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Obesity has reached epidemic proportions in several countries and is believed to contribute significantly to morbidity and mortality. All of the adverse health consequences of obesity can be reversed by weight loss, but uncertainty over the etiology of obesity hampers the development of effective strategies to attain and maintain optimal weight. If a hypocaloric diet is maintained for six months, 96 percent of patients can lose 5 kg (11 lb) or more. Only one half of patients maintain this weight loss after one year, and by five years this number drops to 11 percent. Toubro and Astrup studied the significance of the rate of initial weight loss on long-term outcome and the efficacy of two different maintenance programs.

Forty-three obese patients attending a Danish nutrition clinic were recruited and were randomly assigned to either a rapid or slow initial weight loss program. The two men and 41 women studied had stable weights with body mass indexes (BMI) between 27 and 40 kg per [m.sup.2]. None of the patients were taking medications, and all were free of diabetes and hepatic, liver or endocrine disease. All of the patients had normal blood pressure, electrocardiographic findings and blood chemistry findings.

The rapid weight loss program consisted of five daily doses of a nutritional solution plus vitamin and mineral supplements for eight weeks. The conventional program used a diet plan based on recommended amounts of ordinary foods for 17 weeks. All of the patients received an anorectic compound of ephedrine, 20 mg, plus caffeine, 200 ma, three times daily. At weekly clinic visits, measurements were made, any adverse effects were recorded, and nutritional and behavior therapy were provided. The 37 patients who completed the initial weight reduction phase were randomized into two maintenance programs.

The "ad lib" maintenance group was provided with dietary leaflets and advice on maintaining a diet that produced up to 25 percent of energy from fat, at least 55 percent from carbohydrates and the rest from proteins. The "fixed energy intake" maintenance program used a system of counters and exchanges to provide 7.8 MJ per day. No anorectics were used in this phase, but regular follow-up counseling, support and educational sessions were provided.

Although the rate of weight loss was about twice as rapid in the low energy group than in the conventional group, the mean weight loss (12.6 kg [27 lb, 12 oz]) achieved during this phase was identical in the two groups. The ad lib maintenance program was more successful than the fixed energy maintenance program. After six months, patients in the ad lib program had an additional weight loss of 2.3 kg (5 lb), compared with a gain of 0.5 kg (1 lb, 1 oz) in the fixed energy group. After one year, the ad lib group showed a nonsignificant weight gain of 0.3 kg (11 oz), compared with a 4.1 kg (9 lb) gain in the fixed energy group. After two years, 65 percent of the ad lib group and 40 percent of the fixed energy group maintained a weight loss of more than 5 kg (11 lb). The rate of initial weight loss had no effect on weight maintenance.

The authors conclude that both rapid and slow initial weight loss programs achieved identical results but, for maintenance of weight loss, the program based on modifications of normal food selection and preparation to achieve low fat and high carbohydrate intake was superior to a "ration" system that maintained fixed energy intake.

Toubro S, Astrup A Randomised comparison of diets for maintaining obese subjects' weight after major weight loss: ad lib, low fat, high carbohydrate diet v fixed energy intake. BMJ 1997;314:29-34.

EDITOR'S NOTE: Weight loss is a very personal experience in which family physicians can play a key role. Some patients crave the gratification of a rapid initial weight loss and lose confidence with a slower approach; others need the steady assurance of a gradual weight loss program. Findings of this study indicate that both approaches are valid, allowing individualization of plans for initial weight loss for each patient. For long-term maintenance, the program that used practical advice and disarmingly simple but enduring changes in food selection and preparation was significantly superior to the complicated system of counters and daily energy calculations. However, significant proportions of patients in both groups successfully maintained weight loss.

Again, the important factor is to individualize nutritional advice. Some patients benefit from the systems of food values and are uncomfortable with fairly nonspecific advice. The basic role of family physicians is to assist the patient in selecting the method(s) that will work for him or her, translate all the science and pseudoscience into practical advice, be supportive and encouraging and, above all, celebrate successes.