Weight Loss: The Options And The Evidence - Bpac

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NUTRITIONENDOCRINOLOGYC ARDIOVASCUL ARWeight loss: the options andthe evidenceThe benefits of intentional weight loss in people who are overweight are undeniable. However, the vast numberof diets, products and lifestyles marketed to consumers presents a challenge for health professionals wanting torecommend healthy, evidence-based and sustainable interventions.KEY PR AC TICE POINTS:The overriding principle of weight loss is that energy intakeneeds to be less than energy expenditure; there is noconsistent evidence that any one calorie-restricted diet isbetter than another at achieving weight lossThe two most important factors when considering thebenefit of a dietary regimen are:1. Is the diet healthy, i.e. balanced, nutritious and energyappropriate?2. Can the diet be maintained long-term?At least 2.5 hours of moderate intensity physical activity perweek should be included in all weight loss interventionsContrary to popular belief, rapid weight loss is notassociated with an increased risk of weight regaincompared to gradual weight lossVery low-calorie diets ( 800 kcal/d) should only beconsidered for people who are obese and have a clinicalwww.bpac.org.nzneed to rapidly lose weight (e.g. prior to surgery). Thediet must be nutritionally complete and followed for amaximum of 12 weeks (continuously or intermittently),and patients should receive ongoing clinical support.Patients should then switch to a maintenance weight lossprogramme.Pharmacological interventions may be considered only afterdietary, exercise and behavioural approaches have beeninitiated and evaluated for people who are obese or as anadjunct to diet and lifestyle interventions, after the potentialharms and benefits of treatment have been reviewedBariatric surgery is an effective weight loss interventionthat is publicly funded for eligible people according to anational scoring system. It should be considered for peoplewho have not achieved or maintained adequate weightloss, despite engaging with all appropriate non-surgicalinterventions.April 20221

This is a revision of a previously published article.What’s new for this update:Evidence supporting lifestyle interventions asan effective strategy for the management andremission of type 2 diabetes is now availablein a separate article, see: bpac.org.nz/2021/diabetes-weight.aspxA section added on the use of a whole foodplant-based diets to support long-term weightmanagementTwo new pharmacological interventionsapproved in New Zealand (but not funded) forweight management:– Liraglutide (a GLP 1 receptor agonist)– Naltrexone bupropionObesity in New ZealandThe proportion of the New Zealand population who areobese is growing. In 2020/21, over one-third of New Zealandadults (1.42 million) had a BMI 30 kg/m2.1 There are, however,marked differences in the rates of obesity for some groups;Pacific peoples (63%) and Māori (48%) are more likely to beobese than European/Others (29%) and Asians (16%).1 Peopleliving in the most deprived communities are 1.8 times as likelyto be obese than those living in the least deprived.1 Ongoinginequity in the social determinants of health is resulting in anincreasing burden of obesity and obesity-related disease (e.g.type 2 diabetes) on Māori and Pacific peoples.2Studies have shown that Asian populations are at higherrisk for type 2 diabetes, high blood pressure and lipid levelsat lower BMI thresholds than other ethnic groups;3 for a fixedBMI, New Zealand Chinese have a higher percentage body fatcompared to New Zealand Europeans and Asian Indians.4 TheWorld Health Organization proposed a lower BMI cut-off forAsians where a BMI of 23 kg/m2 is considered overweight.3 NewZealand guidelines recommend considering a lower treatmentthreshold for Asian patients with central/abdominal obesity.5Achieving a healthy weight underpins the preventionand management of numerous long-term health conditions.6However, halting the obesity epidemic requires societalchange. While primary health care professionals are not ableto address all of the health determinants relating to obesity,on an individual level they can encourage patients to havehealthy lifestyles that prevent excessive weight gain, and offerinterventions and support to people who would benefit froma reduction in body weight. Beginning a weight loss journeycan be daunting; identifying and addressing any psychologicalbarriers to weight loss and assessing readiness to change willhelp ensure that the lifestyle, pharmacological or surgicaltreatments are effective.2April 2022For further information on the effect of weight loss on themanagement and remission of type 2 diabetes, see: bpac.org.nz/2021/diabetes-weight.aspxInformation to support patients who are initiating a weightloss plan is available from: our-weight/getting-started-your-weightloss-planThe principles of weight managementObesity is a chronic disease that results from complexinteractions between genetic, metabolic, hormonal,behavioural and environmental factors. 6 Key lifestyleinterventions to promote weight loss include behaviourchange strategies, reducing calorie intake, improvingthe nutritional value of the diet and increasing energyexpenditure.6 The clinical benefits of weight loss begin oncean overweight person loses as little as 5% of their body weightand benefits increase as the ideal weight range is approached.If lifestyle interventions alone are unsuccessful, treatmentcan be stepped up to include pharmacological or surgicaltreatment.Key aspects of weight loss management include:Optimising the management of co-morbidities andconsidering other potential causes of weight gain, e.g.adverse medicine effects, undiagnosed conditions orpsychosocial issuesDeveloping an individualised plan with SMARTER* goals(Specific, Measurable, Achievable, Relevant, Time-bound,Enjoyable and evaluate, Record and reward) and a planfor review and monitoring. Lifestyle changes shouldbe sustainable so that reductions in body weightcan be maintained. Individualising managementbased on cultural factors is also important to supportweight loss; for example, a review of studies relatingto obesity management in New Zealand primary caredemonstrated that including whānau and values suchas manaakitanga (enhancing the integrity of the person),pātaka mātauranga (sharing knowledge that leads tounderstanding and responsibility) and whanaungatanga(support or connectedness) aided the success ofinterventions.7Recommending dietary interventions that are affordableand recognise the cultural and social significance of food,e.g. manaakitanga in Māori culture centres on generoushospitality often involving food, and this concept isshared by many other Pacific and Asian culturesRecommending behavioural interventions as appropriate,e.g. encouraging regular meals and meal planning,www.bpac.org.nz

self-monitoring, stimulus control, stress management,slowing the rate of eating, ensuring social support,problem-solving, thought modification, relapseprevention and strategies to deal with weight regain.5If additional support is needed, referral to weight losssupport groups or counselling (depending on localavailability).Recommending physical activity and exerciseinterventions that are appropriate for the patient’s fitnesslevel and encouraging an increase in intensity as theirfitness and mobility improves (see: “Exercise should beincluded in every weight loss regimen”)Re-framing the discussion to focus on improving themanagement of long-term conditions, e.g. type 2diabetes or dyslipidaemia, rather than weight loss maymotivate patients to engage with lifestyle changes orstep treatment up to include weight loss medicines, ifindicated8* Information for patients on SMARTER goals is available aking-changes-goal-setting/For further information on psychological and behaviouralinterventions for obesity management, see:Appendix 2 in the Ministry of Health’s Clinical guidelinesfor weight management in New Zealand adults newzealand-adultsv2.pdfCanadian adult obesity clinical practice 08/10Psych-Interventions-2-v3-with-links FINAL.pdfRapid weight loss is not associated with an increased riskof weight regainRapid weight loss, e.g. a 10% reduction in body weight overfive weeks, is associated with the same risk of weight regainafter nine months, compared to a 10% reduction in bodyweight over three months.9 Therefore, even though diets thatbegin with significant calorie restriction and rapid weight lossmay not be sustainable long-term, there is no evidence theyare any less successful than those involving more gradualchanges, and no more likely to cause a relapse into unhealthybehaviours.Simply advising people to lose weight makes them morelikely to tryAlthough it can be a confronting topic, health professionals(including doctors, dietitians, nurses and pharmacists) shouldraise the issue of weight loss if a person is likely to benefitfrom a reduction in body weight. A meta-analysis of 12 studieswww.bpac.org.nzfound that people who were advised to lose weight by a healthprofessional in primary care were almost four times morelikely to attempt to do so than those who did not receive thisadvice.10Dietary approaches to weight lossKey features of calorie-restricted diets that are effective forweight loss are summarised in Table 1. In general, the weightloss efficacy of energy-matched dietary regimens withdifferent macronutrient compositions, e.g. low carbohydrateor low-fat, is similar. However, regimens that minimise or“forbid” the intake of particular food groups may result innutritional deficiencies, e.g. insufficient fibre, iron or calcium, orexcessive intake of saturated fat. These diets are also often notsustainable in the long-term or practical to manage, e.g. familymeals may not be easy to adapt or there may be difficulties infinding foods to match the diet when dining out or at otherpeople’s homes.The two most important factors, therefore, in determining thebenefit of a dietary regimen are:5,1 11. Is the diet healthy, i.e. balanced, nutritious and energyappropriate?2. Can the diet be maintained long-term, e.g. is it affordable,sustainable within a person’s lifestyle and with their comorbidities, and is it culturally and socially acceptable?Referring to a dietitianPeople with sub-optimal nutrition may benefit from adiscussion with a dietitian. Funded consultations for peoplewho are obese are generally for those with diabetes anduncontrolled hyperglycaemia, although referral criteria differbetween DHBs. Dietitians are also available privately.Contact details for local dietitians are available from:dietitians.org.nzDietary supplements: no evidence of effectiveness andmay cause adverse effectsAdvise people against using dietary supplements, e.g.amarasate, garcinia and other botanicals, for weight lossas there is no evidence of benefit, often the safety has notbeen established and they may interact with medicines.Supplements may be unaffordable for many patients and canbe associated with adverse effects such as liver failure, colitisand gastrointestinal irritation.23 Some supplements containcaffeine or capsaicinoids that may increase energy expenditureto promote weight loss, but can result in tachycardia orarrhythmias, which is problematic in people with pre-existingcardiac conditions.23Similarly, there is no conclusive evidence that herbalpreparations, slimming teas or high fibre tablets as appetiteApril 20223

Table 1: Dietary regimens with evidence of effectiveness for weight loss or reduced cardiovascular disease (CVD) risk.5Modified terraneanThree iet/art-200478011. Increased consumption ofomega-3 fats from fish and plantsourcesA substantial amount of supportingshort and long-term evidence,including a lower risk of CVD events,reduced triglycerides, a reducedrisk of diabetes, lower HbA1c andreduced circulation of inflammatorymarkers12,13Serving sizes are not specified andit can be difficult to estimate calorieintake.(Recommended by theMinistry of Health)3. Consumption of a diet high infruit, vegetables and wholegrains to increase fibre andantioxidant intakes andconsumption of very fewproducts made from refinedgrains2. Substitution of saturated andtrans fats for non-hydrogenatedunsaturated fatsIron intake may be insufficient, andsupplementation may be required.Vegetables and fruit are central,monounsaturated fats areprominent, sourced mainly fromolive oil. Includes cereals, nuts andlegumes, a moderate amount ofpoultry, fish and dairy products andlittle to no red meat.Low fat, e.g. Dietaryapproach to stophypertension 56Includes vegetables, fruits, fish, nutsand low-fat dairy products that arenaturally low in sodium. Red meatmay be eaten in moderation.Associated with lower bloodpressure and a reduced risk of CVDand type 2 diabetes, and improvedglycaemic control and blood lipidprofile.12Serving sizes are not specified andit can be difficult to estimate calorieintakeAlthough not intended as a weightloss programme, weight loss mayresult as the diet facilitates healthiermeal and snack ommended by theMinistry of Health)Low (and very low)carbohydrate*, e.g.Atkins, y low carbohydrate[ketogenic] diets are notrecommended by theMinistry of 20111182(Paleo diets are not recommendedby the Ministry of Health)Low carbohydrate dietscontain 40% of total energyfrom carbohydrates. Very lowcarbohydrate diets contain 20%(20 – 60 g/day).5Red meat, poultry, fish, shellfishand eggs are the primary source ofnutrition.Associated with reductions in bloodpressure, triglyceride levels, HbA1c,and insulin resistance.14, 15Fibre and micronutrient consumptionmay be inadequate, consumption ofsaturated fat may be excessive.Ketogenesis may cause a reductionin appetite.13High LDL-C as a result of ketogenicdiets may compromise artery functionand worsen heart disease.16Initial adverse effects include lowenergy levels, “brain fog”, increasedhunger, sleep problems, nausea,digestive discomfort, bad breath andpoor exercise performance.The saturated fat content maybe particularly high in versionsmarketed as ketogenic.Hard to sustain in the long term andmost of the initial weight loss seen isoften associated with fluid losses.16Focuses on foods theoreticallyeaten during early human evolution,e.g. lean meat, fish, vegetables,eggs, nuts and berries, and avoidsgrains, dairy, salt, refined fats,sugars and processed foods.Often lower in carbohydrate, higherin protein and moderate to highin fat; however, the macronutrientprofile can differ substantiallydepending on the palaeolithicculture/region inspiring the specificpaleo diet.Includes some patterns ofbehaviour known to be beneficial,e.g. drinking water, limiting refinedsugar.Only a few small studies of shortduration have been conducted withmixed effects on weight, HbA1c andlipids.15Requires the elimination of two wholefood groups (dairy and grains). Thereis a risk of nutrient inadequacy (e.g.fibre, calcium, iron and vitamin D) andit may be difficult to follow. Ensuringadequate calcium is of particularconcern, particularly for those at risk ofosteoporosis.17* It is thought that these patterns of eating shift the body away from glucose as a source of energy and towards fatty acids and fatty-acid derived ketones,at the same time fat storage is reduced 22† Ketogenic diets are very low in carbohydrate and high in fat4April 2022www.bpac.org.nz

Whole food plantbased guide#foods-to-eatFocuses on consuming foods intheir most natural form, e.g. grains,legumes, vegetables, fruit and nuts.Excludes heavily processed andrefined foods and avoids or limitsmeat, eggs and nvegan-plant-based-diet.htmlVegetarian or -way.htmlVery low w-calorie-diets/Long-term sustainable method ofsignificant body weight reductionsdespite no caloric or portion sizerestrictions.18Associated with a slight raise inresting metabolic rate, reducedrisk of type 2 diabetes, CVD andhypertension.18May provide insufficient dailyquantities of vitamins B12 and D, andcalcium; encourage a wide varietyof plant-derived foods to ensurethe diet is balanced and sustainable.Supplements may be necessary.Vegans need to ensure a reliable sourceof vitamin B12.May be protective against insulinresistance.18If excluding dairy, vegan sourcesof calcium or supplementation isnecessary.Those who follow plant-based dietsare categorised as:Lacto-ovo vegetarian: eat dairyfoods and eggs but not meat,poultry or seafoodOvo-vegetarian: include eggsbut avoid all other animal foods,including dairyLacto-vegetarian: eat dairy foodsbut exclude eggs, meat, poultryand seafoodVegan: exclude all animalproducts including dairy, eggs,and sometimes honeyVegetarian diets, including vegandiets, are associated with improvedcardiometabolic risk factors, and areduced risk of type 2 diabetes andCVD.12Requires calorie restriction to beeffective for weight loss.Typically used for rapid weight lossover 8 to 12 weeks prior to a weightloss maintenance programme or ifthere is clinical need to lose weightrapidly (e.g. prior to surgery).19Energy intake is usually 3350 kJ/day ( 800 kcal/d).19Reductions in BMI, blood pressureand triglycerides can lead to longterm weight management, reducedCVD risk and obesity relatedco-morbidities (e.g. diabetes).5May include high amounts of saturatedfats, e.g. coconut oil, and processedfoods high in calories, sugar andsodium.Vegan regimens may be low in iron,vitamin B12, calcium and iodine andsupplementation may be required.May cause a reduction in appetite.20Food usually replaced with anutritionally balanced product (e.g.shake, soup, bar) with high proteincontent to minimise the loss oflean tissue, supplemented withvitamins, minerals, electrolytes andfatty acids.Hard to sustain and should generallyonly be used for short periods ( 12 weeks), ideally under medicalsupervision, before switching to amaintenance diet. No guidance onfood selection is provided; educationmay be required to ensure healthyoptions are chosen during the weightmaintenance phase.Not appropriate for many people, e.g.children, pregnant women, peopleaged over 65 years, those with eGFR 30 mL/min/1.73m2 or recent acutecoronary syndrome.5The reduced energy intake may causetransient adverse effects includingalopecia, tiredness, dizziness and coldintolerance.Regular follow ups are required whichmay not be achievable for somepeople or able to be offered by someclinics; follow-up by phone may be anappropriate solution in some cases.Intermittent ebasedmedicine.org/intermittent-fasting/A pattern of eating that cyclesbetween energy restriction andnon-fasting. The most common isthe 5:2 dietary regimen where anormal calorie intake of healthyfood is maintained for five days perweek and substantially less eatenon two days, e.g. 2100 – 2500 kJ/day (500 – 600 kcal).5Time-restricted eating is anothertype of intermittent fasting thatinvolves fasting for at least 12 hoursevery 24 hours, e.g. by abstainingfrom food from 7 pm – 7 am.There is no compelling evidence tosupport other types of short-term“fasts”, e.g. the cabbage soup diet,for long-term weight loss; many ofthese diets involve extremely lowcaloric intake, and people oftenregain weight once a normal diet isresumed.www.bpac.org.nzIntermittent fasting is as effectiveas a continuous energy restricteddietary regimen in terms of weightloss.5 However, some people mayfind intermittent fasting easier toadhere to rather than reducing theamount of food they eat every day.Furthermore, with time restrictedeating, the focus is on when to eat,not on what to eat.Little is known about the long-termrisks and benefits.It is not known what the optimaltiming of fasting or level of calorierestriction is to achieve maximal weightloss.Some concerns that people mayconsume excess calories on thenon-fasting days, however, studiesto date have not found this to be thecase compared to other weight lossmethods.People with diabetes who take insulinor sulfonylureas are at increased riskof hypoglycaemia on fasting days.21Requires planning and frequentmonitoring to ensure appropriatedose adjustment on fasting days toreduce this risk.21 Not recommendedfor people with type 1 diabetes. Alsonot suitable for adolescents or duringpregnancy or breastfeeding.April 20225

suppressants, are effective for inducing long-term weight loss,and excessive use may cause nausea, vomiting, abdominalpain and diarrhoea.24Patient information on weight loss supplements isavailable from: df#search %22chitosan%22Exercise should be included in every weightloss regimenExercise alone is less effective than a calorie-restricted dietfor achieving weight loss.25 However, some form of physicalactivity should be included in every weight loss interventionas it augments weight reduction, helps maintain weightloss and confers additional benefits, e.g. increased musclemass and fitness, decreased central adiposity, and improvedcardiovascular and mental health.25, 26Recommend that people start with exercises they enjoy,are familiar with and are appropriate for their age andcapabilities. In general, weight bearing exercises are moreeffective at reducing BMI than non-weight bearing exercise.For example, walking or jogging uses approximately 30% moreenergy over the same time period than swimming or cycling.27The amount and type of exercise should be extended asfitness improves.How much physical activity is recommended?Discussions with patients about physical activity can be guidedby the following points:11, 261. Sit less and move more, e.g. after sitting for 30 minutes,get up from your seat and walk around2. Do at least 2.5 hours of moderate activity per week*, e.g.brisk walking, swimming, playing social games/sports,gardening, vacuuming, mowing the lawn. This can bereduced by half if it is vigorous activity*, e.g. running,hill walking, fast cycling, aerobic dancing, competitivesports, carrying heavy loads, shovelling/digging.3. For additional benefits increase the duration ofmoderate to vigorous activity; all adults should beencouraged to do more physical activity than isrecommended to balance the effects of high levels ofsedentary behaviour4. Perform muscle strengthening activities two days ofeach week5. Some level of physical activity is better than none;reducing sedentary time and increasing physical activityof any intensity is beneficial* Moderate activity noticeably increases heart rate; vigorous activity causesrapid breathing and a substantial increase in heart rate. Exercise intensityis dependent on fitness level and mobility.6April 2022Further information about types of physical activitiessuitable for different age groups is available from: -activity-and-sleep/physical-activityDiabetes New Zealand provides exercise suggestionsincluding activities appropriate for those with an injury ordisability, available from: tiesMaintaining positive changeFollowing a reduction in body weight, changes in appetiteregulating hormones make maintenance of weight lossdifficult.25 The hormone ghrelin that causes hunger may remainincreased for several years and leptin, which decreases hunger,is suppressed.28 Furthermore, a person’s resting metabolic rateslows following weight loss which also makes weight regainmore likely.25To counteract these physiological and metabolic changespeople need long-term monitoring and support in primarycare; accountability may be a motivating factor for somepeople to maintain weight loss. A recent randomised controlledtrial showed that telephone follow-up after a lifestyle weightloss intervention was more effective at reducing weightregain than education alone. 29 While the cost and timeinvolved in individual telephone sessions is a major barrier toimplementing this in primary care, people can be encouragedto instigate a ‘buddy’ system or join a group to maintain (orcontinue) their weight loss.Other services and groups which can help with ongoingsupport include:Green PrescriptionWhānau Ora providersWeight loss groups: www.meetup.com/topics/weightloss/nz/Walking groups, e.g. Walking New Zealand: www.walkingnewzealand.co.nz/walking-groups or Parkrun(participants can walk, jog or run): www.parkrun.co.nzCommunity fitness classes, e.g. ZumbaLittle is known about the benefits of smart phone appsSmart phone apps and activity tracking devices may be usefulfor some people to monitor dietary intake or record (andpotentially share) the duration and intensity of exercise. Ingeneral, mobile health technology is associated with positivebehaviour change, e.g. increased consumption of vegetablesand fruits and more physical activity, however, little data areavailable on long-term effectiveness.30www.bpac.org.nz

New Zealand based nutrition/healthy eating and exerciseapp reviews used are available from: www.healthnavigator.org.nz/apps/n/nutrition-apps/ and trition Apps reviewed by a Registered Dietitian can befound here: dietitians.org.nz/public-infoPharmacological interventions for weightmanagementThere are four medicines approved for weight loss in NewZealand (none funded; Table 2): liraglutide, phentermine,orlistat and naltrexone bupropion. These medicines areassociated with modest weight loss which must be balancedagainst the risk of adverse effects. Weight loss medicines canaugment the extent of weight loss beyond which dietaryand lifestyle interventions can achieve alone, and somecan also help to prevent weight regain.5 Current Ministry ofHealth advice is that medicines for weight loss should only beconsidered when:5Lifestyle changes have not produced clinically significantbenefits after six months; andThe person has a BMI 30 kg/m2 *Patients who are taking medicines for weight loss should bemonitored monthly for the first three months.5 Treatmentbeyond three months should not be considered unless thepatient is tolerating the medicine, a clinically significant benefithas occurred, e.g. 5% reduction in body weight, and there areno concerns about ongoing treatment.5* Liraglutide, naltrexone bupropion and phentermine are also indicatedfor use in people with a BMI 27 kg/m2 if they have at least one weightrelated co-morbidity, e.g. impaired glucose tolerance, hypertension,dyslipidaemia or obstructive sleep apnoea32Laxatives should not be used for weight loss. There is noevidence to support the use of over the counter or prescriptionlaxatives for weight loss.5 In general, most laxatives act on thelarge intestine, while the majority of food processing andensuing calorie intake occurs in the small intestine.31 Any shortterm weight reduction after taking laxatives is not sustainableas it is mostly due to temporary fluid loss; overuse can lead todehydration and electrolyte disturbances, and in some casesdependence.31Metformin may be considered for people at high riskof type 2 diabetesMetformin is the first-line medicine for most people with type2 diabetes. The main actions of metformin are to decreasegluconeogenesis and increase peripheral utilisation ofglucose.32The use of metformin may contribute to weight loss andthe prevention of diabetes (unapproved indication) in peoplewww.bpac.org.nzwho are at high risk of type 2 diabetes, i.e. HbA1c 41 – 49 mmol/mol.40 Metformin is occasionally used to assist with weightloss in people with a HbA1c 40 mmol/mol (unapprovedindication). A recent retrospective cohort study found thatthe average weight loss at six and 12 months for patientswith type 2 diabetes/pre-diabetes was approximately 6.5 kgand 7.3 kg, respectively.41 A meta-analysis demonstrated thatpeople who were overweight or obese without diabetes lost2.3 kg following the use of metformin for three to four months,compared to people treated with a placebo.42For information on metformin dosing, adverse effects andinteractions with other medicines, refer to the New ZealandFormulary: www.nzf.org.nz/nzf 3715Surgical interventions for weight lossBariatric surgery is a major and generally irreversibleweight loss procedure, superior to non-surgical weight lossinterventions. Surgery is effective for motivated patients whoare able to maintain lifelong altered eating habits and lifestylechange.5 One year after bariatric surgery, weight loss can be 40– 50 kg with significant improvements in blood pressure, lipidlevels and HbA1c (including remission of diabetes), obstructivesleep apnoea, gastro-oesophageal reflux and venouscirculation.5, 43 Unlike dietary or pharmacological approaches,some types of bariatric surgery may change the body fat ‘setpoint’* such that it is permanently set at a lower level. Peopleundergoing bariatric surgery have been found to maintain theirnew, lower body weight for 20 years or more and to live longeron average than individuals not receiving surgery, presumablydue to red

Rapid weight loss is not associated with an increased risk of weight regain Rapid weight loss, e.g. a 10% reduction in body weight over five weeks, is associated with the same risk of weight regain after nine months, compared to a 10% reduction in body weight over three months.9 Therefore, even though diets that

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