Maintenance and relapse behavioral aspects1

Susan Kayman, William

Obese

after weight
Judith
weight

loss in women:

Bruvold,
women who

and
regained

S Stern
after suc-

ABSTRACT

cessful weight reduction (relapsers, n = 44); formerly obese, average-weight women who maintained weight loss (maintainers, n = 30); and women who had always remained at the same average, nonobese weight (control subjects, n = 34) were interviewed. Most maintainers (90%) and control subjects (82%) ex-

ercised regularly, were conscious oftheir behaviors, used available social support (70% and 80%, respectively), confronted problems directly (95% and 60%, respectively), and used personally developed strategies to help themselves. Few relapsers exercised (34%), most ate unconsciously in response to emotions (70%), few used available social support (38%), and few confronted problems directly (10%). These findings suggest the
advisability vidualized ofdevelopment and treatment programs prospective designed evaluation to enhance of mdiexercise, 1990;52:

loss and regain in laboratory animals and in humans are associated with increased metabolic efficiency and rapid regain on refeeding. The decreased energy requirement needed for weight maintenance could predispose people to regain weight and make subsequent dieting more difficult. Numerous investigators (12-16) have concluded that different processes and strategies are needed to maintain weight than to lose weight. Processes and strategies may vary at different stages ofthe behavior-change process, suggesting that intervention to prevent relapse would best address the problem at each
individuals point in the behavior-change process. Brownell et

Downloaded from ajcn.nutrition.org by guest on October 20, 2013

coping
800-7.

skills,

and social

support.

Am J C/in

Nuir

KEY WORDS stress and coping, Introduction

A

Obesity,

maintenance,

relapse,

weight

loss,

social

support,

exercise

weight and

major problem faced is that the majority

is also treatment common programs

by people who cannot maintain

in people treated

succeed these
for drug,

in losing losses (1).

alcohol,

Recidivism

tobacco

dependency.

Relapse
are

rates
reported

for drug,

alcohol,
range

and
of

tobacco

to be in the

relapse rates for obesity and other dependencies could be overestimates of actual rates since most reports are from clinical programs and are based on people who have received formal treatment. In addition, these figures could overstate the problem: frequently, only the most difficult cases are seen in research-oriented treatment programs and often
only one attempt to change is studied. People attempting to

50-90%

(2, 3). Reported

al (1 5) suggest that there are at least three stages of behavior change: 1) commitment and motivation to change, 2) initial change, and 3) maintenance ofchange. Others propose that an additional stage, 4) dealing with success, or living with the changes, is essential (12, 13). This refers both to living with a smaller, thinner self, as well as accepting the changes as part of ones life rather than as unusual things to do as part ofa temporary diet. Surprisingly little is known about those who lose weight and regain it outside of formal treatment programs since most data are from clinical interventions (15). It is difficult to isolate the factors that influence relapse because it is so hard to fully evaluate patients after treatment has ended. Few follow-up studies report long-term results and few studies report results for untreated control subjects. In the present research long-term weight-loss maintainers were sought to learn how they differed from women who relapsed after weight loss and from women who had never been obese. We hoped to gather clues for more
I

From

the Department

of Regional

Health

Education,

Kaiser

Per-

manente, Oakland, CA; the Department ofSocial and Administrative Health Sciences, School of Public Health, University of California, Berkeley; and the Departments ofNutrition and Internal Medicine and
the Food
2

Intake

Laboratory,

University

ofCalifornia

at Davis.

change on their frequently (4). Although the

stance abuse,

own

may

be successful of relapse
problem

and plagues
for obese

may

relapse

less

Supported in part by grants to SK from the Dr EE Dowdle Fund and the University ofCalifornia Chancellors Patent Fund; by Biomedical Support Grant S-S07-RROS441, National Institutes of Health, to

problem

all areas
people

of subbecause

it is a particular

repeated weight loss followed by weight gain may have mental health, metabolic, and psychological consequences.
idemiologic studies (5) reveal positive effects of weight

detriEploss in

the School of Public Health, by a postdoctoral fellowship

Prevention Research cine.
3

University of California, Berkeley; and to 5K from the Cardiovascular Disease

(grant HL-07034), Stanford Center for Stanford University School of Mcdi-

Training in Disease

Program Prevention,

lowering blood pressure and cholesterol and improving glucose tolerance (6). However, when an equal amount ofweight is regained, negative effects on blood pressure and cholesterol may be greater than the positive effects when the weight was lost (7). Some investigators (8- 1 1) found that repeated cycles of weight 800
Am J C/in Nuir

gional
CA

Address reprint requests to S Kayman, Kaiser Permanente ReHealth Education, 1950 Franklin Street, 17th floor, Oakland,
May4, 1989.

94612-2998.

Received

Accepted
Printed

for publication
in USA.

December

20, 1989.
Society for Clinical Nutrition

l990;52:800-7.

1990 American

LONG-TERM

WEIGHT

MAINTENANCE

801
weight range, or average overweight weight, was or were 20% by us-

successful groups.

obesity

treatment

from

a comparison

of these

three

within

a desirable

overweight.

Twenty-percent

calculated

Subjects Experimenia/ Research and Nagel

and methods design methods (17) and are oftwo basic types, Selltiz et al (18). One
the second employed the ifa Joint large

ing the midpoint woman for a given

ance Tables. The

of the weight range for a medium-frame height in the 1959 Metropolitan Life InsurNIH Consensus Development Conference on

the
health

Health
risks present 20%

Risks alarming.
research

of Obesity Thus,
to focus

(19)

concluded
level whose 20%

that
were

long-term
undesirable

at the 20 percent

overweight on women

according to Cohen type is used for hy-

and even
the

this level ofoverweight health

=

was used
overweight

in
put

pothesis generation and tion. This study expressly erate this worthy dure hypotheses method called is successful

for hypotheses confirmaa method designed to genMethod number research.

them

at increased
overweight,

risk
had

for

problems.
lost

Relapsers
oftheir weight

were
one

previously

( 1 7, 18). In general,
ofpotential hypoth-

eses are generated

ofsubsequent for were conducting

and

initially
confirmatory the Joint why and weight

assessed
Method

to identify
was used.

those

most
proce-

or more times but regained it (n these women were neither gaining ers were of average weight and
overweight weight for and had as adults, elapsed groups. Interviews

44). At the time ofthe study, nor losing weight. Maintainhad previously been 20%
the average current At least in all reduced weight weight 1 y had three

A standard

Extreme

but had reduced and maintained 2 y (n = 30). Control subjects were remained for the last within pregnancies pregnancy 3.6 kg oftheir except

groups
eses nificant

were

identified

and a large
one did

number
group not

ofpotential
ofwomen regain

hypothlost a siganthe to

always since

tested amount

to explain of weight average

(n

34).

it, whereas Briefly, hypotheses by talking

and

delivery

other
always Joint were

group
Method generated

lost but regained.

involved two by reviewing

A third

group

ofwomen
selected.

who had

maintained

was also

steps: first, potential the literature and

women in the three ond, these potential

dard tually were statistical differed. selected

contrasting hypotheses
that

groups selected were screened

assessed whether

for study. Secby use of stanthe groups acideas to de-

Subjects oped

were

interviewed for this study.

by use The

of a questionnaire following method was

develused

specifically

procedures

In this way, the more useful explanatory from the larger group and these were used

to develop the questionnaire: 1) Exploration: tapes were made offocused, with 12 subjects (6 relapsers and 6 maintainers)
issues to include in the questionnaire. 2) A preliminary by use ofthe issues until

open interviews to identify key was developed,

the tapes.

velop efforts. Subjects

initial

theory

to guide

future

confirmatory

research

open-ended
and topics

questionnaire
identified from

Potential
nance

subjects

were recruited
the Kaiser

from a central

a large area

health ofthe

mainteOffices in

organization,

Permanente

Medical

3) The questionnaire was tested, revised, and tested again the questions elicited the desired information. The final questionnaire was used to interview the 108 relapsers,
maintainers, Questions tionnaire: and control subjects who met the study criteria. in the quesexperiences; in on the overweight following history topics were included and childhood food

Fremont,

CA. As women

entered

medical

offices, they received = 1475) and signed interviewed. Seven

a questionnaire, ifthey wished hundred

which they completed (n to volunteer (n = 902) to be categorized themselves

volunteers

into
erage ifthey

three
weight. were

weight

groups:
had

relapsers,

maintainers,

or always
potential infants,

av-

dieting and weight-loss history; reasons for gaining, maintaining, or sustaining weight; positive and negative involvement

Volunteers pregnant,

were not considered recently delivered

subjects had never

attempted to lose weight, had lost < 9 kg, were losing weight, were gaining weight, or had experienced a weight change due to illness. From the 700 women who categorized themselves as relapsers, These maintainers, or always average weight, 50 were selected

weight control from and alcohol intake; lems, medications,

graphic data troubling with on age,

other people; pregnancy history; smoking meal and snacking patterns; health proband surgeries; exercise patterns; demomarital status, employment, and educa-

tion;
cent

emotion-related
situation

eating;
or

perceived
event version

social
and of the

support;
coping Ways

and
responses, of Coping

re-

evaluated

an open-ended

randomly loss history, health status.

from

each

weight
were

category
telephoned

for further
to determine

screening.
weight-

1 50 individuals

of maintenance of reduced weight, and meeting all criteria (see next section) and agreeing to be interviewed (n = 108) received letters explaining the study and confirming interview appointments. Potential
subjects view mately author was and were telephoned before their interview to reconfirm. If ultifirst

length Those

questionnaire (20). The study protocol was approved by the Kaiser Permanente Medical Care Program, Northern California Region, Institutional Review Board, and the Human Subjects Committee of
the University ofCalifornia, Berkeley.

Coding

and statistica/ and coded

ana/yses responses from and differences the questionnaires between groups were were as-

the prospective
interviewed. each

subject
All interview

cancelled
so that subjects lasted

the appointment,
all potential were from subjects interviewed 1 to 1 .5 h.

the interwere by the

rescheduled

Comments grouped and

sessed with analyses of variance for continuous with chi-square analysis for categorical variables. cance groups ofdifferences of primary subjects was Throughout between interest, further the relapsers and assessed analysis, then and with for maintainers additional qualitative,

variables and The signifithe two and conchi-square open informa-

Criteriafor Weight
ance Tables

subjects standards ( 1 9) were from

used

maintainers,

the

1959

Metropolitan
whether

Life Insurwomen were

trol

to determine

analyses.

802
I Sociodemographic control subjects*

KAYMAN

ET

AL

TABLE

TABLE
characteristics of relapsers, maintainers, and Comparison ofreduced Control subjects (n = 34)

3
ofweight-loss weight5 methods used by relapsers and maintainers

Relapsers

Characteristic Age(y)
21-44
45-73 Marital Married Divorced,widowed,single

(n

44)

Maintainers (n = 30)

Weight-loss

method
plan

Relapsers (n = 44) 17 (39) 16(36) 19 (43) 13(29) 1 5 (34) 2 1 (47) 5(11) 4 (9)

Maintainers (n = 30) 22 (73) 23(76) 3(10) 3(10) 6(20) 1 (3) 1(3)

-

21 (48)
23(52)

21 (70) 9(30)

25(73) 9(26) 25 (74) 9(26) 6(18) 16(47) 12(35) 32(94) 2(6)

Devised personal-eating Exercised

Attended

Weight Watcherst
programs or

status 36 (84)
7(16) 22 (50) I 3 (30) 9(20)

23

(77)

Attended other groups

7(23) 8 (27) 1 3 (43) 9(30) 29 (97) 1(3) 7(23) 23 (77)

Followed

doctors

orders

Educational level <HS or HS graduate Some college

Collegegraduate Ethnic group

Took pills, shots Fasted Underwent hypnosis

Followed
Total
S

book, magazine
used ofsubjects;

diet

1 1 (25)
I2 1
-

3(10)
28
-

Caucasian
Hispanic,black

40 (9 I )
4(8)

methods Number

Occupational status Homemakeronly Employed for salary

S

percent

in parentheses.

23(54)
20 (46)t percent from in parentheses. maintainers,

7(21) 27 (79)

t Concord, t Methods
used).

CA. preceding preceding

weight regain (combinations successful maintenance.

of methods

were

Number
Significantly

ofsubjects; different

0.05.

Methods
Weight-loss

methods

tion was differences analyses.

categorized, coded, among the groups.

and grouped to highlight key SPSSX (2 1) was used for data

Results
Sample characteristics

Maintainers and relapsers were primarily Caucasian (97% and 91%, respectively), married (74% and 84%, respectively), and middle-aged (mean ages 41 and 47 y, respectively). More maintainers than relapsers completed college (30% vs 20%) and had salaried positions in addition to theirjobs as homemakers (77% vs 46%, P > 0.05). Maintainers did not differ from control subjects in their race, marital status, age, education, or employment (Table 1). Maintainers, relapsers, and control subjects did not differ significantly in the percent who had children (77%, 83%, and 74%,
respectively) 5 in all three or in their groups). mean However, number ofpregnancies gained (range significantly 1relapsers

more weight from pregnancy compared with maintainers

to 1 y after their and control subjects

last pregnancy (Table 2).

TABLE

Weight gain after pregnancies: and control subjects*

comparison

ofrelapsers,

maintainers,

Control
Relapsers Weight gain (kg) by I y afterlastpregnancy
S

Maintainers

subjects

11.7

lO.4t

S.97.2f

1.8 2.3

SD.
different different from maintainers subjects, and control 0.001. subjects,

t Significantly
PO.OOl. Significantly

from control

A key finding ofthis study was that although the maintainers used many similar strategies to lose weight, each maintainer used these strategies in ways that were specific to her own lifestyle. Few women successfully maintained reduced weight after learning a package of strategies from a class or with the help of a physician or nutritionist (although these resources were available). Maintainers made decisions to lose weight and then devised personal weight-loss plans to fit their lives. These plans usually included regular exercise or activity and a new eating style of reduced fat, reduced sugar, more fruits and vegetables, and much less food than previously eaten. Maintainers reported being patient, setting small goals that they could meet, and sticking to their personally devised weight-loss plans. Some used ideas from earlier weight-loss experiences, some used diets from books, but all persisted until new eating patterns were established. Maintainers reported that ultimately they did not want to eat as much and that such foods as candy and donuts were no longer appealing because they were too sweet or fatty. They changed their cooking methods to avoid frying foods with extra fat and found themselves able to deemphasize food in their lives. However, they did not completely restrict favorite foods and made efforts to avoid feelings of deprivation while changing food patterns. In contrast, few relapsers (36%) had exercised to help lose weight. They had lost weight by taking appetite suppressants, fasting, or going on restrictive diets that they could not sustain. They took diet formulas and went to weight-control groups and programs many times(Table 3). While dieting they did not permit themselves any of the foods they enjoyed and perceived their diet foods as special foods, different from the foods their family could have and different from foods they really wanted. They felt deprived on the restrictive diets and easily went back to old patterns. Many relapsers (77%) reported regaining in response to a negative life event that made it impossible for them to prepare special foods anymore or continue exercising. 0thers reported that they just went back to old ways without even

LONG-TERM
TABLE 4 How maintainers women (control)

WEIGHT

MAINTENANCE felt hungry, and then

subjects triggered

803 ate what

were efforts

she wanted
also able to to cut back

but in small
notice on food small intake

quantiweight and to

ofreduced weight and always-average-weight subjects stay at their d esired weights5 Control subjects (n = 34)

ties. gains,

Control which

exercise
Se/f-image

more.

Strategy

Maintainers (n = 30)

Whereas
Watches weight on scale (monitors weight) Is active (more active) Eatsless Watchesintake Reduces intake ofhigh-fat foods Reduces intake ofhigh-sugar foods Changed to good eating habits Changed attitude toward food and
eating

most

maintainers

and

control

subjects

(86%

and

26 (87) 25 (83) 25(83) 18(60) 17 (57) 17 (57) 17 (57)t

l4(47)j

26 (76) 30 (88) 25(73) 18(50) 13 (38) 17 (50) 10 (29)

3(9)

94%, respectively) weight or a little

thought of themselves out of shape (referring

as thin or of average to fitness level) re-

lapsers
70%

were
ofrelapsers

mostly

dissatisfied

with

their their

bodies.
25%

More and

than 43%

saw themselves

as heavy

or ugly,

of relaps-

ers wanted ofrelapsers

Activity

to change everything about wanted to be thinner.

bodies,

Eats what she wants and does not feel guilty about what was eaten, deny, or deprive herself: ifgoes offdiet, does not hate herself or feelbad Knows size by feel ofclothes Does not eat three meals/d Fantasizes, uses imagery techniques Avoids snacking by engaging in activity incompatible with eating Goes to Weight Watchers or other maintenanceprogram Recalls old feelings ofhow bad she felt Knows and avoids situations when she would overeat
S

A major
their activity subjects(82%)

difference
patterns. reported 30 mm) less frequently

between
Most exercising whereas and than

maintainers
maintainers regularly few regainers

and
(90%)

relapsers
and three reported maintainers.

was
control times reg-

(at least (34%) than

9(30) 7 (23) 6 (20) 3 (10) 3 ( 10) 3(10) 2(7)

2 (7)

1(3) 10(29) 13 (38) 0(0) 1 (3) 1(3) 0(0)

1

a week for ular exercise

exercising

(Fig 1). Those also reported

time activity

relapsers engaging

who did exercise

reported and

less vigorously

Maintainers
daily work

in more leisure time did relapsers (P < 0.001).

Eating

ofsnacks

and meals groups

meals)

Women
beverage

in all three
eaten between

reported
every day

eating

snacks

(food

or

or almost

daily.

How-

(3)

Number

ofsubjects: different different

percent

in parentheses. subjects, subjects, P P

<
<

t Significantly :1:Significantly

from control from control

0.05. 0.001.

ever, relapsers ate significantly more snacks each day than did women in the other groups (mean number ofsnacks eaten daily 4.6, 1 .5, and 2 for relapsers, maintainers, and control subjects, respectively; P < 0.000 1 ). Relapsers ate more candy and chocolate than did women in the other two groups (41% vs 17% and 1 5%, respectively; P < 0.05). Both relapsers and maintainers drank more diet soda than did control subjects (4 1% and 31% vs 8%, respectively; P < 0.05), an interesting finding that may
merit differences additional between investigation. the groups There choices were ofother no snack significant foods or

realizing Relapsers
prised

it or that lifestyle changes made it impossible to diet. seemed to see their lost weight as gone and were surto find themselves heavy strategies again.

beverages,
vegetables,

which
sweet

included
baked

chips,
goods,

crackers,
ice cream,

cheese,
and coffee.

pizza,

fruits,

Weight-maintenance

Unlike relapsers, maintainers were aware to continue to be conscious of the quantity

they consumed as well as the level of activity

that they and type

necessary

needed of food
to stay

100

at reduced weights. eating and activity

reported using

In addition to remaining conscious behaviors, maintainers and control

of other strategies to maintain

of their subjects
desired

80

a variety

weights, response
able

as listed in Table 4. These strategies were generated in to the question, How do you think that youve been
at the weight you want to be?

60
C

a)
C.)

to stay

Control subjects did not see themselves as women without a weight problem. They consciously stayed trim and worked to keep in shape. They were uncomfortable in their clothes when they gained after a vacation or a period of eating more and reduced their food intake until they returned to their desired weight. They always purposely aware wore of their close-fitting bodies. They clothing knew to keep how they themselves

8.

40

20
U)

C 0
C.)

wanted their bodies to feel to exercise, avoid fats and to eat. One woman said be interested in talking to

(and look) and this prompted them sugar, skip meals entirely, or forget the interviewer probably would not her because she only ate when she

FIG I . Percent of relapsers, maintainers, and control subjects who exercise regularly (at least three times per week, 30 mm per session). 5Significantly different from maintainers and from control subjects, 0.00 1.

804
TABLES Weight-control

KAYMAN

ET

AL

help requested

by relapsers

and maintainers5 Relapsers (n=44) Maintainers (n=30)

Checkups with referral suggestions, information, concernedMD Support group, diet partner Emotional help, understanding about needs related to weight, from family, health professional
S

problem-solving or confrontive ways ofcoping with their problerns, compared with maintainers or control subjects, and were more likely to use emotion-focused or escape-avoidance ways of coping, such as eating, sleeping more, or wishing the problem would go away, than were maintainers or control subjects. In contrast, more control subjects reported using relaxation techniques, exercising, or working more when troubled than
did maintainers or relapsers.

15(34) 10 (22)

2(6) 3 (10)

Social

support

9 (20) in parentheses.

1 (3)

Number

ofsubjects:

percent

Most ofthe women in all three groups ate lunch and dinner every day and rarely skipped these meals. However, more relapsers than maintainers and control subjects skipped breakfast
(43%, 37%, and 23%, respectively, skipped
<

breakfast

either

ev-

ery day or most Professional

None ofthe

ofthe

time;

0.01). with weight

a physician

help or other
women

assistance
that

control
or other health

In addition to using more problem-focused than emotionfocused coping in response to problem situations, more maintainers and control subjects sought support or help in dealing with their problems from family, friends, and professionals than did relapsers (Fig 2). More relapsers reported that they had few people available for support or help with their problems than did maintainers (Fig 3). More than half the women in all three groups reported that their husbands were not supportive, either for problems or troubling aspects of their lives or for their weight-control efforts. There were no significant differences in the number of relapsers, maintainers, or control subjects who reported that they had supportive spouses.
Self-reported akohol consumption and smoking

reported

professional was helpful one maintainer reported

maintainers and control

to them although three relapsers that a physician was not helpful.

subjects (83% and 76%,

and Most for

that In

respectively)

reported

that

they

did not want

efforts was food intake

help,

that

help from

others

Most maintainers and control subjects reported themselves to be light drinkers whereas relapsers were divided about equally between the non- and light-drinker categories (Table 7). There was a slight tendency for control subjects to report

their weight-control weight control and

not an issue were their

for them, and own concerns.

contrast, only 36% of relapsers did not want help (P < 0.0001 comparing relapsers with maintainers). Most relapsers (64%) wished they had more help for their weight-control efforts. Table 5 details the kinds of help these women, as well as the few
maintainers might like who were to receive. interested in receiving some assistance,

TABLE
Coping control

6
with problems: subjects comparison ofrelapsers, maintainers, and

Relapsers

Maintainers

Control subjects

Copingresponse
Escape-avoidance Eats, smokes, tranquilizer

(n=35)
27 (7O)t

(n=24)
8 (33)

(n=26)
9 (35)

Coping

with problems

Most relapsers, maintainers, and control subjects (87%, 80%, and 76%, respectively; differences between groups NS) were able to report a stressful or troubling issue, event, or situation in response to the question, What would you say is the most stressful or troubling aspect of your life right now? More relapsers reported experiencing problems related to their overweight and/or their health than did maintainers or control subjects (56%, 10%, and 2%, respectively; P < 0.05). There were no significant differences in the other types of problems reported by women in the three groups, which included problems
with interpersonal relationships (parents, children, husband,

drinks,

takes

Sleeps more
Wishes problems away Seeks social support would go I S (38)t 17 (70) 2 1 (80)

Talks out feelings

Seeks professional help Self-controlling Keeps feelings to self Goes over things to self 5(13) 4(164 10(43)

Problem

solving and/or
4(lO) 1 (2) 23(95) 4 ( I 7)j 15(60) 1 1 (42)

and friends), self-fulfillment problems and issues, and job or career problems. Though most women reported a stressful issue or problem, there were significant differences in the ways relapsers, maintainers, and control subjects reported coping with these problerns. Coping-response categories were developed from answers to the question, How are you dealing with this? after the problem or stressful issue was described. These coping-response categories were based on coping-response scales developed from the revised Ways ofCoping checklist (20, 22). Categories are not mutually exclusive and include all reported coping responses. As shown in Table 6, few relapsers used

confronting Tension reduction Exercises, does extra work Shops Uses relaxation techniques Totals

52

56

66

S Ofthe study subjects, 87% ofthe relapsers, 80% ofthe maintainers, and 76% ofthe control subjects stated they had problems now; data in this table are based on the subjects who reported problems. Percents in

parentheses.

t Significantly :t Significantly

different from maintainers: tP < 0.01; P different from control subjects, P < 0.05.

<

0.001.

LONG-TERM
100

WEIGHT

MAINTENANCE TABLE
Alcohol
7

805

intake

and smoking:

comparison

of relapsers,

maintainers,

and control 80
C

Control

a)
C.)

Relapsers
(n
=

Maintainers
(n
=

subjects
(n
=

8. 60
Alcohol intake 40
Nondnnker Light (<5 intake drinks/wk) heavy

44)

30)

34)

2 1 (47.7)t I 8 (40.9)

7 (23.3) 19 (63.3) 4

( 1 1.8)

23 (67.6) 7(20.6)

20

Moderate, (>5

to 10 dnnks/wk)

5 ( 1 1.4) 23(52.3) 1 2 (27.3)

9 (20.5)

( I 3.3)

Smoking

emotion-focused

probImfocused
ways of coping

seek soc suppor

Neversmoked Former smoker Smoker now

S

14(46.7)
8 (26.7) 8 (26.7)

24(70.6)
6(17.6) 4

( 1 1.8)

Number
Significantly

ofsubjects;
different

FIG 2. Percent ofrelapsers(U), (0) who used emotion-focused

maintainers(D),

and control

subjects

t or

percent in parentheses. from maintainers and from control subjects,

<

0.01.

or problem-focused

ways of coping

who sought social support to aid in coping with problems. Ways-ofcoping categories from Folkman and Lazaruss Ways ofCoping checklist (20, 22). * 55Significantly different from maintainers: 5P < 0.01; **P< 0.001.

ables associated with weight-loss maintenance. These factors were also important for the maintainers in this study. Most maintainers and control subjects in this study exercised
regularly whereas other studies that few relapsers did so. exercise differentiates Exercise has been intake. ofweight on food It was also observed maintainers and shown to increase, efforts Continued in redeare

more moderate-to-heavy drinking than did relapsers. Relapsers reported preferring to eat food rather than drink alcoholic beverages. Problem smoking drinking was not assessed in the current study.

lapsers
crease,

( 1 3, 24-28).
or have

no effect and

needed
tite,

to elucidate

the relationships
maintenance

among begin energy

to the

food
loss.

intake,

appeintake

There
reported

was no significant

difference
groups.

in current

or former

self-

exercise,

Ifcalorie

in the three

does not increase or even decreases

exercise nance. resting routine Another metabolic

when obese subjects (29), the additional

may contribute

exercising (29, 30), output ofa regular

weight-loss maintemay increase

Discussion The results ofthe present study support several hypotheses of possible correlates of successful maintenance after weight loss suggested by other investigators (1 5, 16, 23-27). These investigators reported that exercise, positive self-statements related to
. weight-reduction

possibility is that regular rate (3 1 ). In any case,

exercise

to facilitate maintenance.
may elevate

behaviors necessary Some investigators

mood and feelings

exercise seems to help to achieve long-term weight (32, 33) suggest that exercise
which may facili-

ofwell-being,

appropriate and early

efforts, and self-regulatory activities, such as goal setting, self-monitoring of eating or weight, recognition of weight regain, were important vari-

1 00

tate other positive behaviors conducive to successful maintenance ofweight loss. In the present study, weight regain (relapse) was frequently attributed to negative emotional states and unexpected or unpredictable stressful life events. This was also observed by other investigators (34). In addition to supporting this observation, the present study identified an important difference in the way in which maintainers and relapsers coped with their problems.
Whereas maintainers and relapsers (and control subjects) all

80

C a)
C.)

60
S

reported unexpected and unpredictable stressful life events, maintainers believed themselves capable of handling their problems and used problem-solving skills to cope with their
difficulties.
S

a)

0.

In contrast,

relapsers

did

not

deal

with

their

prob-

40

lems directly (perhaps because they lacked effective problemsolving skills) and reported that they used food to make themselves feel better when upset. These findings offer additional

20

0
1 or2 # people FIG 3. Percent ofrelapsers (#{149}) and maintainers (D) reporting that 0, 1 or 2, or 3 people were available for support or help with problems. 5Significantly different from maintainers, P < 0.0 1. 3ormore

support for Marlatt and Gordons theory of relapse (3), which suggests that an individual who has successfully made a behavior change will return to a former negative behavior pattern when a high-risk (problem) situation occurs for which coping skills are lacking. Social support or the perception that family or friends are
available seemed to discuss troubles greater for and the offer help when than needed for the significantly maintainers

relapsers

in the present

study.

There

is some

indication

that

806
social behaviors support (35). plays Social a role support in the maintenance acts of new to buffer

KAYMAN health (20)

ET

AL

References
1. Council on Scientific Affairs, American Medical Association. Treatment ofobesity in adults. JAMA 1988;260:2547-S 1. 2. Marlatt GA, Gordon JR. Determinants ofrelapse: implications for the maintenance ofbehavior change. In: Davidson P0, Davidson

probably

stress

and may be used to assist people in making stressful decisions (36), but exact mechanisms and details for the role social support plays in maintenance of long-term weight loss are yet to be defined and should be investigated (37). The many genetic and physiologic factors that may be related to maintenance of long-term weight loss such as resting
metabolic bution, mass interact rate, number or type offat cells, adipose-tissue distrilipoprotein lipase activity, or ratio of fat to lean body not the assessed behavioral in this study. How explored these in this factors study may and with factors

SM, eds. Behavioral York: Brunner/Mazel,

medicine: changing 1980:410-52.

health

lifestyles.

New

were

the role each factor may play in contributing to the difficulty relapsers have in becoming long-term weight-loss maintainers is not known. A prospective study to assess genetic and physiologic social, differences cognitive, and and the interplay of these factors with psychological, lose It would and also behavioral as individuals

3. Marlatt GA, Gordon JR, eds. Relapse prevention: maintenance strategies in addictive behaviorchange. New York: Guilford, 1985. 4. Schachter S. Recidivism and self-cure ofsmoking and obesity. Am Psychol 1982;37:436-44. S. Simopoulos AP, Van Itallie TB. Body weight, health, and longevity. Ann Intern Med 1984; 100:285-95. 6. Bray GA, Gray DS. Obesity. Part I-Pathogenesis. West J Med

1988;
7.

149:429-41.

Ashley FW, Kannel WB. Relation atherogenic traits: the Framingham

ofweight change study. J Chronic

to changes in Dis l974;27:

then

maintain

reduced
treatments

weights

could

help
individuals.

to define

the most

103-14.
8. Keys A, Brozek J, Henschel A, Mickelson 0, Taylor H. The biology of human starvation. Minneapolis: University of Minnesota Press, 1950. 9. Leibel RL, Hirsch J. Diminished energy requirements in reducedobese patients. Metabolism 1984; 33:164-9. 10. Brownell KD, Greenwood MRC, Stellar E, Schrager EE. The effects of repeated cycles of weight loss and regain in rats. Physiol Behav 1986;38:459-64. 1 1. Blackburn G, Kanders B, Brownell K, et al. The effect of weight cycling on the rate of weight loss in man. Int J Obes 1987; 1 1: 448A(abstr). 12. Stuart RB. Weight loss and beyond: are they taking it offand keeping it off? In: Davidson P0, Davidson SM, eds. Behavioral medicine: changing health lifestyles. New York: Brunner/Mazel, 1980:
15 1-94.

appropriate

for different

be of interest to investigate whether findings reported here for three relatively small groups of mostly white women are true for men, other ethnic groups, and lower-income women. Also, a prospective study to determine ifrelapsers who lack problemsolving skills could be taught these skills and be helped to lose

and then maintain stressful life events, numbers ofsubjects search with greater
trolled, prospective

weight losses, even when experiencing is needed. Preliminary findings with small are encouraging (38-40) but additional renumbers of individuals is needed in constudies to confirm the hypotheses gener-

atedhere(l7, Though
diet-composition maintainers their desired choices

18). routine,
and the

regular
changes control each

exercise,
sustained subjects woman

lower
over thought

caloric
time about study

intake,
permitted to stay herself The

and
the at and

in this

weights, she these did

about
food unique greatly achieved

her life in ways

behaviors

that
and

made
and

it possible
thought

for her to make

patterns in their

the
own

to continue

to exercise.

women vary weight

ways. Based in the ways

on this observation, that individuals they achieve successful long-term

loss maintenance, we suggest treatment be assessed before

selection ing the ability rently of the most same program

that any

each person intervention

treatment, suggestion

who and
rather implies

comes guided
than

for in

13. Colvin RH, Olson SB. A descriptive analysis of men and women who have lost significant weight and are highly successful at maintaming the loss. Addict Behav 1983; 8:287-95. 14. Brownell KD. The psychology and physiology ofobesity: implications for screening and treatment. J Am Diet Assoc 1984; 84:40614. 15. Brownell KD, Marlatt GA, Lichtenstein E, Wilson GT. Understanding and preventing relapse. Am Psychol 1986;41:76S-82. 16. Wilson GT. Psychological prognostic factors in the treatment of obesity. In: Hirsch J, Van Itallie TB, eds. Recent advances in obesityresearch: IV. London: John Libbey and Co Ltd. 1985:301-1 1.
17.

appropriate to all. This

offer-

Cohen

MR, Nagel E. Introduction

to logic and scientific

method.

ofa variety oftreatment options, which may available in all areas, a problem that should be addressed.

the availnot be cur-

In addition, the outcomes of a weight-management screening and referral program should be evaluated to determine if this approach will increase the number of successful long-term
weight maintainers.
El

New York: Harcourt Brace, 1934. 18. Selltiz C, Wrightsman LS, Cook SW. Research methods in social relations. 3rd ed. New York: Holt, Rinehart & Winston, 1976. 19. Burton BT, Foster WR, Hirsch J, Van Itallie TB. Health implications ofobesity: an NIH consensus development conference. Int J Obes l985;9:lSS-69. 20. Lazarus RS, Folkman S. Coping and adaptation. In: Gentry WD,

ed. The handbook

21.

of behavioral

medicine.

New York: Guilford,

Grateful thanks to S Leonard Syme, Richard Lazarus, and Sheldon Margen for guidance and helpful discussions of this work; to John Sommer, Sharon Levine, Tom Shimizu and his staff, Harvey Kayman, Susan Bacigalupa, and the Patient Education Committee of Fremont Kaiser Permanente Medical Offices for their exceptional cooperation and assistance during recruitment and interviewing; to Steve Selvin and

I984:282-325. Nie NH, Hull CH, Jenkins JG, Steinbrenner K, Bent DH. SPSSX Statistical Package for the Social Sciences. 2nd. ed. New York: Mc-

22.

Graw-Hill, 1986. Folkman 5, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. Dynamics ofa stressful encounter: cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol l986;50:992-l003.
Brownell KD. Behavioral, psychological and environmental dictors of obesity and success at weight reduction. Int preJ Obes

Bob Sholtz for statistical

advice: to Judith

Wilhite

for telephoning

par-

23.

ticipants; and to Irene Hepps for coding assistance. Special thanks to the study participants, who so candidly and graciously shared their lives and their stories. Thank you to Kelly Brownell for helpful comments on an earlier draft and to Abby C King for her encouragement and helpful advice during development ofthe manuscript.

1984; 8:543-50.
24. 25. Marston AR, Criss J. Maintenance of successful weight dence and prediction. Int J Obes l984;8:43S-9. Gormally J, Rardin D, Black S. Correlates of successful loss: mciresponse

LONG-TERM

WEIGHT

MAINTENANCE
33. Folkins CH, Sime WE. Physical fitness training and mental

807
health.

26.

27. 28.

to a behavioral weight control clinic. J Couns Psychol l98O;27: 179-91. Gormally J, Rardin D. Weight loss and maintenance and changes in diet and exercise for behavioral counseling and nutrition education. J Couns Psych 198 l;28:295-304. Miller PM, Sims KL. Evaluation and component analysis of a comprehensive weight control program. Int J Obes 198 l;S:57-65. Pavlou KN, Krey S. Stefee WP. Exercise as an adjunct to weight

Am Psychol 198 l;36:373-89. 34. Leon GR, Chamberlain K. Emotional

arousal,

eating patterns,

and

loss and maintenance

Nutr l989;49:l 1 15-23.

in moderately
exercise

obese subjects.
and weight.

Am J Clin
Addict Behav

body image as differential factors associated with varying success in maintaining a weight loss. J Consul Clin Psychol 1973;40:47480. 35. Cohen 5, Syme SL. Social support and health. New York: AcademicPress, 1985.

36. Janis IL. The role ofsocial

sions. 37. Levy Am Psychol RL. Social support

support
and

in adherence
salient

to stressful
methodological

deci-

29. 30.

Epstein LA, Wing RR. Aerobic l980;S:37 1-88. Woo R, Garrow iS, Pi-Sunyer

l983;38:l43-60. compliance:

prolonged

exercise

FX. Voluntary food intake during in obese women. Am J Clin Nutr 1982; 36:47838. 39.

problems

in compliance

research.

i Compliance

Health

Care

1986; 1:189-98. DZurilla Ti. Problem-solving therapy. New York: Springer, 1986. Black DR. Scherba DS. Contracting to problem solve versus contracting to practice behavioral weight loss skills. Behav Ther 1983; 14:100-9.

84. 31. Mole AP, Stern iS, Schultz CL, Bernauer EM, Holkomb BJ. Exercisc reverses depressed metabolic rate produced by severe caloric restriction. Med Sci Sports Exerc l989;21:29-33. 32. Hughes JR. Psychological effects of habitual aerobic exercise: a critical review. Prey Med 1984; 13:66-78.

40. Black DR. A minimal intervention program and a problem-solving program for weight control. Cognit Ther Res 1986; 1 1:107-20.