If I asked 100 people, “What is the biggest benefit of exercising?” how many of those people would say something along the lines of, “It helps you lose weight?”

I bet that it would be the most common answer.

Think about it for a minute. Imagine a man holding a clipboard walking on a crowded street and from a distance you see him stopping what appears to be random people asking a quick couple questions to each. As you continue to walk towards the man, being the curious character you are, you decide to see what all the commotion is about. Eventually, you stop next to him and he asks a variety of questions for a survey he’s doing, and one of the questions is, “What is the biggest benefit of exercising?” What would be your answer?

In my opinion, I would guess some of the most common responses would include:

  • Helps to lose weight
  • Helps to stay fit
  • Builds muscle
  • Better sex life (Check out my articles to see how exercise and sex interact – Male Article or Female Article)

But for me and my money, the benefits of exercise are far greater than just weight loss, but because of the current obesity predicament we’re in as a country, exercise is and has been strongly associated with weight loss for many years now.

Before we go any further, let’s take a quick pause to set the stage.

 

Status Update: Adult Obesity in America

Over the past 30 years, obesity has become one of America’s greatest health problems. Between 1988-1994, 33.1% of the US population was considered overweight, 22.9% obese, and 2.8% severely obese. Between 1988-1994, 58.8% of the US population was overweight and obese. Fast forward closer to today, data from 2015-2016 shows those numbers have increased to 31.0% overweight, 40.0% obese, and 8.0% severely obese. Using these numbers, 79% of the US population is considered overweight or obese, which is a 34% increase over that time span. [1]

 

Overweight, Obese, and Extremely Obesity Among Adults in the US
RangeOverweightObeseSObeseTotal% Increase
1988-199433.1%22.9%2.8%58.8%
2015-201631.0%40.0%8.0%79%34.35%

*SObese = Severe Obesity

 

 

Status Update: Childhood Obesity in America

The obesity epidemic is not only affecting adults, it is also affecting children. Data from 1971-1974 shows the overweight and obesity rates among children and adolescents aged 2-19 to be 10.2% overweight, 5.2% obese, and 1.0% severely obese for a total of 16.4% of children and adolescents aged 2-19 considered to be overweight and obese. Data from 2015-2016 showed children and adolescents aged 2-19 have become drastically more overweight and obese. As of 2015-2016, 16.6% of children and adolescents are now overweight, 18.5% are now obese, and 5.6% are now severely obese. Using these numbers, 40.7% of the US population aged 2-19 years old is now considered overweight or obese which is a ridiculous 148% increase over that time span! [1]

 

Children and Adolescents aged 2-19 Overweight and Obesity
RangeOverweightObeseSObeseTotal% Increase
1971-197410.2%5.2%1.0%16.4%
2015-201616.6%18.5%5.6%40.7%148.17%

 
Trends in obesity among children and adolescents aged 2–19 years, by age: United States, 1963–1965 through 2013–2014

 

End Obesity Update and Moving On…

If there’s any business or industry that has benefits the most from the obesity epidemic it’s the fitness industry. The fitness industry as a whole is a $31 billion industry [2] and according to the International Health, Racquet and Sportsclub Association (IHRSA) data, the number of health club memberships in the United States rose in 2014 (latest data available) to 54.1 million, up from 51.4 million in 2011. [3]

As we all know, the internet has given many snake oil salesmen a platform to sell you their version of Lose 20 pounds in 20 days Exercise Program, which reinforces the association of exercise and weight loss to the general public.

But is this even true? Does exercise really make the immediate impact on weight loss that many people claim?

Considering that the number of health club memberships is now at an all-time high with more than 54 million people owning a membership, one would assume that the general population would be trending towards becoming more fit. However, the data doesn’t demonstrate that and instead we see the obesity epidemic continue to worsen with just under 80% of American adults now considered overweight or obese.
But when we think about what is the biggest benefit of exercise, most people probably think weight loss and getting fit. Something doesn’t add up.

 

Does Exercise Help With Weight Loss?

Check out this research.

A 3-month randomized, controlled study [4] recruited 43 overweight or obese adolescent boys (12-18 years old) who were physically inactive which was quantified as no participation in structured physical activity over the previous 3 months except school physical education classes. All subjects were asked to follow a weight maintenance diet during the 3-month intervention period to determine the effects of exercise without caloric restriction. Subjects were split into three groups: aerobic exercise, resistance training, or control. The aerobic exercise program consisted of treadmill, elliptical, or stationary bike sessions three times per week for 60 minutes per session at approximately 50% of VO2peak and increased to 60 minutes at 60-75% of VO2peak by week two. The resistance training program consisted of ten exercises such as leg press, chest press, latissimus pull downs, seated row, among others. The week 1-4 protocol was to perform 1-2 sets of 8-12 repetitions at 60% of baseline. During weeks 4-12, subjects performed two sets of 8-12 repetitions to fatigue.

While these are not the most challenging training protocols known to mankind, keep in mind that these are adolescent boys who have puberty to thank for the plethora of androgenic hormones pumping through their veins for the first time and they are also novice exercisers which will allow them to make faster progress than any other population. These two factors, adolescent in age and novice exercisers, should create a perfect cocktail where exercise could make a huge impact on body composition.

However, the data showed that after three months, exercise had very little impact on weight loss. (Remember, 1 lb.= 2.2 kgs.)

  • Control group gained 2.6 + 1.0 kg body weight
  • Aerobic exercise group lost 0.04 + 0.8 kg body weight
  • Resistance training group lost 0.6 + 0.8 kg body weight

This is not just a one off study.

Another study [5] recruited 65 adults who completed an exercise protocol in which they were randomly assigned to one of two exercise groups: aerobic exercise or combined aerobic and resistance exercise. Aerobic exercise progressed from 15 minutes three times per week to 30-45 minutes five days per week over the course of 12 weeks. The combined aerobic and resistance exercise protocol consisted of the same aerobic exercise in addition to a twice per week strength training regimen which consisted of six compound strength training exercises designed to work large muscle groups for up to 3-6 sets and 10 repetitions beginning at 50% 1RM the first four weeks and transitioning to 2-3 sets and 10 repetitions at 75-80% 1RM. At the conclusion of 12 weeks, the aerobic group lost 3.7 kgs body weight and the aerobic + resistance lost 3.8 kgs body weight, which although statistically significant, it is less than 9 lbs. and not the most dramatic change magazines and online gurus might make you believe.

And to hammer home the point…

A 16-month study [6] with 74 participants aged 17-35 years were assigned to either a control group or exercise group. All participants were previously sedentary and did not expend more than 500 calories on physical activity per week. The exercise was primarily done on a treadmill, progressing from 20 minutes at baseline to 45 minutes at 6 months. The exercise intensity progressed from 60% heart rate reserve at baseline to 75% at 6 months. Participants were required to expend 400 calories per exercise session and approximately 2000 calories per week, which was achieved throughout the course of the study. Energy intake was ad libitum and was measured at baseline and 5 other time points over the 16 months. At the conclusion of the study, the men in the exercise group had only lost 5.2 kg body weight while the women lost only 0.4 kg body weight.

And finally, a meta-analysis found the mean weight loss of men who completed 30 weeks of exercise was a measly 2.6 kg. Women compared similarly, on average losing 3.0 kg over the course of 14 weeks. [7]

So what’s going on here? Exercise is and has been promoted as an effective weight loss tool but the research clearly shows otherwise? Why might exercise not benefit weight loss as much as the general public might tend to believe? Let’s take a look at some potential reasons why exercise might not be the ‘be all, end all’ for weight loss.

 

1. Basics of Energy Expenditure

There are only so many ways the human body is able to expend energy and exercise is one of those ways. Total daily energy expenditure (TDEE) is the total energy (or calories) a person uses to perform all functions of life such as breathing, blood circulation and brain activity as well as digestion and exercise. TDEE can be broken down into four categories: basal metabolic rate (BMR), non-exercise activity thermogenesis (NEAT), thermic effect of food (TEF), and exercise activity thermogenesis (EAT). [8]

In mathematical terms, {TDEE = BMR + NEAT + TEF + EAT} but the tricky part is that all of these components are dynamic. [8] Meaning that it is not a static formula. During the process of losing weight, the body makes adaptations to the components of total daily expenditure. See the chart below for more details.

Component of TDEE% of TDEE (approximate)DefinitionChange during Weight Loss
Basal Metabolic Rate (BMR)70%Amount of energy required to keep bodily functions processing at restWeight loss reduces metabolically active tissue which decreases BMR
Non-Exercise Activity Thermogenesis (NEAT)15%Energy expended during “non-exercise” movement such as fidgeting or normal daily activitiesEvidence suggests that NEAT is decreased when in caloric restriction and remain reduced even after subjects return to freely feeding.
Thermic Effect of Food (TEF)10%Energy expended during process of ingesting, absorbing, metabolizing, and storing nutrients from foodMagnitude maintains but overall reduction because of caloric restriction
Exercise Activity Thermogenesis (EAT)5%Energy used during exerciseExercise will increase this component but as you continue exercising with a weight loss goal, a reduction in body mass will reduce the energy requirement needed to complete a given amount of activity. Meaning as you lose weight, you expend less energy for the same amount of activity.

Modified from Trexler, Smith-Ryan, & Norton, 2014. [8]

Not only are these components reduced during the active weight loss phase, but research indicates that the adaptive thermogenesis and decreased energy expenditure continue long after the active weight loss phase. [8]

The human body is incredibly intelligent, and its purpose is to maintain survival. During weight loss, the body makes these adaptations to ensure survival by minimizing the energy deficit which reduces additional loss of body mass and encourages weight regain in weight loss subjects. [8]

 

2. Exercise Burns Way Less Calories Than Most People Realize

We have all sat next to the person who ate something, like a Big Mac Meal which has 1100 calories, who proceeded to laugh and joke about the need to exercise to burn this food off. But 1100 calories, or whatever the case may be depending on what the individual ate, is no walk in the park.

Check out this chart which displays a variety of exercise modes and the caloric expenditure after 30 minutes based on body weight. I would be willing to bet the calories burned for each exercise is much less than what many people would predict.

 

Calorie Expenditure 30 minutes Exercise
Activity Mode110 lbs.143 lbs.187 lbs.220 lbs.
Aerobic Dance150253433599
Moderate Cycling (12-13.9 mph)184311531735
Circuit Training184311531735
Bodybuilding/Powerlifting139232397551
Rowing, Moderate 100W160273464646
Running (10 min./mi.)231389665919
Running (7 min./mi.)3235439381286
Basketball Game184311531735
Boxing, Sparring139348598830
Soccer Game231389665919
Walking 3.0mph76130219305
Swimming Laps231389665919
Energy Expenditure (kcal/min) = (METs x 3.5 x Body Mass)/200

Hoffman, Jay. Norms for Fitness, Performance, and Health. Human Kinetics, 2006. [9]

 
Keep in mind, most beginner exercisers who have a weight loss goal will struggle to exercise at a reasonable pace for 30 consecutive minutes. Over time, 30 minutes may turn into 60 minutes but that is not an overnight process. Also, a new client should not go from sitting on the couch for the previous few months or years to all of a sudden exercising every day of the week. Too much exercise too fast could cause injury which would reduce progress even further. Starting slower allows the body to adapt appropriately as well as leaves room to increase exercise when a plateau occurs. With that in mind, it is reasonable to assume that a new client might exercise three times per week. Let’s take a look at how this might work using our caloric expenditure chart above:

 

Day of WeekExercise Type and TimeCalorie Expenditure
MondayStrength Training, 45 min.826
Walking (3.0 mph), 15 min.152
WednesdayStrength Training, 45 min.826
Walking (3.0 mph), 15 min.152
FridayStrength Training, 45 min.826
Walking (3.0 mph), 15 min.152
Total Caloric Expenditure2934

 
This is great exercise and caloric expenditure but to lose one pound it is estimated that there needs to be a 3500 calorie deficit. This sample exercise protocol only expends an additional approximately 2900 calories which is about 600 calories short of one pound of weight loss per week. This is an overly simplistic look at the static weight loss formula because, as previously stated, the components of total daily energy expenditure are dynamic. Because the components are dynamic and not static the components of TDEE are constantly modifying themselves to prevent excessive body composition changes in an effort to preserve itself.

 

Compensatory Mechanisms of Exercise: Energy Intake

To make the situation even more complicated, let me introduce another factor—compensatory mechanisms of exercise. Compensatory mechanisms of exercise can include the previously mentioned changes to metabolism caused by a hypocaloric state but there’s another important mechanism at play. Your appetite.

When you’re active compared to inactive, are you typically more or less hungry? I’m not talking about hungry the second you stop running or moving. I’m talking about when you’ve been a little more active than usual for maybe a few days in a row. Typically, I think the answer would be “more hungry” and the research backs this up.

A study [10] with 35 overweight and obese sedentary male and female subjects participated in a 12-week exercise program that was individually designed the participants would expend 500 calories per session at approximately 70% max HR five days per week. While the overall mean weight loss was 3.7 + 3.6 kg over the duration of the study, the body weight changes ranged from a reduction of 14.7 kg to an increase of 1.7 kg. When the researchers looked closer at the data, they noticed a divide in the subjects which they then labeled the two separate groups: “compensators” and “non-compensator”. A compensator was a participant who lost less weight than their predicted amount, while the non-compensators lost more than or equal to the amount of weight than was predicted.

While there was no difference in exercise induced energy expenditure or the proportion of exercise sessions attended between groups, there was however a significant difference in the energy intake between groups. The compensators increased their energy intake by 268.2 + 455 kcal/day while the non-compensators decreased energy intake by -130 + 485 kcal/day.
This is a huge difference and helps to explain the substantial variability between subjects in not only this study, where weight changes ranged from losing 14.7 kg to gaining 1.7 kg, but also in a practical sense where two clients may perform the exact same exercise but get completely different results.

More research finds similar results.

A study [11] of more than 500 public school students found that for every 60 minutes of additional physical activity there was an increase in energy intake by 292 calories.
Another study [12] found that 12 of the 13 subjects whose energy intake was measured through multiple doubly labeled water and body composition measurements increased dietary intake as a result of an exercise protocol.

And if you thought to yourself, “If there is compensation from exercise, why not just exercise more to compensate for the compensation?” Research has shown that more exercise may lead to more compensation.

A 6-month study [13] of 411 women assigned to one of three exercise groups which expended either 4, 8, or 12 kcal/kg/week (KKW) found that the highest intensity exercise group, 12 KKW lost only 1.5 kg which was a paltry 53.5% of the predicted weight loss. Not only this, but the 12 KKW group lost less body weight than the 8 KKW group, 2.1 kg and was essentially the same as the 4 KKW group which lost 1.4 kg body weight. The authors suggest compensatory mechanisms such as increased energy intake to be the driving factor.

And while this is just a few studies, more comprehensive review of clinical exercise and weight loss research shows similar findings. Ross et al. [14] found that in studies lasting greater than 25 weeks in duration the average weight loss was only approximately 30% of the predicted weight loss.
Other researchers have also noted that when subjects are able to eat ad libitum, energy intake is underreported by as much as 20-50% and underreporting increases as overweight and obesity increase. [15]

Underreporting is only exacerbated by the current conditions of ample food supply for the majority of the population. There is absolutely no amount of increase in physical activity that is able to offset a positive energy balance when overeating, especially when research clearly shows that increased energy intake does not result in an increase in energy expenditure through more physical activity. [16]

 

4. Long Term Benefit to Exercise?

While in the short term, exercise’s impact on weight loss appears bleak, it may be a different story when it comes to exercise and long-term weight loss.

A group of researchers [17] conducted a survey of 500 people to determine the characteristics of individuals who were able to maintain weight loss (maintainers) from individuals who had lost weight but regained it (regainers) and/or individuals with no history of weight loss (controls). At the time of the survey, the weight loss maintainers had maintained an average of 37.7 + 28.7 lbs. for 7.7 + 8.4 years. While all three groups had no differences in the frequency of moderate activity, those who were able to maintain weight loss engaged in significantly more strenuous activities than regainers. In fact, 52% of maintainers reported performing three or more strenuous exercise sessions over a seven-day week compared to only 32-36% of regainers and maintainers nearly doubled regainers in their total activity score.

 

Behavioral characteristics of weight-loss maintainers, weight-loss regainers, and controls
Weight-loss
maintainers
(n=69)
Weight-loss
regainers
(n=56)
Controls
(n=113)
Significance
Food Habits Quesitonnaire (mean±S)*
Avoid fat as a seasoning2.7±0.62.9±0.62.9±0.6NS
Modify meat preparation1.7±0.82.0±0.82.0±0.9‖p<0.03§
Avoid frying1.5±0.41.7±0.5†1.7±0.5†p<0.01
Substitute low-fat for high-fat2.4±0.92.9±0.8†2.8±0.9†p<0.001
Total summary score2.1±0.52.4±0.42.4±0.5p<0.001
Leisure Time Exercise Questionnaire (mean±S)
Number of mild activities/week2.9±2.72.3±3.32.2±2.3NS
Number of moderate activities/week1.4±2.30.9±1.50.9±1.7NS
Number of strenuous activities/week1.3±2.40.5±1.0†0.8±1.4¶p<0.02
Number of sweat episodes/week2.8±2.51.8±1.7¶1.9±2.4†p<0.03
Total activity score27.8±28.216.2±17.6†18.2±19.5†p<0.01
Hours of TV or VCR/week (mean±S)13.7±9.515.2±10.515.4±10.9NS
Weigh at least once a week: % (n)55.1 (38)35.7 (20)†34.5 (39)†p<0.02
Restraint Scale (mean±SD)
Concern about dieting8.2±3.67.9±3.75.0±2.9†‡p<0.001
Weight fluctuation8.3±3.08.0±3.14.7±2.6†‡p<0.001
Total Score16.7±5.516.1±5.39.7±4.1†‡p<0.001
* Scores positively correlate with dietary fat intake.
† Different from weight-loss maintainer with and without controlling for gender, ethnicity, and current BMI.
‡ Different from weight-loss regainer with and without controlling for gender, ethnicity, and current BMI.
§ Not significantly different from controlling for gender, ethnicity, and current BMI.
¶ Significantly different from weight-loss maintainer after controlling for gender, ethnicity, and current BMI.
NS, not significant
‖ Different from weight-loss maintainer without controlling for gender, ethnicity, and current BMI.

McGuire, M. T., Wing, R. R., Klem, M. L., & Hillf, J. O. (1999). Behavioral strategies of individuals who have maintained long‐term weight losses. Obesity research, 7(4), 334-341.

 
In addition, the largest study ever of individuals who were highly successful at long-term maintenance of weight loss conducted by the National Weight Control Registry (NWCR), found similar results. [18] The study included self-reported data from 655 female subjects and 155 male subjects who had lost greater than 30 lbs. and maintained the weight loss for at least 1 year. On average, subjects who were able to maintain weight loss expended 2827 + 2792 calories per week through exercise, which is the equivalent to walking 28.1 miles per week. Cycling (48.1%) was the most frequently reported medium-intensity activity and weight lifting (35.6%) was the most reported high-intensity activity.

While all of this sounds great, there is still a huge problem: Exercise adherence is absolutely terrible in the long term and the problem is not new.

Data from a 1986 study [19] shows that 42% of individuals assigned to the exercise intervention group reported no exercise after 18 months and the remaining 58% of individuals reported an average of a meager 46 minutes per week.

Another study [20] reported that 72% of individuals discontinued exercising after completing an initial 12-14 week protocol.

And finally, another study [21] reported 56-70% attendance at group exercise sessions during the first 6 months which subsequently dropped to 16-37% during months 6-12.

 

Summary

Let me be clear about the intention of this article: Exercise has many benefits, however, it is not a magical weight loss cure. Weight loss is complex and starting an exercise program doesn’t necessarily lead to weight loss, especially in the short term.

If your preferred method of weight loss is only exercise without any nutritional restrictions, you will reduce your chances of seeing significant body composition changes. Research shows that a weight loss strategy that combines exercise and diet will produce better results than exercise alone. [22]

In addition, exercise comes with compensatory changes to your body such as down regulation of the components of TDEE and for many, an increase in energy intake. There are many individual variables to consider when attempting to lose weight and each person will have some variation. Take precautionary steps such as a planned, structured exercise routines and a diet with a specific caloric intake in mind to ensure that you see the changes you are hoping to make. If the desired changes aren’t happening or aren’t happening as quickly as you like, because you have been tracking your exercise and nutrition you now have something to manipulate and experiment with to get different results.

While exercise in the long term clearly shows a positive relationship to sustained weight loss, it appears it is difficult for most people to keep up with the healthy habit, which is the point of exercise needing to be rebranded. If the message around exercise was more about the amazing health benefits exercise provides, rather than exercise being a way to lose weight, I believe more people would stick with an exercise program in the long run.

Be patient. Slow and steady, consistent exercise done intelligently and with purpose, week after week will lead to results.

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References

  1. National Center for Health Statistics. (2018, September 05). Retrieved May 21, 2019, from https://www.cdc.gov/nchs/data/hestat/obesity_adult_15_16/obesity_adult_15_16.htm
  2. “Gym, Health & Fitness Clubs in the US: Market Research Report.” Gym, Health & Fitness Clubs in the US Market Research | IBISWorld. IBIS World, Aug. 2017. Web.
  3. IBISWorld. “IBISWorld Industry Market Research: The U.S. Gym, Health & Fitness Clubs Industry Is Expected to Earn Revenue of $30.1 Billion in 2016.” PR Newswire: News Distribution, Targeting and Monitoring. IBIS World, 23 Nov. 2016. Web.
  4. Lee, S., Bacha, F., Hannon, T., Kuk, J. L., Boesch, C., & Arslanian, S. (2012). Effects of aerobic versus resistance exercise without caloric restriction on abdominal fat, intrahepatic lipid, and insulin sensitivity in obese adolescent boys: a randomized, controlled trial. Diabetes, 61(11), 2787-2795.
  5. Sanal, E., Ardic, F., & Kirac, S. (2013). Effects of aerobic or combined aerobic resistance exercise on body composition in overweight and obese adults: gender differences. A randomized intervention study. Eur J Phys Rehabil Med, 49(1), 1-11.
  6. Donnelly, J. E., Hill, J. O., Jacobsen, D. J., Potteiger, J., Sullivan, D. K., Johnson, S. L., … & Sharp, T. (2003). Effects of a 16-month randomized controlled exercise trial on body weight and composition in young, overweight men and women: the Midwest Exercise Trial. Archives of internal medicine, 163(11), 1343-1350.
  7. Garrow, J. S., & Summerbell, C. D. (1995). Meta-analysis: effect of exercise, with or without dieting, on the body composition of overweight subjects. European journal of clinical nutrition, 49(1), 1-10.
  8. Trexler, E. T., Smith-Ryan, A. E., & Norton, L. E. (2014). Metabolic adaptation to weight loss: implications for the athlete. Journal of the International Society of Sports Nutrition, 11(1), 7.
  9. Hoffman, J. (2006). Norms for fitness, performance, and health. Champaign, IL: Human Kinetics.
  10. King, N. A., Hopkins, M., Caudwell, P., Stubbs, R. J., & Blundell, J. E. (2008). Individual variability following 12 weeks of supervised exercise: identification and characterization of compensation for exercise-induced weight loss. International journal of obesity, 32(1), 177.
  11. Sonneville, K. R., & Gortmaker, S. L. (2008). Total energy intake, adolescent discretionary behaviors and the energy gap. International Journal of Obesity, 32(S6), S19.
  12. Thomas, D. M., Bouchard, C., Church, T., Slentz, C., Kraus, W. E., Redman, L. M., … & Heymsfield, S. B. (2012). Why do individuals not lose more weight from an exercise intervention at a defined dose? An energy balance analysis. Obesity Reviews, 13(10), 835-847.
  13. Church, T. S., Martin, C. K., Thompson, A. M., Earnest, C. P., Mikus, C. R., & Blair, S. N. (2009). Changes in weight, waist circumference and compensatory responses with different doses of exercise among sedentary, overweight postmenopausal women. PloS one, 4(2), e4515.
  14. Ross, R., & Janssen, I. A. N. (2001). Physical activity, total and regional obesity: dose-response considerations. Medicine & Science in Sports & Exercise, 33(6), S521-S527.
  15. Donnelly, J. E., & Smith, B. K. (2005). Is exercise effective for weight loss with ad libitum diet? Energy balance, compensation, and gender differences. Exercise and sport sciences reviews, 33(4), 169-174.
  16. Westerterp, K. R. (2010). Physical activity, food intake, and body weight regulation: insights from doubly labeled water studies. Nutrition reviews, 68(3), 148-154.
  17. McGuire, M. T., Wing, R. R., Klem, M. L., & Hillf, J. O. (1999). Behavioral strategies of individuals who have maintained long‐term weight losses. Obesity research, 7(4), 334-341.
  18. Klem, M. L., Wing, R. R., McGuire, M. T., Seagle, H. M., & Hill, J. O. (1997). A descriptive study of individuals successful at long-term maintenance of substantial weight loss. The American journal of clinical nutrition, 66(2), 239-246.
  19. Perri, M. G., McAdoo, W. G., McAllister, D. A., Lauer, J. B., & Yancey, D. Z. (1986). Enhancing the efficacy of behavior therapy for obesity: effects of aerobic exercise and a multicomponent maintenance program. Journal of Consulting and Clinical Psychology, 54(5), 670.
  20. Saris, W. H. (1990). Weight maintenance and resting metabolic rate 18-40 months after a diet/exercise treatment. International journal of obesity, 14(4), 347-359.
  21. Wing, R. R., Venditti, E., Jakicic, J. M., Polley, B. A., & Lang, W. (1998). Lifestyle intervention in overweight individuals with a family history of diabetes. Diabetes care, 21(3), 350-359.
  22. Miller, W. C., Koceja, D. M., & Hamilton, E. J. (1997). A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention. International journal of obesity, 21(10), 941.
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