Ill Never Eat Again I Am So Fat English
Med Clin North Am. Author manuscript; available in PMC 2019 Jan one.
Published in final edited class every bit:
PMCID: PMC5764193
NIHMSID: NIHMS904015
Maintenance of lost weight and long-term management of obesity
Kevin D. Hall
iNational Institute of Diabetes & Digestive & Kidney Diseases
Scott Kahan
2Johns Hopkins Bloomberg School of Public Health
threeGeorge Washington University School of Medicine
Synopsis
Weight loss can exist achieved through a variety of modalities, just long-term maintenance of lost weight is much more challenging. Obesity interventions typically effect in early 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 near-ubiquitous body weight trajectory and the implications for long-term weight management. Treatment of obesity requires ongoing clinical attention and weight maintenance-specific counseling to support sustainable healthful behaviors and positive weight regulation.
Keywords: obesity treatment, weight loss, weight maintenance, behavioral counseling, ambition, physiology
Introduction
Robert is a 47 year old patient who initially weighed 270 pounds. He lost 85 pounds iii years ago by carefully post-obit your guidance to decrease his caloric intake to 1500 calories per day and practice half-dozen days weekly. Today he comes in for his annual physical examination. You were excited to hear well-nigh his continued progress and see how much more he's lost, simply you felt immediately dejected to see that he had regained almost threescore pounds. "I don't know what to practise…the weight keeps coming back on. I keep trying, but there must exist something wrong. I'm sure my metabolism is in the dumps. Information technology feels like every moment of the day I can't aid merely recollect nearly food – information technology was never like this earlier I lost the weight. And no matter how hard I try to finish eating after one serving, I just can't seem to practise information technology anymore." Feeling defeated, he says "I don't fifty-fifty know what's the point of doing this anymore!"
Frustrated, you remind him that he was able to exercise it just fine when he was losing weight initially, and he but needs to keep working hard at it. "I know it'due south non easy, merely I can't assistance you unless you're willing to help yourself. You just need to work harder and have command of this once more." You feel for him, simply you know that you need to be stern to get him past this backsliding. Hoping to motivate him, you remind him how bad he will feel if he regains more weight, and you tell him to make a follow-upward engagement for 6 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 handling modalities, just long-term sustenance of lost weight is much more challenging, and weight regain is typical1–3. In a meta-analysis of 29 long-term weight loss studies, more than one-half of the lost weight was regained inside two years, and by v years more than than 80% of lost weight was regained (Effigy 1)4. Indeed, previous failed attempts at achieving durable weight loss may accept contributed to the recent decrease in the percentage of people with obesity who are trying to lose weight5 and many now believe that weight loss is a futile endeavor6.
Average time course of weight regain after a weight loss intervention.
Data from Anderson JW, Konz EC, Frederich RC, et al. Long-term weight-loss maintenance: a meta-analysis of Usa studies. Am J Clin Nutr 2001;74(5):579–584.
Here, nosotros describe our current understanding of the factors contributing to weight proceeds, physiological responses that resist weight loss, behavioral correlates of successful maintenance of lost weight, too as the implications and recommendations for long-term clinical management of patients with obesity.
Why is information technology so difficult to lose weight and keep 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 food system7 involving increased product and marketing of inexpensive, highly-processed foods8–10 with supernormal appetitive propertieseleven,12. Ultraprocessed foodsxiii at present contribute the bulk of calories consumed in Americaxiv and their overconsumption has been implicated as a causative factor in weight gain15. Such foods are typically more calorically dense and far less good for you than unprocessed foods such as fruits, vegetables, and fish16. Food has progressively become cheaper17, fewer people prepare meals at home18,19, and more food is consumed in restaurants18. In addition, changes in the physical activeness environment have made it more challenging to exist active throughout the 24-hour interval. Occupations have go more sedentary20 and suburban sprawl necessitates vehicular transportation rather than walking to piece of 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 activeness, and ultimately weight gain.
Physiological responses to weight loss
Outdated guidance to physicians and their patients gives the mistaken impression that relatively pocket-size diet changes will consistently and progressively consequence in substantial weight loss at rate of one pound for every 3500 kcal of accumulated dietary calorie arrears21–24. For case, cutting merely a couple of cans of soda (~300 kcal) from one's daily nutrition was idea to lead to about 30 pounds of weight loss in a year, 60 pounds in ii years, etc. Failure to achieve and maintain substantial weight loss over the long term is and then just 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 now know that the simple calculations underlying the old weight loss guidelines are fatally flawed because they fail to consider failing energy expenditure with weight loss26. More realistic calculations of expected weight loss for a given alter in energy intake or physical action are provided by a web-based tool called NIH Body Weight Planner (http://BWplanner.niddk.nih.gov) that uses a mathematical model to account for dynamic changes in human energy balance27.
In addition to adaptations in free energy expenditure with weight loss, body weight is regulated by negative feedback circuits that influence food intake28,29. Weight loss is accompanied past persistent endocrine adaptationsxxx that increase 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 aid explain the near-ubiquitous weight loss fourth dimension course: early rapid weight loss that stalls after several months, followed by progressive weight regain32. Dissimilar interventions result in varying degrees of weight loss and regain, but the overall fourth dimension courses are similar. As people progressively lose more and more 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 excursion controlling long-term calorie intake has greater overall force than the feedback circuit decision-making calorie expenditure. Specifically, it has been estimated that for each kilogram of lost weight, calorie expenditure decreases by about 20–30 kcal/d whereas appetite increases by about 100 kcal/d above the baseline level prior to weight loss31. Despite these predictable physiologic phenomena, the typical response of the patient is to blame themselves as lazy or defective in willpower, sentiments that are frequently reinforced by healthcare providers, as in the example of Robert, above.
Using a validated mathematical model of homo energy balance dynamics27,31, Effigy 2 illustrates the free energy residuum dynamics underlying the weight loss time courses of 2 example xc kg women who either regain (bluish curves) or maintain (orange curves) much of their lost weight after reaching a plateau inside the first year of a diet intervention. In both women, large decreases in calorie intake at the first of the intervention upshot in rapid loss of weight and body fat leading to a modest decrease in calorie expenditure that contributes to slowing weight loss. However, the exponential ascension in calorie intake from its initially reduced value is the primary factor that halts weight loss within the first year. In contrast to the modest driblet in calorie expenditure of less than 200 kcal/d at the weight plateau, appetite has risen by 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, energy intake, free energy expenditure, appetite, and effort for two hypothetical women participating in a weight loss program. The curves in blueish describe the typical weight loss, plateau and regain trajectory whereas the orange curves show successful weight loss maintenance.
These mathematical model results dissimilarity with patients' reports of eating approximately the aforementioned diet afterwards 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 exist possible to reconcile such data with considerately quantified increases in calorie intake. It is entirely possible that patients truly believe they are sticking with their nutrition despite not losing whatever more weight or even regaining weight.
The patient'due south perception of ongoing nutrition maintenance despite no further weight loss may arise because the physiological regulation of ambition occurs in brain regions that operate below the patient'southward conscious awareness37. Thus, signals to the encephalon that increase appetite with weight loss could introduce subconscious biases such as portion sizes creeping upwards over fourth dimension. Such a tiresome drift upwards in free energy intake would be difficult to detect given the large 20–30% fluctuations in energy intake from day to day38,39. Furthermore, a relatively persistent effort is required to avert overeating to match the increased appetite that grows in proportion to the weight lost31. For example, the model-calculated intervention effort for the fake patient who experiences the weight plateau at 6 months followed past weight regain (Figure 2, blueish curves) maintains more than ~lxx% of their initial intervention endeavour until the plateau. Perhaps cocky-reported diet maintenance before and afterward the weight plateau is more than representative of the patients' relatively persistent endeavour to avoid overeating in response to their increased appetite31. New technologies using repeated weight monitoring tin can exist used summate changes in calorie intake and effort over time40 and aid guide individuals participating in a weight loss intervention41–44.
Weight regain versus maintenance
From a purely calorie remainder perspective, a patient who maintains lost weight after the starting time year of an intervention (Figure ii, orange curves) may be eating just most 100 kcal/d fewer than a patient who experiences long-term weight regain (Figure ii, blue curves). Nevertheless, such a modest difference in food intake behavior is somewhat misleading considering that prevention of weight regain requires nearly 300–500 kcal/d of increased persistent effort to counter the ongoing slowing of metabolism and increased appetite associated with the lost weight. The more than typical pattern of long-term weight regain is characterized past a waning effort to sustain the intervention.
There are likely many factors that business relationship 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 ecology determinants of such individual variability will be an agile area of obesity research for the foreseeable futurity45.
The function of nutrition limerick
The laws of thermodynamics dictate that the energy derived from macronutrients beingness 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 corresponding change in body weight. Alternatively, manipulation of nutrition composition can result in differences in the endocrine status in a way that could theoretically influence the propensity to accumulate body fat or affect subjective hunger or satiety. These possibilities practice not necessarily violate the laws of thermodynamics since whatever change in the body's overall energy stores (i.due east. fat mass) must be accompanied by changes in calorie intake or expenditure. Therefore, information technology is theoretically possible that a detail diet could result in an advantageous endocrine or metabolic land that promotes weight loss. This promise provides forage for the diet manufacture and false hope to the patient with obesity since it implies that if they simply choose the correct nutrition then weight loss can be easily accomplished.
In recent years, there has been a reemergence of low-carbohydrate, loftier-fat diets equally popular weight loss interventions. Such diets have been claimed to reverse the metabolic and endocrine derangements resulting from following advice to consume low-fat, high-saccharide diets that allegedly acquired the obesity epidemic. Specifically, the so-chosen "saccharide-insulin model of obesity" posits that diets high in carbohydrates are particularly fattening considering they increase the secretion insulin and thereby drive fatty aggregating in adipose tissue and away from oxidation by metabolically active tissues, and this altered fat sectionalization results in a country 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-carbohydrate, high-fat diet should result in effortless weight loss47. Unfortunately, important aspects of the carbohydrate-insulin model have failed experimental interrogation48 and, for all practical purposes, "a calorie is a calorie" when it comes to body fat and energy expenditure differences between controlled isocaloric diets varying in the ratio of saccharide to fatty49. Nevertheless, depression-carbohydrate, high-fat diets may lead to spontaneous reduction in calorie reduction and increased weight loss, particularly 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, but the boilerplate differences between diets is likewise small to exist clinically significant54. Furthermore, the similarity of the mean weight loss patterns between diet groups in randomized weight loss trials strongly suggests that there is no generalizable advantage of i diet over another when it 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 composition during weight loss55,56 and has a small positive effect on resting metabolism57. Diets with higher protein may as well offer benefits for maintaining weight loss58, peculiarly when the overall nutrition has a depression glycemic alphabetize59. This might exist partially mediated by dietary protein'due south greater effect on satiety compared to carbohydrate and fat55,56 forth with the possibility of increased overall energy expenditurethreescore. More research 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 diet trails have non resulted in articulate superiority of i diet over another with respect to average weight loss, within each diet group at that place is a loftier degree of individual variability and anecdotal success stories abound for a broad range of weight loss diets33. Some of this variability may be due to interactions between diet type and patient genetics62,63 or baseline physiology such every bit insulin sensitivity64–67. Such interactions offer the promise of personalized diets that optimize the patient'southward chances for long-term weight loss success45,63. Unfortunately, nutrition-biology interactions for weight loss have not e'er been reproducible68,69 and likely explain only a fraction of the individual variability.
It is certainly possible that the patients who successfully lost weight on i diet would accept been equally successful had they been assigned to an alternative nutrition. In other words, long-term success with a weight loss diet may take less to exercise with biology than factors such as the patient's nutrient environment, socioeconomics, medical comorbidities, and social support, as well as practical factors, such equally developing cooking skills and managing job requirements. Such non-biological factors probable play a strong office 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 offering the following recommendations for clinical practise and then present an alternative preferable depiction of the opening case example.
Long term benefits crave long term attention
Long term behavioral changes and obesity management crave ongoing attention. Even the highest quality short-term interventions are unlikely to yield continued positive outcomes without persisting intervention and support. Several studies show that ongoing interaction with healthcare providers or in group settings significantly improves weight maintenance and long-term outcomes, compared with treatments that end after a brusque menstruation of time (Effigy iii)70,71. The importance of long-term intervention has been codified in the obesity treatment guidelines, which state that weight loss interventions should include long term comprehensive weight loss maintenance programs that continue for at least 1 twelvemonth72.
Weight management programs with a focus on maintenance of lost weight demonstrate improved long-term weight loss (reddish bend) compared to programs without maintenance visits (blueish curve).
Adjusted from Perri MG, McAllister DA, Gange JJ, et al. Furnishings of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol 1988;56(4):529–534; with permission.
With respect to the example written report at the start of this paper, the md should non await ongoing weight loss without ongoing support and interaction. Rather than asking Robert to turn things effectually on his own, the doctor has an opportunity to reengage with Robert to offer guidance and support in a more than intensive and regular manner than sending him off on his own for six months, or if this is not realistic in a busy primary care do, he could refer Robert to an obesity medicine specialist, registered dietitian, comprehensive weight management clinic, or recommend that he engage in a community weight management group, such as the Diabetes Prevention Program (now covered past Medicare for patients with prediabetes), or a commercial program, such equally Weight Watchers.
Use weight maintenance-specific counseling/strategies
Behavioral strategies for initiation of weight loss are described elsewhere in this book []. Weight-loss specific behaviors associated with long term success include: frequent self-monitoring and self-weighing, reduced calorie intake, smaller and more than frequent meals/snacks throughout the 24-hour interval, increased physical activity, consistently eating breakfast, more frequent at-home meals compared with restaurant and fast-nutrient meals, reducing screen time, and use of portion-controlled meals or repast substitutes2,73–75. Weight maintenance-specific behavioral skills and strategies help patients to build insight for long-term management, anticipate struggles and prepare contingency plans, moderate behavioral fatigue, and put into perspective the inevitable lapses and relapses of any long-term appointment.
Although the research is mixed, several studies show improved weight loss outcomes in patients receiving weight maintenance-specific preparation, 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 advantage of watching the scale decrease and clinical measures (east.g., lipid levels) better can increase motivation, the extended menstruum of weight maintenance has fewer of these explicit rewards. To support motivation and make salient satisfaction with outcomes, call attention to patients' progress, which often becomes overlooked. Providers tin can point to the magnitude of weight that has been kept off, putting information technology into context in terms of boilerplate expected weight loss (described below), also as clinical improvements in risk factors, such as claret pressure and glycemic control. Additionally, showing patients "earlier and afterward" photographs of themselves and other tangible evidence of progress helps them to build awareness of and appreciate the benefits they have already achieved, which may improve long-term persistence with weight maintenance efforts.
Relapse prevention training
Anticipating and managing high-risk situations for "slips" and lapses helps patients minimize lapses, become back on track, and avoid giving up. This counseling often includes self-weighing and identifying weight thresholds that signal the need for reengaging with a back up squad 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 edifice strategies for non-food activities and coping mechanisms, such equally engaging in hobbies or mindfulness activities, to minimize counterproductive coping mechanisms, such as emotional eating.
Cognitive restructuring
Cycles of negative and maladaptive thoughts (e.thou., "What's the bespeak…I failed once more and I'll never lose weight!") and coping patterns (e.g., rampage eating in response to gaining a few pounds) are counterproductive and demotivating. Helping patients to recognize and restructure the core beliefs and idea processes that underlie these patterns helps minimize behavioral fatigue and forbid 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 make large, absolute changes in an "all-or-none" style via rigid rules, such equally aiming for "no carbs" or very restrictive intake. Much as a sprinter can run all-out for a short race, but not for the entirety of a marathon, expecting strict, all-out efforts and clear-cutting, black-and-white outcomes over the lifelong direction of obesity is a recipe for frustration and failure. Instead, learning to accept that rigid expectations and "perfect" adherence to behavioral goals is unrealistic and building cerebral flexibility to take in footstep when 1'south plans do not go according to program is a core competency for long term sustainable behavioral changes and weight management.
Entreatment to patients' deeper motivations
External, superficial rewards are unlikely to support the long term endurance needed for weight maintenance. For example, studies of financial rewards to incentivize behavioral changes, such equally 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 likely when patients take buying of their behavioral changes and goals, and appoint in them because they are deeply meaningful or enjoyablefourscore,81. Equally an example, compared with difficulty of sticking to a strict depression-fat or low-carb nutrition, which are often arbitrarily prescribed and of footling personal significance to the patient, and therefore difficult to maintain, countless millions throughout the globe 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 environment or gym activities is unlikely to be fruitful, whereas supporting patients to find more enjoyable physical activities, such as sports or grouping trip the light fantastic-practice classes, increases the likelihood of continuing over fourth dimension.
Manage expectations – both for patients and providers
Both patients and healthcare providers accept wildly unrealistic expectations for weight loss outcomes. In 1 report, patients entering a diet and exercise program expected to lose twenty–xl% 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, adequate behavioral weight loss was considered to be a loss of 21% of initial torso weight83. In contrast, numerous studies show that diet, exercise, and behavioral counseling, in the best of cases, only leads to five–x% boilerplate weight loss, and few patients with significantly elevated initial weights accomplish and maintain an "platonic" torso weight. From a cognitive psychology perspective, a waning intervention effort may exist due to disappointment 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 will deter weight loss success, it stands to reason that excessive discrepancies between expectations and actual outcomes would be demoralizing and increase negative thoughts and cocky-blame (which itself is associated with numerous negative health outcomes85), and may diminish long term persistence for continued behavioral change and weight loss maintenance. We recommend advising patients about the physiologic challenges of long term weight loss and the degree of weight loss that can exist realistically expected from behavioral interventions. At minimum, there'southward no known harm of offer this insight and being frank with patients nearly expectations, and it may help them navigate the minefield of unscrupulous diet programs and promises that promise miraculous outcomes.
Withal, positive outcomes of behavioral counseling extend across weight loss. Despite the modest weight losses associated with behavioral interventions, pocket-size weight losses can lead to impressive health improvements and risk gene reductions. In the Diabetes Prevention Program, 7% weight loss over six months led to 58% reduction in evolution of diabetes, despite one-half the weight being regained over three years86. In the Expect Ahead trial, half-dozen% weight loss over viii 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 scale become downwards is all-too-oftentimes driven by cultural norms for thinness and healthcare provider-imposed weight loss directives. These external motivations tin move the weight loss needle in the short-run, but they rarely lead to long-lasting determination. Every bit described in the section in a higher place, long term management is improved when motivations are aligned with personal values and preferences. Helping patients shift their locus of motivation from weight loss lone to intrinsically meaningful areas, such as health comeback, tin improve long term weight and behavioral outcomes89.
Escalate treatment as needed
For patients that do not achieve sufficient weight loss or health improvements with basic counseling in primary care settings, there are several opportunities to intensify therapy. Consider referral to a registered dietitian, obesity medicine medico, or comprehensive weight management clinic, as well equally targeted specialists (such as a behavioral psychologist for patients with rampage eating disorder or body dysmorphia). For patients with BMI greater than 30 kg/grandtwo (or 27–30 kg/10002 with obesity-related comorbid weather), obesity pharmacotherapy leads to every bit much every bit fifteen% weight loss in responders, with weight loss being maintained in several studies for several yearsxc–92. For patients with BMI greater than xl kg/mii (or 35–40 kg/thou2 with comorbidities), bariatric surgery is a well-studied and valuable option that leads to big, sustainable weight losses in nearly patients93.
Using the principles discussed to a higher place, a more productive encounter in response to Robert's presentation might get similar this:
Dr.: "I empathise, and I know information technology's challenging. It sounds like you're feeling frustrated because you've worked then hard and y'all feel like you lot've got nothing to show for information technology."
He nods and says, "Exactly. What'south the point of doing this anymore."
Physician: "From my view, the evidence we have shows something different: You'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 almost 10% down from where you started…that'due south impressive. Few people lose that much weight and continue it off for three years. Studies show that even under the all-time of circumstances with aggressive counseling, average weight loss is between 5–ten% of starting trunk weight – then you're doing better than most! You've been able to get off several blood pressure medications and y'all no longer have the pain medicine for your back and knees. And, we know from studies that losing simply 7%, fifty-fifty if part of it is regained over the years, lowers the risk of diabetes by 60%!" His eyes widen. "Weight goes upwardly and downward, and our bodies fight back confronting weight loss, so this is never easy. Some regain and relapse is inevitable – just like in other areas of life." He takes a deep breath and clearly seems more engaged and hopeful. "So allow'due south figure out how we can motility forward and keep getting the benefits, and I'll be hither with you to help forth the way. Let's agree on a couple of adjacent steps, and we'll run across again in a few weeks to see how it'southward going. If we demand, we can also consider additional strategies or treatments."
Conclusion
The degree of weight loss and its maintenance should not be 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 encounter national guidelines94,95. Such lifestyle changes over the long-term volition likely improve the health of patients even in the absence of major weight loss96.
Acknowledgments
Funding: This research was supported by the Intramural Research Programme of the NIH, National Found of Diabetes & Digestive & Kidney Diseases.
KDH has received funding from the Nutrition Science Initiative to investigate the effects of ketogenic diets on man free energy expenditure. KDH as well has a patent on a method of personalized dynamic feedback control of body weight (The states Patent No 9,569,483; assigned to the National Institutes of Health).
Footnotes
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Conflicts of Involvement: SK has no relevant disclosures.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/
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