|
Items in cart [4] |
Questions? Call 888-624-8373 |
PAPERBACK + PDF PAPERBACK PDF BOOK PDF CHAPTERS Free Resources |
||||||||||||||||
|
||||||||||||||||
|
|
|||||||||||||||
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 179
A
Workshop Agenda and Abstracts
Military Weight-Management Program Workshop
State of the Art and Future Initiatives
Subcommittee on Military Weight Management
Committee on Military Nutrition Research
Food and Nutrition Board
Institute of Medicine
The National Academies
October 2~26, 1999
Monday October 25, 1999
9:00 Welcome on Behalf of the Food and Nutrition Board
Dr. Allison A. Yates, Director, Food and Nutrition Board
9:05 Welcome on Behalf of the Subcommittee on Military Weight Manage-
ment
Dr. Richard Atkinson, Chair, Subcommittee
9:15 Opening Comments on Behalf of the Military
LTC Karl E. Friedl, U.S. Army Medical Research and Materiel Com-
mand, Fort Detrick, Frederick, MD
9:30 Important Historical Military Data: Obesity and Mortality
Dr. William Page, Medical Follow-Up Agency, The National Acad-
emies
179
OCR for page 180
180
WEIGHT MANAGEMENT
Part I: Weight Management in the Military Today (Moderator: Richard
Atkinson)
Panel: Current Military Policies and Approaches to Body-Weight Man-
agement
LCDR Sue Hite, Health and Physical Fitness Branch, USN
LTC Francine LeDoux, Health Promotion Policy Officer, USA
LTC Leon Pappa, Training Program Branch, USMC
COL Esther Myers/LTC Regina Watson, Health Promotion, USAF
Discussion
l 1:00 Break
1 1:15 Challenges to Military Weight Standards and Maladaptive Practices of
Service Members to Meet These Weight Standards
MAJ Stephen Bowles, M.D., U.S. Army Soldier Support Institute, Ft.
Jackson, SC
12:30 Lunch
Part II: Current Military Weight-Loss/Management Programs (Moderator:
John Vanderveen)
1:30 Panel: Effective Military Programs
Air Force Weight-Management Program - LTC Joanne Spahn, Elmen-
dorfAFB, Alaska
The Air Force LEAN Program - CAPT Trisha Vorachek, McConnell
AFB
Impact of a Shipboard Weight-Control Program - Dr. Karen E. Dennis,
Veterans Affairs Medical Center, University of MD School of
Medicine
Nutrition and Diet Aboard Submarines - LT Deborah White, Naval
Submarine Medical Research Lab, Groton, CT
The Army's LEAN Program: Current Update-LTC Larry James, Wal-
ter Reed Army Medical Center
Army Weight-Management Instruction to Master Fitness Trainers - Dr.
Lou Tomasi, LT Kerryn Davidson, Army Physical Fitness School,
Ft. Benning, GA
Discussion
3:45 Break
OCR for page 181
APPENDIXA
181
Part III. Factors Affecting Weight Management (Moderator: John Fern-
strom)
4:00 Behavior
Dr. Patrick O 'Neil, Medical University of South Carolina
Dr. Gary Foster, University of Pennsylvania
Discussion
Adjourn
Tuesdav. October 26. 1999
Part III. Factors Affecting Weight Management (cont.) (Moderator: Wil-
liam Dietz)
9:00 Genetic Influences on Obesity
Dr. Anthony Com?=zi, Southwestern Foundation for Biomedical Re-
search
Effects of Age, Gender, and Ethnicity on Ideal Weight
Dr. June Stevens, University of North Carolina - Chapel Hill
Discussion
1 0:30 Break
Pharmacological Aids (Moderator: Steven Heymsfield)
11:00 The Pharmacology of Weight Loss and Its Potential Application in the
Military Setting
MAJH. Glenn Ram os, M.D., Fort Gordon, GA
Use of Pharmacologic Aids in Weight Management
Dr. Frank Greenway, Pe,~nington Biomedical Research Center
Discussion
12:00 Lunch
Physiology - Physical Activity (Moderator: Barbara Hansen)
1:00 Effects of Exercise, Diet, and Weight Loss on Lipid Metabolism
Dr. Marcia Stefanick, Stanford University
Reproductive Health Issues in Fitness and Weight-Control Programs
Dr. Anne Loucks, Ohio University
OCR for page 182
182
2:00 Obesity: An Infectious Disease?
Dr. Nikhil Dhurandhar, Waryne State University
Discussion
WEIGHT AL4NAGEMENT
Part IV: Factors Affecting Long-Term Maintenance of Weight Loss (Mod-
erator: Arthur Frank)
Dr. George Blackb urn, Harvard Medical School
Dr. John Jakicic' Miriam Hospital and Brown University
Discussion
Break
Part V: Effective Strategies for the Military Setting (Moderator: Gail
Butterfield)
4:00 Panel Discussion
Military Speakers:
CAPT Trisha Vorachek (USAF)
LT Deb orah White (USE
Dr. H. Glenn Ram os LISA)
LTKerryn Davidson (USAJ
Civilian Speakers:
Dr. Frank Greenway
Dr. John Jakicic
Dr. Patrick O 'Neil
Summary of the Workshop
Dr. Richard Atkinson, Subcommittee Chair
Dr. John Vanderveen, Vice-Chair
Adjourn
OCR for page 183
APPENDIXA
183
WORKSHOP ABSTRACTS
THE ARMY WEIGHT CONTROL PROGRAM (AR 600-9)
LTC Francince M. LeDoux, Health Promotion Policy Off cer
The primary objective of the Army Weight Control Program (AWCP) is to
ensure that all personnel are able to meet the physical demands of their duties
under combat conditions and to present a trim military appearance at all times.
Proper weight control assists Army personnel in establishing and maintaining
discipline, operational readiness, optimal physical readiness, and effectiveness.
The regulation establishes appropriate body-fat standards and provides proce-
dures by which personnel are counseled to assist them in meeting the prescribed
standards.
Historical Perspective
Prior to 1981, height/weight tables and a physician's assessment were used
to determine body-fat standards. In 1981 DOD implemented the Physical Fitness
and Weight Control Program (DOD Directive 1308.19. This program stated that
various tests were acceptable for use in determining body fat. Between 1983 and
1986, the Army used the "pinch test" to determine body fat. Beginning in 1987,
the DOD revised Directive 1308.1 stating that the skinfold measurement test
would no longer be used, and that only the "Tape" measurement method should
be used to measure body fat. The Army Weight Control Program (U.S. Army,
1986) was published in 1986. In 1994, Interim Change 101 specified that all
soldiers were to be issued Handbook/Issue 15. In 1995, DOD Directive 1308.1
was revised, changing the body-fat standards and establishing fat standards for
pregnant soldiers (DOD, 1995~.
Rationale
The AWCP is based on body composition (body fat vs. total body mass).
Physical fitness is key to body composition. Fit soldiers are better able to carry
their load. They have less body fat and more muscle mass. In contrast, overfat
soldiers are: less able to perform physical tasks, are at greater risk of developing
injury, and have lower Army Physical Fitness Test scores. Excessive body fat
also detracts from soldierly appearance.
Key Requirements
Soldiers are weighed every 6 months. If a soldier is overweight (exceeds the
weight-for-height standard) he or she will be measured for percent body fat us-
OCR for page 184
184
WEIGHT MANAGEMENT
ing the "tape test" circumference method. The measurement sites for males are:
abdomen, neck with a range of 20-26 percent body fat (maximum); and for fe-
males: neck, forearm, wrist, and hip with a range of 20-36 percent body fat
(maximum). If a soldier is overfat he or she is enrolled in the AWCP.
AWCP Enrollment
Soldiers enrolled in the AWCP will have a permanent record on file. Each
soldier enrolled is required to attend nutritional counseling and is weighed on a
monthly basis. A soldier may only be removed from the program when body-fat
standards have been achieved. The height/weight table standards will not be
used. The standard requires a loss of 3-8 lb per month. If a soldier fails to make
satisfactory progress in two consecutive months, he or she can be discharged per
AR 635-200, Chapter 18, Personnel Separations (U.S. Army, 2000~.
Medical Limitations and Pregnant Soldiers
Medical limitations include pregnancy, hospitalization, prolonged medical
treatment, and positive profiles according to Mandatory Medical Review
Boards.
Once a female soldier is diagnosed as pregnant, she is exempt from the
standards of AR 600-9 during pregnancy and for 6 months postpartum. The sol-
dier will remain in the program if she was enrolled previously. After 6 months
postpartum, she will continue on the AWCP with physician clearance. Postpar-
tum soldiers may request to be weighed anytime before 6 months. This standard
implements DOD Directive 1308.1, July 20, 1995.
References
DOD (U.S. Department of Defense). 1995. DOD Physical Fitness and Body Fat
Program Procedures. Department of Defense Directive 1308.1. July 20.
Washington, DC: U.S. Government Printing Office.
U.S. Army. 1986. The Army Weight Control Program. Army Regulation 600-9.
September 1. Washington, DC: U.S. Government Printing Office.
U.S. Army (U.S. Department of the Army). 2000. Enlisted Personnel. Army
Regulation 635-200. November 1. Washington, DC: U.S. Government
Printing Office.
OCR for page 185
APPENDIXA
CHALLENGES TO MILITARY WEIGHT STANDARDS
AND MALADAPTIVE PRACTICES OF SERVICE
MEMBERS TO MEET THESE WEIGHT STANDARDS
MAJ Stephen V. Bowles, PhD, United States Army Soldier Support Institute,
Director, USAREC Command Psychological Operations, Fort Jackson, South
Carolina
185
At the time this abstract was written, no information on service members
who exceed weight standards or have been discharged from the service in 1999
could be obtained from DOD or individual services. It has been reported that as
many as 40 percent of the soldiers discharged from the Army was due to service
members being overweight (James et al., 1997~. The military faces several
challenges to include: overweight accessions into the military, lifestyle practices
of overweight service members, and command awareness of lifestyle change
programs.
Challenges to Military Weight Standards
With current recruitment shortfalls, the number of overweight recruits
(meeting accession standards but not the services retention standard for weight)
may be increasing due to a smaller applicant pool. This can translate into a
considerable number of overweight personnel entering yearly that meet
accession standards but do not meet military retention standards at that time.
This may place extra strain on the system to get personnel physically fit, while
preparing new service members for the complexities of the military. In addition,
this also places increased stress on young service members who are in many
cases away from home for the first time in their first job.
With this in mind, educating recruiters on healthy lifestyle changes for new
recruits may be beneficial. This may help reduce the time spent on new
overweight service members and retain more personnel. Recruiters can be
provided with lifestyle change training in recruiting school and provide recruits
with approaches to healthy lifestyle change. Similarly, military academies and
ROTC programs can provide training to new officers throughout their school
years. Students must be trained in maintaining healthy lifestyles in accordance
with military weight guidelines. These are important preventative measures in
stressful academic environments, which may preclude students from engaging in
maladaptive eating behaviors.
Eating on the run is sometimes dictated by our mission. When training new
service members today we have attempted to offer adequate time to eat in
dinning, facilities. This is different from the past where older, overweight service
members have identified early dining experiences as eating as much as they can
in as little time as possible. This set the pattern of their eating over the course of
OCR for page 186
186
WEIGHT A~4NAGEMENT
their military careers. When providing new personnel training and education on
healthy lifestyle behaviors, we must incorporate these changes into our training
structures as best we can. As a tradition, service members have complained
about the food provided to them in the mess hall or galley. However, great
improvements have been made in the quality of foods. More effort needs to be
initiated in educating cooks (James et al., 1999) to provide more variety in the
low-fat main dishes served for lunch and dinner. Furthermore, there should be
uniformity across dining facilities in the education of customers on calorie and
fat gram amounts per food served.
Maladaptive Practices of Service Members
While there are differences in each of the services' military weight/body-fat
standards, the goal of each service member twice a year is to meet the weight
standard and pass the physical fitness test. The family is well aware of the
borderline or overweight service member's plight at these times of the year.
There is often tension in the home emanating from the service member's desire
and actions to stay off the weight program. This may involve physical fitness
training five times or more a week. Additionally, a service member will attempt
to lose weight by using over-the-counter medication. They may go to the local
health food store and purchase different herbal supplements or attend a local
weight-reduction clinic and get on prescription medication. They will sit in the
sauna, or they may obtain laxatives through the local drug store or their medical
facility if they are on the hospital staff. If they are looking for the more popular
diets, they can choose from protein, blood, cabbage, grapefruit or what ever the
most recent diet is. Of the 108 applicant records examined for the Eisenhower
LIFE Program, 34 percent reported starving or fasting, 33 percent reported using
laxatives or over-the-counter medication, and 4 percent reported purging at
some time in their career.
Meeting Military Weight Standards: Lifestyle Change
Programs
Across the services there is a need to become more familiar with various
programs available in local areas and encourage the use of these programs. Units
that have used local lifestyle change (weight) programs are able to save financial
resources for their organizations and save units time if their armed service
program is several hours or states away from where they are located.
As a group, the medical field must educate the commanders in their area on
services available to assist service members in weight reduction. Commanders,
after seeing the results of their service members in lifestyle change programs,
will be a steady referral source to programs. The Eisenhower LIFE Program (a
week-long day-treatment program and 1 year follow-up) disseminated an 11
OCR for page 187
APPENDIX A
187
question survey asking commanders and supervisors for their feedback on the
program. The results of 9 of the questions from the survey are found in Figure 1.
Ninety percent of the respondents were from the Army, while the remainder of
the respondents were Mom the Air Force, Navy, and Marines.
The results of the survey indicate that 22 out of 24 commanders/
supervisors responding, were satisfied with the program. Most respondents
agreed that the program saved their unit time (81 percent), prevented the service
member from separation from the military (91 percent), taught the service
member new information for weight management (96 percent), and provided a
comprehensive multidisciplinary program for weight reduction (91 percent). In
addition, 96 percent believed a specialized physical training program is helpful
for weight reduction, while 86 percent supported a specialized LIFE physical
training program. While 95 percent believed weekly support groups are helpful,
only 73 percent supported service members attending weekly support groups.
Though some commanders/supervisors prefer to operate their own physical
training and follow-up support (perhaps due to unit esprit de corps or due to
shortage of work personnel), these results suggest that overall, commanders
support this lifestyle change program.
-
Supporrt Weeldy meetngs
Believe in v~eeldy support groups
Support Specialized UFE PT
1
Provided Comp. Multi-disciplinary
Sepcialized Pt Program
Satistaction
program
Taught New Irdo
Prevented Separation
Saving Unit Time
l
1
1
0 10 20 30 40 50 60 70 80 90 100
Percentage
FIGURE 1 Command Satisfaction Survey.
l
OCR for page 188
188
WEIGHT MANAGEMENT
These findings suggest that commands are open to assistance from weight-
reduction programs to maintain readiness levels in their organizations. Similar
education and training can be provided across the services to assist service
members in meeting their organizations' weight standards. The training pro-
vided to service members and in support of service members can be provided
through healthy lifestyle change programs.
References
James LC, Folen RA, Garland EN, Edwards C, Noce M, Gohdes D, Williams D,
Bowles S. Kellar MA, Supplee E. 1997. The Tripler Army Medical Center
LEAN program: A healthy lifestyle model for the treatment of obesity. Mil
Med 162:328-332.
James LC, Folen RA, Page H. Noce M, Brown J. Britton C. 1999. The Tripler
LEAN program: A two-year follow-up report. Mil Med 164:389-395.
THE SENSIBLE WEIGH LIFESTYLE CHANGE
PROGRAM: AN AIR FORCE WEIGHT-
MANAGEMENT PROGRAM
Joanne M. Spahn, Lt Col' USAF, BSC, MS, RD
The health risks associated with overweight and obesity are well established
(NHLBI, 1998; Van Itallie, 1985) end the incidence of overweight continues to
rise (Kuczmarski et al., 1994~. In the military, sustained overweight can end an
otherwise successful career. An increased operations tempo, decreased physical
activity, and easy availability of calorie-dense foods may frustrate earnest
weight-management efforts. Until the 1990s, the typical Air Force treatment
program for overweight entailed a single group class where military members
were given instruction on a low calorie diet, typically 1,200-1,800 calories,
information on behavior modification, and counseled to exercise three to five
times a week for 30 minutes. In the late 1980s and early 1990s, numerous
published or home-grown multisession programs were established at a variety of
sites. These programs for the most part emphasized increased physical activity,
modest calorie restriction, skill development in selecting and preparing healthy
foods, and behavior modification techniques. At most sites, these programs
could accommodate few participants. There was fear among active duty person-
nel that weight loss would be too slow to meet weight-loss requirements.
In the early 1990s, the National Institutes of Health held a Technology
Assessment Conference on Methods for Voluntary Weight Loss and Control. In
1995, Weighing the Options: Criteria for Evaluating Weight-Management
Programs was published (IOM, 1995~. These materials were utilized to guide
development of The Sensible Weigh Program initiated in 1997. Practical
OCR for page 189
APPENDIXA
189
managerial constraints and Weight Management Program (WMP) guidelines
factored into program development. Specifically, this included the need for
military members to loss 3 to 5 lb the first month identified as overweight to
avoid disciplinary action and the need for Wing and Army Commander support
of treatment incorporating increased use of duty time. Deployment of The
Sensible Weigh to a large number of bases with varying levels of manpower
support has also shaped program implementation across the Air Force.
The Sensible Weigh is a lifestyle change program aimed at optimizing
weight and fitness of military members and their families. It is a science-based
protocol designed to prevent weight gain, facilitate weight loss, and the
maintenance of weight loss. It was developed to support the Air Force WMP and
as an avenue for commanders and health care providers to intervene with
concerned individuals early, before negative consequences occur. This multi-
disciplinary program offers participants a variety of strategies from which to
choose to improve their nutrition, fitness, and health. Program materials are
available on the web at the following site: http://aimam.satx.disa.mil.
Clients enrolling in The Sensible Weigh can either self-refer, be sent by
their squadron, or be referred by a medical provider. The protocol begins with a
thorough assessment of anthropometric, biochemical parameters, comorbidities,
medications, family history, weight and dieting history, exercise habits, diet
readiness, and evaluation of the Physical Activity Readiness Questionnaire.
Nursing personnel review the assessment form with clients and use standardized
guidelines to refer clients to medical providers when the need arises. Assessment
data is used to tailor the program to meet client needs, discuss the benefits of
weight management in terms other than pounds lost, and to facilitate measure-
ment of program efficacy.
Program length varies from 4 to 12 weeks. The first four core classes are
taken by all participants in The Sensible Weigh and provide a foundation of
information and skills. The first class orients clients to the concept of lifestyle
change, the diverse benefits of weight management, addresses relapse preven-
tion and diet readiness, and encourages increased physical activity. Clients are
instructed on how to complete a food and exercise diary and are required to
monitor their eating habits for the coming week. This is an important class for
establishing rapport, venting anger, and building a trusting relationship. This
was a difficult class to implement because of the immediate penalties incurred if
members did not lose the prescribed weight in the first 30 days. Members and
supervisors were concerned that the member did not "get the diet."
During the second class, each client receives a calorie and fat budget
following Step I diet recommendations. Clients are offered a variety of strategies
from which to choose to modify their diet. Strategies include calorie counting,
fat gram counting, following food guide pyramid guidelines, and following a
calorie controlled meal plan. Pros and cons of each method are discussed and
clients select the strategy they feel best meets their needs. The food and exercise
OCR for page 230
230
WEIGHT MANAGEMENT
The fast-food market has increasingly become a staple of American food culture
over the years. Effective marketing strategies coupled with broader, inexpensive
choices have made this industry a prime culprit in the American obesity
epidemic. Unfortunately, with the increase in variety, palatability, convenience,
and availability of food, there has also been a decline in the amount of exercise
performed by the average American. Sedentary desk jobs, computers, fewer safe
places for exercise, and more elevators and drive-through restaurants are only a
few of the contributors to this escalating problem.
With the changing environment and the discouraging rates of weight regain,
it is imperative that we take a closer look at long-term weight maintenance and
the various methods successful maintainers utilize to prevent weight gain. To get
a better perspective in this area, it is appropriate to review a portion of the long-
term data provided by the National Weight Control Registry (NWCR). The
NWCR is a registry of individuals who have been followed in a prospective
manner having been successful at maintaining significant weight losses. Partici-
pants in the NWCR have lost, on average, more than 65 pounds and maintained
their weight losses for 5.7 years (McGuire et al., l999b). Long-term studies of
weight loss in individuals participating in the NWCR indicate that those who
regain weight typically show a demonstrated decline in self-monitoring. This
includes techniques such as frequent self-weighing as well as keeping food and
exercise diaries. These individuals showed a marked decrease in physical activ-
ity of more than 800 calories per week, coupled with increases in the percentage
of calories taken in from fat. The study also showed the re-gainers to have a
higher lifetime level of intentional weight cycling (McGuire et al., l999b).
Those who regained weight were more likely to have sought assistance for
weight loss rather than utilizing self-directed weight loss methods, and were
more likely to have used a liquid formula diets for their initial weight loss. In
comparison, it has been shown that 72 percent of successful weight losers lost
weight on their own, 20 percent used commercial weight-loss programs, and 5
percent utilized a university-based program (McGuire et al., 1998~. Those who
gained weight also were shown to have been heavier at their maximum weight,
initially lost a greater percentage of their maximum weight (> 30 percent) and
had maintained their weight loss for fewer years than maintainers (McGuire et
al., l999b).
What predicts successful weight maintenance? Research has shown the five
most common links appear to be (1) physical activity, (2) self-monitoring, (3)
problem solving, (4) continued contact, and (5) stress management (Foreyt,
1 9991.
Physical Activity
Longitudinal studies with 2-10 years of follow-up results have observed
that physical activity is related to less weight gain over time (NHLBI, 19981. It
OCR for page 231
APPENDIXA
231
is a well-known fact that physical activity is a good predictor of weight mainte-
nance (Foreyt, 1999~. A review of successful weight maintainers reveals that
they engaged in more strenuous activities such as running, weight lifting and
aerobics than regainers, and participated in more activities that made them sweat
(McGuire et al., 1999a). Specifically, 52 percent of maintainers reported engag-
ing in three or more episodes that made them sweat in a typical 7-day week
compared with 32-36 percent of the regainers and controls (McGuire et al.,
1999a). Although, it is important to note it has been demonstrated that both
gainers and maintainers reported decreases in total calories expended thorough
physical activity. However, maintainers reported a decrease of only 500 calories
per week where gainers reported a decrease of almost 1,000 calories per week at
1-year follow-up (McGuire et al., l999b).
Self-Mon~toring
Self-monitoring is the cornerstone of behavioral treatment (Foreyt, 1999~.
One of the common findings observed in individuals who are successful at long-
term weight loss is that maintainers report extensive use of behavioral strategies
for reduction in dietary fat intake, self weighing, and physical activity (McGuire
et al., 1 999a). Taking a closer look at self weighing as a form of self-monitoring,
it has been shown that 55 percent of maintainers reported weighing themselves
at least once each week, where only 35 percent of the regainers reported weigh-
ing themselves frequently (McGuire et al., 1 999a). Other forms of self-
monitoring, such as keeping a food or exercise record, functions to assist the
patient in assessing overall intake of various foods in relation to the amount of
exercise performed. Despite the fact that caloric intake may be underestimated,
the records sensitize patients to the eating and exercise portion of their lifestyle
(Blackburn and Kanders, 1994~.
Problem Solving
Generally, it has been shown that those individuals who confront life's
stressors with a positive problem-solving attitude are more likely to have greater
success in any endeavor (Foreyt, 1999~. All aspects of effective obesity treat-
ment involve improved problem solving and confrontational skills. A survey of
weight maintainers showed that 95 percent of them utilized problem solving or
confrontational technique. In comparison, only 10 percent of those who relapsed
used problem solving skills and instead, tended to use escape-avoidance ways of
coping with stress, such as eating, smoking, or taking tranquilizers (Blackburn
and Kanders, 1994~. These findings support the theory that once an individual
makes a behavioral change, relapse occurs in the face of insufficient coping
skills (Blackburn and Kanders, 1994~.
OCR for page 232
232
Continued Contact
WEIGHT MANAGEMENT
Frequent patient-provider contact is associated with the best maintenance of
weight loss (Anderson and Wadden, 1999~. This contact does not have to be
given solely by the physician, but by a registered dietitian, nurse, or office staff.
Contact can be made to patients, via phone, fax, or email. These continued visits
have been shown to enhance motivation, troubleshooting, and teach patients a
new set of skills. Overall, the longer patients remain in behavioral treatment the
longer they are expected to maintain their weight loss (Anderson and Wadden,
1 999).
Stress Management
Literature has shown that stress has a facilitating effect on the eating behav-
ior of individuals most likely to be patients in a weight-loss program (Blackburn
and Kanders, 1994~. This excessive stress appears to predict early drop out from
organized weight-loss programs (Foreyt, 1999~. It is essential to help patients
identify a strategy when confronted with stressful events to allow them to gain
quick composure in order to use other behavioral techniques (Blackburn and
Kanders, 1994~. Working with patients to help address and alleviate the stress-
eating relationship in weight-loss treatment and maintenance is of key impor-
tance (Foreyt, 1999~. Four basic stress management procedures used in weight
maintenance include self-monitoring, environmental control, relaxation training,
and contingent relaxation (Blackbum and Kanders, 1994~.
Conclusion
Regardless of the weight-loss option selected, patients should strive to
develop the skills that have been reported by successful weight-loss maintainers.
These techniques include exercising regularly, monitoring weight frequently,
eating a low-fat diet, recording food intake, and developing effective problem
solving skills (Anderson and Wadden, 1999~. In addition, believing in yourself
(Fletcher, 1994) and not relying on willpower can help your patients achieve
success in their weight-maintenance endeavors.
References
Anderson DA, Wadden TA. 1999. Treating the obese patient. Suggestions for
primary care practice. Arch Family Med 8:15~167.
Blackburn GL, Kanders BS. 1994. Obesity: Pathophysiology, Psychology and
Treatment. New York: Chapman and Hall.
Fletcher AM. 1994. Thin for Life. 10 Keys to Success from People Who have
Lost Weight and Kept it Off: Shelburne, VT: Chapters Publishing.
OCR for page 233
APPENDIXA
233
Foreyt JP. 1999 (July). Strategies for Maintenance and Relapse Prevention. Ab-
stract and slides presented at the Harvard Obesity Conference.
McGuire MT, Wing RR, Klem ML, Hill JO. 1999a. Behavioral strategies of
individuals who have maintained long-term weight losses. Obes Res 7:334-
341.
McGuire MT, Wing RR, Klem ML, Lang W. Hill JO. l999b.What predicts
weight regain in a group of successful weight losers? J Consult Clin Psy-
chol 67:177-185.
McGuire MT, Wing RR, Klem ML, Seagle HM, Hill JO. 1998. Long-term
maintenance of weight loss: Do people who lose weight through various
weight loss methods use different behaviors to maintain their weight? Int J
Obes 22:572-577.
NHLBI (National Heart, Lung and Blood Institute). 1998. Clinical guidelines on
the identification, evaluation, and treatment of overweight and obesity in
adults: The evidence report. Obes Res 6:5 lS-209S.
Rippe JM, Crossley S. Ringer R. 1998. Obesity as a chronic disease: Modern
medical and lifestyle management. JAm Diet Assoc 98:S9-S15.
Shick SM, Wing RR, Klem ML, McGuire MT, Hill JO, Seagle H. 1998. Persons
successful at long term weight loss and maintenance continue to consume a
low energy, low fat diet. JAm Diet Assoc 98:408~13.
Williamson DF, Derdula MK, Serdula MK, Anda RF, Levy A, Byers T. 1992.
Weight loss attempts in adults: Goal, duration and rate of weight loss. Am J
Public Health 82:1251-1257.
FACTORS AFFECTING LONG-TERM MAINTENANCE OF WEIGHT
LOSS AND WEIGHT REGAIN
John M. Jakicic, PhD, Assistant Professor, Brown University School of Medi-
cine, Miriam Hospital Weight Control and Diabetes Research Center
Obesity is a significant health problem in the United States, and it is
estimated that in excess of 50 percent of adults are considered overweight (BMI
> 25 kg/m2~. Despite documented short-term success in weight-loss programs, it
has been shown that typically, one-third of weight lost will be regained within
1-3 years, with total regain occurring within 3-5 years. Therefore, it is
important to examine the most effective implementation of strategies that have
been shown to maximize long-term weight loss and prevent weight regain.
Despite the belief that most individuals are unsuccessful at long-term
weight loss, the National Weight Control Registry (NWCR) has identified a
large number of individuals that have successfully maintained at least a 30-lb
weight loss for a minimum of 1 year (Klem et al., 1997~. Close examination of
this data set shows that there are individuals that have maintained a weight loss
of approximately 60 lb and have maintained this for 5.6 ~ 6.8 years. Therefore,
OCR for page 234
234
WEIGHT M4NAGEMENT
results from this study should be examined closely to determine if there are
unique strategies that can be used to enhance long-term weight loss in over-
weight adults.
Exercise
An interesting finding in the NWCR is that individuals continue to
participate in strategies to maintain both healthful eating and exercise behaviors.
However, a unique finding in these data is that these individuals are maintaining
extremely high levels of exercise, with leisure-time activity being 2,000 to 2,500
kcal/week for both men and women (Klem et al., 1997~. This value is much
greater than the current public health recommendation for physical activity to
improve health (HHS, 1996; Pate et al., 1998~. However, this level is similar to
the amount of activity shown by Schoeller and colleagues (1997) to minimize
weight regain in overweight women, and this amount of activity was verified
using doubly labeled water. Jakicic and colleagues (1999) have shown that when
combined with dietary modification, weight regain in the 12 months following
was minimized when exercise exceeded 150 minutes per week. However, of
interest is that there was no weight regain in women exercising greater than 200
minutes per week throughout the entire 18 months of treatment. Thus, overall,
these results appear to verify the conclusion of Pronk and Wing (1994) based on
a review of the literature, that physical activity is one of the best predictors of
long-term weight maintenance.
Despite the evidence presented above, debate remains regarding the optimal
intensity of the activity that will enhance long-term weight loss and minimize
weight regain. In a 20-week study of overweight women, Duncan and
colleagues (1991) showed that total energy expenditure rather than exercise
intensity is the key factor for regulating body weight. However, data from the
NWCR suggests that individuals successful at long-term weight loss participate
in a high level of vigorous intensity activity (Klem et al., 1997~. Despite these
findings, the results of this study are cross-sectional and have not been
confirmed by a randomized clinical trial. Currently, Jakicic and colleagues are
conducting a randomized clinical trial to examine the dose-response of exercise
(intensity and energy expenditure) on weight loss across a 24-month period of
time.
Despite the debate over the optimal amount of activity that is necessary to
maximize long-term weight loss, little debate exists as to the importance of
physical activity for overweight adults. Data from the Center for Aerobics
Research at the Cooper Institute have shown that physical fitness can have a
significant impact on mortality rates independent of body weight. Lee and
colleagues (1998) have shown that there is a significant reduction in mortality
rates in overweight adults that also have higher levels of physical fitness, and
this mortality rate is similar to leaner unfit adults. These results suggest that
OCR for page 235
APPENDIXA
235
interventions that improve physical fitness in overweight adults can have
significant health benefits independent of changes in body weight. Therefore, it
is important to develop and implement strategies to increase exercise participa-
tion in overweight adults.
Recently, Dunn and colleagues (1999) have shown that a home-based
lifestyle activity intervention cart be as effective over 18-24 months as a
structured clinic-based exercise intervention. In addition, in studies of over-
weight women, Jakicic and colleagues (1995, 1999) have shown that multiple
short bouts of exercise can be effective in previously sedentary individuals.
Therefore these strategies should be considered when implementing inter-
ventions to address body-weight regulation within the military.
Changes in the Micro and Macro Environments
It has been suggested that we live in a "toxic environment" relative to
factors that affect body weight. There are a number of factors, such as
accessibility of high fat/calorie foods and labor saving devices that affect our
eating and exercise behaviors. However, it has been shown that the environment
can be manipulated to have a positive impact on eating and exercise behaviors.
For example, French and colleagues (1997) showed that lowering prices in
vending machines for low-fat snacks increased the amount of low-fat snacks that
were purchased. In addition, Andersen and colleagues (1998) have reported that
posting signs to encourage the use of stairs in a shopping mall can have a
positive impact on activity patterns.
It may also be important to increase access to healthier foods and provide
opportunities for physical activity, and this can be done to both the macro and
micro environments. For example, Sallis and colleagues (1990) showed that
individuals living in close proximity to exercise facilities were more active than
those living further away from these facilities. Jakicic and colleagues (1997)
showed that there was a significant correlation between physical activity and
having home-exercise equipment. More recently, Jakicic and colleagues (1999)
reported that providing overweight adults with home treadmills increased
exercise participation. Therefore, these findings suggests that modifications to
the environment may have a positive impact on health behaviors related to body-
weight regulation.
Long-Term Changes in Dietary Intake
Despite the fact that exercise appears to be one of the best predictors of
long-term weight loss, the impact of eating behaviors on this process should not
be overlooked. It has been shown in short-term studies that exercise alone has
little impact on body weight when compared with diet or the combination of diet
plus exercise (Wing et al., 1998~. Moreover, the effectiveness of exercise in
OCR for page 236
236 WEIGHT MANAGEMENT
long-term weight loss may be partially explained by its link to healthful eating
behaviors. For example, Klem and colleagues (1997) reported that individuals
successful at long-term weight loss maintained healthfi~1 eating behaviors along
with high levels of exercise. Unpublished data from a study conducted in our
laboratory has shown that individuals that have maintained high levels of
exercise also report maintaining more healthful eating behaviors than those not
maintaining their exercise over a period of 18 months. Thus, these results appear
to suggest that both dietary and exercise behaviors should be targeted to enhance
long-term weight loss and to prevent weight regain.
Continued Contact
It has been suggested that obesity is a chronic disease and should be treated
with a chronic disease intervention. Perri and colleagues (1987) have shown that
maintaining contact with a weight-loss program long-term enhances weight loss.
However, from a clinical perspective, it becomes difficult to keep individuals in
treatment programs for long periods of time. Thus, the typical model of
providing group sessions during the maintenance phase of treatment may not be
appealing to individuals participating in these programs. Therefore, maintaining
contact through other means may prove to be more effective in long-term
intervention programs. Some of the strategies that have been shown to be
successful are telephone contacts and mailings. In addition, interventions using
social support strategies and computers are currently ongoing. Therefore, these
intervention strategies may be appealing to the military when attempting to
deliver interventions to soldiers that may be deployed throughout the world.
Targeting High Risk Periods for Weight Gain
There is some evidence that there are specific periods when individuals may
be at risk for weight gain, and this may be an important factor for the military to
consider. One period of time is during early adulthood, and weight gain is
typically accompanied by a trend for decreases in physical activity. For
example, unpublished data from our laboratory has shown that college-aged men
and women participating in regular exercise gained less weight during their
college years than those not regularly participating in exercise.
Weight gain may also occur in individuals that are already moderately
overweight. We have shown that moderately overweight adult men left
untreated will gain a significant amount of weight over a period of 16 weeks,
whereas participation in a program to modify exercise behaviors and minimize
fat intake appears to have a beneficial effect on body weight in these individuals
(Leermakers et al., 1998~. Therefore, it may be important for the military to
identify individuals that are moderately overweight and encourage changes in
exercise and eating behaviors to prevent further weight gain.
OCR for page 237
APPENDIX A
237
The postpartum period may be an extremely important time for women with
regard to body-weight regulation, and interventions targeting this period may be
extremely important. For example, in a study of women following pregnancy,
women left untreated lost 4.9 kg with 11.5 percent returning to prepregnancy
weight, whereas those participating in a correspondence-based treatment pro-
gram lost 7.8 kg and 33 percent returned to prepregnancy weight (Leermakers et
al., 1998~. Therefore, it may be important for the military to consider offering
postpartum interventions to minimize the retention of body weight in women
during this period.
Application to Weight-Regulation Initiatives in the Military
There may be some debate in the various branches of the military regarding
acceptable body-weight values and methods of measuring these parameters.
However, regardless of the absolute value that is determined to be acceptable, it
should be recognized that there are soldiers in the military that are at risk for
weight gain. Therefore, the military should consider implementing strategies
that may minimize weight gain in these individuals, and these could include
changes in the environment and providing access to programs related to eating
and exercise behaviors.
In addition, the military should consider implementing interventions early
on (i.e., basic training) that will permit soldiers to transfer their activity and
eating behavior outside of a controlled environment setting. For example, when
an individual enters the military, it is commonly believed that they are in an
environment in which they have little control over their eating and exercise
behaviors, and these factors are controlled by the military. However, soon after
that period of time, soldiers have more freedom of choice, and this is a period
when they could potentially relapse into typical behavioral patterns. Thus,
providing opportunities for soldiers to maintain their newly developed exercise
and eating behaviors may minimize body weight-regulation concerns in this
population. Moreover, one factor that should be considered is the history of the
soldier prior to entering the military. It is likely in some cases that an individual
lost weight just prior to entering the military in order to conform to the military
standards and to be accepted into the military. However, the period following
this initial weight loss is a high-risk time for weight regain. Identifying
individuals that meet these criteria, and targeting interventions at this group of
individuals may prove to be beneficial in preventing relapse while in the
military.
OCR for page 238
238
WEIGHT MANAGEMENT
References
Andersen RE, Franckowiak SC, Snyder J. Bartlett SJ, Fontaine KR. 1998. Can
inexpensive signs encourage the use of stairs? Results from a community
intervention. Ann Intern Med 129:363-369.
Duncan JJ, Gordon NF, Scott CB. 1991. Women walking for health and fitness:
How much is enough? JAm Med Assoc 266:3295-3299.
Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl III HW, Blair SN. 1999.
Comparison of lifestyle and structured interventions to increase physical ac-
tivity and cardiorespiratory fitness. JAm Med Assoc 281 :327-334.
French SA, Jeffery RW, Story M, Hannan P. Snyder MP. 1997. A pricing strat-
egy to promote low-fat snack choices through vending machines. Am JPub-
lic Health 87:849-851.
HHS (U.S. Department of Health and Human Services). 1996. Physical Activity
and Health: A Report of the Surgeon General. Atlanta, GA: Centers for
Disease Control and Prevention and National Center for Chronic Disease
Prevention and Health Promotion.
Jakicic JM, Wing RR, Butler BA, Jeffery RW. 1997. The relationship between
the presence of exercise equipment and participation in physical activity.
Am J. Health Promot 11:363-365.
Jakicic JM, Wing RR, Butler BA, Robertson RJ. 1995. Prescribing exercise in
multiple short bouts versus one continuous bout: Effects on adherence, car-
diorespiratory fitness, and weight loss in overweight women. Int J Obes 19:
893-901.
Jakicic JM, Winters C, Lang W. Wing RR. 1999. Effects of intermittent exercise
and use of home exercise equipment on a&erence, weight loss, and fitness
in overweight women. JAm Med Assoc 282: 155~1560.
Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. 1997. A descriptive
study of individuals successful at long-term maintenance of substantial
weight loss. Am JClin Nutr 66:239-246.
Lee CD, Jackson AS, Blair SN. 1998. U.S. weight guidelines: Is it also impor-
tant to consider cardiorespiratory fitness? Int J Obes Relat Metab Disord
22:S2-S7.
Leermakers EA, Anglin K, Wing RR. 1998. Reducing postpartum weight reten-
tion through a correspondence intervention. Int J Obes Relat Metab Disord
22:1103-1109.
Leermakers EA, Jakicic JM, Viteri J. Wing RR. 1998. Clinic-based vs. home-
based interventions for preventing weight gain in men. Obes Res 6:346-
352.
Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D,
Ettinger W. Heath GW, King AC, Kriska A, Leon AS, Marcus BH, Morris
J. Paffenbarger RS, Patrick K, Pollock ML, Rippe JM, Sallis J. Wilmore JH.
1998. Physical activity and public health: A recommendation from the Cen-
OCR for page 239
APPENDIXA
239
ters for Disease Control and Prevention and the American College of Sports
Medicine. JAm Med Assoc 273:402~07.
Perri MG, McAdoo WG, McAllister DA, Lauer JB, Jordan RC, Yancey DZ,
Nezu AM. 1987. Effects of peer support and therapist contact on long-term
weight loss. J Consult Clin Psychol 55:615~17.
Pronk NP, Wing RR. 1994. Physical activity and long-term maintenance of
weight loss. Obes Res 2:587-599.
Sallis JF, Hovell ME, Hofstetter CR, Elder JP, Hackley M, Caspersen CJ, Pow-
ell KE. 1990. Distance between homes and exercise facilities related to fre-
quency of exercise among San Diego residents. Public Health Rep
105:179-185.
Schoeller DA, Shay K, Kushner RF. 1997. How much physical activity is
needed to minimize weight gain in previously obese women? Am J Clin
Nutr 66:551-556.
Wing RR, Venditti E, Jakicic JM, Polley BA, Lang W. 1998. Lifestyle interven-
tion in overweight individuals with a family history of diabetes. Diabetes
Care 21:350-359.
OCR for page 240
Representative terms from entire chapter:
weight management
