Slow and Steady Weight Loss Wins the Race

It’s no secret. The world is getting fatter. The obesity rate has been climbing for decades and it doesn’t appear to be stopping anytime soon. What is similarly concerning are the statistics on weight maintenance. Many are able to successfully lose weight, but very few are able to keep this weight off long-term, further facilitating the current crisis. It has been reported that as little as 15-20% of those who lose weight are able to sustain their loss over multiple years (1,2).

To combat this statistic, it has become commonly proposed that slower rates of weight loss results in better long-term outcomes than more aggressive rates of weight loss (3). The rationale is that with a slower rate of loss, changes in lifestyle and diet are more gradual, and as such, are more likely to become permanent. Thus, the individual will not revert back to their unhealthy ways and regain the weight they originally lost.

This belief seems to have emerged as a reaction to nutritionally insufficient very-low-calorie diets in the 1960s and has since been propagated for over half a century (4). To this day, it is commonly recommended to not exceed 1-2 lbs of weight loss per week (5). Many textbooks echo this proclamation, with some reporting rates of weight loss greater than 2 lbs per week as dangerous, and that a rate of loss less than 1 lb per week may be ideal for obesity treatment (4).

What Does the Data Actually Say?

In a study titled “The association between rate of initial weight loss and long-term success in obesity treatment: does slow and steady win the race?” (6), participants were encouraged to consume 1,200 kcal per day and to increase physical activity to reach 10,000 steps per day, or simply 3,000 more than baseline levels, for 6 months.

Following this intervention, subjects took part in a 12-month follow-up program involving contact twice per month in the form of group sessions, telephone contact, or newsletters. In this program, subjects were instructed to maintain their new eating and exercise habits.

For the data analysis, the participants were divided into groups based on their rate of weight loss during the initial intervention. The FAST group lost more than 1.5 lbs per week, the MODERATE group lost more than 0.5 lbs per week but less than 1.5 lbs, and the SLOW group lost less than 0.5 lbs per week.

The results displayed that from baseline to 18 months, weight changes in the FAST, MODERATE, and SLOW groups were -10.9, -7.1, and -3.7 kg, respectively. At 18 months, 50.7% of participants in the FAST group, 35.6% of participants in the MODERATE group, and 16.9% of participants in the SLOW group maintained a clinically significant 10% reduction in body weight.

In accordance, a paper titled “Evaluation of early weight loss thresholds for identifying non-responders to an intensive lifestyle intervention” (7) found similar outcomes. In this research, data from the Look AHEAD trial was evaluated. It featured 2,327 participants who underwent an intensive lifestyle intervention. Participants were prescribed a calorie goal of 1200-1800 calories per day (depending on their initial body weight) and advised to consume <30% of total calories from dietary fat.

The analysis showed that 50.1% of individuals achieving a >/= 2% weight loss at month 1 attained a >/= 10% weight loss at year 1, whereas only 15.2% of those who had a weight loss <2% at month 1 reached the milestone. In addition, it was found that the higher the initial weight loss, the greater the proportion of participants who were successful at year 1. These results were likely explained by the fact that those who achieved a greater initial weight loss were motivated by their progress, thus improving dietary adherence and ultimately leading to long-term success.

In another study titled “The effect of rate of weight loss on long-term weight management: a randomised controlled trial” (8), subjects were randomized to either a rapid weight loss program, which included 450-800 kcal per day for 12 weeks, or a gradual weight loss program, which featured a typical 400-500 kcal deficit for 36 weeks. The intervention was then followed by a weight maintenance phase. In phase 2, for 144 weeks, participants were instructed to follow an individualized diet for weight maintenance.

The results reported that 76 of the 94 rapid weight loss participants achieved 12.5% or more weight loss, compared with 53 of 85 gradual weight loss participants. By week 144 of phase 2, average weight regain was 10.4 kg in the gradual weight loss group and 10.3 kg in rapid weight loss group. Despite vastly different dietary interventions, in the end, weight regain was virtually the same between conditions.

What is particularly interesting about this study is that significantly more participants discontinued the gradual weight loss program (18%) than the rapid weight loss program (3%). The main reason for withdrawal was difficulty adhering to the diet. This phenomenon may be explained by a lack of motivation to adhere to the diet due to lackluster progress.

Lastly, in an experiment titled “The effect of rate of weight loss on long-term weight regain in adults with overweight and obesity” (9), participants were randomly assigned to a 12-week low-calorie diet of 1,250 kcal per day or a 5 week very low-calorie diet of 500 kcal per day. The end goal for each group was a weight loss of 10% of body weight.

The weight loss period resulted in similar body weight changes in the slow weight loss group and rapid weight loss group (-8.2 +/- 0.5 kg vs. -9.0 +/- 0.4 kg), with an average weight loss of 0.7 kg/week and 1.8 kg/week, respectively. In the 9-month follow-up period, mean weight regain was 4.2 kg in the low-calorie diet group and 4.5 kg in the very low-calorie diet group. Again, despite very different rates of weight loss, weight regain was nearly identical between groups.

It is important to note that the results of these recent studies are similar to past meta-analyses which found that very low energy density diets were associated with greater weight loss retention in the long-term (10,11).

So Which is Better?

You may be thinking, “So which is it? Should I lose weight quickly or slowly?” The answer is the almighty and ever so annoying “it depends.” Faster rates of weight loss are likely a better option for those with a lot of weight to lose. The research seems to suggest that faster rates of weight loss are more motivating for individuals, thus improving dietary adherence. These individuals are also likely to be burdened by certain diseases which are a direct byproduct of their poor body composition. As such, a quicker rate of weight loss to reverse these conditions as soon as possible is beneficial. In addition, the types of very-low-calorie diets which facilitate rapid weight loss seem to do a better job of suppressing appetite by way of nutritional ketosis (8,12), further improving dietary compliance, despite severe restriction. The potential benefits of nutritional ketosis are something I discuss in another article from this series. Despite what many self-proclaimed “evidence-based practitioners” love to harp on about, very-low-calorie diets are in fact safe under professional supervision (13,14).

For leaner individuals with less weight to lose, rate of weight loss should be more conservative (0.5-1% per week) in order to prevent losses in muscle mass (15), though this issue can be further offset by increasing protein intake to 2.3-3.1 g/kg of fat-free mass (16). For overweight individuals, this isn’t a concern. Some research suggests that aggressive rates of weight loss result in more fat-free mass loss and subsequent greater reductions in resting metabolic rate (9,12,17), but these trials do not include the two best tools to preserve muscle mass: a high-protein diet (minimum of 1.6g/kg of protein per day) and resistance exercise. When these factors are accounted for, there is more than enough adipose tissue to spare the potential breakdown of muscle while dieting.

Take Home Message

All diets work, and they work because they reduce calorie intake (18,19). The issue does not lie in the diet selected per se. If you have 20 lbs to lose, it doesn’t matter if you choose to pursue a very-low-calorie diet under medical supervision for 6 weeks (I would also recommend checking out Lyle McDonald’s “The Rapid Fat Loss Handbook”), or a paleo diet for 16 weeks. As laid out in this article, the rate of weight loss during a diet is not a predictor of future weight regain. The issue is in the exit strategy, or lack thereof, as most diets don’t provide this crucial information on what to do when the weight loss goal is achieved and the diet is over. The number of calories and level of activity required to lose weight is much different than what is required to maintain weight, and these adjusted figures need to be established and then followed once the dieting phase has been completed.

Despite the shocking statistics, it is likely easier to maintain your weight than to lose weight since the former allows for more food consumption and less activity, but some guidelines need to be in place for weight maintenance success. Without a plan for weight maintenance, bad habits will likely return and weight regain will occur. Evidence from The National Weight Control Registry, the largest ongoing study of individuals who have been successful at maintaining a weight loss of at least 30 lbs for a minimum of 1 year, shows that individuals who engage in high levels of physical activity, consistently monitor their body weight and food intake, and consume low-energy, low-fat diets, tend to do a better job at maintaining their weight (20).

References

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  2. Ayyad C, Andersen T. Long-term efficacy of dietary treatment of obesity: a systematic review of studies published between 1931 and 1999. Obesity reviews : an official journal of the International Association for the Study of Obesity. https://www.ncbi.nlm.nih.gov/pubmed/12119984. Published October 2000. Accessed June 4, 2019.
  3. Myths, Presumptions, and Facts about Obesity | NEJM. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMsa1208051. Published January 31, 2013. Accessed June 4, 2019.
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  5. Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults. eat right. https://jandonline.org/article/S2212-2672(15)01636-6/pdf. Published 2016. Accessed June 4, 2019.
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  8. Purcell K, Sumithran P, Prendergast L, Bouniu C, Delbridge E, Proietto J. The effect of rate of weight loss on long-term weight management: a randomised controlled trial. The Lancet Diabetes & Endocrinology. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70200-1/fulltext. Published October 2014. Accessed June 2019.
  9. Vink RG, Roumans NJT, Arkenbosch LAJ, Mariman ECM, van Baak MA. The effect of rate of weight loss on long-term weight regain in adults with overweight and obesity. Obesity (Silver Spring, Md.). https://www.ncbi.nlm.nih.gov/pubmed/26813524. Published February 2016. Accessed June 4, 2019.
  10. Astrup A, Rössner S. Lessons from obesity management programmes: greater initial weight loss improves long‐term maintenance. Obesity Reviews. https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1467-789x.2000.00004.x?sid=nlm:pubmed. Published December 25, 2001. Accessed June 4, 2019.
  11. Anderson JW, Konz EC, Frederich RC, Wood CL. Long-term weight-loss maintenance: a meta-analysis of US studies. The American journal of clinical nutrition. https://www.ncbi.nlm.nih.gov/pubmed/11684524. Published November 2001. Accessed June 4, 2019.
  12. Ribeiro Coutinho S, With E, Rehfeld J, Kulseng B, Truby H, Martins C. The impact of rate of weight loss on body composition and compensatory mechanisms during weight reduction: A randomized control trial. Clinical Nutrition. https://www.sciencedirect.com/science/article/pii/S0261561417301474. Published April 25, 2017. Accessed June 4, 2019.
  13. Sumithran P, Proietto J. Safe year-long use of a very-low-calorie diet for the treatment of severe obesity. The Medical journal of Australia. https://www.ncbi.nlm.nih.gov/pubmed/18341463. Published March 17, 2008. Accessed June 4, 2019.
  14. Pi-Sunyer FX. The role of very-low-calorie diets in obesity. The American journal of clinical nutrition. https://www.ncbi.nlm.nih.gov/pubmed/1615890. Published July 1992. Accessed June 4, 2019.
  15. Eric R Helms, Alan A Aragon, Peter J Fitschen. Evidence-based recommendations for natural bodybuilding contest preparation: nutrition and supplementation. Journal of the International Society of Sports Nutrition. https://jissn.biomedcentral.com/articles/10.1186/1550-2783-11-20. Published May 12, 2014. Accessed June 4, 2019.
  16. Helms ER, Zinn C, Rowlands DS, Brown SR. A systematic review of dietary protein during caloric restriction in resistance trained lean athletes: a case for higher intakes. International journal of sport nutrition and exercise metabolism. https://www.ncbi.nlm.nih.gov/pubmed/24092765. Published April 2014. Accessed June 4, 2019.
  17. Ashtary-Larky D, Ghanavati M, Lamuchi-Deli N, et al. Rapid Weight Loss vs. Slow Weight Loss: Which is More Effective on Body Composition and Metabolic Risk Factors? International journal of endocrinology and metabolism. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5702468/. Published May 17, 2017. Accessed June 4, 2019.
  18. Anton SD, Hida A, Heekin K, et al. Effects of Popular Diets without Specific Calorie Targets on Weight Loss Outcomes: Systematic Review of Findings from Clinical Trials. Nutrients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579615. Published July 31, 2017. Accessed June 4, 2019.
  19. Makris A, Foster GD. Dietary approaches to the treatment of obesity. The Psychiatric clinics of North America. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222874/. Published December 2011. Accessed June 4, 2019.
  20. Ogden LG, Stroebele N, Wyatt HR, et al. Cluster analysis of the national weight control registry to identify distinct subgroups maintaining successful weight loss. Obesity (Silver Spring, Md.). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562400/. Published October 2012. Accessed June 4, 2019.

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