Abstract
Background. Short-term weight loss is often successful, but the obtained results are difficult to maintain. Therefore, a study focusing on obese people who successfully lost weight, with special emphasis upon methods applied and background factors, is of major importance.
Methods/subjects. This study was based upon a web-based questionnaire, which the participants filled in after registration. Altogether 316 people were recruited through articles in newspapers all over Finland, and of them 184 met the inclusion criteria: age 18–60 years, body mass index (BMI) ≥ 30 kg/m2 before weight loss, a weight loss of at least 10%, and maintaining it for a minimum of 2 years.
Results. A total of 158 participants (100 women and 58 men) were included in the final analyses. The mean age was 44.5 years, average BMI before weight loss 35.9 kg/m2 and after weight loss 26.1 kg/m2, average weight loss was 26.5% or 32.4 kg. Compared with the general Finnish population the participants smoked less (P = 0.009), used less alcohol (P ≤ 0.001), and were physically more active (P ≤ 0.001).
Conclusions. People who were successful in long-term weight loss have a much healthier lifestyle than the general Finnish population. Increased physical activity seems to be a major determinant of successful long-term results.
Successful long-term weight loss is possible by changing lifestyle.
Those successful in weight loss consume markedly less alcohol than the general population, and this might be an important underlying factor.
Regular exercise and little screen time were associated with successful weight control.
Introduction
The rapid increase in overweight and obesity and the increasing costs of obesity-related disorders are major global health concerns (Citation1). In Finland 46% of women and 66% of men are overweight or obese (body mass index (BMI) > 25.0 kg/m2), around 20% are obese (BMI ≥ 30 kg/m2) (Citation2). It is well known that overweight and obesity are associated with a multitude of different adverse health outcomes. Therefore weight loss and weight management are of utmost importance from a public health point of view. Short-term weight loss is often successful, but long-term maintenance of the achieved results is often challenging and difficult (Citation3,Citation4). Therefore focusing upon people who successfully lost weight and managed to maintain the achieved weight, with special emphasis upon methods applied and personality-related traits, is of great interest and major importance.
Many people are successful in losing weight by themselves without taking part in any organized group activity. The knowledge about their success and the methods applied does not usually reach the health care personnel and is one reason why it is difficult to get reliable information about those who are successful in losing weight. In the United States there is a registry, the National Weight Control Registry (NWCR), which has collected information from subjects who were successful in long-term weight loss (Citation5). To our knowledge there is a similar registry in Portugal (Citation6). Due to cultural differences the results from the US registry cannot be directly applied to other countries.
The aims of the overall study were: 1) to describe the characteristics of those who are successful in weight loss, 2) to study typical motivational factors associated with successful weight loss, 3) to study the means by which a long-term weight loss has been achieved, and 4) to study methods employed in weight loss and control.
The present manuscript focuses upon study design, methods, and background characteristics of those who are successful in weight loss.
Material and methods
Study design, recruitment, and time schedule
This study was based upon a weight loss registry, and based upon a web-based questionnaire that the participants filled in after registration.
The study participants were recruited () through articles and advertisements in larger newspapers and magazines all over Finland between January 2012 and August 2013. Information about the study was also distributed to health care centres and hospitals in order to enrol participants.
Figure 1. Recruitment.
Initially the study participants filled in a web-based registration form and provided baseline information. One researcher (S.S.) checked that the registered participants met all inclusion criteria. Of them, 184 met the inclusion criteria and were invited to participate. Thereafter, they received an e-mail with detailed personalized instructions on how to participate in the study.
The inclusion criteria were: age 18–60 years, body mass index ≥ 30 kg/m2 before initiating weight loss, and weight loss > 10% lasting at least for 2 years. The exclusion criteria included bariatric surgery and drug treatment for obesity.
We compared the results obtained in the present study with characteristics in the general Finnish population, and therefore we aimed at using the same lifestyle questions as in the National FINRISK Study.
Ethical approval for this study was obtained from the Ethics Committee, Department of Medicine, Helsinki University Hospital on 3 August 2011 (number 196/13/03/01/2011).
Data collection
All data were based on self-reported information. Information was collected through electronic forms. Body mass index (BMI) before and after weight loss was calculated as weight in kilograms divided by height in meters squared (kg/m2).
The questionnaire () included questions on socio- demographic status, general health, weight history, history of weight loss attempts and methods, as well as changes in diet, motivation, eating habits, and physical activity. The questions were structured and multiple choice questions, but free text was also allowed. The lifestyle questions were identical with the ninth Finnish National FINRISK study 2012. This gave us an opportunity to compare the results with those in the general Finnish population. The National FINRISK study is a population-based health survey taking place at 5-year intervals since 1972. In year 2012 the random FINRISK sample consisted of 10,000 persons, aged 25–74 years, from five geographical areas. Within the FINRISK sample 58% were overweight (BMI 25.0–29.9 kg/m2) or obese (BMI ≥ 30 kg/m2) (Citation5).
Table I. Variables collected in the study.
Statistical analysis
Categorical variables are described as frequencies (percentages) and continuous variables as means (min–max).
The associations between categorical variables were analysed using cross-tabulation and Pearson's chi-square test. Statistical analyses were carried out using IBM SPSS Statistics for Windows, version 21 (IBM Corp., Armonk, NY, USA). P-values less than 0.05 were considered statistically significant.
Results
A total of 158 participants were included in the study, 100 women and 58 men. The mean age of the participants was 44.5 years ± SD 11 years ().
Table II. Socio-demographic factors.
Mean BMI before the successful weight loss was 35.9 kg/m2 (range 29.2–64.8), and BMI after the weight loss 26.1 kg/m2 (range 17.3–41.2). Mean weight loss was 26.5% (range 10.5–49.6), or 32.4 kg (range 9–81), with a minimum sustained weight loss of 10%.
Of the participants, 53.2% had maintained the weight loss for 2 to 3 years, 20.3% for 4 to 5 years, 15.8% for 6 to 8 years, and 10.7% at for least 9 years.
Of the participants, 31.6% (n = 50) reported that they were trying to lose weight for the first time. Of the study participants 12.0% reported one, 25.9% two to three, and 29.7% four or more previous attempts.
Of the participants, 37.9% had a low level of educational attainment (≤ 12 years) (). About one-third reported earnings < 2,000 €/month. Shift working was reported by 15.2% of participants.
General health and family history of overweight/obesity
The participants rated their general health, and 84.8% considered their subjective health on a five-step Likert scale (very good, pretty good, medium, pretty bad, very bad) as very or pretty good. In general the study participants were fairly healthy, and 42.4% reported that they had no chronic disease (). More than half of the women (53.5%) reported that their menstruation began before age 12 years.
Table III. Health, diseases, medication, and obesity.
Among those participants who had children the majority (69.2%) reported that none of their children was overweight. Furthermore, 60.9% reported that their spouse was not overweight. More than half or 58.2% reported that their mother was overweight, while the corresponding number for the father was 45.6%. A total of 23.4% of the participants reported that both their parents were overweight ().
Lifestyle—smoking, alcohol consumption, exercise
gives detailed information of lifestyle habits among the study participants, and shows a comparison with the general Finnish population. Of the participants only 10.2% reported daily smoking, while 5.1% smoked occasionally. One-fifth (19.1%) did not use alcohol at all. Almost half of the participants (47.8%) reported regular vigorous exercise more than 3 hours per week. Similarly almost half of the participants (44.6%) did leisure time physical activity four times or more weekly. One-third (30.1%) of the participants reported commuting exercise over 30 minutes daily.
Figure 2. Lifestyle habits (smoking, alcohol intake, leisure time physical activity, and commuting exercise) among study participants compared with the general Finnish population. *) P ≤ 0.01; **) P ≤ 0.001.
Table IV. Lifestyle characteristics among study participants.
More than half of the participants (57.3%) had a sedentary job, 78.5% reported watching television at the most 2 hours per day, and 84.2% spending at the most 2 hours at the computer on a daily basis.
Compared to the general population, the participants smoked less (P = 0.009), used less alcohol (P ≤ 0.001), and reported more leisure time physical activity (P ≤ 0.001) and commuting exercise (P ≤ 0.001) ().
Discussion
People who are successful in losing weight often do it outside the traditional health care system and setting. Therefore information on methods and achievements does not necessarily reach the health care professionals. We aimed at identifying obese people who had lost weight successfully and maintained it. Certain characteristics were identified. Those who were successful in losing weight and maintaining it had a healthier lifestyle than the general population in Finland. They smoked less, used less alcohol, and were much more physically active particularly in their leisure time but also in commuting. There was only one difference when looking at the figures by sex: women's smoking habit was not significant.
In the United States the National Weight Control Registry has been collecting information on subjects who are successful in long-term weight loss (Citation5). There were several similarities observed between the findings of the Finnish and the US Registry. The mean age of the participants was similar, i.e. 45 and 46 years, respectively. The majority of the people in the registries were women, 77% in the US registry compared with 63% in the Finnish registry. About one-third were single in both registries. The large majority of the participants in the US registry were Caucasians (97%) while all participants were white Caucasians in the Finnish registry (Citation5). The similar background characteristics between these registries could be one factor explaining the similarities between the findings in the two registries.
Tobacco smoking is known to increase basal metabolic rate, and many smokers who quit smoking experience an increase in body weight (Citation7). There is also a general belief that smoking helps in maintaining a normal body weight. It is also supposed to prevent weight gain (Citation8). Interestingly, in the current study only 15.4% of the study participants were smokers, while the prevalence in the general Finnish population was 24.2% (Citation9). Of the participants 40.8% had stopped smoking. These findings clearly show that it is possible to quit smoking and still succeed in a significant weight loss. Compared to the general population the study participants also used less alcohol. Almost 60% of the study participants used alcohol less frequently than once a month, or not at all; the corresponding number in the general Finnish population is 34.3%. Also in general the lifestyle habits seemed to be healthier among the study participants compared with the general population. To our knowledge, there are no data on alcohol consumption or smoking published for NWCR members, so a comparison cannot be made.
Increasing the amount of physical activity seems to be an important underlying factor characterizing those who were successful in their weight loss attempts (Citation10,Citation11). Compared to the general Finnish population (Citation9), almost half of the participants (44.6%) were highly active in their leisure time and exercised at least four times per week. The corresponding percentage for the Finnish population is 28.3%. Not only leisure time physical activity level was higher among the study participants, also commuting exercise was twice as common among the study participants. These findings show that physical activity is important and helpful in weight maintenance (Citation12). Data from the US registry (NWCR) are similar to those reported in the present study. Subjects in the NWCR registry reported expending 11,830 kJ/wk (2,817 kcal/wk) on physical activity, which corresponds to e.g. 45 km walking/wk (Citation5), equal to at least 1 hour daily exercise, e.g. brisk walking (Citation13). There was, however, a large variability in the amount of physical activity: 34.9% reported spending over 3,000 kcal/wk on leisure time physical activity, while on the other hand 25.3% spent less than 1,000 kcal/wk (Citation14). A recent follow-up study on NWCR registry members showed that a decrease in leisure time physical activity (Citation15), being sedentary, and not meeting recommended levels of physical activity (Citation16) were associated with greater weight regain.
One can assume that a major part of the participants lose weight in order to avoid typical obesity-related metabolic diseases. The overall prevalence of chronic diseases was low in our study population. This certainly explains the high subjective health rate. Of the participants 84.8% reported their subjective health as very or pretty good. The corresponding number among the general Finnish populations is 62.6% (Citation9).
There is a genetic component in overweight and obesity, and these conditions commonly run in families. One study suggested that obesity in men was more dependent on childhood circumstances, while adult socio-economic circumstances correlate more strongly with obesity among women (Citation17). Obesity was not particularly common among first-degree relatives of our study subjects, and only 23.4% reported that both parents were overweight. Among those who had children 69.2% reported that none of the children was overweight. However, one must keep in mind that we do not have the actual BMI figures for the first-degree relatives since they were self-reported by the participants. Anyhow, one might assume that it is easier to achieve successful long-term results in a setting where family members are not overweight. It might be more difficult to lose weight successfully when family history of obesity is strong because this might be associated more strongly with genetic factors.
Very little is known about how many weight loss attempts a person has had before succeeding or giving up. We observed that long-term results can be achieved despite several previous attempts, and the majority (68.7%) had previous weight loss attempts in their history. The corresponding number in the NWCR was even higher, nearly 91% (Citation5).
Social class and socio-economic positioning is associated with overweight and obesity. Low income levels and low educational attainment are proposed to be one reason for not eating according to recommendations. One Finnish study (Citation18) observed that this association can be explained only to a certain extent by the income level. Our findings are similar, and successful weight loss was possible in all socio-economic groups. Of those successful in the US registry 18.4% had an educational attainment in the lowest level (high school or less) (Citation5). One German population-based study also suggested that earnings or educational attainment did not predict successful weight loss maintenance (Citation3).
Due to the study design it is not possible to have a control group in the traditional way in this study. However, we believe that the comparisons with the general Finnish population are relevant since the same questions and questionnaires were used whenever possible. This study might appear small, but it is proportionally of the same size as the US study. When comparing to the US or Portugal registry, the sample size is in relative terms even bigger, when taking into account the population size in these countries (sample size in US 0.02‰ (4,800/300 million) and in Portugal 0.02‰ (198/10.5 million) versus in Finland 0.03‰ (158/5.4 million). However, we do not know how well the study participants represent all who are successful in weight loss because it is commonly known that usually the most active people take part in studies. Furthermore, women tend to participate more actively. In the present study over one-third of the participants were men. Furthermore, the participants differed in educational attainment and earning levels as well as marital status.
In conclusion, successful long-term weight loss is associated with a healthier overall lifestyle compared with that of the general population. Alcohol intake was much lower among the study participants, and a high level of physical activity was one factor explaining successful weight loss. However, it is not possible to give an exact recommendation for the optimum amount of physical activity because of large variability in the amount (Citation3,Citation14,Citation15,Citation19). Our findings support the importance of stressing individual factors and an individualized approach. There are obviously several roads to successful weight loss, also when some of them have been tried before.
Funding: This study was supported by grants from Finska läkaresällskapet Liv och Hälsa and Samfundet Folkhälsan.
Declaration of interest: The material is original research, has not been previously published, and has not been submitted for publication elsewhere while under consideration. The authors declare no conflict of interest.
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