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Keywords:

  • weight maintenance;
  • lifestyle modifications

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Objective: To evaluate the long-term weight loss maintenance after 2 to 4 years in severely obese subjects after a lifestyle intervention at a weight loss camp in Denmark.

Research Methods and Procedures: In a retrospective follow-up study, we assessed weight loss after 21 weeks of treatment at a weight loss camp, weight loss maintenance after 2 to 4 years, and numbers of subjects with a weight loss maintenance of ≥10% of a total number of 435 severely obese adults participating in an intensive lifestyle intervention with a primary focus on physical activity.

Results: We obtained follow-up data of 249 subjects (180 women and 69 men) with an initial body weight of 142 ± 32 kg. After 21 weeks at the camp, the subjects had reduced their body weight with a mean of 21.9 ± 13 kg (corresponding to a 15% weight loss). The average weight loss maintenance was 5.3% at a follow-up after 2 to 4 years, and 28.3% had maintained a weight loss above 10% after 4 years of follow-up.

Discussion: Weight loss camps are a relatively new commercial approach in treating severely obese subjects. However, the results demonstrate that even with a multidisciplinary intensive setting with focus on diet, exercise, and psychological counseling, only 28% had maintained a weight loss above 10% after 4 years. This emphasizes that obesity is a chronic condition that needs additional strategies after a weight loss intervention in the efforts to maintain a sufficient weight loss.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Obesity has taken on epidemic proportions in the last decades (1). It is estimated that 10% to 30% of the adults in Western countries are obese (BMI ≥ 30 kg/m2), and 1.5% to 4% are very obese (BMI ≥ 40 kg/m2) (1, 2). Obesity, especially visceral obesity, increases the risk of type 2 diabetes, coronary heart diseases, respiratory problems, and certain types of cancer (3). The cornerstone in obesity treatment is lifestyle modifications in the form of hypocaloric diet and increased physical activity, occasionally supplemented with pharmacotherapy. The beneficial effects of lifestyle modification with and without supplementary pharmacotherapy is well documented, with maximal weight loss generally obtained after intervention for 6 to 12 months and followed by a gradual weight regain even if the intervention continues. The weight losses obtained through intensive behavioral programs are, in general, 5% to 10% after treatment for 6 to 12 months (4, 5, 6); in contrast, weight losses as high as 20% of the initial body weight can be achieved using very low-energy diets (7, 8). In addition to the rather small weight losses obtained through lifestyle intervention, a substantial number of subjects enrolled in such intervention programs will observe weight regain after the initial weight loss with only ∼10% of the subjects maintaining a weight loss after 5 years (9). This seems to leave bariatric surgery as the only obesity treatment with documented effect on long-term weight loss maintenance (10). However, it is still important to remember that even a weight loss of only 3 to 4 kg sustained for 3 to 4 years is able to reduce the development of type 2 diabetes up to 58% (11, 12).

These obvious problems in treating obesity have opened up for several (commercial) weight loss programs. However, a recently published review evaluating different commercial weight loss programs in United States did not provide new evidence of long-term weight loss maintenance in these programs compared with more conventional treatments (13). Weight losses achieved through 3 to 4 weeks of participation in residential weight loss programs consisting of diet, physical activity, and psychological counseling are found to be maintained after 1 year (14), whereas the weight loss maintenance after 5 years is insignificant (15). The concept of residential weight loss programs in Denmark has developed into commercial weight loss camps that offer mainly very obese subjects month-long lifestyle modification courses where the goal, besides weight loss, is to provide the subjects with tools to monitor and alter their eating behavior and their attitudes toward physical activity.

The short-term effect of 12 weeks of lifestyle intervention at such a weight loss camp was recently reported to initiate a weight loss of ∼12% paralleled with improvements in metabolic parameters such as fasting insulin and a reduction in inflammatory markers (16, 17). No evidence exists that this rather new concept manifests itself in more long-term weight loss maintenance and whether this concept is superior to conventional treatment.

Our aim was to investigate the long-term weight loss maintenance after 2 to 4 years in a group of severely obese subjects who participated in 21 weeks of intensive lifestyle modification at a weight loss camp in Denmark that included a low-calorie diet (LCD)1 (approximately 15 kcal/kg of body weight per day), special focus on structured intensive physical activity, and behavioral therapy.

Research Methods and Procedures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

At a private health resort (weight loss camp) in Ebeltoft in the county of Aarhus, Denmark, severely obese adults were treated with an intensive lifestyle modification program of a mean duration of 21 weeks. The price for 1 week of treatment at the weight loss camp at the present time is $700. During the intervention, the subjects were accommodated in small houses with sleeping and kitchen facilities. To estimate long-term weight loss maintenance, a retrospective follow-up study was designed. Individuals who had completed a minimum of 8 weeks of treatment at the weight loss camp in the period from September 2000 through January 2003 were invited to participate in the study.

Exclusion criteria were: less than 8 weeks of treatment, a new enrollment (restart) at the weight loss camp after the inclusion period, subjects who did not respond after several and repeated contacts, and subjects who were treated with bariatric surgery after leaving the weight loss camp. Weight loss maintenance ≥10% of the initial body weight was considered as successful to reduce the risk of developing obesity-health related complications, which is in accordance with the general guidelines for weight loss success.

Subjects

The subjects were, in general, characterized by a low socioeconomic status. At baseline, 46% were unemployed, and 31% had no vocational training. Furthermore, 68% reported that at baseline, they were physically inactive, with no or less than 1 hour of physical activity per week, and only 6% reported that they followed the public health recommendations of 30 minutes of physical activity each day. Ten percent reported that they had type 2 diabetes, 9% had hypertension, 6% had a mild depression, 12% had low back pain, and 6% reported degenerative knee problems. The reported level of medication for all subjects during the follow-up was, in general, unchanged compared with baseline.

Due to low economic status or as an action plan to re-establish the subjects in the labor market, at least 60% had their courses paid or were supported by various social and local authorities. No subjects received financial support from the Danish Health Care system regardless of their medical status.

Treatment

All subjects received the same lifestyle modification program consisting of a conventional LCD, structured physical activity, and cognitive therapy. The program was supervised by a multidisciplinary group that included dieticians, physical therapists, and a psychologist. Upon arrival at the weight loss camp, all subjects were prescribed a diet of 9.2 MJ/d (2190 kcal/d). The diet was based on the recommendation of the Nordic Nutrition Recommendations with a dietary composition of 55% to 60% carbohydrates, 15% protein, and <30% fat (18). On a weekly basis, the subjects had their body weight measured and, if necessary, their food intake readjusted to maintain a negative energy balance. In addition to the diet intervention, the participants took part in an education program where they were instructed to calculate their food intake, to estimate an appropriate portion size, and to use different behavioral strategies in their home environment to maintain the achieved weight loss. The cornerstone of the weight loss program was the daily intensive physical activity. For at least 120 min/d, all subjects took part in structured physical activities supervised by a physical therapist. The exercise program consisted of group-based activities such as swimming, aerobic exercise, strength training, walking, and ergometer bicycling with an estimated intensity of 50% to 60% of Vo2max. The exercise program played a central role in achieving a high initial weight loss, and the combination of diet and exercise was estimated to give a weight loss of ∼1 to 1.5 kg/wk. On a weekly basis, the subjects participated in sessions with focus on cognitive strategies supervised by a psychologist.

The program was scheduled from Monday to Friday from 7:30 am to 4 pm starting with a brisk walk for 30 minutes before breakfast. The late morning program consisted of classes with physical activity: swimming, aerobic, strength training, or bicycling followed by classes in nutrition and classes in behavioral modification with focus on self-esteem, self-confidence, and personal development. A snack was provided before lunch. The afternoon program was scheduled similar to the late morning program with similar options as outlined above. The subjects prepared dinner from provided groceries. Between dinner and bedtime, several options were possible, e.g., sports activities, guest speakers, or personal time. A snack was served before bedtime.

Follow-up

From the database at the weight loss camp, data about age, height, initial body weight, and weight loss of 435 severely obese subjects during the stay at the camp were obtained. Information about the weight status from the time the subjects left the weight loss camp until the research team contacted them was not registered. At the time of follow- up, the subjects were divided into three separate cohorts: a 2-year follow-up cohort featuring 78 subjects, a 3-year follow-up cohort including 196 subjects, and a 4-year follow-up cohort including 161 subjects.

Current body weight and information about socioeconomic status, chronic and musculoskeletal diseases, and medication were gathered using a mailed questionnaire followed up by a structured telephone interview. If no response was obtained from the mailed questionnaire, another one was sent after approximately 3 weeks. Thereafter, the subjects were contacted by telephone.

Subjects living in the county of Aarhus were invited to visit our clinic at the hospital to obtain an estimate of the discrepancy of the self-reported body weight and the body weight assessed at our clinic. The discrepancy between the self-reported body weight and the body weight measured at our clinic (n = 18) showed an underestimate of the self-reported body weight of 1.3 ± 2% (p = 0.012). Subjects who had already completed one course, but later (minimum after 3 months) returned to the weight loss camp to participate in another course, had their baseline data registered to the latest start.

Statistical Analysis

The statistical software packet (SPSS, Chicago, IL) was used for all calculation. For descriptive statistics, values are presented in proportions and means ± standard deviation.

Baseline characteristics for the total cohort, for men and women, and for the three separate cohorts with 2-, 3-, and 4-year follow-up data are described by age, BMI (kilograms per meter squared), and initial body weight. Paired and unpaired Student's t tests were used to compare body weight before and after treatment and body weight before treatment and body weight at follow-up within and between the cohorts. An unpaired Student's t test was used to compare baseline characteristics for subjects lost to follow-up with subjects included in the follow-up analysis and to compare relevant anthropometrics between men and women. A non-parametric test was used for variables with a non-normal distribution, and Tukey's test was used to adjust for multiple comparisons. χ2 Test was used to compare the number of subjects maintaining a 10% weight loss in the three cohorts and between genders. The chosen significance level was a two-tailed p value of <0.05.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Participants

A total number of 435 severely obese subjects who took part in courses at the weight loss camp from September 2000 to January 2003 were included in the study. Eighty-two subjects (19%) were excluded from the analysis due to the following reasons. Forty-nine subjects did not complete the minimum of 8 weeks of treatment at the camp, one was diagnosed with hypothyroidism, 27 had restarted at the weight loss camp after the inclusion period, and five were dead. Thus, of 354 eligible subjects, we obtained follow-up data from 249 subjects (180 women and 69 men). Ninety-four (26.5%) subjects were lost to follow-up or refused to participate in the study. Eleven subjects were treated with bariatric surgery after they had left the weight loss camp and were excluded from the follow-up analysis. The percentage of successful follow-up answers was lowest in the 2-year follow-up cohort (57%) and highest in the 4-year follow-up cohort (79%).

Anthropometric

The baseline characteristics for the total cohort, for men and women, and for the three separate follow-up cohorts are illustrated in Table 1. On average, the subjects participated in the lifestyle modification program for 21 weeks. The subjects were very obese with a mean initial body weight for all subjects of 142 kg (range, 76 to 284 kg), which corresponds to a BMI of 47.5 kg/m2 (range, 30 to 94 kg/m2).

Table 1.  Baseline characteristics for total number of subjects and after separation by gender and length of follow-up
 TotalWomenMen2-yr cohort*3-yr cohort4-yr cohort
  • Values are mean ± standard deviation.

  • *

    Average follow-up time: 30.0 ± 1 month.

  • Average follow-up time: 39.2 ± 3 months.

  • Average follow-up time: 50.9 ± 3 months.

Number249180692712399
Age (years)39.2 ± 1138.8 ± 1140.3 ± 1137.4 ± 938.3 ± 1140.8 ± 12
BMI (kg/m2)47.5 ± 947.0 ± 948.9 ± 1047.0 ± 748.1 ± 946.8 ± 9
Body weight (kg)142.0 ± 32134.0 ± 27163.0 ± 34140.9 ± 25144.0 ± 33139.9 ± 33

Weight Loss during the Stay at the Camp

After 21 weeks of treatment at the camp, the average weight loss was 21.9 kg (range, 1 to 115 kg), equaling a body weight reduction of 15% (Figure 1; Table 2). Men and women lost 27.7 ± 11 and 19.7 ± 17 kg, respectively. Correlation analysis showed that heavier subjects lost more weight, both in kilograms (men, r = 0.51, p < 0.001; women, r = 0.56, p < 0.001) and as a percentage of initial weight (men, r = 0.3, p = 0.012; women, r = 0.23, p = 0.002).

image

Figure 1. Initial body weight for the 2 to 4-year cohorts was 142 ± 2 kg. After 21 weeks of treatment, the body weight was reduced by 21.9 ± 1 kg (15%). Weight regain at 2 to 4 years of follow-up was comparable in the 3 cohorts with an average of 13.2 ± 1 kg, reflecting an average weight loss maintenance of 5.3%. Data represent mean and standard error.

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Table 2.  Change in body weight during the stay at the camp and after follow-up for 2 to 4 years for total number of subjects and after separation by gender and length of follow-up
 Total (n = 249)Women (n = 180)Men (n = 69)p value*2-yr cohort (n = 27)3-yr cohort (n = 123)4-yr cohort (n = 99)p value
  • Values are mean ± standard deviation.

  • *

    Women as compared to men.

  • 2-yr cohort, 3-yr cohort, and 4 yr-cohort as compared to each other.

Initial body weight (kg)142.0 ± 32134.0 ± 27163.0 ± 34p < 0.01140.9 ± 25144.0 ± 33139.9 ± 33p = 0.6
Body weight after 21 weeks of treatment at the camp (kg)120.3 ± 26114.4 ± 23135.9 ± 27p < 0.01117.4 ± 24121.8 ± 26119.3 ± 27p = 0.7
Weight loss (kg)21.9 ± 1319.7 ± 1127.7 ± 17p < 0.0123.4 ± 1222.6 ± 1420.6 ± 13p = 0.4
Weight loss (%)15.0 ± 714.3 ± 716.4 ± 7p = 0.0316.7 ± 815.2 ± 714.2 ± 7p = 0.2
Weight at follow-up (kg)133.6 ± 32126.6 ± 30152.0 ± 32p < 0.01130.5 ± 27134.9 ± 31132.9 ± 35p = 0.8
Weight regain (kg)13.2 ± 1912.3 ± 1815.8 ± 21p = 0.213.5 ± 1313.5 ± 1813.5 ± 21p = 0.9
Weight loss maintenance (kg)8.4 ± 227.4 ± 1911.0 ± 28p = 0.310.3 ± 209.0 ± 237.1 ± 20p = 0.7
Weight loss maintenance (%)5.3 ± 135.1 ± 135.8 ± 15p = 0.76.8 ± 145.6 ± 134.6 ± 14p = 0.7

Weight Regain after a Follow-up for 2 to 4 Years

The weight regain for all subjects at follow-up after 2 to 4 years (mean, 42.9 months) was 13.2 ± 19 kg, resulting in weight loss maintenance of 5.3% of the initial body weight (Figure 1; Table 2). No difference in the relative weight loss maintenance was observed between gender or among the three cohorts (follow-up after 2 to 4 years) (Table 2).

A successful weight loss maintenance, defined as maintaining a weight loss ≥10% (see “Research Methods and Procedures”), was obtained in 28.9% of all subjects and was similar among the three separate 2- to 4-year cohorts (p = 0.9, Table 3). In addition, no gender difference was observed (men, 30% vs. women, 28%; p = 0.86, Table 3). At follow-up, subjects with a weight loss maintenance of ≥10% were more physically active compared with subjects with a weight loss maintenance <10%. Approximately 40% in the former group reported a level of physical activity in accordance with public health recommendations compared with 16% in the latter group (p < 0.01) (data not shown). There was no association between successful weight loss maintenance and self-payment: 25% in the group with weight loss maintenance of ≥10% reported to have paid all costs themselves, which was similar to the 21% (p = 0.48) in the group with weight loss maintenance <10%.

Table 3.  Total number and percentage of subjects who achieved a reduction in initial body weight of <5%, ≥5%, ≥10%, ≥20%, or ≥30% for total number of subjects and after separation by gender and length of follow-up
 TotalWomenMen2-yr cohort3-yr cohort4-yr cohort
Number249180692712399
<5%139 (55.8%)102 (56.7%)37 (53.6%)14 (51.9%)60 (48.8%)65 (65.7%)
≥5%110 (44.2%)78 (43.3%)32 (46.4%)13 (48.1%)63 (51.2%)34 (34.3%)
≥10%72 (28.9%)51 (28.3%)21 (30.4%)8 (29.6%)36 (29.3%)28 (28.3%)
≥20%28 (11.2%)20 (11.1%)8 (11.6%)3 (11.1%)12 (9.8%)13 (13.1%)
≥30%15 (6.0%)9 (5.0%)6 (8.7%)1 (3.7%)8 (6.5%)6 (6.0%)

There was a significant trend toward a dose-response effect between the duration at the camp and long-term weight loss maintenance. Subjects participating >21 weeks (mean initial weight, 142.0 kg) maintained a weight loss of 8% after 2 to 4 years compared with subjects participating <21 weeks (mean initial weight, 141.8 kg) who maintained a weight loss of 3% after 2 to 4 years (p < 0.05) (data not shown).

As described in “Research Methods and Procedures,” of 354 eligible subjects, 94 (26.5%) were either lost to follow-up or refused to participate. In addition, we excluded 11 subjects who subsequently went through bariatric surgery. To describe or estimate a possible parallel worst case scenario in relation to weight loss maintenance, we described these patients as failures in maintaining a weight loss of ≥10%. In addition to this, we used the observation that the self-reported weight data were under-reported with 1.3%. All together, these assumptions reduced the percentage of subjects with successful weight loss maintenance from 29% to 20% as compared with the actual findings (Figure 2). Of importance, no difference in BMI at baseline (47.5 ± 9 vs. 47.8.±9 kg/m2, p = 0.69) or difference in initial weight loss after 21 weeks of treatment (21.9 ± 13 vs. 20.9 kg, p = 0.51) were observed between subjects with follow-up data and subjects lost to follow-up.

image

Figure 2. Actual scenario (black bars) displaying percentage of subjects maintaining a weight loss ≥10% and a parallel “worst case scenario” (white bars), where subjects lost to follow-up (n = 77), refusing to participate (n = 17), or treated subsequently with bariatric surgery (n = 11) were defined as failures in maintaining a weight loss ≥10% and included in the analysis as such. The self-reported 1.3% underestimate of body weight was also added to the “worst case scenario.”

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Influence of Initial Body Weight

Subjects with the highest initial body weight were found to have the most pronounced weight loss both in kilograms and as a percentage of initial weight during their stay at the camp as compared with those with less overweight. If the subjects were divided in accordance to their initial body weight, subjects in the highest quartile of BMI (mean BMI, 59 kg/m2; mean weight, 180 kg) as compared with subjects in the lowest quartile (mean BMI, 37 kg/m2; mean weight, 111 kg) had an initial weight loss of 31 (17%) vs. 13 (11%) kg (p < 0.01; p < 0.01) and maintained a weight loss of 15.4 (8%) vs. 0.5 (0%) kg (p < 0.01; p < 0.01) after 2 to 4 years (Figure 3). Men in the highest quartile of BMI (mean BMI, 62 kg/m2; mean weight, 209 kg) as compared with men in the lowest quartile (mean BMI, 38 kg/m2; mean weight, 132 kg) initially lost 40 (19%) vs. 16 (12%) kg (p < 0.01; p = 0.02) and maintained a weight loss of 27 (11%) vs. 2 (1.3%) kg (p = 0.03; p = 0.04) after 2 to 4 years. Women in the highest quartile of BMI (mean BMI, 58 kg/m2; mean weight, 168 kg) as compared with women in the lowest quartile (mean BMI, 37 kg/m2; mean weight, 105 kg) initially lost 27 kg (16%) and maintained a weight loss of 10 kg (6%) after 2 to 4 years vs. a complete weight regain for women in the lowest quartile of BMI (p = 0.03) (Figure 3).

image

Figure 3. Body weight before (baseline) and after treatment at the camp and body weight at follow-up for 2 to 4 years were divided according to the lowest and highest BMI quartiles of all subjects (BMI < 41 kg/m2 vs. BMI > 53 kg/m2), men (BMI < 43 kg/m2 vs. BMI > 54 kg/m2), and women (BMI < 41 kg/m2 vs. BMI > 53 kg/m2). Data represent mean values and standard error. * p < 0.05; ** p < 0.01, as compared to baseline.

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

In this retrospective follow-up study, we present data on weight loss and weight loss maintenance for 2 to 4 years in a group of severely obese subjects who participated in an intensive lifestyle intervention for 21 weeks at a weight loss camp with the primary focus on physical activity. The mean initial body weight of all participants was ∼142 kg (mean BMI, 47.5 kg/m2), and the mean weight loss after the lifestyle treatment at the camp was 21.9 kg, corresponding to a weight loss of 15%. The participants were divided into three groups according to the time of follow-up after the stay at the camp: 2, 3, and 4 years of follow-up, respectively. In accordance with the literature, we defined successful weight loss as maintaining at least a 10% weight loss. Surprisingly, weight loss success at the 10% level was similar in the three groups; i.e., follow-up after 2 to 4 years. Thus, taken together, successful weight loss maintenance was obtained in 28.9% of all participants. More than 5% weight loss maintenance was obtained by 48% of the participants at follow-up after 2 years and in 34.3% at follow-up after 4 years. Among the three cohorts, there was no significant difference in the percentage of weight loss maintenance: 6.8% after follow-up for 2 years and 4.6% after follow-up of 4 years (p = 0.5).

The role of physical activity to prevent weight regain has been described previously in the meta-analysis of Anderson et al. (19). In our study, subjects with successful weight loss maintenance ≥10% reported a significantly higher level of daily physical activity compared with subjects with weight loss maintenance below 10%, confirming the results by Anderson et al.

When comparing the present study with other weight loss interventions, it should be taken into account that the participants in our study were severely obese with an initial mean body weight of 142 kg, where initial body weight in most other lifestyle and pharmacological intervention studies generally is in the range of 100 to 110 kg (11, 20, 21). As demonstrated in the present study and in accordance with other studies (7, 16), there is a positive association between initial body weight and weight loss. The weight loss maintenance of 5% at follow-up after 2 to 4 years in the present study is generally in agreement with the weight loss maintenance obtained in other long-term lifestyle interventions (7, 8). In the Xendos study (a 4-year double-blind study investigating Xenical vs. placebo plus lifestyle modifications in obese subjects with an initial mean body weight of 110 kg), the weight loss after 4 years was ∼2.7% in the placebo group vs. 5.4% in the Xenical group (20). With intensive lifestyle modifications, the weight loss in the Diabetes Prevention Program (initial mean body weight, 94 kg) was ∼4.2% at the end of this 4-year intervention (11). The weight losses in the two above-mentioned studies were associated with significant reduction in the development of type 2 diabetes (11, 20). Successful weight loss maintenance as defined by maintaining at least a 10% weight loss was in the Xendos study obtained by 26.2% in the Xenical group (in completers) and by 15.6% in the placebo group after 4 years (20) as compared with 28.3% in the present study.

To make additional comparisons with other studies, we subdivided our population in accordance to initial body weight (Figure 3). From this analysis, it was shown that only the very obese obtained a pronounced weight loss during the stay at the camp and a high weight loss maintenance at follow-up after 2 to 4 years. In the quartile of subjects with the lowest initial body weight (mean, 111 kg), the weight loss during the stay at the camp was 13 kg, with no weight loss maintenance after 2 to 4 years of follow-up. The latter group is, according to initial body weight, the most comparable with other published studies.

In the highest quartile of initial body weight (mean, 209 kg for men and 168 kg for women), the weight loss during the stay at the camp was 40 ± 24 kg (18%) (men) and 27 kg (16%) (women), and the weight loss maintenance after 4 years was 11% in men and 6% in women. The initial (short-term) weight loss could be compared with weight loss obtained after gastric procedures for the treatment of obesity (22), but the weight loss maintenance in the present study is lower than the maintenance obtained after obesity surgery (20% to 35%) (10). Previous studies have suggested that a high initial weight loss could be a predictor of weight loss maintenance (19). Our results support this hypothesis because the subjects in the highest quartile of BMI had the highest weight loss, both in kilograms (31 kg) and as a percentage of initial weight (17%), and the highest weight loss maintenance [15.4 kg (8%)] compared with subjects in the lowest quartile of initial BMI who only lost 13 kg (11%) and maintained a weight loss of 0.5%.

The cost for 21 weeks of treatment at the weight loss camp is equivalent to ∼U.S. $14,000. Such a cost is only available for a very limited number of subjects in the present group of very obese subjects characterized with low economic status. Due to these high costs, a relatively high number of subjects received financial support from various social and local authorities. This raises the question of whether the money spent from these social and local authorities could be spent with greater success on simpler and cheaper weight loss interventions, e.g. low-energy diets that are documented to provide similar long-term weight loss results (7, 8).

If we calculate what we defined as the worst case scenario (including under-reporting of body weight and suggesting that all subjects that did not respond to our questionnaires were failures concerning weight loss maintenance), the numbers of subjects with a weight loss maintenance after 4 years at the 10% level were reduced from 29% to 20%.

In conclusion, weight loss maintenance at a level above 10% after a stay at a weight loss camp with primary focus on physical activity was obtained in 20% to 29% of the obese subjects after 4 years. Weight loss maintenance was very dependent of initial body weight with a high degree of success in the severely obese subjects (BMI > 53 kg/m2), whereas nearly no weight loss maintenance was obtained in those with BMI below 40 kg/m2. Thus, treatment with LCD and intensive physical activity at a weight loss camp seems only to be of benefit for the most severely obese subjects.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

We thank subjects and staff (Christian Sørensen and Flemming Darre) at Ebeltoft Kurcenter for participating in the study. The study was supported by the Danish National Board of Health, the Aarhus County for Public Health, and the Society of Physiotherapists in Denmark.

Footnotes
  • 1

    Nonstandard abbreviation: LCD, low-calorie diet.

  • The costs of publication of this article were defrayed, in part, by the payment of page charges. This article must, therefore, be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  • 1
    World Health Organization (2000) Obesity: Preventing and Managing the Global Epidemic: Report of a WHO Consultation, i-253. World Health Organization Geneva, Switzerland.
  • 2
    Flegal, K. M., Carroll, M. D., Ogden, C. L., Johnson, CL (2002) Prevalence and trends in obesity among US adults, 1999–2000. JAMA 288: 17231727.
  • 3
    Hu, F. B., Willett, W. C., Li, T., Stampfer, M. J., Colditz, G. A., Manson, JE (2004) Adiposity as compared with physical activity in predicting mortality among women. N Engl J Med. 351: 26942703.
  • 4
    Arterburn, D. E., Crane, P. K., Veenstra, DL (2004) The efficacy and safety of sibutramine for weight loss: a systematic review. Arch Intern Med. 164: 9941003.
  • 5
    Hutton, B., Fergusson, D. (2004) Changes in body weight and serum lipid profile in obese patients treated with orlistat in addition to a hypocaloric diet: a systematic review of randomized clinical trials. Am J Clin Nutr. 80: 14611468.
  • 6
    Padwal, R., Li, S. K., Lau, DC (2004) Long-term pharmacotherapy for obesity and overweight. Cochrane Database Syst Rev.: CDfirst.
  • 7
    Anderson, J. W., Vichitbandra, S., Qian, W., Kryscio, RJ (1999) Long-term weight maintenance after an intensive weight-loss program. J Am Coll Nutr. 18: 620627.
  • 8
    Wadden, T. A., Frey, DL (1997) A multicenter evaluation of a proprietary weight loss program for the treatment of marked obesity: a five-year follow-up. Int J Eat Disord. 22: 203212.
  • 9
    Wadden, TA (1993) Treatment of obesity by moderate and severe caloric restriction: results of clinical research trials. Ann Intern Med. 119: 688693.
  • 10
    Sjöström, L., Lindroos, A. K., Peltonen, M., et al (2004) Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 351: 26832693.
  • 11
    Knowler, W. C., Barrett-Connor, E., Fowler, S. E., et al (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 346: 393403.
  • 12
    Tuomilehto, J., Lindstrom, J., Eriksson, J. G., et al (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 344: 13431350.
  • 13
    Tsai, A. G., Wadden, TA (2005) Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med. 142: 5666.
  • 14
    Maffiuletti, N. A., Agosti, F., Marinone, P. G., Silvestri, G., Lafortuna, C. L., Sartorio, A. (2005) Changes in body composition, physical performance and cardiovascular risk factors after a 3-week integrated body weight reduction program and after 1-y follow-up in severely obese men and women. Eur J Clin Nutr. 59: 685694.
  • 15
    Sjöström, M., Karlsson, A. B., Kaati, G., Yngve, A., Green, L. W., Bygren, LO (1999) A four week residential program for primary health care patients to control obesity and related heart risk factors: effective application of principles of learning and lifestyle change. Eur J Clin Nutr. 53 (Suppl 2): S72S77.
  • 16
    Bruun, J. M., Helge, J. W., Richelsen, B., Stallknecht, B. (2006) Diet and exercise reduce low-grade inflammation and macrophage infiltration in adipose tissue but not in skeletal muscle in severely obese subjects. Am J Physiol Endocrinol Metab. 290: E961E967.
  • 17
    Christiansen, T., Richelsen, B., Bruun, JM (2005) Monocyte chemoattractant protein-1 is produced in isolated adipocytes, associated with adiposity and reduced after weight loss in morbid obese subjects. Int J Obes Relat Metab Disord. 29: 146150.
  • 18
    Becker, W. (2005) New Nordic nutrition recommendations 2004: physical activity as important as good nourishing food. Lakartidningen 102: 27572762.
  • 19
    Anderson, J. W., Konz, E. C., Frederich, R. C., Wood, CL (2001) Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr. 74: 579584.
  • 20
    Torgerson, J. S., Hauptman, J., Boldrin, M. N., Sjöström, L. (2004) XENical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients. Diabetes Care 27: 155161.
  • 21
    Wadden, T. A., Berkowitz, R. I., Womble, L. G., et al (2005) Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Engl J Med. 353: 21112120.
  • 22
    Buchwald, H., Avidor, Y., Braunwald, E., et al (2004) Bariatric surgery: a systematic review and meta-analysis. JAMA 292: 17241737.