what percentage of persons who lose weight are able to maintain it for more than a year?
Med Clin North Am. Author manuscript; bachelor in PMC 2019 Jan one.
Published in concluding edited form as:
PMCID: PMC5764193
NIHMSID: NIHMS904015
Maintenance of lost weight and long-term management of obesity
Kevin D. Hall
aneNational Establish of Diabetes & Digestive & Kidney Diseases
Scott Kahan
2Johns Hopkins Bloomberg School of Public Health
3George Washington University School of Medicine
Synopsis
Weight loss tin exist accomplished through a diverseness of modalities, but long-term maintenance of lost weight is much more than challenging. Obesity interventions typically result in early on rapid weight loss followed past a weight plateau and progressive regain. This review describes our current understanding of the biological, behavioral, and environmental factors driving this most-ubiquitous body weight trajectory and the implications for long-term weight management. Treatment of obesity requires ongoing clinical attending and weight maintenance-specific counseling to support sustainable healthful behaviors and positive weight regulation.
Keywords: obesity treatment, weight loss, weight maintenance, behavioral counseling, appetite, physiology
Introduction
Robert is a 47 year sometime patient who initially weighed 270 pounds. He lost 85 pounds three years agone by carefully post-obit your guidance to decrease his caloric intake to 1500 calories per day and exercise half dozen days weekly. Today he comes in for his annual physical examination. Y'all were excited to hear most his connected progress and run across how much more he'south lost, but you lot felt immediately dejected to see that he had regained well-nigh 60 pounds. "I don't know what to do…the weight keeps coming dorsum on. I keep trying, but there must exist something wrong. I'm sure my metabolism is in the dumps. It feels like every moment of the day I can't assist but think about food – it was never like this earlier I lost the weight. And no matter how hard I effort to stop eating after one serving, I merely can't seem to do information technology anymore." Feeling defeated, he says "I don't even know what's the point of doing this anymore!"
Frustrated, you remind him that he was able to do it just fine when he was losing weight initially, and he just needs to go along working hard at it. "I know it's not easy, only I can't aid you unless y'all're willing to aid yourself. You lot just need to work harder and take control of this over again." You feel for him, but you know that you need to be stern to go him by this backsliding. Hoping to motivate him, y'all remind him how bad he will feel if he regains more than weight, and you tell him to make a follow-up appointment for six months and warn him that if he doesn't turn things around quickly he will have to restart his claret pressure medications.
Substantial weight loss is possible across a range of treatment modalities, but long-term sustenance of lost weight is much more than challenging, and weight regain is typical1–3. In a meta-assay of 29 long-term weight loss studies, more than half of the lost weight was regained inside two years, and by five years more than 80% of lost weight was regained (Effigy i)4. Indeed, previous failed attempts at achieving durable weight loss may have contributed to the recent decrease in the per centum of people with obesity who are trying to lose weight5 and many now believe that weight loss is a futile endeavor6.
Average time grade of weight regain subsequently a weight loss intervention.
Information from Anderson JW, Konz EC, Frederich RC, et al. Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr 2001;74(5):579–584.
Hither, we depict our current understanding of the factors contributing to weight gain, physiological responses that resist weight loss, behavioral correlates of successful maintenance of lost weight, besides every bit the implications and recommendations for long-term clinical management of patients with obesity.
Why is it and so difficult to lose weight and proceed it off?
The obesogenic surround
Long term weight direction is extremely challenging due to interactions between our biology, beliefs, and the obesogenic environment. The rise in obesity prevalence over the past several decades has been mirrored by industrialization of the nutrient system7 involving increased production and marketing of inexpensive, highly-processed foods8–10 with supernormal appetitive propertiesxi,12. Ultraprocessed foods13 now contribute the majority of calories consumed in America14 and their overconsumption has been implicated as a causative gene in weight gain15. Such foods are typically more calorically dense and far less healthy than unprocessed foods such as fruits, vegetables, and fish16. Food has progressively become cheaper17, fewer people set up meals at homeeighteen,nineteen, and more than food is consumed in restaurants18. In add-on, changes in the physical activity environment take made information technology more challenging to be active throughout the day. Occupations have go more than sedentary20 and suburban sprawl necessitates vehicular transportation rather than walking to work or schoolhouse as had been common in the past. Taken together, changes in the food and physical activity environments tend to drive individuals towards increased intake, decreased action, and ultimately weight gain.
Physiological responses to weight loss
Outdated guidance to physicians and their patients gives the mistaken impression that relatively modest diet changes volition consistently and progressively result in substantial weight loss at rate of 1 pound for every 3500 kcal of accumulated dietary calorie arrears21–24. For instance, cut just a couple of cans of soda (~300 kcal) from ane's daily diet was idea to lead to about 30 pounds of weight loss in a twelvemonth, 60 pounds in 2 years, etc. Failure to reach and maintain substantial weight loss over the long term is and then simply attributed to poor adherence to the prescribed lifestyle changes, thereby potentially farther stigmatizing the patient as lacking in willpower, motivation, or fortitude to lose weight25.
We at present know that the simple calculations underlying the sometime weight loss guidelines are fatally flawed because they fail to consider declining energy expenditure with weight loss26. More than realistic calculations of expected weight loss for a given alter in energy intake or physical activeness are provided by a spider web-based tool called NIH Body Weight Planner (http://BWplanner.niddk.nih.gov) that uses a mathematical model to business relationship for dynamic changes in human energy balance27.
In addition to adaptations in energy expenditure with weight loss, body weight is regulated by negative feedback circuits that influence nutrient intake28,29. Weight loss is accompanied by persistent endocrine adaptations30 that increment appetite and subtract satiety31 thereby resisting continued weight loss and conspiring against long-term weight maintenance.
Explaining the weight plateau
The overlapping physiological changes that occur with weight loss help explain the near-ubiquitous weight loss fourth dimension course: early rapid weight loss that stalls after several months, followed by progressive weight regain32. Different interventions upshot in varying degrees of weight loss and regain, but the overall time courses are similar. As people progressively lose more and more than weight, they fight an increasing battle against the biological responses that oppose further weight loss.
Ambition changes probable play a more than important role than slowing metabolism in explaining the weight loss plateau since the feedback circuit controlling long-term calorie intake has greater overall forcefulness than the feedback excursion controlling calorie expenditure. Specifically, information technology has been estimated that for each kilogram of lost weight, calorie expenditure decreases by about xx–30 kcal/d whereas ambition increases past about 100 kcal/d to a higher place the baseline level prior to weight loss31. Despite these anticipated physiologic phenomena, the typical response of the patient is to arraign themselves as lazy or lacking in willpower, sentiments that are often reinforced by healthcare providers, every bit in the case of Robert, above.
Using a validated mathematical model of human free energy residue dynamics27,31, Effigy 2 illustrates the energy rest dynamics underlying the weight loss time courses of two example ninety kg women who either regain (blue curves) or maintain (orange curves) much of their lost weight after reaching a plateau within the starting time twelvemonth of a nutrition intervention. In both women, large decreases in calorie intake at the kickoff of the intervention result in rapid loss of weight and body fat leading to a small decrease in calorie expenditure that contributes to slowing weight loss. However, the exponential ascension in calorie intake from its initially reduced value is the principal gene that halts weight loss inside the get-go year. In contrast to the modest drop in calorie expenditure of less than 200 kcal/d at the weight plateau, ambition has risen past 400–600 kcal/d and energy intake has increased by 600–700 kcal/d since the start of the intervention.
Mathematical model simulations of body weight, fat mass, free energy intake, free energy expenditure, appetite, and effort for two hypothetical women participating in a weight loss program. The curves in blue depict the typical weight loss, plateau and regain trajectory whereas the orange curves show successful weight loss maintenance.
These mathematical model results contrast with patients' reports of eating approximately the same diet after the weight plateau that was previously successful during the initial phases of weight loss33. While self-reported diet measurements are notoriously inaccurate and imprecise34–36, it may be possible to reconcile such information with objectively quantified increases in calorie intake. It is entirely possible that patients truly believe they are sticking with their diet despite not losing any more weight or even regaining weight.
The patient's perception of ongoing diet maintenance despite no further weight loss may arise because the physiological regulation of appetite occurs in brain regions that operate below the patient's conscious awareness37. Thus, signals to the brain that increase appetite with weight loss could introduce hidden biases such every bit portion sizes creeping upwards over fourth dimension. Such a slow migrate upwards in energy intake would exist difficult to detect given the large twenty–thirty% fluctuations in free energy intake from day to twenty-four hour period38,39. Furthermore, a relatively persistent effort is required to avoid overeating to match the increased appetite that grows in proportion to the weight lost31. For example, the model-calculated intervention endeavor for the faux patient who experiences the weight plateau at half-dozen months followed past weight regain (Figure 2, blue curves) maintains more ~seventy% of their initial intervention effort until the plateau. Perhaps self-reported nutrition maintenance earlier and after the weight plateau is more representative of the patients' relatively persistent try to avoid overeating in response to their increased appetite31. New technologies using repeated weight monitoring can exist used calculate changes in calorie intake and endeavor over fourth dimension40 and help guide individuals participating in a weight loss intervention41–44.
Weight regain versus maintenance
From a purely calorie balance perspective, a patient who maintains lost weight afterwards the first year of an intervention (Figure 2, orange curves) may be eating just about 100 kcal/d fewer than a patient who experiences long-term weight regain (Effigy ii, blue curves). Nonetheless, such a small difference in nutrient intake behavior is somewhat misleading considering that prevention of weight regain requires about 300–500 kcal/d of increased persistent attempt to counter the ongoing slowing of metabolism and increased appetite associated with the lost weight. The more typical pattern of long-term weight regain is characterized by a waning attempt to sustain the intervention.
There are likely many factors that account for the ability of some patients to achieve and maintain large weight losses over the long term whereas others experience substantial weight regain. Unravelling the biological, psychosocial, educational, and environmental determinants of such individual variability volition be an agile expanse of obesity research for the foreseeable futurity45.
The function of nutrition composition
The laws of thermodynamics dictate that the energy derived from macronutrients being oxidized via the intricate biochemical pathways of oxidative phosphorylation inside cells can be equated to the values measured by combusting these fuels in a bomb calorimeter. However, this equivalence does not necessarily imply that "a calorie is a calorie" when it comes to diets with different macronutrient proportions differentially impacting weight loss.
Altering dietary macronutrient limerick could theoretically influence overall calorie intake or expenditure resulting in a respective change in trunk weight. Alternatively, manipulation of diet composition tin can result in differences in the endocrine status in a way that could theoretically influence the propensity to accumulate torso fat or affect subjective hunger or satiety. These possibilities practice non necessarily violate the laws of thermodynamics since any change in the body's overall energy stores (i.eastward. fat mass) must be accompanied by changes in calorie intake or expenditure. Therefore, information technology is theoretically possible that a particular nutrition could issue in an advantageous endocrine or metabolic country that promotes weight loss. This hope provides fodder for the diet industry and fake hope to the patient with obesity since it implies that if they merely choose the right diet so weight loss can be easily achieved.
In contempo years, there has been a reemergence of low-carbohydrate, high-fat diets every bit popular weight loss interventions. Such diets have been claimed to reverse the metabolic and endocrine derangements resulting from post-obit communication to consume low-fat, high-carbohydrate diets that allegedly caused the obesity epidemic. Specifically, the so-called "saccharide-insulin model of obesity" posits that diets high in carbohydrates are especially fattening considering they increase the secretion insulin and thereby drive fatty aggregating in adipose tissue and away from oxidation by metabolically agile tissues, and this altered fat sectionalisation results in a state of "cellular starvation" leading to adaptive increases in hunger, and suppression of energy expenditure46. Therefore, the sugar-insulin model implies that reversing these processes by eating a low-sugar, high-fat diet should effect in effortless weight loss47. Unfortunately, of import aspects of the carbohydrate-insulin model accept failed experimental interrogation48 and, for all practical purposes, "a calorie is a calorie" when information technology comes to torso fat and free energy expenditure differences between controlled isocaloric diets varying in the ratio of carbohydrate to fatty49. Nevertheless, depression-carbohydrate, high-fat diets may lead to spontaneous reduction in calorie reduction and increased weight loss, peculiarly over the short term50–52. Meta-analyses of long-term weight loss have suggested that low-fat weight loss diets are slightly, if statistically, inferior to low-saccharide diets53, only the average differences betwixt diets is too small to exist clinically significant54. Furthermore, the similarity of the hateful weight loss patterns between diet groups in randomized weight loss trials strongly suggests that there is no generalizable advantage of i nutrition over some other when information technology comes to long-term calorie intake or expenditure33.
In contrast to the near equivalency of dietary sugar and fat, dietary protein is known to positively influence body limerick during weight loss55,56 and has a small positive effect on resting metabolism57. Diets with higher poly peptide may besides offering benefits for maintaining weight loss58, especially when the overall diet has a low glycemic index59. This might exist partially mediated by dietary protein's greater event on satiety compared to carbohydrate and fatty55,56 along with the possibility of increased overall energy expenditurelx. More enquiry is needed to better sympathize whether these potentially positive attributes of higher protein diets outweigh concerns that such diets mitigate improvements in insulin sensitivity that are typically accomplished with weight loss using lower poly peptide diets61.
Whereas long-term nutrition trails have not resulted in clear superiority of one diet over some other with respect to average weight loss, within each diet group in that location is a high degree of individual variability and anecdotal success stories grow for a wide range of weight loss diets33. Some of this variability may exist due to interactions between nutrition type and patient genetics62,63 or baseline physiology such as insulin sensitivity64–67. Such interactions offer the promise of personalized diets that optimize the patient's chances for long-term weight loss success45,63. Unfortunately, diet-biology interactions for weight loss take non always been reproducible68,69 and likely explicate but a fraction of the individual variability.
It is certainly possible that the patients who successfully lost weight on one diet would take been equally successful had they been assigned to an alternative diet. In other words, long-term success with a weight loss diet may have less to practice with biology than factors such as the patient'due south food environs, socioeconomics, medical comorbidities, and social support, also as practical factors, such every bit developing cooking skills and managing job requirements. Such non-biological factors likely play a strong function in determining whether diet adherence is sustainable.
Clinical recommendations for long term weight management counseling
Given the physiologic and environmental obstacles to long-term maintenance of lost weight described above, we offer the post-obit recommendations for clinical practice and and then present an alternative preferable depiction of the opening case example.
Long term benefits require long term attending
Long term behavioral changes and obesity direction require ongoing attention. Even the highest quality short-term interventions are unlikely to yield connected positive outcomes without persisting intervention and support. Several studies show that ongoing interaction with healthcare providers or in grouping settings significantly improves weight maintenance and long-term outcomes, compared with treatments that end after a short period of time (Figure iii)70,71. The importance of long-term intervention has been codified in the obesity handling guidelines, which state that weight loss interventions should include long term comprehensive weight loss maintenance programs that go along for at least 1 twelvemonth72.
Weight direction programs with a focus on maintenance of lost weight demonstrate improved long-term weight loss (ruby curve) compared to programs without maintenance visits (blue curve).
Adapted from Perri MG, McAllister DA, Gange JJ, et al. Effects of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol 1988;56(iv):529–534; with permission.
With respect to the case study at the start of this paper, the physician should not expect ongoing weight loss without ongoing support and interaction. Rather than asking Robert to turn things effectually on his own, the physician has an opportunity to reengage with Robert to offering guidance and support in a more intensive and regular manner than sending him off on his own for six months, or if this is not realistic in a decorated primary intendance practice, he could refer Robert to an obesity medicine specialist, registered dietitian, comprehensive weight management clinic, or recommend that he appoint in a customs weight management grouping, such as the Diabetes Prevention Plan (at present covered by Medicare for patients with prediabetes), or a commercial program, such as Weight Watchers.
Utilize weight maintenance-specific counseling/strategies
Behavioral strategies for initiation of weight loss are described elsewhere in this volume []. Weight-loss specific behaviors associated with long term success include: frequent cocky-monitoring and self-weighing, reduced calorie intake, smaller and more frequent meals/snacks throughout the day, increased physical activity, consistently eating breakfast, more frequent at-habitation meals compared with restaurant and fast-food meals, reducing screen time, and use of portion-controlled meals or meal substitutes2,73–75. Weight maintenance-specific behavioral skills and strategies aid patients to build insight for long-term direction, conceptualize struggles and prepare contingency plans, moderate behavioral fatigue, and put into perspective the inevitable lapses and relapses of any long-term engagement.
Although the research is mixed, several studies bear witness improved weight loss outcomes in patients receiving weight maintenance-specific training, compared with those who only receive traditional weight loss training76–79. Strategies are discussed below for weight maintenance-specific counseling.
Strengthen satisfaction with outcomes
People tend to focus on what they haven't achieved, rather than what they've already accomplished. Unlike with weight loss, during which the external reward of watching the calibration subtract and clinical measures (e.g., lipid levels) improve can increase motivation, the extended flow of weight maintenance has fewer of these explicit rewards. To back up motivation and brand salient satisfaction with outcomes, call attention to patients' progress, which often becomes disregarded. Providers can point to the magnitude of weight that has been kept off, putting it into context in terms of average expected weight loss (described beneath), as well every bit clinical improvements in adventure factors, such as blood force per unit area and glycemic command. Additionally, showing patients "before and after" photographs of themselves and other tangible evidence of progress helps them to build awareness of and appreciate the benefits they have already accomplished, which may improve long-term persistence with weight maintenance efforts.
Relapse prevention training
Anticipating and managing loftier-risk situations for "slips" and lapses helps patients minimize lapses, become back on track, and avert giving upwards. This counseling oft includes self-weighing and identifying weight thresholds that point the need for reengaging with a support team or initiating contingency strategies; proactively developing plans and practicing strategies for managing and coping with lapses; problem solving to identify challenges, formulate solutions, and evaluate options; and building strategies for not-food activities and coping mechanisms, such as engaging in hobbies or mindfulness activities, to minimize counterproductive coping mechanisms, such as emotional eating.
Cognitive restructuring
Cycles of negative and maladaptive thoughts (eastward.k., "What's the betoken…I failed again and I'll never lose weight!") and coping patterns (eastward.thousand., binge eating in response to gaining a few pounds) are counterproductive and demotivating. Helping patients to recognize and restructure the cadre behavior and thought processes that underlie these patterns helps minimize behavioral fatigue and prevent or productively manage slips and lapses.
Developing cognitive flexibility
Many tendencies that promote initial weight loss are unrealistic over the long term. For example, many patients aim to brand large, absolute changes in an "all-or-none" fashion via rigid rules, such as aiming for "no carbs" or very restrictive intake. Much as a sprinter can run all-out for a short race, merely not for the entirety of a marathon, expecting strict, all-out efforts and clear-cut, black-and-white outcomes over the lifelong management of obesity is a recipe for frustration and failure. Instead, learning to take that rigid expectations and "perfect" adherence to behavioral goals is unrealistic and building cerebral flexibility to take in stride when one's plans do not become according to plan is a core competency for long term sustainable behavioral changes and weight direction.
Appeal to patients' deeper motivations
External, superficial rewards are unlikely to support the long term endurance needed for weight maintenance. For instance, studies of financial rewards to incentivize behavioral changes, such as weight loss or tobacco cessation, yield initial benefits that invariably wane precipitously over time80,81. Whereas "white knuckling" and external, controlled motivations, such every bit directives from a spouse or healthcare provider, may lead to short-term weight loss, longer term sustained motivation is more probable when patients take buying of their behavioral changes and goals, and engage in them because they are deeply meaningful or enjoyable80,81. As an example, compared with difficulty of sticking to a strict low-fat or low-carb diet, which are oftentimes arbitrarily prescribed and of little personal significance to the patient, and therefore difficult to maintain, countless millions throughout the world rigorously stick to comparably strict kosher, halal, or vegan eating patterns, which are aligned with their religious, upstanding, or other deeply held beliefs and values. Similarly, prescribing daily gym visits to someone who hates the gym environs or gym activities is unlikely to be fruitful, whereas supporting patients to detect more enjoyable concrete activities, such as sports or group dance-exercise classes, increases the likelihood of continuing over time.
Manage expectations – both for patients and providers
Both patients and healthcare providers take wildly unrealistic expectations for weight loss outcomes. In one report, patients entering a diet and practise programme expected to lose xx–40% of their starting body weight - amounts that can only realistically be achieved by bariatric surgery82. Physician expectations are similarly inflated: in a survey of primary care physicians, acceptable behavioral weight loss was considered to be a loss of 21% of initial body weight83. In contrast, numerous studies show that diet, exercise, and behavioral counseling, in the best of cases, simply leads to 5–10% average weight loss, and few patients with significantly elevated initial weights reach and maintain an "ideal" body weight. From a cerebral psychology perspective, a waning intervention effort may be due to thwarting in the degree of weight loss actually achieved82 leading the patient to conclude that the effort is non worth the achieved benefits84.
Although the published data is mixed on whether unrealistic outcomes volition deter weight loss success, it stands to reason that excessive discrepancies between expectations and actual outcomes would exist demoralizing and increment negative thoughts and cocky-blame (which itself is associated with numerous negative health outcomes85), and may diminish long term persistence for connected behavioral change and weight loss maintenance. We recommend advising patients virtually the physiologic challenges of long term weight loss and the degree of weight loss that can be realistically expected from behavioral interventions. At minimum, there'south no known harm of offer this insight and beingness frank with patients about expectations, and it may help them navigate the minefield of unscrupulous diet programs and promises that promise miraculous outcomes.
Nonetheless, positive outcomes of behavioral counseling extend across weight loss. Despite the modest weight losses associated with behavioral interventions, small weight losses tin lead to impressive wellness improvements and adventure factor reductions. In the Diabetes Prevention Plan, vii% weight loss over six months led to 58% reduction in development of diabetes, despite half the weight being regained over three years86. In the Look Ahead trial, half dozen% weight loss over eight years yielded improvements in a range of cardiovascular risk factors, including glycemic control and lipids, as well as less medication usage, and reduced hospitalizations and healthcare costs87,88.
While losing weight is important for improved health, people's motivations for seeing the calibration go down is all-likewise-oft driven by cultural norms for thinness and healthcare provider-imposed weight loss directives. These external motivations can motion the weight loss needle in the curt-run, but they rarely atomic number 82 to long-lasting determination. As described in the section above, long term direction is improved when motivations are aligned with personal values and preferences. Helping patients shift their locus of motivation from weight loss solitary to intrinsically meaningful areas, such as health comeback, can improve long term weight and behavioral outcomes89.
Escalate handling every bit needed
For patients that do not accomplish sufficient weight loss or health improvements with bones counseling in primary care settings, there are several opportunities to intensify therapy. Consider referral to a registered dietitian, obesity medicine physician, or comprehensive weight management clinic, too every bit targeted specialists (such equally a behavioral psychologist for patients with rampage eating disorder or body dysmorphia). For patients with BMI greater than thirty kg/thousand2 (or 27–30 kg/chiliad2 with obesity-related comorbid conditions), obesity pharmacotherapy leads to every bit much as 15% weight loss in responders, with weight loss being maintained in several studies for several years90–92. For patients with BMI greater than 40 kg/g2 (or 35–forty kg/m2 with comorbidities), bariatric surgery is a well-studied and valuable option that leads to big, sustainable weight losses in most patients93.
Using the principles discussed above, a more than productive encounter in response to Robert'south presentation might become like this:
Physician: "I sympathize, and I know it's challenging. It sounds like y'all're feeling frustrated because you've worked so hard and you feel similar you lot've got nothing to show for it."
He nods and says, "Exactly. What'southward the point of doing this anymore."
Physician: "From my view, the show we have shows something different: Y'all're actually doing quite well in the scheme of things. I actually see quite a lot of progress for your efforts. You're down 25 lbs, right? That's well-nigh x% down from where you started…that's impressive. Few people lose that much weight and proceed it off for three years. Studies show that even under the all-time of circumstances with aggressive counseling, average weight loss is between 5–10% of starting body weight – so y'all're doing better than about! You've been able to get off several blood pressure medications and you no longer take the pain medicine for your back and knees. And, we know from studies that losing just 7%, fifty-fifty if role of it is regained over the years, lowers the gamble of diabetes by sixty%!" His eyes widen. "Weight goes upwards and down, and our bodies fight dorsum against weight loss, so this is never easy. Some regain and relapse is inevitable – only like in other areas of life." He takes a deep breath and conspicuously seems more engaged and hopeful. "So let's figure out how we tin motion forrad and continue getting the benefits, and I'll be here with you to help forth the manner. Let's hold on a couple of adjacent steps, and we'll come across once again in a few weeks to run into how it's going. If we need, we can also consider additional strategies or treatments."
Determination
The degree of weight loss and its maintenance should non exist the sole metric of obesity treatment success. Rather, physicians should support and encourage patients to make sustainable improvements in their diet quality and physical activities if these behaviors fail to meet national guidelines94,95. Such lifestyle changes over the long-term will likely improve the health of patients even in the absence of major weight loss96.
Acknowledgments
Funding: This inquiry was supported past the Intramural Research Plan of the NIH, National Institute of Diabetes & Digestive & Kidney Diseases.
KDH has received funding from the Diet Scientific discipline Initiative to investigate the effects of ketogenic diets on homo energy expenditure. KDH also has a patent on a method of personalized dynamic feedback command of trunk weight (US Patent No 9,569,483; assigned to the National Institutes of Wellness).
Footnotes
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Conflicts of Interest: SK has no relevant disclosures.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/
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