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research original research trying to lose weight diet strategies among americans with overweight or obesity in 1996 and 2003 tatiana andreyeva phd michael w long mph kathryn e henderson phd ...

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                                                                                                                                        RESEARCH
             Original Research
             Trying to Lose Weight: Diet Strategies among
             Americans with Overweight or Obesity in 1996
             and 2003
             TATIANA ANDREYEVA, PhD; MICHAEL W. LONG, MPH; KATHRYN E. HENDERSON, PhD; GABRIELLE M. GRODE, MPH
             ABSTRACT                                                                             any Americans struggle to lose weight and are
             Background Health professionals recommend that individ-                     Mlooking for guidance on appropriate weight loss
             uals with overweight and obesity lose weight by reducing                             strategies. Based on clear findings (1) that the
             energy intake while maintaining a healthful diet. This                      macronutrientcompositionofdietsisunrelatedtoweight
             study was designed to examine trends in weight loss                         loss, clinicians, as well as public health campaigns, have
             attempts and strategies for adults with overweight or                       focused recent weight loss education efforts on energy
             obesity among different sociodemographic groups.                            restriction while encouraging a healthful overall diet
                                                                                         (2,3).
             Methods Data from the 1996 and 2003 Behavioral Risk                            Despite the increased focus on energy restriction in
             Factor Surveillance System were used to estimate                            expert weight loss recommendations, public interest in
             changes in weight loss attempts and strategies across                       diets limiting intake of particular macronutrients with-
             population groups. Data were analyzed in 2009.                              out emphasizing energy restriction persists (4). While
             Results Slightly more adults with overweight or obesity                     many different diet strategies have been popularized in
             attempted weight loss in 2003 compared to 1996. There                       the United States (3), this research focuses on low-fat
             weresubstantialchangesinthedietapproachesreported:                          diets. Low-fat diets were widely promoted in the 1990s
             rates of those using energy restriction to lose weight                      (2,4), receiving significant expert endorsement (eg, Amer-
             doubled between 1996 and 2003, whereas low-fat dieting                      ican Heart Association), drawing many adherents, and
             decreased by one third. Hispanic and less-educated                          prompting food manufacturers to flood the market with
             adults did not shift away from low-fat diets. Attempted                     low-fat products (5). Determining the extent and speed
             weight loss was associated with higher fruit and vegeta-                    withwhichdifferentpopulationgroupshaveshiftedaway
             ble consumption for most population groups.                                 fromlow-fatdietstostrategiesfocusingonenergyrestric-
             Conclusions Increasingly more adults with overweight or                     tion could inform clinical and public health responses to
             obesity tried to lose weight through energy reduction, but                  ongoing misconceptions about weight loss (6-9).
             some at-risk groups did not follow this beneficial trend                        In addition to encouraging weight loss through energy
             between 1996 and 2003. Dietetics practitioners and pub-                     restriction, the National Heart, Lung, and Blood Insti-
             lic health campaigns should target such groups with con-                    tute’s clinical guidelines for the treatment of overweight
             crete recommendations to reduce energy intake while                         andobesity emphasize the importance of implementing a
             maintaining a healthful diet, including adequate con-                       weight maintenance program to prevent commonly expe-
             sumption of fruit and vegetables.                                           rienced weight regain (10). As a part of this program, the
             J Am Diet Assoc. 2010;110:535-542.                                          NationalHeart,Lung,andBloodInstituteguidelinesrec-
                                                                                         ommendconsumptionofdietsrichinfruitandvegetables
                                                                                         as good sources of vitamins, minerals, and fiber, which
                                                                                         may aid in weight maintenance (10). In observational
             T. Andreyeva is director of economic initiatives, K. E.                     studies, higher fruit and vegetable consumption has been
             Henderson is director of school and community initia-                       linked to long-term weight maintenance (11,12). Limited
             tives, and G. M. Grode is a research associate, Rudd                        experimental evidence suggests that increasing fruit and
             Center for Food Policy and Obesity, Yale University,                        vegetable consumption may aid in weight loss when com-
             NewHaven, CT. M. W. Long is a doctoral student, De-                         bined with energy restriction or reduction in dietary fat
             partment of Society, Human Development, and Health,                         (13-15). Diets rich in fruit and vegetables also reduce
             Harvard University School of Public Health, Cam-                            chronic disease risk, which is particularly elevated in
             bridge, MA.                                                                 overweight and obese populations (10,16). Given the low
                Address correspondence to: Tatiana Andreyeva, PhD,                       rates of adequate fruit and vegetable consumption in the
             Rudd Center for Food Policy & Obesity, Yale University,                     United States (17) and clinical and public health recom-
             309 Edwards St, New Haven, CT 06520-8369. E-mail:                           mendationstoconsumelow-energydietsrichinfruitand
             tatiana.andreyeva@yale.edu                                                  vegetables to lose or maintain weight (2,18), it is impor-
                Manuscript accepted: November 2, 2009.                                   tant to determine whether those trying to lose weight
                Copyright © 2010 by the American Dietetic                                consume adequate amounts of fruit and vegetables.
             Association.                                                                   This study used data from the 1996 and 2003 Behav-
                0002-8223/10/11004-0004$36.00/0                                          ioral Risk Factor Surveillance System (BRFSS) to exam-
                doi: 10.1016/j.jada.2009.12.029                                          ine nationwide trends in reported weight loss diet strat-
             ©2010bytheAmericanDietetic Association                                                         Journal of the AMERICAN DIETETIC ASSOCIATION    535
           egies for Americans with overweight or obesity (19,20).       gaining weight)?” and “Are you using physical activity or
           Specifically, the analysis assessed changes in the preva-      exercise to lose weight (or keep from gaining weight)?”
           lence of reported weight loss attempts and key diet strat-    Our analysis focused on self-reported attempts to lose
           egies among adults with overweight or obesity between         weight (with a yes/no indicator for trying to lose weight)
           1996and2003,identifiedsociodemographicdifferencesin            and several key diet strategies evaluated in the BRFSS:
           these trends, and estimated the association between try-      trying to eat fewer calories vs trying to eat less fat vs
           ing to lose weight and reported consumption of diets rich     trying to eat both fewer calories and less fat. Note that
           in fruit and vegetables.                                      these diet strategies were assessed among adults report-
                                                                         ing weight loss attempts. The high percentage of partic-
           METHODS                                                       ipants with overweight or obesity reporting using diet
                                                                         methods to lose weight (about 90%) and the lack of evi-
           Sample                                                        dence supporting exercise as a weight loss strategy (21)
           The study source is the BRFSS, which provides state-          prompted us to concentrate on diet practices in this
           specific estimates of health conditions, preventive health     analysis.
           practices, and risk behaviors among adults in the United      Fruit and Vegetable Consumption. The BRFSS module on
           States. The BRFSS is a random-digit-dial telephone sur-       fruit and vegetables poses the same six questions in all
           vey conducted by state health departments on indepen-         survey years the module was administered. Probed by
           dent probability samples of state residents aged 18 years     interviewerstoconsiderthefoodtheyusuallyeatordrink
           or older. It is the world’s largest ongoing telephone health  at home and away from home, participants report the
           systemsurvey;ithasgrowntoincludemorethan350,000               frequencyofconsumingfruit(excludingfruitjuice),green
           adults annually. The survey data are weighted by race/        salad, potatoes (excluding french fries, fried potatoes, and
           ethnicity, age, and sex to represent the probability of       potato chips), carrots, other vegetables, and fruit juice.
           selection and each state’s population. A detailed descrip-    Interviewers give examples of frequency responses
           tion of the BRFSS data and methodology is available           (“twice a week, three times a month,andsoforth”),butno
           elsewhere (19,20).                                            definition of a serving size. Participants can report the
             The analysis draws data from the earliest (1996) and        frequency of eating or drinking per day, week, month,
           latest years (2003) of the BRFSS in which fruit and veg-      year, or never. These responses are used to create the
           etable and weight control modules were administered in        daily number of servings of individual food items, which
           all states. There were 124,085 participants in 1996 and       are summedtoconstructthemeasuresoftotaldailyfruit
           264,684respondentsin2003,amuchlargersampleinthe               consumption,totalvegetableconsumption,andtotalfruit
           later wave because the BRFSS increased participation          and vegetable consumption (sum of the two measures).
           over time. Exclusion criteria included participants under       The assessment of fruit and vegetable consumption
           age 18 years; missing age or older than age 85 years;         was based on a summary fruit and vegetable servings
           pregnant women; and participants missing information          index available in the survey. It categorizes the daily
           for questions about weight or height, reported fruit and      intake of fruit and vegetable servings on a 4-point scale,
           vegetable consumption, reports of trying to lose weight       including less than once per day or never, once but less
           and diet-related questions from the weight control mod-       than three times per day, at least three but less than five
           ule, and sociodemographic characteristics (education,         times per day, and five or more times per day. A variable
           sex, or race/ethnicity). Participants reporting attempts to   was created for whether individuals reported eating the
           lose weight but not reporting using either diet or physical   Centers for Disease Control and Prevention recom-
           activity weight loss strategy were also excluded. Another     mended intake—at the time of the survey—of a mini-
           important restriction was limiting this sample to adults      mumoffivedaily servings of fruits and vegetables (18).
           with overweight or obesity (body mass index [BMI] of 25         Weight status was assessed based on the BRFSS self-
           andabove). Normal weight and underweight people were          reported body measurements with participants assigned
           excluded to address weight loss attempts and strategies       into three weight groups: overweight (BMI25 to 29.99),
           amongthoseatelevatedriskforexcessiveweight-related            obese Class I (BMI30 to 34.99), and obesity Class II/III
           diseases. After all exclusions, 57,464 individuals in 1996    (BMI35).Therewerenosignificantdifferencesineither
           and 136,756 participants in 2003 remained eligible for        the prevalence of weight loss attempt, diet practices, or
           analysis.                                                     fruit and vegetable intake between adults with BMI of 35
             This study was deemed exempt from institutional re-         to 39.99 and BMI 40, so these groups were combined.
           view board approval under federal regulation 45 CFR
           §46.101(b).
                                                                         Statistical Analysis
           Measures                                                      Comparative analyses of sociodemographic differences in
           Weight Loss and Diet Strategies. The weight control module    weight loss practices across population groups and their
           starts with a question to all participants: “Are you now      changes over time focused on rates of trying to lose
           trying to lose weight?” If the response is negative, the      weight, diet strategies used, and reported fruit and veg-
           module continues with, “Are you now trying to maintain        etable consumption in 1996 and 2003. Differences in
           your weight, that is to keep from gaining weight?” Only       means between groups were tested using t tests, and
           participants reporting affirmatively to either of the two      associations between categorical variables were assessed
                                                                         using   2
           questions are asked the questions “Are you trying to eat             tests. Stratifying by sex, weight status, race/
           fewer calories or less fat to lose weight (or keep from       ethnicity, and education, the hypothesis that weight loss
           536   April 2010 Volume 110 Number 4
                                        Table 1. Trends in prevalence of trying to lose weight among adults with overweight or
                                        obesity (n194,220) between 1996 and 2003
                                                                                         1996                        2003
                                                                               Men          Women         Men           Women
                                        Characteristic                         (n29,554) (n27,910) (n65,679) (n71,077)
                                                                               4™™™™™™™™™™™™™™™™™%a™™™™™™™™™™™™™™™™™3
                                                                                                 b             c             bc
                                        Overall                                41.7         62.9          44.1          64.9
                                        Body mass index
                                        25-24.99                               35.1         59.2          34.6          59.3
                                        30-34.99                               58.4b             b             b             b
                                                                                            68.4          59.5          70.2
                                                                                   b             b             b             bc
                                        35 and above                           65.5         70.9          69.9          75.2
                                        Race/ethnicity
                                                                                                               c             c
                                        White                                  42.2         63.3          44.7          65.8
                                                                                   b             b             bc            b
                                        African American                       35.4         58.5          40.5          60.7
                                        Hispanic                               41.5         65.5          43.1          65.1
                                        Other                                  48.3         67.3          44.4          64.7
                                        Education
                                                                                   b             b                           b
                                        Less than high school                  34.2         51.2          37.3          54.0
                                        High school                            38.1         61.8          39.9          62.4
                                                                                   b             b             b             b
                                        Some college/technical school          44.2         67.9          45.7          68.7
                                                                                   b             b             b             b
                                        College graduate and above             46.9         69.7          48.9          70.2
                                        Professional advice to lose weight
                                                                                                                             c
                                        Not received                           36.3         56.5          37.2          58.6
                                                                                   b             b             bc            b
                                        Advice received                        73.8         82.4          77.5          82.8
                                        a
                                         The reported estimates are percentages weighted to be nationally representative.
                                        bRates of trying to lose weight different within groups (body mass index: compared to overweight; race/ethnicity:
                                        compared to white non-Hispanic adults; education: compared to people with high school diploma; professional advice:
                                        compared to not receiving advice to lose weight) significant at P0.01.
                                        cRates of trying to lose weight different between 1996 and 2003 significant at P0.01.
             practices in the group remainedunchangedbetween1996                         ducted using Stata (version 9.0, 2008, Stata Corporation,
             and 2003 was tested using a t test.                                         College Station, TX).
                To determine whether trying to lose weight was asso-
             ciated with fruit and vegetable consumption and if this
             relationship differed across demographic groups, a mul-                     RESULTS
             tivariate linear probability regression model for the di-                   Trying to Lose Weight
             chotomous measure of meeting the five per day fruit and                      The prevalence of adults with overweight or obesity at-
             vegetable servings* was estimated. The model was run                        tempting weight loss varied significantly across demo-
             separately for men and women from the 1996 survey, the                      graphic groups (Table 1). Women with overweight or obe-
             2003 wave and the combined 1996 and 2003 sample. It                         sity were 1.5 times more likely to attempt weight loss
             included measures of trying to lose weight, weight group,                   than men, and they started doing so at much lower BMI
             age, race/ethnicity, education, household income, receiv-                   levels. The sex difference in trying to lose weight dimin-
             ing professional advice to lose weight, and a year dummy                    ished with increasing BMI, but remained statistically
             in the combined 1996 and 2003 sample. Interactions be-                      significant. Although the differences in attempted weight
             tween trying to lose weight and race/ethnicity, weight                      loss by sex and degree of overweight were most notable,
             group, education and income were considered, and those                      there were also significant gradients by education and
             with significant effects such as weight group and race/                      race.Theleasteducatedparticipants(lessthanhighschool)
             ethnicity were retained. To account for the complex sam-                    were the least likely to try to lose weight even though they
             pling design and obtain nationally representative es-
             timates, individual sample weights were used in all                         had significantly higher rates of obesity, especially severe
             analyses. The Huber-White estimator of variance was                         forms(eg,amongtheleasteducated,7.4%and13.7%ofmen
             used to calculate standard errors. All analyses were con-                   and women, respectively, had BMI of 35 in 2003; for men
                                                                                         and women with a graduate degree, these rates were 4.6%
                                                                                         and 5.4%, respectively). African Americans were less likely
                *While one typically does not include truly dichoto-                     to try to lose weight than white non-Hispanic and Hispanic
             mous outcomes in linear regression models, the underly-                     individuals. It is notable that Hispanic adults with over-
             ing distribution of fruit and vegetable consumption can                     weightorobesityhadratesofattemptedweightlosssimilar
             be considered continuous with a true zero point and in-                     to white non-Hispanic participants. Receiving professional
             finite possible positive true values.                                        advice to lose weight was associated with considerably
                                                                                               April 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION    537
               Table 2. Trends in prevalence of diet methods among adults with overweight or obesity who are dieting to lose weight, 1996 and 2003
               (n92,596)
                                                                               1996                                                2003
                                                           Fewer           Less        Fewer calories         Fewer           Less          Fewer calories
              Characteristic                               calories        fat         and less fat           calories        fat           and less fat
                                                                                                             a
                                                           4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™% ™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™3
                                                                                                                   b               b
              Overall                                      11.3            41.6        47.1                   24.9            29.1          46.0
              Sex
                                                                                                                   b               b
              Male                                         13.2            40.3        46.5                   26.2            28.9          44.8
                                                               c               c                                   bc              b            c
              Female                                        9.6            42.8        47.6                   23.7            29.2          47.1
              Body mass index
                                                                                                                   b               b
              25-24.99                                     10.7            42.7        46.6                   25.3            29.3          45.3
                                                                                                                   b               b
              30-34.99                                     12.3            40.7        46.9                   24.2            29.0          46.7
                                                                               c                                   b               b
              35 and above                                 11.7            38.5        49.7                   24.6            28.6          46.8
              Race/ethnicity
                                                                                                                   b               b
              White                                         9.9            40.9        49.1                   26.0            25.1          48.8
                                                               c                            c                      bc              bc           c
              African American                             16.0            39.8        44.2                   22.8            34.5          42.7
                                                               c               c            c                      bc              c            c
              Hispanic                                     13.6            46.9        39.5                   21.8            43.8          34.3
                                                               c                            c                      c               bc
              Other                                        17.4            43.6        38.9                   21.8            31.1          47.1
              Education
                                                                                                                   b               c            c
              Less than high school                        13.5            43.8        42.7                   21.1            39.9          38.9
                                                                                                                   b               b
              High school                                  12.2            41.6        46.2                   23.9            32.5          43.6
                                                                                                                   b               bc           c
              Some college/technical school                10.7            43.3        45.9                   24.6            28.8          46.5
                                                               c                            c                      bc              bc           c
              College graduate                              9.6            38.6        51.8                   27.3            22.1          50.5
              Professional advice to lose weight
                                                                                                                   b               b
              Not received                                 11.7            42.9        45.4                   25.8            29.6          44.6
                                                                               c            c                      c               b            c
              Advice received                              10.3            38.6        51.1                   22.9            28.1          48.9
               a
               The reported estimates are percentages weighted to be nationally representative.
               bDiet methods different between 1996 and 2003 significant at P0.01.
               cDiet methods different within groups (sex: compared to males; body mass index: compared to overweight; race/ethnicity: compared to whites; education: compared to people with high
               school diploma; professional advice: compared to not receiving advice to lose weight) significant at P0.01.
             higher rates of attempted weight loss, for example, almost                 pants. At the same time, the low-fat diet without energy
             doubling rates for men.                                                    restriction dropped in prevalence by one third, with
                Agreater proportion of adults with overweight or obe-                   greater reductions among college graduates and white
             sity tried to lose weight in 2003 than in 1996, although                   non-Hispanic participants. In contrast, Hispanic and
             theincreasewasrelativelymodest(53%vs51%,P0.01).                           least-educated individuals continued to use low-fat diet-
             This increase was twice as high for men as for women,                      ing without energy restriction at virtually the same rate
             which reduced the sex difference in attempted weight                       in 2003 as in 1996.
             loss. The largest gains in rates of attempted weight loss
             between 1996 and 2003 emerged for African-American
             menwithoverweightorobesity, white non-Hispanic par-                        Fruit and Vegetable Consumption
             ticipants, and women with BMI 35. Although some                           Ashypothesized,adultswithoverweightorobesitytrying
             sociodemographic differences in attempted weight loss                      to lose weight were more likely to report consuming the
             narrowed during this time, significant gradients re-                        recommended servings of fruit and vegetables than their
             mained, especially by education (Table 1).                                 peers not attempting weight loss, by about five percent-
             Weight Loss Strategies                                                     age points (Table 3). Even with this gain, only a quarter
                                                                                        of them met the recommendation for fruit and vegetable
             Among adults with overweight or obesity trying to lose                     consumption, which highlights inadequate fruit/vegeta-
             weight, about 86% of men and 92% of women reported                         ble intake in this population. Attempting to lose weight
             either eating less energy (energy restriction), or eating                  was associated with higher rates of meeting the recom-
             less fat (low-fat dieting), or following both strategies.                  mended intake of fruit and vegetables across most popu-
             Between 1996 and 2003, there were substantial changes                      lation groups, with the largest difference among those
             in the distribution of these diet approaches among adults                  with BMI of 35 and above. However, such differences in
             withoverweightorobesitytryingtoloseweight(Table2).                         fruit and vegetable intake were small for minorities and
             The proportion of people who reported using energy re-                     men. Despite all the promotional messages in recent
             striction alone doubled during this period with even                       years to increase fruit and vegetable consumption, rates
             larger increases for women and highly educated partici-                    of meeting the recommended intake of five servings of
             538    April 2010 Volume 110 Number 4
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...Research original trying to lose weight diet strategies among americans with overweight or obesity in and tatiana andreyeva phd michael w long mph kathryn e henderson gabrielle m grode abstract any struggle are background health professionals recommend that individ mlooking for guidance on appropriate loss uals by reducing based clear ndings the energy intake while maintaining a healthful this macronutrientcompositionofdietsisunrelatedtoweight study was designed examine trends clinicians as well public campaigns have attempts adults focused recent education efforts different sociodemographic groups restriction encouraging overall methods data from behavioral risk despite increased focus factor surveillance system were used estimate expert recommendations interest changes across diets limiting of particular macronutrients population analyzed out emphasizing persists results slightly more many been popularized attempted compared there united states focuses low fat weresubstantialchangesi...

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