Him ORIGINAL CONTRIBUTION Prevalence of Attempting Weight Loss and Strategies for Controlling Weight Mary K. Serdula, MD, MPH AIH, Mokdad, PhD David EW Deborah A. Galuska, P = M. Mendlein, PhD, MPH Se, MPH Gregory W. Heath, EIGHT LOSS IS AN IM portant concern for the US population Consumers spend $33 billion annually for weight loss prod- ucts and services.! Despite these expenditures, overweight and obesity have been increasing in the United States.*? Although long-term weight loss is difficult to achieve, research suggests that changes in both dict and physical activity are important to long-term success." For losing weight, both the US Department of Agriculture's Dietary Guidelines and the National Heart, Lung, and Blood Institute's Clinical Guidelines recom mend decreasing calorie intake and increasing physical activity.*” Both guidelines recommend at least 30 minutes oF more of moderate physi- cal activity om all or most days of the week forall Americans We used data from the 1996 state- based Bchavioral Risk Factor Surveil lance System (BRFSS) to examine the following: (1) the prevalence of trying to lose oF maintain weight and factors associated with those attempts, 2) what ‘weight control strategies persons re- port using in regard to diet and physi- éal activity, and (3) what persons who are trying lo control their weight re- port they weigh and what they would ike to weigh ‘Context Overweight and obesity are increasing in the United States. Changes in diet and physical activity are important for weight control. ‘Objectives To examine the prevalence of attempting to lose or to maintain weight and to describe weight control strategies among US adults. Design The Behavioral Risk Factor Surveillance System, a random-cigit telephone survey conducted in 1996 by state health departments. ‘Setting The 49 states (and the District of Columbia) that participated in the survey. ticipants Adults aged 18 years and older (N=107 804) ‘Main Outcome Measures Reported current weights and goal weights, prevalence ‘of weight loss or maintenance attempts, and strategies used to control weight (eating fewer calories, eating less fat, or using physical activity) by population subgroup. Results The prevalence of attempting to lose and maintain weight was 28.8% and 35.1% among men and 43.6% and 34.4% among women, respectively. Among those ‘attempting to lose weight, a common strategy was to consume les fat but nat fewer ‘alories (4.9% of men and 40.0% of women); only 21.5% of men and 19.4% of ‘women reported using the recommended combination of eating fewer calories and ‘engaging in at least 130 minutes of leisure-time physical activity per week. Among men trying to lose weight, the median weight was 90.4 kg with a goal weight of 81.4, kg, Among women, the median weight was 70.3 kg with a goal weight of 59.0 kg, Conclusions Weight loss nd weight maintenance are common concerns for US men ‘and women. Mast persons trying to lose weight are not using the recommended com- bination of reducing calorie intake and engaging in leisure-time physical activity 150 minutes or more per week. {ANA 1999;282 1383-1355 ama com METHODS {ewer calories or less fat to lose weight The BRFSS is a random-digit tele- (or keep {rom gaining weigh)?” and phone survey conducted by state health (2) “Are you using physical activity or departments. Each state selects an in- exercise to lose weight (or keep {rom dependent probability sample of resi-_ gaining weight)?” Attheend of theinter- dents 18 years of age) based on view respondents were asked lo report random-digit dialing methods. Repre- both their height and weight without scnlativesamples from 49 tatesand the shoes. Immediately alterthe question on District of Columbia are then pooled." self-reported weight, respondents were [Addcialed description of survey meth- cds s available elsewhere.” ‘Autor tons: Dvsonsof ution aa Phys Respondents were asked, “Are you fl Actwty (Or Serdua Molaad Calis, tnd now tying to lose weight?” Those who Mende Dae Tandaton ian ang sald “no" wereasked, “Areyou now ity- Center fr Chane Disa Pevenbon and ro ing to mainiain your weight, that, to Sb Gro Bene Cont nein keep from gaining weight?” Only those Corespnding Author and Rept: Mary K Ser respondents who answered “yes” 10 Slat Bethan any coher question were asked the follow. flv, Cvene Dass uton Bh Ceres ing questions: (1) “Areyoutryingto cat Matsop 26 Afni, Gh 03413717 (©1900 American Medial Association. All rights reserved, JAMA, Ccser 13, 1993_ol 282, No.4 1353 Downloaded From: on 11/21/2017WEIGHT LOSS AND WEIGHT CONTROL asked about their goal weight: “How ‘much would youike to weigh?” Weecal- culated actual and goal body'mass index (BMI as weight (in kilograms) divided by height (in meters squared) and grouped respondents into the follow- ing categories: normal weight, BMI of less than 25.0; overweight, BMI of 25.0 toless than 30.0; and obese, BMI of 30.0 Participants were asked about the type, duration, and frequency of the 2 leisure-time physical activities they had participated in most frequently during the preceding month. The categories (<150 minutes per week and ‘utes per week) were based on national {guidelines of at least 30 minutes or more of physical activity on most or all days of the week.*? Because we did not have information on total minutes of physi- cal activity per day, we defined our eat- cegories based on the average weekly physical activity in the last month, 150min- In 1996, 49 states and the District of Columbia participated in the BRESS and asked all weight control questions (= 118 265). We excluded the follow- ing persons fromall analyses: women who were pregnant or thought they might be pregnant (1 =1756); and persons who did notreportsociodemographicorsmok- inginformation (n= 1585),whether they were tying to lose or maintain weight (n= 1644), or their weight, height, orgoal weight (n=5476). In ouranalyses ofspe- cific weight control practices, weexcluded persons whodid not report such practices (n= 1334) orleisure-time physical activ- lty (n= 1767). Themedian state coopera donate (the number of completed inter- views divided by the number of com- pleted, refused, and terminated interviews) was 77.9% (range, 54.1%-04 49). To identify variables associated with Laying to lose or maintain weight, we used separate multiple logistic regressions to estimate the prevalence odds ratios for trying to lose weight vs doing nothing (Ge, neither trying to lose nor maintain \weight) and for uying to maintain weight vsdoing nothing. The independent vari- ables in the model were age, education, race or ethnicity, smoking, and BML To account for the complex sampling de- sign and to report weighted findings, SUDAAN was tsed."” RESULTS About half the respondents were men (40.6%). The majority were white (79.0%); 10.1% were African Ameri- can and 6.0% were Hispanic. Slightly ‘more than half (53.2%) had atleast some college edueation and about one fifth (23.79%) were 60 years of ageand older. The reported prevalence of trying 10 lose weightwas 28.8% for men and 43.6% for women, Women hada higher preva- lence of trying to lose weight than did ‘men within every sociodemographicand ‘weight category (TABLE 1). Amongboth ‘Table 1. Prevalence of Weight Cont Statue By Sex and Selacted Charaterstcs Ten Women Tryingto Lose Trying to Maintain TToing te Lose Trying to Maintain Wott, te Weightse Neither, % "Weight, te Weight, Neither, Characteristics (m=19046) (n= 15786) is) n=20179) n= 2048) ora 2 3 Be ae Faay ibzo a4 aa. 268 a0 Wa a Be a 38 5 as a zo ar ao oon Ee ae Ee 70 2 Ez EE Face oratmcly aa 229 250 220 Bea ae aa Be 22. span BE as 32 72a her uD ao at 2a) Eaten es than high school 218 an. 207 Fgh schoat 30 Bar Br ‘Smo colege o Tocca soroaT Ea aS, aa Colege graduate wz az ma Sroung Never 205. ara 434 260 206. Former Be 3a as wa Toa Carant 2a Ba a ao 22. Bay mae ax EA Neal 86 204 52 aa aa 220 eerwaght 7. "a 2s. 3, 758 Tae Toase eat Ts Tat Tat ra] 12a 1254 JAMA, Oxtober 13,1992 Downloaded From: on 11/21/2017 (©1900 American Medical Association, All rights reserved,sexes, trying to lose weight varied by so- ciodemographic categories, butwas most strongly associated with BMI (TABLE 2), However, among women, 28.7%of those with normal BM reported trying to lose weight. Among men, the adjusted odds oftryingtolose weight vsdoing nothing were similar across most age groups; however, theodds wereabout 20% higher for those aged 40 t0 49 years and 30% lower for those aged 70 yeats and older compared with those aged 180 29 years. Amongwomen, theodds oftyingtolose weight decreased withage. Among both sexes, the odds of trying o lose vsdoing nothing about weight increased with edu- calionand were about 4% loweramong current smokers and 30% higheramong {ormersmokers than neversmokers. The odds of trying to lose weight were lower among blacks than among whites. Trying to maintain weight was reported by 35.1% of men and 34.4% of women. In contrast to trying to lose ‘weight, the prevalence of tying to main- tain weight was inversely associated with BMI category (Table 1). However,among men, theadjusted odds of eying to main- lain vsdoing nothing about weight were 90% to 70% higher among the over weight and obese subjects than among those with normal weight (Table 2). Among both sexes, the odds of wying to maintain vsdoing nothing about weight increased with education and were 30% to 40% lower among current smokers thanamong neversmokers, Amongmen, the odds of trying to maintain weight vs doing nothing about weight were 20% to 25% higher among those aged 30 to 69 years compared with those aged 18 to 29 years, Among women, the odds of toying to maintain weight decreased ater the age of 50 years. The odds of trying tomiaintain weight were about 20% lower amongblack women, L%higher among black men, and 20% higher among His- panic men than among whites, Among both sexes trying to lose , about 00% reported modifying WEIGHT LOSS AND WEIGHT CONTROL their diet, common strategy amongall subgroups examined (TABLE 3). Among both sexes, about half reported consum- ing fewer calories (with or without less fa); 34.0% of men and 40.0% of women reported consuming less fat only (data not shown). Although two thirds re- ported using physical activity, only 42.3% of men and 36.8% of women re- ported engaging in 150 minutes or more of leisure-time physical activity per week (data not shown). Using physical activ- fay asa strategy to lose weight decreased with age and BMI and increased with cedication level, The combination of any diet modification and exercising 150 minutes or more per week were Fe- ported by 36.7% of men and 34.2% of ‘women (data not shown). The combi- nation of eating fewer calories (with or ithout less fat) and exercising 150 min- ‘utes oF more per week was reported by 21.5% of men and 19.4% of women, ‘Among persons trying to maintain weight, ahout 60% of men and 70% of ‘Table 2. Multple Logistic Regresion Estimates of Odds Ratios (ORs) ana 95% Confidence Intervals (CIs) Assodatea WIR TAME To Lose lor iaintsin Weight Compared With Not Doing Either Tem Wonen Characteristics “Ting to Lose Weight Trying to Maintain Weight_‘Tiying to Lose Weight _ Trying to Maintain Weight id oo 1.00 fetes 4.00 erent 4.00 erent 1.00 feterence) 039 TOT OSE 128 (0-134) 095 087-10 2.98 90-7067 a TZ (TOT) 125 (1638) 094 086-100 TOT 095.1) 039 TTT O98 2H 128 1ST) T7O/O8EO7H O86 07035) wo 705 0951 79 TAT IOT SEY 04a OAT. ‘OTe OTT OBS 7 Des weo-O7EY Tos ET TIE OIOA 55 BOOBY ae 1.0 etree 4.0 (eres) 1.0 erence) Baa Dex o7e-0947 Tazo PETES Dato TeDoIT span TEBE 118 (108-139) 713 090-125) a2 0.90516 Oe 136 (11ST 8H 100 086-1 1) TBs 056075) 2.5 S507) Fcaton tess than hgh school 1.0 rete 4.0 (eres 1.0 erence) Fighectoo PEATORIEES] F200 10134) ETSI Ta TST Some colege ortedvical sched T5413 132 (1 2O-T aay 198 (0721 THB SETA Colege graduate Zi: 182 (155200) Tae 7eZ TH one 1.0 etree 4.0 (eres) 4.0 (erence) 1.0 erence) Famer Taira ay ToT O96-105p 120 Tap D9 Oae-TO5y arent DES OELOEE 785 0570. TEs O5F07 2 Ose-DBB) Boa ase do A Neral 1.0 etree 4.0 (eres) 4.0 (erence) 1.0 erro) Drewes 76 (7078.15) TTT TST BO) Bia Ga7SSI TIES] eee ESA 156 TAT 778 650-72) 99 90-108) (©1900 American Medical Association, All rights reserved, Downloaded From: on 11/21/2017 JAMA, October 13, 1993_Vol 262, No. 4 1355WEIGHT LOSS AND WEIGHT CONTROL ‘Table 3. Prevalence of Spectic Weight Contal Practices by Sex and Selecied Chatactefsbes Among Persons THINS ToLose cor Maintain Weight” Ten Wonen Exercising Exercising 150 mini and 150 miniwi and Characteristics Diet Physical Activity __“FewerGaoris_Diet__ Physical Actty Fewer Gales Persons Teng fo Lose Weight Overt 258 wo 215 s22 194 *iboo 842 728 200 s08 m5, 208 3039 555 708 208 22 205 ao 27. 0 213 3a ia 5059 eB. 09 Bia sat ig wo sre al 20 730 1a 70 25.1 a7 216 305 156 Face ocataaly hte. 268 e6 226 se 204 Bik 65.1 3 73 ona 785 Fepanie B19 wo iB 22. 153 Ore 39 0 181 ee ia ERicaton te than hgh school 223 146 232 262 mm Hah ez 86 193 525 630 a0 Some college orTedica schoo) 680 212 333 03 ia Cologe graduate eB 257 525 Tae 235) Never 282 220 soa 676 198 Famer B59 228 waa 5. 203 arent Bie Ta on 60.0 72 oy mse ox BATE rma 830 23 ou 222 rerwoght 555 219 27 Bis Tat eee 875 205 we 355 156 Persons Teng to Maintain WaahTS Overt 208 20 130 708 aad 100 Fibco 499 610 113 650 23 10 5039 582 56.4 20 Ey 5a 3a ao Bi Bia 137 733 aoa Toa 5059 eit 26.1 1a 7a a5 Ta wo et w. a7 7a 350 as 70 B18 350. 15: ws 286 as Face ocataaly hte. soa 129 nA 207 102 Bik 610 ee 122 a7 338 oa pani ST Si Ta ere ais 7S: tne ei 03 155 686 72, Eines te than hgh school 540 86 652 12 Hah ez 55. Ta 705) a Some colegsotedvical school 60.8 iad 718 Toa Colege graduate Bia 15S 725 Ts Never eoa 132 720 506 102 Famer eat Tao 735. a8 108 arent 53. Ts B50. a5 a7 oy mse ETE oral 646 120 e08 530 107 eerie ead ia 736 386 a7 eee 6 Tt 76S za er 1856 JAMA, Oxtter 13, 1999_Vol 22, No. 1©1900 American Medical Association, A rights reserved. Downloaded From: on 1 nuiwomen reported modilying their diet (Table 3). Among both sexes, slightly ‘more than one fourth reported eating {ewer calories (with or without less ft) 31.7% of men and 42.6% of women te ported consuming less fat only (data not shown). About half reported using physical activity asa strategy; 46.0% of ‘men and 35.6% of women reported ex- cercising 150 minutes or more per week (data not shown). Using physical ac- tivity asa strategy decreased with age and BMI and increased with educa- tion. Any diet modification and engag- {ng in 150 minutes or more of leisure- time physical activity per week were reported by 28.6% of men and 26.0% of women (data not shown). Eating fewer ealories and exercising 150 min- tutes of more per week were reported by 13.0% of men and 10.0% of women, ‘Among men trying to lose, the me- dian reported weight was 90.4 kg and the goal weight was 81.4 kg with ame- dian difference of 8.6 kg (9% of cur- rent body weight) (TABLE 4). Among women, the median current weight was 70.3 kg and the goal weight was 59.0 kg, with a median difference of 8.0 kg (13% of current body weight). "Among persons trying to lose both the median current BMI and goal BMI were higher for men than for women. More than half of men trying to lose were currently overweight, and cone third were obese, Among women tying to lose, slightly more than one third were currently normal weight, slightly more than one third were over- weight, and about one fourth were obese. Among men, 379% had a goal BML {n the normal weight range compared with 82% among women, Among per- sons trying to maintain weight, the me- dian eurrent weight was 80.6 k for men and o1.0kg for women. The median dif- ference between current weight and goal weight was 0 kg for men and 1.8 kg for women (3% of current body weight). Among those trying to main- tain weight, both the median current BML and goal BMI were higher for men than women. Among men, 52% had a goal weight in the normal weight eat- egory, whereas 87% of women did so. COMMENT ‘Our survey showed that more than wo thirds of US adults are trying to lose oF maintain weight. Only’ fith of those tuying to lose weight reported using a ‘combination of eating fewer caloriesaind ‘engaging in 150 minutes or more of le- sure-time physteal activity each week. Thus, although most Americansreported using diet, physical activity, or both for weight loss, only a minority were using the recommended combination." Whether this disparity reflects lack of knowledge about weight control meth- ‘ods or an inability to implement these methods effectively, or both, cannot be answered with the BRESS study. The prevalence of attempted weight loss in the 1996 BRFSS—20% among menand 44% among womet what higher than that previously re- ported. Both the 189 BRFSSand 1990, National Health Interview Survey found that 23% of men and 40% of women re- ported trying tolose weight." Thisin- ‘erease may reflect the secular increase WEIGHT LOSS AND WEIGHT CONTROL {in obesity in the population.*? The Na- ‘ional Health Interview Survey found that among those trying t lose weight, 76% ‘omen and 82%6 of women reported they ‘were“eatingles,"and about 60% ofboth sexes reported increasing physical ac- Livity, In the Weight Loss Practices Sur- vey, nationally representative survey of persons trying to lose weight, 81% of men and 87% of women reported “eat- ingdilferently"and78%ofmenand 8% fof women reported using exercise.” Thus, these national surveys generally support our findings that most persons try to lose weight by eating less and ex- cercising more. Weound strong sexdifferencesin the prevalence of tying tolose weight; how- ever, we did not find differences in ‘weight loss strategies. Women report try- {ng to lose weight at a lower BML than men; in fact, about 30% of normal weight women reported trying to lose weight The distribution of ying to lose weight seemed to move up a level in women with 60% of overweight women trying ‘Table 4. Distibution of Curent and Goal Weight and Body Mass Index (SMI) by Sex and Weight Control status Tien Wer Toingte Tringto "Tinga ‘Thingto Lose Weight Maintain Weight Lose Weight Maintain Weight (= tg0de) "fas t5780) "n= 20 179) 488) coat Mein weight ky soa 703 610. itecan BM kgm 255 ‘Corent eM 119 at ra 35 Toe za 250 ai =r Median weight ky aia 500 536. iter BM ka Zar Zs 26 aaa Normal aight 268 sea 820 a2 Srerwsight SE a 760 Ta Obes 20 1 aan afer balnea aa Te cuenta goa waghts Difrencs fra between ‘rent and goa Weights, % 3 coxa eae 608 22 oz az a (©1900 American Medical Association, All rights reserved, Downloaded From: on 11/21/2017 JAMA, October 13, 1993_Vol 262, No. 41387WEIGHT LOSS AND WEIGHT CONTROL to lose, whereas this level was reached only i obese men. Among those tying to lose weight, women were about 2 times more likely than men to report a goal weight in the normal range. We speculate that this greater concern among women may reflect increased socictal pressure toward thinness Despite these sex differences, men and ‘women were equally likely to report eat- ing fewer calories and exercising 150 oF more minutes per week, Because Women, especially overweight women, are more Likely than men to underreport their weight, atleast some ofthe diferences fn sex-specific patlerns of atlempted ‘weight ossby BMI may beexplained by dlfercotial misclassfication of BMI." "Among persons trying to lose weight, cating less fat was a common strategy however, reduction of fat intake is not anelfcctive strategy unless calories are also reduced. It is unclear whether reducing fat without intentional re- duction in calories will, in most cases, ultimately lead to reduced caloric in. take, Allred" has hypothesized that an overemphasis on consumption af low fat foods may have contbuted to an increase in tolal energy intake in the United States. Weight-conscious per sons may restrict calories from high- fat foods only to eat as many or more calories from lower-fat foods." Regular physical activity is a key fac- torinsuccessful weight lossand long-term, ‘weight maintenance." Inourstudy, 10 thirds of personsreported using physical activity asa means of weight loss; how- ever, only 40% reported exercising 150 minutes or more per week, the minimal level ofphysical activity recommended in national guidelines for all Americans.°7 Ofparticularconcern wasthe finding that using physical activity asa method tolose ‘weight was least common among the ‘obese, the least educated, and the oldest. This suggests a need for better comm nication by health care professionals to facilitate the adoption of physical activ ity for weight control, especially among these groups. study of overweight wom ‘enshows that prescribing muliple short boutsofexercise may improveadherence Jbetter than 1 continuous boul This study hasseveral limitations. Al- though the data include representative samples from 49 states and the District ‘of Columbia, nonetheless, the BRFSS was designed to provide state levelestimates. Because respondents tend to underre- port weight." the prevalence of over- ‘weight is likely underestimated. Esti- mates of physical activity arealso likely to be underestimated because respon- dents wereallowed toreportonly 2struc- tured leisure-time activities. However, BRESS estimates of structured leisure ‘ume physteal activity are comparable to those in a national survey based on 20 reported activities." Unstructured ac- jobactivities, werenotassessed. Because the survey did not include an in-depth dietary assessment, calorieand fatreduc- ton could not be quantified. The over- all median state nonresponse of 22.1% and item nonresponse of 7.7% for the questionson currentand goal weight are of concern beeauise the heaviest persons may be more likely to refuse. Even though weight control isa com- monly reported behavior, obes creasing in the United States.*” This in- crease is most likely due to a secular ‘merase in energy intake combined with a decline in physical activity brought about by environmental and societal changes (such as through the use of au- tomobiles,labor-saving devices, and tele- vision/Video entertainment) and through the food supply (such as the ready avail ability of fast foods"). ‘Thus, revers- ing the trend in obesity will require change at the societal and environmen- tal as well as atthe individual level. At the individual level, there és a need for health care professionals to develop ex- pertise in counseling patients to pre- vent weight gain oF to lose weight through lower total calorie consump- don and increased physical activity. jes, such as housework or on-the- aS 4. Getnd 8, Gayl, Hubbard Veta. Com Imercal Waigt Lose Produce and Programs: What Consume tanto Gan and Lore Washington OC: Feet rage Commision, Bueavof Corsuer Pc fection 1998. 2, Kucamasti Regal KM. Campbell, ohrson Giinceasng prevalence of ovenrapit ang US Mis ANIA Te94.272.205.211 3 Centr for Deas Control and Prevention. Up- Gite pretalenceot overweight among cen ago lescnts, ang adutUnted States, 1988-1998. ‘MMW ho Mart Wkly Rep. 197: 46 185-202 4 Kang AC TableDL Therol cf xecise nwalgh felon ononaletesSports ad. 1991, 11331-3 5S Prone NP, Wing RR Pryscal avy and long feammamtenance of weight less. Obes Res. 1994, 587-098, 6 Natonainstttes of Heath, National Heat Lung Sd Bloed site, Ost Education tate Ci {2 Guidelines one erteation Evaluation, and Treatment of Overweight and Obesity in Adal Bethends, Md: Nation Isttates of Meath: June 1998, 7, Dietary Guidelines Advisory Commitee Report of the Detry Cundses Adar Commitee onthe 1258 JAMA, Oxtter 13, 1999_Vol 29, No 4 Downloaded From: on 11/21/2017 Dietary Guidelines fr American. 1995, Washing fon, OC: US Dep of Agatre,Agncutural Re Sect Sevier. 1295, 2 Schama) Can FSS data be pool for ational imats Pape presented athe eth nul BRESS Conterence ay 16,1999; Mineapols, Min. 9. Neon DE, HostamanO: Waller Mt Letainger Cl, ndonK Osjecber ard ds ofthe Behav Rsk Factor Suvelnce system In Prceeangs of the Se tionon ire Methods, Ameen Sata ASoas. tonfatona Mec, Augtt 9-13, 198; Dales, Tex. 40, Shan V, Baral Be, Bier GS, SUDAAN Ur 8 Maal Relese 75. Reseten Tange Pat, NC Research Tangle site, 1997 41. Sera Mk, Willams DF, An RF, Levy A Hesion, Byes Waaht contl pratense ‘an Pubic Healey 204 9821-1828 42. Horm AndesonK Wholn Amercais tyingto (Gee welght Ann inten Med 199371907 paver oe {13 Lewy AS, Heston AWW Weight conte! paces Of US ads tying to lose weight Ann inten Med 1385-11907 pt2) tc, 44: Rowland ML Se-eported weight and height ‘ri Cn te 199052125-1138 15, Ale 8 Too mucho a good thing? JAm Diet Aesoe 19959501 7-418 46. Caputo FA, Mattes RD. Human dietary re- Sponsest pereived manipulation fat contet fs day mean Obes elt Meta Dsrd. 1993, 7237-20, 47 She, Role norman about the ftcon- tent of preldenfuence every intake m hey Women! Am Det Aro, 1995595953 998 4a fouchard Dees. Treaty Execse and busty: Obes fs 19957-13347 58 sromel KD Exerc andobesty treatment py helopeal spel Io J Obes Relat Meta Disord 43959 upp 4) St22-S125, 20. ace I Wing RR Bue BA Roberson RP ‘ernngexeoseimulpleshot bos vesas ene on tinuous bout lo J Obes felt Meta Ord 1995, 19493 908 21. US Department of Heath and Human Sees Physical Actin and Heal. A Repor of the Sur ‘ean General Alanta, US DeptofHeatnand Hu than Sere 1996. 2. eer Ri, Corimunty programs for obey ore- ‘ent: te Minnesota Hea etn Progra. Obes Fes, 1995 supp 22835-2885, (©1900 American Medical Association, All rights reserved,