Weight Cycling

National Task Force

the Prevention and Treatment of

Obesity
tio of attempts at weight loss, given cur rent scientific knowledge.
METHODS

Objective.\p=m-\Toaddress concerns about the effects of weight cycling and to provide guidance on the risk-to-benefit ratio of attempts at weight loss, given current scientific knowledge. Data Sources.\p=m-\Originalreports obtained through MEDLINE and psychological abstracts searches for 1966 through 1994 on weight cycling, "yo-yo dieting," and weight fluctuation, supplemented by a manual search of bibliographies. Study Selection.\p=m-\English-languagearticles that evaluated the effects of weight change or weight cycling on humans or animals. Data Extraction.\p=m-\Studieswere reviewed by experts in the fields of nutrition, obesity, and epidemiology to evaluate study design and the validity of the authors' conclusions based on published data. Data Synthesis.\p=m-\Themajority of studies do not support an adverse effect of weight cycling on metabolism. Many observational studies have shown an association between variation in body weight and increased morbidity and mortality. However, most of these studies did not examine intentional vs unintentional weight loss, nor were they designed to determine the effects of weight cycling in obese, as opposed to normal-weight, individuals. Conclusions.\p=m-\Thecurrently available evidence is not sufficiently compelling to override the potential benefits of moderate weight loss in significantly obese patients. Therefore, obese individuals should not allow concerns about hazards of weight cycling to deter them from efforts to control their body weight. Although conclusive data regarding long-term health effects of weight cycling are lacking, non\x=req-\ obese individuals should attempt to maintain a stable weight. Obese individuals who undertake weight loss efforts should be ready to commit to lifelong changes in their behavioral patterns, diet, and physical activity.
(JAMA. 1994;272:1196-1202)

Original reports through MEDLINE

weight fluctuation, supplemented by a manual search of bibliographies. Fortythree English-language articles that evaluated the effects of weight change or weight cycling on humans or animals
were
man

obtained were and psychological abstracts searches for 1966 through 1994 on weight cycling, yo-yo dieting, and

reviewed in

emphasized. Cited studies were reviewed by experts in the fields of nutrition, obesity, and epide miology to evaluate study design and the validity of the authors' conclusions based on the published data.
were

subjects

depth. Studies of hu

THE NATIONAL TASK FORCE ON THE PREVENTION AND TREATMENT OF OBESITY

WEIGHT CYCLING refers to the re peated loss and regain of weight. When weight cycling is caused by repeated attempts at weight loss, it is popularly known as " - dieting." Regrettably, with currently available dietary treat ments for obesity, many people who lose weight will later regain it. Repeated bouts of weight loss and regain are dis-

tressing both to patients and their caregivers, making the search for ways to prevent the development of obesity and for more effective means of long-term maintenance of utmost importance. Much attention has been focused by both the lay press12 and professional litera ture34 on possible physiological and psy chological hazards of weight cycling.

Members.\p=m-\RichardL. Atkinson, MD, University of Wisconsin, Madison; William H. Dietz, MD, PhD, Tufts University School of Medicine, Boston, Mass; John P. Foreyt, PhD, Baylor College of Medicine, Houston, Tex; Norma J. Goodwin, MD, HEALTH WATCH Information and Promotion Service, New York, NY; James O. Hill, PhD, University of Colorado, Denver; Jules Hirsch, MD, Rockefeller University, New York, NY; F.
Scientific

Pi-Sunyer, MD, St Luke's-Roosevelt Hospital Center, Columbia University, New York, NY; Roland L. Weinsier, MD, DrPH, University of Alabama, Birmingham; Rena Wing, PhD, University of Pittsburgh (Pa)
Xavier School of Medicine. National Institutes of Health, Staff Members.\p=m-\JayH. Hoofnagle, MD, James Everhart, MD, Van S. Hubbard, MD, PhD, and Susan Zelitch Yanovski, MD, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md.

From the National Task Force on the Prevention and Treatment of Obesity, National Institutes of Health, Bethesda, Md. Dr Hirsch is a consultant to the Hoffman\x=req-\ La Roche Company and a member of the board of directors of the Nutrasweet Company. Reprint requests to Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bldg 31, Room 9A23, Bethesda, MD 20892 (Susan Zelitch Yanovski, MD).

Standard texts of nutrition and dietet ics now present the detrimental effects of weight cycling as established fact.56 Some have suggested7 that remaining obese may be preferable to undergoing repeated failed attempts at permanently reducing body weight. The purpose of this article is to address concerns about the effects of weight cycling and to pro vide guidance on the risk-to-benefit ra-

Table 1.Definitions of
Author and Year

Weight Cycling
Obese
men

In Human Studies of Metabolic and

Psychological

Effects
Definition of

Population
and
women

Variables Measured*

Weight Cycling

Blackburn et al,201989

repeating a weight
program
Beeson et al,10 1989
Dale and
1989

loss

43 F

Weight change

Chart review of Individuals repeating a very low-calorie diet program, with regain of at least 20% of their weight loss during the interdiet period, which ranged from 68-2860 d Chart review of individuals repeating an 8-wk very low-calorie diet program 18 mo after similar previous diet Self-report of frequent dieting and at least two bouts of weight loss and regain of >10 kg
_

Obese

women

weight
van

loss program

repeating

4F

Weight change Weight change, RMR, FFM,

Obese
a

women

Saris,18

weight

loss program

undergoing

20 F

Wadden et

al,22

1992

Obese
a

women undergoing weight loss program

50 F

llpolysis Weight change, RMR, FFM,

Subjects

Melby etal,23

1991

Obese women undergoing a weight loss program

29 F
27 M

Weight change, RMR, WHR,

lifetime weight loss Self-reported history of weight loss/regain >18 kg

subdivided by fertiles based on self-reported number of diets resulting in weight loss >4.5 kg; "high cyclers" reported a mean of 7.8 diets and a 76-kg

Steen et al,24 1988

Melby et al,25
Manore

1990

Adolescent wrestlers and physically active

25 M

etal,301991

noncycllng controls Normal-weight women

23 F

RMR, FFM,

McCargar and

Crawford,271992

Collegiate wrestlers

14M

expenditure Diet records, RMR, FFM,

exercise energy

"Cyclers" reported "cutting weight" by >4.5 kg at least 10 times during the wrestling season; frequency of weight cutting reported as "often" or "always" "Cycling" wrestlers reported reducing weight by <4.5 kg at least 10 times per wrestling season during preceding 3 y "Cyclical dieters" reported intermittent caloric restriction for >7-10 d four times in preceding year, with no caloric restriction for >2 mo before testing "Cycling" wrestlers reported "often" or "always" dieting, "cutting weight" by at least 3 kg before competitions, and "cutting weight" more than six times per competitive
season

Schmidt et al,2 1993

Adolescent

cycling wrestlers, noncycling

24 M

RMR, FFM

physically active noncycling controls McCargar et al,281993

"Cyclers" reported a history of weight cycling during at least three previous wrestling seasons, verbally stated intentions to continue this pattern during forthcoming wrestling seasons, and at least 10 >4.5-kg cycles during the first year and at least five >4.5-kg cycles during the
second year

Light-weight
Obese

rowers

14 F

Diet records, RMR, FFM,

women

11 F

WHR, Glu, Ins BMR, FFM WHR, Glu, Ins

McCargar et al,81993

Normal-weight women

18F

Diet records, RMR, FFM,

Rodin et

al,34

1990

Normal-weight women

87 F

WHR

Holbrook et

al,5519

Jefferyetal,531992

Rancho Bernardo Cohort (men and women aged 50 y or older) Obese men and women

886 M 1114 F
101 M 101 F

Glu, OGTT
Diet records, FFM,

"Cyclers" reported history of >5-kg weight loss at least three times (once yearly from 3-6 y) before competition Three experimental cycles of 2 wk of very low-calorie diet followed by 4 wk of free diet throughout 18 wk Self-report of "often" or "always" dieting for a minimum of 10 y, dissatisfaction with weight, attempted weight loss >4 times during previous year, and loss and regain of 3-9 kg at least once yearly for 5 y Self-reported weight loss of >4.5 kg at least once, exclusive of weight loss associated with menstrual cycle, illness, or pregnancy; continuous "weight cycling index" based on frequency and amount of reported weight loss Self-reported weight change >4.5 kg between ages 40 and 60 y (both gain and loss)
Quartiles of

WHR, BP, TC, HDL-C, TG, Glu,

cycling based on self-reported weight history including number of previous weight cycles of >4.5 kg, total weight lost in prior weight loss attempts, and difference between highest and lowest weight as an
adult

Rebuff-Scrive et al,29 In press

Normal-weight and mildly

24 F

Diet records, RMR, FFM,

van

der

Kooy et al,38
al,31
1990

1993

Obese

men

and

women

17M

T/E, WHR, MRI, lipoprotein lipase, basal and stimulated lipolysis BP, TC, HDL-C, TG, Glu, Ins, OGTT FFM, WHR, MRI BMR, FFM, WHR, T/E, BP, TC, HDL-C, TG, OGTT Glu, hemoglobin A,c

"Cyclers" reported losing and regaining >4.5 kg 10 times or more since completion of puberty (exclusive of pregnancy), "often" or "always" dieting, and considered themselves "yo-yo dieters"
Regain
of >30% of initial weight loss 61-77 wk after weight loss treatment (average weight loss, 12.9 kg; average regain, 11.9 kg)

15F
Baltimore Longitudinal Study of Aging Men with
846 M

Lissner et

Schotteetal,541991

327 M

diabetes mellitus

non-insulin-dependent

Foreyt

et

al,33 in press

Normal-weight and obese

and women

255 M 242 F

Psychometric scales
Psychometric scales

Kuehnel and Wadden,60 1994

Obese women with and without binge-eating disorder

70 F

variability in body weight about the slope of weight over a mean of 13.7 y Chart review with cycling defined categorically (weight loss and regain or weight gain and reloss) based on changes from initial body weight of at least 10% followed by a weight within 10% of initial weight and defined continuously by coefficient of variation of body weight; body weight evaluated on at least four occasions over at least 1 y (range, 1-7.9 y) "Fluctuators" had self-reported history of "yo-yo" dieting on Brownell Weight Cycling Questionnaire (described in article) Subjects subdivided by fertiles based on lifetime number of self-reported diets; "high cyclers" reported five or more diets with mean lifetime loss of 75.5 kg

Intraindividual

*RMR indicates resting metabolic rate; BMR, basal metabolic rate; FFM, fat-free mass; MRI, visceral adipose tissue by magnetic resonance imaging; WHR, waist-to-hip ratio; T/E, ratio of trunk/extremity skinfold thickness; BP, blood pressure; TC, total cholesterol; HDL-C, high-density lipoprotein cholesterol; TG, triglycrides; Glu, serum or plasma glucose; Ins, serum or plasma insulin; and OGTT, oral glucose tolerance test.

Table 2.Definitions of
Author and Year

Weight Cycling

Used in

Population-Based Studies With Mortality as Outcome

Lissner et al,40 1991 Lissner et al,41 1

Population Framingham, Mass Gothenburg,

Outcomes Measured All-cause mortality, cardiovascular disease

Definition of

Weight Cycling

1268 F

cardiovascular disease, diabetes mellitus, and

morbidity and mortality mortality;

Hamm et

al,421989

Western Electric, Chicago, III

1959 M

All-cause, cardiovascular disease, and cancer

mortality
10529 M

Blair et

al,431993

MRFIT Cohort (men at high risk for CHD)* Charleston Heart

All-cause and cardiovascular

disease mortality
444 M 484 F 846 M All-cause

Stevens and Lissner,441990

Study

mortality

al,31

1990

Baltimore Longitudinal Study of Aging

All-cause, cardiovascular disease, and cancer mortality

examinations CV of body weight using recalled weight 5 y before first examination in women and measured weight at two intervals separated by 6 y; in men, three measures of weight were obtained at 4-y intervals Four weight-change groups, using recalled weights at 5-y intervals from age 20-40 y; men were included in "gain and loss" (weight cycling) group (n=98) when maximum gain during any one 5-y period and maximum loss during another 5-y period were each 10% or more Quartiles of intrapersonal SD of measured weight during 6-7 y period; categorical by type of change (cycle, with last change a loss and cycle, with last change a gain) CV of body weight using recalled weight at age 25 y and weight determined at two intervals 3 y apart Intraindividual variability in body weight about the slope of weight over a mean of 13.7 y

Coefficient of variation (CV) of body weight using recalled weight at age 25 y and weight through eight biennial

*MRFIT Indicates Multiple Risk Factor Intervention Trial; CHD, coronary heart disease.

DEFINING WEIGHT CYCLING Much of the confusion about the ef fects of weight cycling and the incon sistencies in the outcomes of studies at tempting to clarify its effects can be traced to the lack of a standardized defi nition for weight cycling. At its sim plest, the definition of a single weight cycle may seem intuitively obvious: a loss followed by a gain (or vice versa). However, the multiple factors involved in both the definition and measurement of weight cycling are formidable, par ticularly when the clinically important variables are not yet known. Such con fusion is reflected in the multiple defi nitions of weight cycling found in both cross-sectional and prospective studies seeking to determine metabolic and psy chological effects of weight cycling (Table 1) and in observational population-based studies with a primary goal of deter mining mortality (Table 2). Although the
term

"cycling" suggests a more regular pattern of weight change than the more general term "fluctuation," the two are
interchangeably. Providing a clinically relevant mea sure for weight cycling encompasses many components. How many cycles are
often used

involved? Is a loss followed by a gain similar in effect to a gain followed by a loss? What is the magnitude of weight change in each cycle? Are several small cycles more or less detrimental than one or two large cycles? What about the duration of each weight cycle? Is a loss that is maintained for 1 year and then regained of greater or less benefit than one that is only maintained for 6 months? Do any detrimental effects of weight cycling on health come about only years after the cycling occurs, or are adverse

caused by intentional weight change the same or different from a cycle that oc curs unintentionally? In which popula tions (if any) does cycling exert its del eterious effectsin women, in men, in normal-weight vs obese individuals, in ethnic minorities? Despite the numer ous studies of weight cycling available, these fundamental questions remain un answered. Even such basic information as the normal degree of weight fluctuation dur ing short periods in nonclinical popula tions is currently unknown. For example, among nine normal-weight women who were recruited as "noncyclers" for an observational study on the basis of selfreports of "rarely or never" dieting and stable weight within 2.3 kg during 5 years, four women experienced weight fluctuations of more than 2.3 kg once or twice during the course of three mea surements during 1 year.8 In a retro spective chart review of 332 overweight adults in a general medical population, Williamson and Levy9 found significant weight fluctuation. Of all subjects, 34% lost weight (mean, 5.3 kg; SD, 4.8 kg) and 66% gained weight (mean, 5.7 kg; SD, 4.8 kg) between two visits 1 to 5 years apart. Studies to determine the prevalence, magnitude, and frequency of weight fluctuation in the general popu lation are therefore needed. Cutter et al have recently critically analyzed the mul tiple issues involved in the definition of weight cycling and have proposed that the number of weight cycles be used as the primary measure, using an arbitrary minimal threshold (eg, 2.3 kg [5 lb]) as a cycle (G. R. Cutter et al, unpublished definition of weight cycling can be endorsed, and studies should attempt to measure multiple components of weight change with the aim of further

nents.

clarifying clinically important

compo

CONCERNS ABOUT WEIGHT CYCLING Most concerns about the adverse ef fects of weight cycling fall into three major areas: the effects on metabolism and weight loss, on morbidity and mor tality, and on psychological well-being.
Influence of Weight Cycling Metabolism There have been numerous studies that have examined the effects of re peated loss and regain of weight on me tabolism and body composition. In 1986, Brownell et al10 reported that weightcycled rats showed an increased food efficiency and that weight cycling made weight loss harder and weight regain easier. The authors hypothesized that animals may regain more body fat in relation to lean body mass during each weight cycle, leading to progressive in creases in body fat content relative to total weight. Reed and Hill11 critically reviewed the published literature on weight cycling in rodents and concluded that the existing data did not support the hypothesis that weight cycling pro moted obesity, increased body fat, or had permanent effects on metabolism. In fact, the majority of available data suggest that weight cycling in animals does not independently affect any pa rameter of energy balance (food intake, body composition, or energy expendi ture). For example, although it is com monly contended that weight cycling in animals reduces fat-free mass and increases body fat over time, most in vestigators have reported that weight cycling does not increase body fat or relative adiposity compared with con trols.1216 Although the few reports of
on

data, 1994). Currently, however,

no

single

effects more likely soon after the weight change occurs? Is the effect of a cycle

Table 3.Conclusions of Authors

Regarding

Metabolic Effects of

Weight Cycling

in Humans*

No Yes Claim of Weight Cycling weight loss harder_20_18, 19,22,23_ Increased total body fat_30_8,17, 18,22,24-27, 29,32,38 Increased central adiposity 8, 18,22-24,27-29,31,138,53 31,f34
Future

Increased visceral fat Lower energy Increased fat preference/intake

29,38
56

expenditure_24,30_8, 17, 18,22,23,25-29,31

Increased blood Increased total cholesterol, triglycrides, decreased high-density lipoprotein Increased Increased

pressure_./._23,24, 29, 31, 53_

fasting fasting plasma glucose Impaired glucose tolerance (oral glucose tolerance test or glycohemoglobin) Alterations In fat metabolism/lipoprotein Upase

23, 29, 31, 53 8,28,29 8, 28, 29, 53, 54

...

31, 55
...

29, 53, 54
18, 29

*The numbers in this table refer to references cited in the reference section. Ellipses indicate no applicable reference. tThis study found an increase in truncal obesity in cyclers, measured by skinfold thickness, but no increase in upper-body obesity measured by waist-to-hip ratio.

obese,182223 those of normal weight,829 or wrestlers who frequently cycle to "make weight."2426 Paradoxically, McCargar et al8 found that the percentage of body fat during three test periods 6 months apart was more stable in cycling than in noncycling normal-weight women. Because visceral adipose tissue depo sition is associated with a variety of ad verse health outcomes,33 the effect of weight cycling on visceral fat deposition is clinically relevant. In a cross-sectional study, Rodin et al34 found a higher waistto-hip ratio, often used as a surrogate marker for increased visceral fat depo sition, among "high" as compared with "low" weight-cycling women. However,
with

BMI, which is known to be correlated waist-to-hip ratio,35 was not ad equately controlled for in this study.
Lissner et al31 found
an

association be

adverse metabolic effects of weight cy cling have been widely quoted both in the lay press and scientific literature, Reed and Hill11 have described limita tions in many of these studies, including choice of control groups, paradigms for producing weight cycling, and effects of gender and aging. They concluded that most, if not all, claims of adverse effects due to weight cycling were not based on strong experimental evidence. The implication of reports of possible detrimental effects of weight cycling in animals prompted research on the prob lem in humans. These studies included small prospective trials that evaluated metabolic effects of weight loss in obese women,1718 as well as studies in persons repeating a weight loss program.1920 In one widely cited study,20 57 individuals repeating a very low-calorie diet pro gram had a significantly lower rate of weight loss during their second attempt. However, there was a great deal of in-

study makes it unclear whether cycling reduced the metabolic

duce their body weight. Other crosssectional and prospective studies have not found differences in energy efficiency between cyclers and noncyclers among athletes,25-28 nonobese women,829 or obese women18,22,23 when adjusted for differ ences in weight and/or lean body mass. Although Manore et al30 found that cy clical dieters had a lower energy expen diture (per kilogram of body weight) during exercise than weight-stable con trols, their weight-cycling subjects were both significantly heavier and fatter than

body weight variability and in creased ratio of subscapular-to-triceps skinfold thickness, suggesting that fluctuators might have greater increases in truncal adiposity. However, the absence of an increased waist-to-hip ratio sug gested that the truncal fat deposition they observed did not appear to favor upper vs lower body obesity. In a study of weight-cycling wrestlers,27 the fat lost during peak season was found to be pref erentially lost from the trunk compared with noncycling controls, although no differences existed between groups by
tween

controls, making appropriate compari

difficult. Lissner et al31 studied the

tersubject variability in time (68 to 2860 days) and in percentage of weight re gained (5% to 440%) between diets. In tervening factors, such as changes in body composition with age, make inter pretation of the results difficult. In ad dition, although the authors made at tempts to study only adherent patients, differences in compliance to the dietary regimen, particularly among outpatients,
may have been a factor in their findings. Smith and Wing21 found that subjects had significantly worse dietary adher ence when repeating a very low-calorie diet program. Furthermore, other studies have ber of previously

found no evidence that body weight fluc tuation was associated with depression in basal metabolic rate; in fact, individu als with the highest variability in body weight had the smallest decreases in metabolic rate over time, whether ad justed for body surface area or for lean

relationship between weight cycling and metabolic rate in 846 men participating in the Baltimore Study of Aging. They

reported weight loss cycles and the efficacy of weight loss.18,2223 Although one study showed that weight-cycling wrestlers had a lower resting metabolic rate than noncycling wrestlers,24 the cross-sectional

found no relationship between the num

body mass. In addition, neither body composition (percentage of fat vs nonfat tissue) nor body fat distribution appears to be ad versely affected by history of weight cycling in humans, independent of body mass index (BMI) (calculated by divid ing the weight in kilograms by the square of height in meters). Prentice et al32 found no detrimental effects on lean body mass as a result of "natural" annual weight cycling in a population of Gambian men. Prospective and cross-sectional studies have generally failed to find differences in body composition between weight cyclers and noncyclers among the

measured via magnetic resonance 14 cycling vs 14 noncycling nonobese and mildly obese women,29 no difference in visceral adipose tissue depo sition existed between groups, although subcutaneous adipose tissue deposition was slightly greater in cyclers. Similar results were observed in a prospective study of obese men and women who un derwent one cycle of weight loss and regain during the course of a year.38 In summary, the majority of studies did not find a higher prevalence of un favorable body fat distribution among weight cyclers, and there was no evi dence that weight cycling led to in creased visceral adipose tissue deposi tion. In a review of the literature on
was

off-season. Other studies81822"24,28 have found no difference in body fat distri bution between weight cyclers vs noncyclers. Anthropomtrie measures, such as skinfold measurements and body circumferences, do not differentiate between visceral and subcutaneous abdominal fat depots, in contrast with computed tomography and magnetic resonance imaging.3637 When visceral fat

imaging in

weight cycling in humans, Wing39 con

cluded that most studies showed no ad verse effects of weight cycling on body composition, resting metabolic rate, body fat distribution, or future successful

weight loss, and subsequently published

(Table 3).
Influence of
on

support this conclusion

Weight Cycling Morbidity and Mortality The potential effects of weight cycling on long-term morbidity and mortality are of greater concern. A number of large population-based observational studies

(Table 3). In a study of 202 obese men and women, Jeffery et al53 found no evi dence that a history of weight cycling worsened cardiovascular risk factors. Similarly, the majority of cross-sectional and prospective studies have not dem onstrated associations between weight cycling and increases in blood pressure,2324293153 fasting blood levels of glu
cose or

have shown increased risks of variations in body weight for all-cause and car diovascular mortality,40"43 whereas two smaller studies showed no such effect.31,44 In some of these studies, variation in weight appeared to be associated with increased mortality, even after control for coronary heart disease risk factors and preexisting disease that might in fluence weight.40,41 In addition to weight cycling, weight loss over time has been found to be associated with increased mortality, even when care has been taken to exclude for smoking and preexisting

tolerance measured by oral glucose tol

insulin,8282953'64 impaired glucose

glycohemoglobin,29'53'54 dyslipidemias23'293153 or alterations in fat me tabolism including fat cell size,29 basal or stimulated lipolysis,1829 and lipoprotein lipase activity.29 Schotte et al54 found no association between weight cycling and glycmie control in 327 men with noninsulin-dependent diabetes mellitus, al though differences in the need for hy poglycmie medications may have ob

illness.4547

These observational studies, however, have several limitations. Only one of these studies attempted to distinguish intentional from unintentional weight loss. In that study,41 a history of volun tary dieting, although associated with a higher coefficient of variation of body weight, did not predict mortality. None of these studies controlled for variabil ity in body composition and fat distri bution, which are known to influence both morbidity and mortality.48,49 In ad dition, the myriad ways in which weight cycling was defined in these studies makes between-study comparisons dif ficult. For example, use of the coeffi cient of variation of weight may not be the best means to determine cycling, because this measure is more sensitive to single large changes in weight, rather than frequent small changes.39 As pre viously discussed, it is unknown if dif ferences in frequency of weight cycling or amount of weight change per cycle influences outcome. Other potential causes of weight change, such as de pression, which significantly affects weight change during long-term followup,50 have rarely been assessed. In fact,

general psychological well-being appears to be associated with weight stability rather than weight gain or loss,51 al though assumptions cannot be made about causality. Finally, mechanisms by which weight cycling might affect mortality in humans remain unexplained. Although studies of changes in cardiovascular risk factors in animals with weight cycling have yielded inconsistent results,11,52 human

studies have not demonstrated any mechanism by which weight cycling in creases risk of cardiovascular disease

scured differences in metabolic control. Holbrook and colleagues,55 in a study of older adults, found that both self-re ported weight gain and weight fluctua tion between ages 40 and 60 years were associated with an elevated relative risk (RR) for diabetes mellitus, as evaluated by oral glucose tolerance test. However, a history of dieting to control weight during this time was not associated with increased risk for diabetes. One study did find an association between body weight variability and decreased glu cose tolerance after an oral glucose tol erance test,31 but the magnitude of the increase in plasma glucose (1 mg/dL [0.05 mmol/L] for every 1-kg deviation about the slope) was only about half the size of the effect of 1-kg weight gain per year on glucose tolerance. Although concerns have been raised about the possibility of weight cycling leading to increased fat consumption, the majority of studies in humans have not shown an association between weight cycling and fat prefer ence or fat consumption.827305456 The majority of subjects in populationbased observational studies were either nonobese or only mildly obese (BMI <30). If weight cycling has deleterious effects on health, such effects may be limited to those who are not obese. Blair and as sociates,43 in an analysis of data from the Multiple Risk Factor Intervention Trial, found that the increased mortality as sociated with body weight variability was limited primarily to men in the low est tertile for BMI (<26.08). Similarly, in a study that examined the effects of weight loss on morbidity and mortality, Pamuk and colleagues45 found that the increase in RR for mortality with weight loss was primarily limited to those in the bottom two fertiles for weight (BMI <29). Among women in the top tertile for weight, all-cause mortality was el evated only among those losing more

than 15% of their total body weight. Among men, RR for death was not in creased with any degree of weight loss. Moderate weight loss (5% to 14% of ini tial body weight) was actually associ ated with reduced cardiovascular mor tality among men in the highest tertile for weight. In addition, the proportion of individuals reporting intentional weight loss is greater in obese than in lean individuals.57 Therefore, weight cy cling and weight loss may have both differing causes and effects in obese and nonobese individuals, and caution should be taken in applying the findings of popu lation-based studies to obese patients. The National Institutes of Health Tech nology Assessment Conference state ment on methods for voluntary weight loss and control58 advised that the data on long-term adverse health conse quences of weight cycling, while pro vocative, were not sufficiently conclu sive to dictate clinical practice. This rec ommendation appears to be appropriate until better data become available.

Psychological Effects Weight Cycling Repeated failed attempts at perma nent weight loss are obviously distress ing. Anecdotes abound regarding the negative effects of such failures on mood and self-esteem. Unfortunately, few
of

well-controlled studies have assessed the impact of weight cycling on psychologi cal functioning. Those that have are gen erally cross-sectional and cannot distin guish between negative effects of weight cycling and preexisting psychological factors that may predispose individuals
to repeatedly lose and regain weight.59,60

the

Currently, scientifically valid data on psychological effects of weight cy cling are not available. Determination of the psychological impact of weight cycling requires further study.

HEALTH RISKS OF OBESITY In contrast to weight cycling, obesity is associated with increased risks of mor bidity and mortality. Furthermore, the biological bases ofthe increased risk have been well described. Both cross-sectional and cohort studies have shown strong associations between obesity and hyperlipidemia, hypertension, and hyperinsulinemia, leading to an increased preva lence of coronary artery disease and noninsulin-dependent diabetes mellitus.6163 Studies have also clearly documented the amelioration ofthese conditions with modest weight loss.64,65 Certain types of apnea, gout, and gallbladder disease are also more prevalent with increasing obe sity.66,67 The economic cost attributable to obesity-related illness has been esticancer, degenerativejoint disease, sleep

mated to exceed $39 billion yearly.68 The elevations in RR for these conditions are particularly striking in younger adults.66 One study found that the pres ence of obesity in adolescent males was associated with increased mortality as long as 50 years later, independent of adult weight.69 Not all individuals with a given weight or degree of obesity have the same risk for medical complications.
amount and location of excess body fat, family history, and the presence of risk

in fatty acid profile of various tissues7273) would be useful. The roles of physical activity, smoking, stress, and alcohol in take in creating weight cycles also de
serve

1988;12:579-583. 10. Brownell KD, Greenwood MRC, Stellar E, Shrager EE. The effects of repeated cycles of weight loss and regain in rats. Physiol Behav. 1986;38:459\x=req-\

further

study.3974

CONCLUSIONS
we conclude the There is no

Based on the currently available data,

Prognostic factors, including gender,

that

factors such as hyperlipidemia, play a role in determining an individual's risk of obesity-related conditions. Evaluation of such risk should determine whether weight loss treatment is medically nec essary, as well as the type and intensity of any intervention.67,70 RECOMMENDATIONS FOR FUTURE STUDIES ON WEIGHT CYCLING Unfortunately, designing studies to correct for the deficiencies identified in this article is exceedingly difficult. For example, even if the issue of voluntary weight loss were to be addressed, not all confounding variables could be ad equately controlled. With 40% of all women and 25% of all men in the United States reporting attempts to lose weight at a single point in time,57 who are the individuals who actually change their weight? Those who consider themselves "chronic" dieters or always on a diet are not necessarily those who lose weight.71

weight cycling in humans has ad effects on body composition, en ergy expenditure, risk factors for car
verse

following: convincing evidence

464. 11. Reed GW, Hill JO. Weight cycling: a critical review of the animal literature. Obes Res. 1993;1: 392-402. 12. Bell RR, McGill TJ. Body composition in mice maintained with cyclic periods of food restriction

Unsuspected illness, psychological dys function, or deterioration in a known

medical condition may contribute to weight change, even in those already attempting weight loss. A randomized, controlled long-term trial of weight loss
or

diovascular disease, or the effectiveness of future efforts at weight loss. The currently available evidence regarding increased morbidity and mor tality with variation in body weight is not sufficiently compelling to override the potential benefits ofmoderate weight loss in significantly obese patients. Therefore, obese individuals should not allow concerns about hazards of weight cycling to deter them from efforts to control their body weight. Determination of the psychologi cal impact of weight cycling requires further investigation. Individuals who are not obese and who have no risk factors for obesityrelated illness should not undertake weight loss efforts, but should focus on the prevention of weight gain by increas ing physical activity and consuming a healthful diet as recommended by the Dietary Guidelines for Americans.,75 Although conclusive data regard ing long-term health effects of weight cycling are lacking, obese individuals who undertake weight loss efforts should be ready to commit to lifelong changes in their behavioral patterns, diet, and

and refeeding. Nutr Res. 1987;7:173-182. 13. Graham B, Chang S, Lin D, Yakubu F, Hill JO. The effects of weight cycling on susceptibility to dietary obesity. Am J Physiol. 1990;259:R1096\x=req-\ R1102. 14. Gray DS, Fisler JS, Bray GA. Effects of repeated weight loss and regain on body composition in obese rats. Am J Clin Nutr. 1988;47:393-399. 15. Hill JO, Thacker S, Newby D, Nickel M, DiGirolamo M. A comparison of constant feeding with bouts of fasting-refeeding at three levels of nutrition in the rat. Int J Obes. 1987;11:201-212. 16. Hill JO, Thacker S, Newby D, Sykes MN, DiGirolamo M. Influence of food restriction coupled with weight cycling on carcass energy restoration during ad-libitum refeeding. Int J Obes. 1988;12: 547-555. 17. Jebb SA, Goldberg GR, Coward WA, Murgatroyd PR, Prentice AM. Effects of weight cycling caused by intermittent dieting on metabolic rate and body composition in obese women. Int J Obes.

1991;15:367-374. 18. van Dale D, Saris WHM. Repetitive weight loss and weight regain: effects on weight reduction, resting metabolic rate, and lipolytic activity before and

after exercise and/or diet treatment. Am J Clin Nutr. 1989;49:409-416. 19. Beeson V, Ray C, Coxon RA, Kreitzman S. The myth of the yo-yo: consistent rate of weight loss with successive dieting by VLCD. Int J Obes. 1989;
20. Blackburn

13(suppl 2):135-139. GL, Wilson GT, Kanders BS, et al. Weight cycling: the experience of human dieters. Am J Clin Nutr. 1989;49:1105-1109. 21. Smith DE, Wing RR. Diminished weight loss and behavioral compliance during repeated diets. Health Psychol. 1991;10:378-383. 22. Wadden TA, Bartlett S, Letizia KA, et al. Relationship of dieting history to resting metabolic rate, body composition, eating behavior, and subsequent weight loss. Am J Clin Nutr. 1992;56:2065\x=req-\

pensive. Thus, innovative approaches to the use of available databases and smallscale clinical studies are needed to de termine answers to this important but difficult question. Descriptive, population-based studies to determine the natural history of weight fluctuation and patterns of weight change in the general population may help to better define the normative level of weight fluctuation and aid the development of a clinically useful defi nition of weight cycling. Studies exam ining health risks of weight cycling in obese populations are also needed, par ticularly because there is some evidence that any adverse effects of weight cy cling may be blunted in those at the greatest medical risk for obesity. Ani mal and human studies that might elu cidate putative mechanisms for adverse effects of weight cycling (such as change

weight cycling vs weight stability or gain would be extraordinarily complex in design, as well as prohibitively ex

physical activity.
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The authors thank David F. Williamson, PhD, for thoughtful review of the manuscript.

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