It is a common belief that weight loss achieved at a slow rate is better preserved than if the weight is lost more rapidly. However, the literature shows that initial weight loss is positively, not negatively, related to long-term weight maintenance. There is evidence from randomised intervention trials to support that a greater initial weight loss induced without changes in lifestyle (e.g. liquid formula diets or anorectic drugs) improves long-term weight maintenance, providing it is followed by a 1-2 years integrated weight maintenance programme consisting of lifestyle interventions involving dietary change, nutritional education, behaviour therapy and increased physical activity. In conclusion, we find evidence to suggest that a greater initial weight loss as the first step of a weight management programme may result in improved sustained weight maintenance.

Weight development, drop-out pattern and changes in obesity-related risk factors after two years treatment of obese men I Andersson and S Ro ÈssnerObesity Unit, Norrbacka plan 3, Karolinska Hospital, S-171 76, Stockholm, Sweden OBJECTIVE: To describe a combined behavioural treatment program for obese men, the`Gustaf' study, and to evaluate treatment success by the means of weight loss, drop-out analysis and changes in metabolic risk factors. SUBJECTS: Eighty-six men, aged 43 AE 9 y (mean AE s.d.) and BMI 37.7 AE 4.4 kg/m 2 , from the waiting list of the outpatient clinic and men directly approaching the Obesity Unit. DESIGN: Combined, behavioural modi®cation treatment, by the means of group sessions, for one hour every week over a two year period. MAIN OUTCOME MEASURES: Weight loss and changes in risk factors after completion of one and two years study and description of treatment success in the form of changes in metabolic risk factors. RESULTS: The one year drop-out rate was 22% and the cumulative rate after two years was 34%. Mean weight decreased signi®cantly from start (121 kg) to one year (114 kg, P`0.001) and to two years (115 kg, P`0.001) in completers. Several metabolic risk factors (waist and hip circumferences, systolic blood pressure, serum cholesterol and plasma insulin) remained signi®cantly decreased after two years of treatment. The complete metabolic syndrome was diagnosed in ®ve men at onset, but in no one after two years. There was no difference in change of metabolic risk factors after one year between the men who lost 8±12% of initial body weight and those who lost more. CONCLUSION: Sixty-six% (57/86) of the obese men who started in the`Gustaf' program were still in the program after two years. In spite of the relatively modest weight loss, the men maintained a large proportion of this weight loss and also maintained their improved metabolic risk factor pattern.

Abstract. Na Èslund E, Andersson I, Degerblad M, Kogner P, Kral JG, Ro Èssner S, Hellstro Èm PM (Danderyd Hospital, Huddinge University Hospital and Karolinska Hospital, Karolinska Institutet, Stockholm, Sweden; and the Health Science Center at Brooklyn, New York, USA). Associations of leptin, insulin resistance and thyroid function with long-term weight loss in dieting obese men. J Intern Med 2000; 248: 299±308.Objective. The aim of the present study was to identify predictors of weight loss in obese men participating in a 2-year behaviour modification programme. Design. Longitudinal, clinical intervention study of a behaviour modifying weight loss program. Setting. University Hospital, Stockholm, Sweden Subjects. Forty-four obese men (age, 42.7 6 1.1 years; BMI, 37.1 6 0.6 kg m 22 , mean 6 SEM) followed for 2 years. Interventions. Behaviour modification weight loss programme. Main outcome measures. Associations between plasma leptin and thyroid function tests, insulin resistance by homeostatic model assessment (HOMA), dietary recall and anthropometrically determined body composition. Results. At baseline, there were significant correlations between plasma leptin and body mass index (BMI), fat-free mass (FFM) and insulin resistance. Median weight loss over 2 years was 4.9 kg (range, ± 27.2 to + 11.9). Baseline serum leptin concentrations adjusted for BMI (leptin/BMI ratio) were significantly correlated with 2-year weight change (r = 0.34, P = 0.04). A subset of seven of the 44 men gained weight over the 2 years. These`gainers' differed significantly in initial leptin/BMI ratio (0.62 6 0.07) compared with the 37`losers' (0.42 6 0.03, P , 0.05). In a multiple regression model, baseline leptin, insulin and age predicted 22% of the variance in weight change with no additional significant contribution from BMI, FFM, waist:hip ratio, thyroid function tests or energy intake. There was a strong correlation between the change in leptin concentrations and the change in insulin resistance from baseline to 2-year follow-up (r = 0.54; P , 0.001). Conclusion. Baseline plasma leptin concentrations predicted long-term weight loss. Inappropriate leptin secretion or disposal, corrected for BMI, was associated with failure to maintain weight loss in obese men in a behaviour modification weight loss programme.

The prevalence of obesity is increasing worldwide both for adults and children. Although obesity has underlying genetic causes, possibly explaining about 50% of the body weight variation, the dramatic recent increase must be due to behavioural reasons. Lifestyle questions must be addressed if new preventive and treatment strategies are to be developed. Since many obese children grow into obese adults with high risks for complications and a low quality of life, more aggressive treatment methods for the obese child could be envisaged.

The role of intermittent very low calorie diet (VLCD) in obesity treatment has received little attention. Since such programs can be carried out with limited medical resources, they may offer an additional therapeutic tool. In two studies the effects of 420 or 530 kcal of Nutrilett 1 given daily to 40 and 61 patients [body mass index (BMI) 39.2 AE 5.1 kgam 2 and 39.0 AE 5.0 kgam 2 , respectively], either continuously for six weeks or for three periods of two weeks with four weeks maintenance interval, were compared. Attrition and weight loss was similar in both groups after 14 and 26 weeks. Intermittent VLCD treatment seems to result in long term weight losses and compliance similar to those obtained by more continuous VLCD therapy. For some individuals less side effects would favour intermittent treatment, for others motivational factors support a more continuous VLCD treatment regimen.