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The definition of weight maintenance

Abstract

There is currently no consensus on the definition of weight maintenance in adults. Issues to consider in setting a standard definition include expert opinion, precedents set in previous studies, public health and clinical applications, comparability across body sizes, measurement error, normal weight fluctuations and biologic relevance. To be useful, this definition should indicate an amount of change less than is clinically relevant, but more than expected from measurement error or fluctuations in fluid balance under normal conditions. It is an advantage for the definition to be graded by body size and to be easily understood by the public as well as scientists. Taking all these factors into consideration, the authors recommend that long-term weight maintenance in adults be defined as a weight change of <3% of body weight.

Introduction

Decades of research have been devoted to the development and testing of strategies to promote weight loss in obese adults. Less work has been carried out on strategies to promote weight maintenance, yet it has become increasingly clear that weight loss is more often achievable by adults than is long-term weight maintenance. Therefore, there is a need for research that identifies the predictors and correlates of weight maintenance and tests interventions to promote weight maintenance. An explicit definition of what is meant by weight maintenance would enhance this research by promoting comparability across studies and conceptual clarity among researchers.

Although weight maintenance literally implies no change in body weight, in free-living individuals weight varies over time, even when fat stores are relatively constant. In addition, there is some measurement error in weight, albeit small. Therefore, a range of change that is considered ‘long-term’ maintenance needs to be established. Both the size and the expression (i.e. units or metric) of the range identified must be considered. Below we review published expert opinions and definitions of weight maintenance for adults used in studies. We then evaluate attributes of potential definitions of weight maintenance with respect to public health/clinical application, comparability across body sizes and influences of measurement error and fluid balance. Finally, we discuss biologic relevance and recommend a definition. This paper addresses adults only, since growth in children changes the interpretation of weight maintenance. Body composition and height changes in the elderly are also not considered. The purpose of this paper is to evaluate relevant issues and then make a recommendation for the definition of long-term weight maintenance in early and middle adulthood.

Expert opinion

Much of the interest in weight maintenance has addressed maintenance following weight loss. In 1993, Atkinson proposed a standard for the successful treatment of obesity that focused on improvement of known obesity-associated complications.1 Since that time a strong consensus has developed that a weight loss of 5–10% of body weight is sufficient to affect health.2, 3, 4, 5, 6 Expert committees have addressed the definition of weight maintenance following weight loss. The Clinical Guidelines on the Evaluation and Treatment of Overweight and Obesity in Adults have defined successful weight maintenance after weight loss as a weight regain of <3 kg (6.6 pounds) in 2 years and a sustained reduction in waist circumference of at least 4 cm.2 The Institute of Medicine defined weight loss maintenance as losing at least 5% of body weight, or reducing body mass index (BMI) by at least 1 unit, and keeping weight below this minimum amount for at least 1 year.7 By this definition, there is no limit on the amount of weight that can be regained, as long as net weight loss remains below the criterion.

Precedents set in published research

In order to examine precedents, we identified studies that defined a category of weight change that was labeled weight maintenance by the investigators. Our purpose was to identify examples of how weight maintenance has been defined, not to be exhaustive. We limited our search to studies published in English in 1999 or later. We examined only studies conducted in adults with a follow-up period of at least 1 year. We excluded studies of weight change with medication or following surgical procedures, radiation or diagnosis of a wasting illness. Many studies examined weight change only as a continuous variable, and these were not included. We divided articles into two categories: weight maintenance following weight loss or weight maintenance with prior weight loss unspecified or avoided.

In studies of weight maintenance after weight loss,8, 9, 10, 11, 12, 13, 14, 15, 16, 17 weight loss was most often defined as losing 5 or 10% of body weight (Table 1). In some studies, weight maintenance was defined with reference to initial weight10, 11, 15, 16, 17 while other studies referred to the weight after weight loss.8, 9, 10, 12, 13, 14 Several authors cited the Institute of Medicine Guidelines7 or the NHLBI Clinical Guidelines2 as the justification for their definition of weight loss maintenance. One well-known study of weight maintenance following weight loss, the National Weight Loss Registry Study, defined weight loss as losing at least 10% of body weight, and weight loss maintenance as maintaining a loss of at least 10% for 1 year.17 As shown in the table, definitions used across studies varied. In fact, several investigators9, 10, 11, 16 have used more than one criterion for weight loss maintenance in a single study. For example, Field et al.9 defined weight maintenance as regaining <5 pounds and as regaining <5% of body weight.

Table 1 Definitions of weight maintenance used in studies examining weight maintenance following weight loss

In total, 35 studies11, 13, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 examining weight maintenance with prior weight loss unspecified or avoided are shown in Table 2. The majority (23) defined weight maintenance using absolute weight change as the metric although several used percent baseline weight.21, 22, 27, 33, 35, 36, 38, 49, 50 The metrics percent BMI,18 absolute BMI unit change28 and weight change per year13, 31, 39 were used less often. Justification for the choice of the definition of weight maintenance was commonly not stated. Length of follow-up varied from 1 to over 20 years. Using the stated weight maintenance definition and published means, we calculated the equivalent mean percent weight change, absolute weight change (pounds) and absolute weight change per year for each study and show these results in Table 2. Results are shown by gender since the mean weight (and thus the percent weight change) varied by gender. Values have ranged from within 1.2 to 8.6%, 2.2 to 11.0 pounds and 0.2 to 9.0 pounds per year, and were similar in men and women.

Table 2 Definitions of weight maintenance used in studies examining weight maintenance with prior weight change avoided or unspecified and calculated equivalent weight changes for women and men expressed as percent weight change, absolute % and weight change and absolute weight change per year

The majority of the studies in Table 2 were observational, but the Pound of Prevention Study tested an intervention to promote weight maintenance. The primary paper from that study53 examined weight change as a continuous variable, and therefore was not included in our table. However, two follow-up articles from this same study categorized weight change using different criteria: a 5.0 pound absolute weight change40 and a 5.0% weight change.27 Similarly, our group has used different definitions of weight maintenance in different studies.47, 48, 49 This illustrates the lack of a standard, accepted definition for weight maintenance.

Public health/clinical application of possible metrics

There are many units of expression in which weight maintenance could be defined usefully: pounds, kilograms, percent of initial weight, BMI, or percent of initial BMI. Pounds or kilograms have appeal for use in public health as they are both well understood by the public, although in the United States pounds is the more familiar of the two measures. Thus, a definition of weight maintenance as, for example, a change of <5 pounds, would have strong public health application in the United States. Percent change in baseline weight is often used in clinical settings, and some obesity treatment guidelines for weight change use this metric.2, 7 Consequently, this is a measure that is familiar to some patients and to physicians and researchers exposed to obesity treatment literature. BMI has increased in popularity over the past decade as a measure of weight adjusted for height. Recommendations for body weight have recently been expressed in terms of BMI in the United States2 and globally.54 This measure is somewhat more complicated to calculate than is percent body weight, but nevertheless is becoming increasingly familiar to the public and is now often used in the lay press.55, 56, 57 Among the metrics being considered here, percent BMI is probably the least familiar, and would be the most difficult to explain to the general public. Also, percent change in BMI is equivalent to percent change in weight when height is constant, and therefore this metric has no additional utility in adults in whom height is stable.

Comparability across body sizes

A definition of weight maintenance in terms of pounds (or kilograms) ignores differences in baseline body size. Such a definition would not take into account whether the subject was thin, obese, short or tall. It is likely that a 5 pound weight change would have different meanings in people of very different sizes, and an absolute number of pounds would indicate different changes in percent body fat.

Heavier individuals tend to have larger fluctuations in weight. This phenomenon was illustrated over the long-term in a study of young adults examined at six time points over 15 years. The correlation between the intraindividual mean BMI and the intraindividual root mean square error (RMSE) of weight measures modeled over time was 0.52.47 Correlations with mean BMI were reduced (r=0.34) when the RMSE was calculated with weight expressed as percent of the intraindividual mean weight.

Setting cutpoints in terms of percent of baseline weight would provide adjustment based on initial body size. In other words, weight maintenance defined as plus or minus a given percentage of body weight would mean that the range (in pounds) specified by the definition would be larger for a heavy compared to a light person. In addition, taller persons would tend to have a larger range of variation allowed within the definition since, on average, taller people weigh more than shorter people. However, adjustment for height would not be uniform, and the correlation of height with weight in adults is approximately 0.4–0.6.58 BMI provides a solution for equalizing changes in individuals of different heights, but it does not provide any adjustment for baseline weight.

Table 3 shows the absolute weight change, in pounds, equivalent to given weight changes in each metric presented in adults of four different body sizes. Equivalent pounds are shown for a 5 pound weight change, a 5% weight change, a 1 unit change in BMI and a 5% BMI change. The sizes of the changes chosen are only illustrative, and the intent is to compare how each measure performs in adults of different sizes (within columns) not the number of pounds indicated by different measures (across rows). Clearly, a change designated in pounds is the same across body sizes, but a change expressed as percent weight changes with initial weight. A change expressed as BMI units differs by height, but not by weight. Percent BMI yields the same number of pounds as percent weight, when height is unchanged. Table 4 shows the percent weight change, BMI unit change and percent BMI change equivalent to a 5 pound weight change for each of the four body sizes. Again, percent weight change and percent BMI change are dependent upon body weight, and BMI unit change is dependent upon height.

Table 3 Absolute weight change equivalent to weight change of specified magnitudes in adults of different body sizes
Table 4 Weight or BMI change equivalent to a 5 pound weight change in adults of different body sizes

Measurement error and fluid balance

Small fluctuations in measured weight can be due to measurement error, clothing, food consumption and fluid balance. Lohman et al.59 have noted that diurnal variations in body weight in adults can be as large as 2 kg (4.4 pounds). Assuming proper calibration of scales and standard technique, inter- and intraobserver error in the measurement of weight is less than one pound.59, 60 Some error can be introduced by clothing. Ordinary indoor clothing without shoes or jackets has been shown on average to weigh slightly more than 2 pounds in men and slightly <2 pounds in women.61 Error introduced by the weight of clothing can be controlled by using the same protocol across study time points. Similarly, changes in weight associated food consumption or evacuation of wastes can be controlled by a standard protocol.

Fluid balance can affect weight in the absence of changes in body fat or lean tissue. Water accounts for about 60% of body weight in men and 50–55% in women.62 Total body water varies with gender, age and ethnicity. These differences are driven by differences in the amount of lean and fat tissue since lean tissue contains more water than fat tissue. Total body water volume can fluctuate up to ±5% daily in healthy individuals.62 However, changes of this magnitude are usually associated with vigorous physical exertion and high ambient temperatures. The brain stimulates a thirst response when about 2% of fluid has been lost.63 In a study setting, standardization of temperature and activity levels and stipulation that subject void before being weighed can reduce the size of fluid-related fluctuations.

Some,64, 65, 66, 67 but not all,68, 69, 70 studies have found changes in weight over the menstrual cycle that are assumed to be associated with cyclical changes in food intake71 and/or fluid retention.66, 72 Median and mean differences of <0.5 kg have been observed between the luteal and the follicular phases. Watson et al.64 measured weight daily for 62–68 days in 28, 18 to 20-year-old women and found that the coefficient of variation across single cycles was between 0.37 and 1.02%. The mean and s.d. of the within individual standard deviation in weight was 0.39±0.18 kg, indicating that the upper bound of weight change would be smaller than 0.75 kg (0.39+(2 s.d.)) for 97.5% of women (of the type of women studied). In this sample that was 1.2% of body weight.

Using equations from Chumlea et al.,73 we calculated the total body water of 40-year-old African American and white men and women at three different body sizes (Table 5). We arbitrarily chose body sizes to represent a wide range of BMI levels. We then calculated the impact of a 2% change in fluid volume (thirst trigger) and a 5% change (extreme conditions) on weight change and percent weight change. The 2% change in fluid balance yields absolute and percent weight changes of <3 pounds and 1.5%, respectively. Since it is desirable for the range that specifies weight maintenance to be larger than changes expected with fluid balance, our definition will need to exceed this level of change. In addition, it is assumed that this definition would not necessarily apply to extremes of hydration status, but to weight in a normal steady state.

Table 5 Total body water and absolute and percent weight change for white and African-American men and women of different body sizesa

Biologic relevance

One way to select the range of weight maintenance would be to determine the amount of weight gain or loss at which changes in obesity-associated health effects are first seen. Although this approach has strong intuitive appeal, in practice it is of limited usefulness. Associations of weight change with health outcomes are generally continuous in nature with no threshold. Therefore, the amount of weight change associated with observable or statistically significant elevations in risk factors (such as plasma glucose, lipids or blood pressure) is heavily dependent upon the precision of the measurements, the sample size and the resulting statistical power. Determination of a cut-point based on biologic relevance must involve a judgment on what is considered a ‘meaningful’ change. This would, of course, vary for each outcome variable.

An additional complication inherent in identifying the amount of weight change associated with a given change (or no change) in risk is the possible influence of the starting weight. Changes in risk over time could differ in subjects who maintain a lean weight compared to those who maintain an obese weight. Our studies comparing obese to normal weight adults in the ARIC cohort indicated that over 9 years, weight maintenance was associated with larger increases in glucose and triglycerides in the overweight, but more favorable changes in other lipids and similar changes in blood pressure.48 More work is needed to understand the impact of weight maintenance in individuals of differing weight status.

Discussion and recommendations

The points raised here have assumed that the body weight around which the bounds of weight maintenance are placed is known; however, this body weight could be chosen using several different methods. In a clinical setting, weight maintenance might refer to maintenance of current weight, weight after weight loss, or some other selected target weight. In the setting of an observational study, weight maintenance could be defined as staying within set bounds of the weight at the first examination, around the mean weight over all examinations, around a time-weighted mean or around a value chosen using other methods. One problem with the use of the weight from the first or baseline observation is regression to the mean.

It is inevitable that any recommendation of bounds to define weight maintenance will be arbitrary to some degree. Nevertheless, there are some attributes that would be desirable. It would be useful for the definition to be applicable to people of widely different body sizes, easily implemented by clinicians and researchers and understood by the public. The range defined as weight maintenance should be larger than usual expected variations in weight driven by normal fluid balance and expected measurement error, but should be smaller than what has become generally recognized as a meaningful change in body weight. The definition should be compatible with current recommendations by national and international expert committees and permit comparisons among studies. Last, the definition should be not be driven by the distribution of weight change observed in any particular study sample. For example, it is not useful to define weight maintenance as usual or median annual weight change in a given population.

Since the current standard for a meaningful change in weight is expressed as a percent of body weight, it seems useful to maintain that metric. The strong consensus that a change in weight of as little as 5% is clinically relevant offers guidance for the upper bound of what might be considered weight maintenance. However, it does not necessarily supply a lower bound. In other words, a decision that a 5% weight loss is clinically relevant does not automatically mean that a weight gain of <5% has no clinical relevance. In a clinical setting, one might urge patients to adopt a goal of losing 5% of their body weight, but it is less likely that complacence would be endorsed as long as weight regain was any amount <5%. Taking all these factors into account, we recommend that weight maintenance be defined as a weight change of less than ±3% of a designated body weight under standardized conditions. We further recommend that changes in weight that are as large as 3%, but <5% be considered small weight fluctuations, while changes of 5% or greater are considered potentially clinically relevant. These recommendations are admittedly somewhat arbitrary and are suggested in the hope of stimulating careful consideration and perhaps revision. Although the exact quantity best used to define weight maintenance is open to debate, it is certain that it would be a service to the field for experts to agree upon a definition that can be used to promote communication, research and understanding of this important concept.

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Acknowledgements

This research was supported by a grant from the National Institutes of Health, R21 HL075314.

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Correspondence to J Stevens.

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Stevens, J., Truesdale, K., McClain, J. et al. The definition of weight maintenance. Int J Obes 30, 391–399 (2006). https://doi.org/10.1038/sj.ijo.0803175

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Keywords

  • epidemiologic methods
  • weight maintenance
  • weight change
  • adults
  • longitudinal studies
  • body mass index

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