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Exercise for maintaining weight loss

This is an excerpt from Science of Long-Term Weight Loss, The by Timothy Lohman & Laurie A. Milliken.

Exercise for Maintaining Weight Loss
Weight loss and the maintenance of weight loss are situations that require different caloric deficits. While weight loss in the short term seems to be easy to achieve with a large enough deficit, weight loss tends to plateau at about 6 months, and partial or complete regain of weight is common. Exercise may play a larger role in the phase after weight loss than in the weight loss phase itself. Wier and colleagues (2001) looked at weight changes over 5 years and found that those who maintained higher physical activity levels had less weight regain in both men and women of all ages (25 to 55 years). A number of reviews have concluded that exercise is an important strategy to include in programs to prevent weight regain (Donnelly et al. 2009; Foright et al. 2018; Swift et al. 2018; Wing 1999). This is especially true for longer-term weight maintenance (>2 years) (Swift et al. 2018). In studies where the weight maintenance phase was randomized and exercise was tested, results were mixed (Fogelholm and Kukkonen-Harjula 2018). It should be stated that, while people who maintain their weight seem to engage in exercise, a causal relationship between exercise levels and weight loss maintenance has not yet been established (Foright et al. 2018).

Using a scientific method called doubly labeled water, where physical activity can be objectively measured, Schoeller, Shay, and Kushner (1997) found that it takes 80 minutes of daily physical activity of moderate intensity to maintain weight loss for 1 year. More evidence for the role of exercise in the maintenance of weight loss comes from the National Weight Loss Registry, which tracks and studies people who have lost significant amounts of weight and maintained their weight loss over several years. When examining participants in the National Weight Loss Registry, Klem and colleagues (1997) reported that they expend over 2,829 kcal each week in physical activity, which is more than 400 kcal most days of the week. Women in the registry reported expending 2,545 kcal/week in physical activity; men reported 3,293 kcal/week. Most members frequently performed about 60 minutes of moderate-intensity activity—walking, weightlifting, or cycling—each day. In these studies, 60 to 80 minutes per day was associated with the maintenance of weight loss.

Commenting on the difficulty of remaining active enough over a 2-year period to prevent weight regain, as described by Jakicic and colleagues (2008) (only 25% of study participants could sustain a 10% weight loss for 2 years), Thompson and Levine (2008) proposed that future interventions include, as a complementary component of a weight maintenance program, a nonexercise activity protocol to sustain caloric expenditure at a higher rate during times of the day not devoted to formal exercise. Levine and Miller (2007) describe a “walk and work desk” for office workers, where they showed that walking at 1 mile per hour (1.6 km/h) can increase caloric expenditure by 125 kcal/hour. Thus, if participants could work at a desk standing and walking for 2 or 3 hours each day, they might better maintain their weight loss.

The ACSM recommends moderate-intensity exercise for 250 to 300 minutes per week, with a caloric expenditure >2,000 kcal/week, to prevent the regain of weight once it is lost (Donnelly et al. 2009). This goal may be difficult to reach since only 26% of men and 19% of women currently meet the minimum physical activity guidelines for health (at least 150 minutes of moderate-intensity physical activity) (USDHHS 2018). As has been stated earlier, exercise can work for weight loss and maintenance when it is done in sufficient volumes, but it often doesn’t work because many people do not achieve or maintain these levels of exercise.

Exercise Motivation
The failure to achieve a long-term change in physical activity after 18 months of an intervention suggests that the behavioral methods used to increase physical activity (self-monitoring, increasing motivation, relapse training, reinforcement strategies, increases in self-efficacy) are not effective in the long run with many individuals. Both the Jakicic and Jeffery studies demonstrate the benefit of increased physical activity for those who are successful physical activity maintainers. It is essential that new ways be found in order to help a greater percentage of people maintain long-term physical activity changes to accomplish higher physical activity levels. This will increase the success of long-term weight loss. It takes 1 hour or more of daily physical activity to successfully maintain weight loss for many individuals. Other than the continuous care model where the intervention continues after 18 months, novel approaches that will foster long-term weight loss with 1 hour or more of daily physical activity need to be tested as an essential part of the approach.

One such approach that is being applied to physical activity is intrinsic motivation. Teixeira and colleagues (2012) completed a systematic review of motivation and sustained exercise behavior. They found that intrinsic motivation is especially important for longer-term exercise participation. However, in general, most behavioral methods rely on extrinsic motivation. In the studies of Jakicic et al. (2008), Jeffery et al. (2003), Tate et al. (2007), and others, the extrinsic motivation of monetary incentives, an exercise coach, telephone calls, a motorized treadmill in the home of each participant, and social support partners was used to achieve higher exercise adherence. When the studies ended, these extrinsic sources of motivation decreased. As to the participants who continued to exercise at high levels, it would be interesting to know if they developed intrinsic motivation as well.

Maintaining Long-Term Exercise
Maintaining physical activity levels over the long run is critical for sustaining weight loss at any age and for preventing sarcopenia and osteoporosis in the older adult population. In their review article, Brawley, Rejeski, and King (2003) found few studies on the effect of long-term sustainability of exercise, particularly in older adults. Sansano-Nadal and colleagues (2019) reviewed several strategies to enhance long-term maintenance of physical activity and concluded that the lack of high-quality studies and the failure to design interventions with sustainability in mind have yielded unclear effects of the maintenance of activity beyond 1 year. Lackman and colleagues (2018) presented a personalized and multicomponent approach to increasing physical activity in older adults with a concern for sustainability of behavioral changes. This model will contribute to future studies on developing better approaches to fostering long-term activity levels.

Two long-term studies stand out in this regard. The Look AHEAD trial was an 8-year weight loss study with an intensive lifestyle intervention carried out in 5,145 overweight or adults with obesity with type 2 diabetes (Look AHEAD Research Group 2014). The reported energy expenditure doubled the first year from 860 kcal/week to 1,738 kcal/week. At year 4 and year 8, the energy expenditure was down to 1,245 kcal/week and 1,014 kcal/week, respectively. This groundbreaking study will be discussed in chapter 9. In the second long-term study (Bone, Estrogen, Strength Training [BEST] Study), 315 women were assigned at random to a weightlifting intervention for 1 year and asked to follow up yearly with bone scans to assess the long-term effect of the intervention, which was designed for sustainability. The 1-year intervention provided free access to weightlifting facilities and trainers along with social support, as described by Metcalfe and colleagues (Metcalfe 2007; Metcalfe et al. 2001). The 4- and 6-year results of the BEST women who continued to exercise showed that exercise adherence and weight lifted was an important determinant of producing favorable body composition changes (Bea et al. 2010) and was an important predictor of bone mineral density changes (Cussler et al. 2005; Milliken et al. 2009).

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