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American Journal of Public Health logoLink to American Journal of Public Health
. 2016 Feb;106(2):321–326. doi: 10.2105/AJPH.2015.302956

Physical Activity and Dietary Determinants of Weight Loss Success in the US General Population

Patrick Wilson 1,
PMCID: PMC4815606  PMID: 26691113

Abstract

Objectives. I studied lifestyle behaviors of long-term weight losers in a nationally representative sample.

Methods. I categorized the dietary and physical activity data of 8012 adults from the 2009–2012 National Health and Nutrition Examination Surveys into (1) long-term weight losers (≥ 10% loss for ≥ 1 year), (2) recent weight losers (≥ 10% loss within past year), and (3) overweight or obese individuals who never lost 10% or more of their weight.

Results. Long-term weight losers consumed fewer calories (2072; 95% confidence interval [CI] = 2011, 2134 kcal vs 2211; 95% CI = 2173, 2249 kcal; P < .001) and were more likely to report any vigorous leisure activity (24.5% vs 20.3%; P = .027) than did overweight or obese individuals. Among those engaging in vigorous leisure activity, long-term weight losers reported a greater quantity (188; 95% CI = 159, 223 min × wk–1 vs 156; 95% CI = 142, 172 min × wk–1; P = .047). Recent weight losers did not differ from overweight or obese individuals on absolute calorie intake but reported less fat (79; 95% CI = 75, 83 g vs 84; 95% CI = 82, 86 g; P = .016) and more activity.

Conclusions. Balanced calorie restriction from all macronutrients and physical activity are important behaviors for successful long-term weight loss in the general population.


Approximately 17% of children and adolescents and 35% of adults in the United States are obese.1 The societal costs of obesity are staggering, with direct and indirect costs rising in a curvilinear fashion with body mass index (BMI; defined as weight in kilograms divided by the square of height in meters).2 On an individual level, obesity is associated with numerous deleterious health outcomes, including type II diabetes, cancer, coronary artery disease, sleep apnea, and cognitive dysfunction.3

As a result of these overwhelming societal and individual costs, much attention has been paid to evaluating the efficacy of various weight loss interventions. Randomized trials of diet and physical activity interventions demonstrate that substantial weight loss can be achieved by most individuals, especially during the initial 6 months of an intervention.4,5 Randomized trials of weight loss, however, are somewhat limited by the expense and difficulty of including extended follow-up periods. In addition, weight loss usually begins to regress toward baseline after a year or more,5,6 which suggests that some of the interventions used may not be optimal for long-term weight loss maintenance. Furthermore, the individuals included in these trials represent a small segment of the general population (e.g., educated non-Hispanic White women are often overrepresented),4–6 preventing inferences about the success or failure of these interventions on a larger scale.

In light of these limitations of randomized trials, observational studies have attempted to characterize lifestyle behaviors of populations that have lost a substantial amount of weight.7–11 Although these investigations provide insight into some of the behaviors associated with successful weight loss, they have either used convenience sampling11 or failed to report extensive information on dietary nutrient intakes and physical activity patterns.7–10 Consequently, the findings from these investigations apply only to a select portion of the general population or lack detail on the specific dietary and physical activity patterns used by the most successful weight losers.

The National Health and Nutrition Examination Survey (NHANES) uses a complex sampling design to achieve a representative sample of the noninstitutionalized US population. NHANES assesses the health status and lifestyle behaviors of Americans through interviews, examinations, and laboratory tests. Information on dietary intake is collected through standardized 24-hour recalls, and participants report physical activity participation and weight history. As a result, NHANES provides an opportunity to examine dietary nutrient intakes and physical activity patterns among Americans who have successfully lost weight as well as among those who have successfully maintained weight loss for a prolonged period.

I compared the dietary and physical activity patterns of overweight or obese individuals with those who have maintained substantial weight loss for more than 1 year as well as those who have lost weight within the past year.

METHODS

I carried out a secondary data analysis using cross-sectional data from the 2009–2010 and 2011–2012 NHANES survey cycles. NHANES uses stratified probability sampling to achieve a representative sample of noninstitutionalized Americans. Sampling is done via stages, which consist of counties, segments, households, and individuals. Select groups are oversampled to improve the reliability estimates within those groups. For all 4 survey years, Hispanics, non-Hispanic Blacks, non-Hispanic Whites, and other races at or below 130% of the poverty level, and non-Hispanic Whites and other races aged 80 years or older were oversampled. For 2011–2012, non-Hispanic Asians were also oversampled. Participants were interviewed in their homes and ultimately invited to receive a physical examination at a mobile examination center.

Participants

A total of 26 703 individuals were screened and invited to participate during the 2009–2010 and 2011–2012 NHANES, of which 19 591 agreed to participate and completed examinations at mobile examination centers (73% response rate). Among this cohort, 11 378 were considered adults (aged ≥ 20 years). Complete data on age, gender, race/ethnicity, education attainment, relationship status, weight history, current weight, physical activity, and dietary intake were additional eligibility criteria. I excluded women who were pregnant at the time of interviews. I did not include normal weight individuals (BMI < 25) who had never lost a substantial amount of weight (≥ 10% maximum weight) in my analysis.

Furthermore, I excluded individuals who reported their lifetime maximum weight to be before adulthood, because their weight loss could have taken place during adolescence and, therefore, is not comparable with intentional weight loss during adulthood. I included 8012 adults (4103 men and 3909 women) in the analytical sample, which represented approximately 165 million Americans (Table 1).

TABLE 1—

Participants’ Demographics and Anthropometrics: National Health and Nutrition Examination Surveys, 2009–2010 and 2011–2012

Characteristic LTWLs (n = 1424), Mean (95% CI) or % RWLs (n = 1312), Mean (95% CI) or % Overweight or Obese Individuals (n = 5276), Mean (95% CI) or %
Age, y 52.1a (51.1, 53.3) 47.6 (46.1, 49.1) 48.6 (47.7, 49.5)
Maximum weight, kg 96.4a (94.4, 98.4) 93.9 (91.9, 95.8) 93.3 (92.4, 94.2)
Weight 1 y ago, kg 76.8a (75.5, 78.1) 90.4b (88.5, 92.3) 88.1 (87.2, 89.1)
Current weight, kg 76.7a (75.2, 78.1) 79.6b (77.9, 81.2) 91.2 (90.3, 92.0)
Current BMI, kg/m2 26.8a (26.4, 27.3) 27.7b (27.3, 28.2) 31.8 (31.6, 32.1)
Female gender 53.0 44.4 48.5
Race/ethnicity
 Non-Hispanic White 71.6a 65.9 67.4
 Mexican American 6.5 8.4 8.9
 Other Hispanic 4.8 6.5 6.2
 Non-Hispanic Black 10.4 13.7 12.5
 Other 6.7 5.5 5.1
≤ high school education 39.8 45.8b 39.1
Relationship status
 Married or living with partner 60.9a 54.8b 64.8
 Divorced, separated, or widowed 26.0 22.9 19.0
 Never married 13.1 22.3 16.3

Note. CI = confidence interval; BMI = body mass index; LTWL = long-term weight loser; RWL = recent weight loser. Sample sizes represent unweighted counts. Means and percentages are weighted to the US population.

a

Significant difference (P < .05) between LTWLs and overweight or obese individuals.

b

Significant difference (P < .05) between RWLs and overweight or obese individuals.

Dietary Intake

Dietary intake data were collected in-person at mobile examination centers using the automated multiple pass method—an efficient method for collecting dietary intakes for large population studies.12 The automated multiple pass method uses a 5-step process that helps ensure participants report foods that are commonly forgotten or missed in the absence of probing. Trained NHANES interviewers quantified the types and amounts of foods and beverages (including water) consumed during the 24-hour period before the interview. Dietary interviews were conducted in a private room in mobile examination centers, and measuring guides (glasses, bowls, mugs, household spoons, measuring cups, rulers, etc.) were available to help participants accurately report quantities.

The automated multiple pass method provides an accurate estimate of group energy13,14 and macronutrient15 intakes, although there has been conflicting evidence with respect to underreporting among obese participants.14,16 Details of the data processing can be found elsewhere.17,18 Nutrients I analyzed for this study were energy (absolute [kcal] and relative to body mass [kcal × kg body mass–1]), carbohydrates, total sugars, fiber, protein, total fat, saturated fat, monounsaturated fat, polyunsaturated fat, alcohol, and plain water. I calculated relative macronutrient contributions to total energy by multiplying total grams of each macronutrient by their respective energy density values (4, 4, and 9 kcal × g–1 for protein, carbohydrates, and fat, respectively) and dividing by total energy intake.

Weight History

Weight history was established with a combination of self-report questions and measured weight. Participants were asked, “How much did you weigh a year ago?” “Up to the present time, what is the most you have ever weighed?” and “How old were you then [at maximum weight]?” Maximum weight responses excluded pregnancy for women. Current weight was measured at mobile examination centers.

Participants had to meet several criteria to be considered a long-term weight loser (LTWL). First, participants needed to achieve 10% or more body weight reduction on the basis of their reported maximum weight and measured current weight. I used a 10% threshold because it is associated with substantial health improvements.19 Second, their reported maximum weight had to be from 1 year ago or longer. Finally, their reported weight from 1 year ago also had to reflect at least a 10% reduction from their maximum weight.

Recent weight losers (RWLs) were participants who had achieved at least a 10% body weight reduction on the basis of their reported maximum weight and measured current weight but whose weight from 1 year ago did not reflect at least a 10% reduction from their maximum weight. As an example, an individual with a reported maximum weight of 120 kilograms (3 years ago), a 1-year-ago weight of 118 kilograms, and a current weight of 105 kilograms would be considered an RWL.

The third category of participants were those who had not lost 10% of weight on the basis of their maximum and current weights and were currently overweight or obese (BMI ≥ 25).

Physical Activity

Physical activity was assessed using the Global Physical Activity Questionnaire.20 The Global Physical Activity Questionnaire inquires about moderate and vigorous work- and leisure-time physical activity as well as time spent biking and walking for transportation. Participants were first asked if they engage in each category of physical activity during a typical week (e.g., vigorous activity at work, moderate activity in leisure time). Participants were instructed to respond “yes” only if they engage in the described activities for at least 10 continuous minutes. Participants responding “yes” to each category were then asked to report the number of days in a typical week they engage in the activity as well as the amount of time in minutes they spend doing that activity on a particular day. I calculated the prevalence of participants engaging in a particular category of physical activity. In addition, I calculated minutes × week–1 spent in each category for participants who responded “yes” to engaging in that particular category of physical activity.

The Global Physical Activity Questionnaire is reliable21 and shows fair to modest validity when compared with accelerometer-based data.21,22 Furthermore, validity appears to increase when examining vigorous physical activity.21

Age, gender, race/ethnicity, education attainment, and relationship status were self-reported during household interviews. Education attainment was dichotomized (≤ high school vs > high school), and 3 categories were used to define relationship status (married or living with partner; widowed, divorced, or separated; or never married).

Statistical Analysis

I downloaded publically available files from the NHANES Web site and merged them using SAS version 9.3 (SAS Institute Inc, Cary, NC). I completed the remaining analyses using SPSS Complex Samples, version 22 (IBM, Armonk, NY). I used NHANES-supplied population weights specific to the dietary data to account for the complex sampling design, nonresponse, and differential allocation by day of the week for the dietary intake data.

Physical activity data expressed as minutes × week–1 were highly skewed and therefore I log-transformed them and back-transformed the means for data presentation. I used the Taylor linearization method to calculate means and 95% confidence intervals (CIs) for continuous variables. I evaluated unadjusted differences in continuous variables between groups (LTWLs, RWLs, overweight or obese individuals) using the general linear model function. I entered continuous variables as dependent variables and the grouping variable (LTWLs, RWLs, overweight or obese individuals) as the factor. I tested pairwise differences by using the estimated means function, with the overweight or obese group serving as the reference category. I examined pairwise differences for categorical variables using the Rao-Scott likelihood χ2 test. To reduce the likelihood that weight changes were unintentional (owing to chronic disease), I conducted additional analyses using only participants aged between 20 and 60 years. All tests were considered significant at a P < .05.

RESULTS

Information on demographics and anthropometrics by the 3 groups (LTWLs, RWLs, overweight or obese individuals) is reported in Table 1. LTWLs were older, were more likely to be non-Hispanic White, were less likely to be married or living with a partner, and had a higher maximum weight than did the overweight or obese individuals. As would be expected, LTWLs had a lower current weight, lower current BMI, and lower weight 1 year ago than did the overweight or obese individuals. The average time since maximum weight for LTWLs was 15.6 years (95% CI = 14.8, 16.4). RWLs did not differ from the overweight or obese individuals with respect to maximum weight but did have a higher weight 1 year ago and lower current weight and BMI. In terms of other demographic factors, RWLs had less education and were less likely to be married or living with a partner than were the overweight or obese individuals.

Dietary nutrient intakes by the 3 groups are presented in Table 2. LTWLs reported consuming less absolute energy, carbohydrate, protein, total fat, saturated fat, monounsaturated fat, polyunsaturated fat, and relative energy from fat than did the overweight or obese individuals. Energy intake standardized against body mass was higher in LTWLs than in the overweight obese. RWLs reported consuming less total fat, saturated fat, and monounsaturated fat than did the overweight or obese individuals.

TABLE 2—

Participants’ Dietary Nutrient Intakes: National Health and Nutrition Examination Surveys, 2009–2010 and 2011–2012

Variable LTWLs (n = 1424), Mean (95% CI) RWLs (n = 1312), Mean (95% CI) Overweight or Obese Individuals (n = 5276), Mean (95% CI)
Energy, kcal 2072a (2011, 2134) 2179 (2074, 2285) 2211 (2173, 2249)
Relative energy, kcal × kg body mass-1 28.3a (27.5, 29.1) 28.9b (27.4, 30.4) 24.7 (24.3, 25.2)
Energy from protein, %, 15.9 (15.4, 16.3) 15.6 (15.2, 16.1) 15.8 (15.5, 16.0)
Energy from carbohydrates, % 49.1 (48.3, 49.4) 49.8b (48.9, 50.6) 48.8 (48.3, 49.3)
Energy from fat, % 32.6a (31.8, 33.4) 32.4b (31.6, 33.2) 33.5 (33.2, 33.8)
Protein, g 80a (77, 83) 82 (79, 86) 85 (83, 87)
Carbohydrates, g 251a (244, 259) 265 (250, 279) 265 (261, 270)
Total sugars, g 113 (109, 118) 117 (107, 126) 118 (115, 121)
Fiber, g 17 (17,18) 18 (17, 19) 18 (17, 18)
Total fat, g 76a (73, 79) 79b (75, 83) 84 (82, 86)
Saturated fat, g 25a (24, 26) 26b (24, 27) 27 (27, 28)
Monounsaturated fat, g 28a (27, 29) 29b (27, 30) 30 (30, 31)
Polyunsaturated fat, g 18a (17, 18) 18 (17, 19) 19 (19, 20)
Alcohol, g 12 (10, 15) 15 (10, 21) 11 (10, 13)
Plain water, g 1065 (976, 1153) 1261b (1142, 1379) 1104 (1046, 1162)

Note. CI = confidence interval; LTWL = long-term weight loser; RWL = recent weight loser. Sample sizes represent unweighted counts. Means are weighted to the US population.

a

Significant difference (P < .05) between LTWLs and overweight or obese individuals.

b

Significant difference (P < .05) between RWLs and overweight or obese individuals.

The percentage of energy derived from carbohydrates was higher and fat was lower in RWLs than in the overweight or obese individuals. Similar to LTWLs, RWLs had higher energy intakes standardized against body mass than did the overweight or obese individuals. In addition, RWLs consumed more plain water. All the differences in dietary nutrients remained significant after excluding individuals older than 60 years, with the exception of percentage energy from carbohydrates between RWLs and the overweight or obese individuals (P = .095).

The percentages of participants within each group that indicated they engaged in various categories of physical activity as well as the average time per week spent among participants that engaged in those specific categories are shown in Table 3. LTWLs were less likely to engage in work-related vigorous activity but more likely to engage in vigorous leisure-time activity than were the overweight or obese individuals. Among participants engaging in vigorous leisure-time activity, LTWLs averaged more minutes × week–1 than did the overweight or obese individuals.

TABLE 3—

Participants’ Physical Activity Engagement: National Health and Nutrition Examination Surveys, 2009–2010 and 2011–2012

Variable LTWLs (n = 1424), Mean (95% CI) or % RWLs (n = 1312), Mean (95% CI) or % Overweight or Obese Individuals (n = 5276), Mean (95% CI) or %
Any moderate PA work 34.5 40.7 38.4
Any vigorous PA work 15.9a 23.4 20.8
Any moderate PA leisure 42.0 44.1 45.5
Any vigorous PA leisure 24.5a 25.3b 20.3
Any biking or walking transportation 26.6 30.0b 24.9
Moderate PA work, min × wk-1 366 (308, 434) 438b (376, 511) 343 (312, 378)
Vigorous PA work, min × wk-1 366 (294, 456) 449 (359, 561) 350 (302, 406)
Moderate PA leisure, min × wk-1 154 (140, 169) 159 (140, 181) 145 (135, 155)
Vigorous PA leisure, min × wk-1 188a (159, 223) 194b (169, 223) 156 (142, 172)
Biking or walking transportation, min × wk-1 187 (163, 214) 180 (159, 205) 170 (154, 188)

Note. CI = confidence interval; LTWL = long-term weight loser; PA = physical activity; RWL = recent weight loser. Sample sizes represent unweighted counts. Means and percentages are weighted to the US population. Data expressed as minutes × week-1 are among the only participants who responded “yes” to participating in that type of activity and represent back-transformed means (95% CI).

a

Significant difference (P < .05) between LTWLs and overweight or obese individuals.

b

Significant difference (P < .05) between RWLs and overweight or obese individuals.

RWLs were more likely to engage in any transportation and vigorous leisure-time activity than were the overweight or obese individuals. Furthermore, RWLs spent more minutes × week–1 in moderate work-related and vigorous leisure-time activities than did the overweight or obese individuals. All the differences in physical activity minutes × week–1 remained significant after excluding individuals older than 60 years, with the exception of percentage of LTWLs and overweight or obese individuals engaging in work-related vigorous activity (P = .156) and time spent in vigorous leisure-time activities between RWLs and overweight or obese individuals (P = .072).

DISCUSSION

I compared dietary and physical activity patterns of overweight or obese individuals with those who have maintained substantial weight loss for more than 1 year as well as those who have recently lost weight. Importantly, I used a nationally representative survey of adult Americans to derive the estimates. The results suggest that individuals who have lost at least 10% of their maximum body weight and have kept it off for more than a year consume less absolute dietary energy than do overweight or obese individuals who have never lost at least 10% of their weight. The reduced energy intake in LTWLs stems from reductions in all 3 major macronutrients (carbohydrates, fat, protein), which concurs with the notion that a reduction in overall energy intake is a more important driving factor behind weight loss than is macronutrient distribution.23

In further support of this conclusion, the relative energy contributions from protein, carbohydrates, and fat were very similar between LTWLs and the overweight or obese individuals, although there was a small but statistically significant lower contribution from fat in LTWLs (32.6% vs 33.5%; P = .021). On the whole, these data suggest that, in the general population, diets with extreme macronutrient compositions (e.g., very low carbohydrate, very low fat) are not the most common means by which individuals successfully sustain substantial weight loss over a period of years.

Although absolute energy intake was lower in LTWLs, relative energy intake (kcal × kg body mass–1) was lower in the overweight or obese individuals, and this difference was also apparent between RWLs and the overweight or obese individuals. The apparent discrepancy between the overweight or obese individuals group’s low relative energy intake and their lack of weight loss may be explained in several ways. First, the degree of energy intake underreporting with 24-hour recalls seems to be positively related to BMI.24 Although there is a general dearth of research on whether weight loss history affects the accuracy of dietary assessments, limited data suggest that individuals with a history of weight loss (≥ 10 lb) are not more likely to underreport energy intake with 24-hour recalls.24 Thus, it seems reasonable that the overweight or obese individuals were more likely to underreport energy intake than were LTWLs. Second, real differences in physical activity could partially account for the lack of weight loss in the overweight or obese individuals. Finally, overreporting physical activity may be more prevalent in obese individuals,25 providing additional rationale for their lack of weight loss despite low reported relative energy intake.

Regarding physical activity patterns of LTWLs, they were more likely to report engaging in any vigorous leisure-time activity but less likely to engage in any work-related vigorous activity. These differences are likely owing, in part, to LTWLs having a larger proportion of non-Hispanic Whites and, although not statistically significant, a higher proportion of women. Previous research has shown that women and non-Hispanic Whites are less likely to work in occupations that require physical activity.26,27 With respect to the quantity of physical activity, LTWLs reported more minutes × week–1 of vigorous leisure-time activity. Although it’s difficult to say what motivations drove these differences, the results are consistent with LTWLs using physical activity—particularly vigorous leisure-time activity—as a means to sustain weight loss, which is consistent with other cross-sectional and prospective observational research.28

Beyond examining the lifestyle patterns of LTWLs, I evaluated the behaviors of RWLs. Somewhat surprisingly, RWLs did not show a statistically significant lower absolute energy intake than did the overweight or obese individuals. Relative energy contributions from protein, carbohydrates, and fat were very similar between RWLs and the overweight or obese individuals, although there were small, statistically significant differences in carbohydrates and fat. However, RWLs reported consuming less total fat and a greater amount of moderate work-related and vigorous leisure-time activities. In addition, they were more likely to engage in any transportation physical activity. Although the observational nature of this study prevents drawing firm causative conclusions, the data are in agreement with research showing that adding physical activity to dietary change can increase the magnitude of weight loss.4 Interestingly, RWLs reported consuming more plain water. Recent research has shown that consuming additional water may be an effective weight loss strategy in some populations.29

Strengths and Limitations

The primary strength of this investigation is the use of a nationally representative sample of Americans, which improves on much of the research that has examined the behaviors and diets of LTWLs. Furthermore, NHANES interviewers are thoroughly trained and use a highly automated dietary collection methodology. Both of these factors help ensure that the dietary nutrient data are as valid as possible within the inherent limitations of 24-hour recall.

A clear limitation of this study is the self-reported nature of weight history and physical activity. Men and women systematically misreport their height and weight, albeit the average differences are relatively small.30 This misreporting is likely exacerbated by the fact that the individuals in this analysis were asked to recall weight from years ago. In addition, the intentionality of weight loss was missing as a part of this analysis, so some of the weight loss for LTWLs and RWLs could have been owing to illness or chronic disease.

However, I conducted additional analyses excluding individuals older than 60 years (because of their higher susceptibility to chronic disease) with minimal changes in the results. The validity of self-reported physical activity is not high, resulting in more measurement error,21,22 but group population differences can still be detected given a large enough sample. Furthermore, validity increases with vigorous activity,21 and there were several differences in vigorous activity shown in this investigation.

Conclusions

Adult Americans who have lost at least 10% of their body weight and have kept it off for more than a year report consuming less absolute energy and more frequently engaging in select types of physical activity than do overweight or obese individuals who have never lost substantial weight. Although relative energy intakes are lower in the overweight or obese individuals (possibly because of underreporting), energy contributions from carbohydrates, fat, and protein are very similar between LWTL, RWLs, and the overweight or obese individuals.

These findings support the notion that modest caloric restriction—which can be achieved by individual intervention or through modifications in the food supply—and continued participation in physical activity are keys to maintaining weight loss for most Americans. The use of diets with extreme macronutrient restrictions does not appear to be a very common practice among LTWLs and RWLs in the US population.

ACKNOWLEDGMENTS

National Health and Nutrition Examination Surveys is a major program of the National Center for Health Statistics, which is part of the Centers for Disease Control and Prevention.

HUMAN PARTICIPANT PROTECTION

National Health and Nutrition Examination Surveys protocols were approved by the National Center for Health Statistics ethics review board, and written informed consent was obtained from participants before data collection.

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