? Am Psychol 1994;49:781-91.
8. French SA, Folsom AR, Jeffery RW, et al. Prospective study of
intentionality of weight loss and mortality in older women:
The Iowa Women's Health Study. Am J Epidemiol 1999;
149:414-24.
9. Williamson DF, Pamuk E, Thun M, et al. Prospective study of
intentional weight loss and mortality in overweight white men
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Received for publication August 25, 1998, and accepted for publication October 15, 1998.
1
University of Minnesota, Division of Epidemiology, School of
Public Hearth, Minneapolis, MN.
2
Centers for Disease Control and Prevention, Atlanta, GA.
Reprint requests to Dr. Simone A. French, University of
Minnesota, Division of Epidemiology, 1300 South 2nd Street, Suite
300, Minneapolis, MN 55454-1015.
519
520
French et al.
17. Snick SM, Wing RR, Klem ML, et al. Persons successful at
long-term weight loss and maintenance continue to consume a
low-energy low-fat dieL J Am Diet Assoc 1998,98:408-13.
18. Jeffery RW, French SA. Preventing weight gain in adults:
design, methods and one year results from the Pound of
Prevention study. Int J Obes 1997;21:457-64.
19. Kuczmarski RJ, Flegal KM, Campbell SM, et al. Increasing
prevalence of overweight among US adults: the National
Health and Nutrition Examination Surveys 1960-1991. JAMA
1994;272:205-ll.
Am J Epidemiol
Vol. 149, No. 6, 1999