articles nature publishing group

Intervention and Prevention

Effect of Diet and Exercise, Alone or

Combined, on Weight and Body Composition
in Overweight-to-Obese Postmenopausal
Women
Karen E. Foster-Schubert1,2, Catherine M. Alfano3, Catherine R. Duggan1, Liren Xiao1,
Kristin L. Campbell4, Angela Kong1, Carolyn E. Bain1, Ching-Yun Wang1,2, George L. Blackburn5
and Anne McTiernan1,2

Lifestyle interventions for weight loss are the cornerstone of obesity therapy, yet their optimal design is debated.
This is particularly true for postmenopausal women; a population with a high prevalence of obesity yet toward whom
fewer studies are targeted. We conducted a year-long, 4-arm randomized trial among 439 overweight-to-obese
postmenopausal sedentary women to determine the effects of a calorie-reduced, low-fat diet (D), a moderate-
intensity, facility-based aerobic exercise program (E), or the combination of both interventions (D+E), vs. a no-lifestyle-
change control (C) on change in body weight and composition. The group-based dietary intervention had a weight-
reduction goal of ≥10%, and the exercise intervention consisted of a gradual escalation to 45-min aerobic exercise
5 day/week. Participants were predominantly non-Hispanic whites (85%) with a mean age of 58.0 ± 5.0 years, a
mean BMI of 30.9 ± 4.0 kg/m2 and an average of 47.8 ± 4.4% body fat. Baseline and 12-month weight and adiposity
measures were obtained by staff blinded to participants’ intervention assignment. Three hundred and ninety nine
women completed the trial (91% retention). Using an intention-to-treat analysis, average weight loss at 12 months
was −8.5% for the D group (P < 0.0001 vs. C), −2.4% for the E group (P = 0.03 vs. C), and −10.8% for the D+E group
(P < 0.0001 vs. C), whereas the C group experienced a nonsignificant −0.8% decrease. BMI, waist circumference, and
% body fat were also similarly reduced. Among postmenopausal women, lifestyle-change involving diet, exercise, or
both combined over 1 year improves body weight and adiposity, with the greatest change arising from the combined
intervention.

Obesity (2012) 20, 1628–1638. doi:10.1038/oby.2011.76

Introduction nonrandomized interventions have demonstrated improve-

The prevalence of obesity has reached epidemic levels over the
past few decades, and concurrent with this rise are increases
in numerous obesity-associated diseases including heart dis-
ease, certain types of cancer, and diabetes (1). The cornerstone
of therapeutic interventions to treat or prevent these diseases
is weight loss via lifestyle modification, including hypocaloric
diet and/or increased physical activity along with behavioral
techniques to support these changes (2). Typical weight loss
resulting from lifestyle change is between 5 and 10% of base-
line weight, so such approaches rarely bring an obese indi-
vidual to a normal body weight (3). However, losing even this
modest amount of weight brings health benefits (4). Multiple
ments in biomarkers relating to diabetes, cardiovascular dis-
ease, and cancer risk (3,5). Smaller-scale randomized studies of
lifestyle change to induce weight loss have shown improvements
in hypertension and metabolic syndrome (6–8). The Diabetes
Prevention Program (DPP) randomized over 3,000 individuals
at high risk for developing diabetes to an intensive, individual-
focused combined diet-and-exercise lifestyle intervention vs.
pharmaceutical therapies or placebo and demonstrated sig-
nificant reductions in diabetes incidence. Particularly, those in
the lifestyle intervention arm experienced the greatest (58%)
decrease in disease incidence over 3 years, providing strong
evidence for the efficacy of the lifestyle program (9).

1
Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; 2University of Washington School of Medicine, Seattle, Washington, USA; 3Office of Cancer
Survivorship, National Cancer Institute, Bethesda, Maryland, USA; 4University of British Columbia, Vancouver, British Columbia, Canada; 5Harvard Medical School,
Boston, Massachusetts, USA. Correspondence: Anne McTiernan (amctiern@fhcrc.org)
Received 1 September 2010; accepted 3 March 2011; advance online publication 14 April 2011. doi:10.1038/oby.2011.76

1628 VOLUME 20 NUMBER 8 | august 2012 | www.obesityjournal.org


Given the health impacts of the obesity epidemic and the
research suggesting that weight loss can ameliorate these prob-
lems, there have been numerous calls for optimal obesity treat-
ment strategies. The NIH Obesity Education Initiative Expert
Panel suggested a caloric deficit of 500–1,000 kcal/day using an
individualized dietary strategy, along with 45 min of moder-
ate-intensity physical activity 5 days/week (5). The Institute of
Medicine recommended at least 1 h/day of moderately intense
physical activity coupled with a caloric deficit whereas the
US Department of Agriculture similarly suggests individu-
als engage in close to 1 h of moderate-to-vigorous intensity
exercise on most days of the week, without exceeding caloric
intake requirements (3,10). The US Center for Disease Control
instead suggests at least 30 min/day of moderate-intensity
exercise most days of the week while maintaining sensible por-
tion sizes (11). The recommendations from these agencies are
all based on expert opinion supported by the available data.
Although numerous studies have examined the effect of life-
style interventions on body weight, few have focused on post-
menopausal women, a group experiencing particularly high
rates of overweight and obesity using a tested intervention such
as that undertaken by the DPP, a program known to reduce
disease risk in other populations, and measured effects over a
12-month period (12). Hence, questions still remain regarding
the best approach for weight loss from lifestyle change for this
group in particular, and randomized, controlled studies are
the best way to demonstrate effectiveness of interventions that
could influence public health recommendations.
We conducted a year-long, group-based lifestyle intervention
to examine the independent and combined effects of physical
activity and dietary weight loss on body weight as well as body
composition among 439 sedentary, overweight/obese post-
menopausal women. We hypothesized that the women rand-
omized to the intervention groups would experience greater
weight loss and improvements in body composition param-
eters than those randomized to the control group (who main-
tained their usual lifestyle), and furthermore that weight loss
and changes in body composition would vary among the inter-
vention groups based on the separate and combined impacts of
diet and exercise on overall energy balance.
Methods and Procedures
The Nutrition and Exercise in Women (NEW) study, conducted from
2005 to 2009, was a 12-month randomized, controlled trial using a
4-arm design to compare the effect of three lifestyle-change interven-
tions (moderate-to-vigorous intensity aerobic exercise, dietary weight
loss, or both interventions combined) vs. control (no lifestyle change) on
body weight and composition. All study procedures were reviewed and
approved by the Fred Hutchinson Cancer Research Center (FHCRC)
institutional review board in Seattle, WA, and all participants provided
signed informed consent.
Participant recruitment, inclusion, and exclusion criteria
The target population for the NEW study included postmenopau-
sal women from the greater Seattle, WA area, aged 50–75 years, who
were overweight or obese (BMI ≥25 kg/m2, or ≥23 kg/m2 for Asian-
American women), and exercising <100 min/week at moderate inten-
sity or greater. Specific exclusion criteria included: diagnosed diabetes,
fasting blood glucose ≥126 mg/dl, or use of diabetes medications; use of
obesity | VOLUME 20 NUMBER 8 | august 2012
articles
Intervention and Prevention
postmenopausal hormone therapy within the prior 3 months; history
of breast cancer or other serious medical condition(s); alcohol intake
in excess of 2 drinks/day or current smoker; contraindication to par-
ticipating in the diet or exercise intervention for any reason, including
an abnormal exercise tolerance test, current or planned participation
in another structured weight loss program, use of weight loss medica-
tions, or additional factors that might interfere with measurement of
outcomes or with the success of the intervention (e.g., inability to attend
facility-based sessions).
Women were recruited through targeted mass mailing campaigns and
media publicity or community outreach (Figure 1). Invitation letters
were sent to 126,802 age-eligible women and 5,621 responded; in addi-
tion we received 2,048 media and community outreach-prompted calls.
929 women were telephone screen-eligible, a total of 703 women attended
the information session, 684 women were screened in clinic, and 439
were randomized into the study (~80% from mass mailings, 20% from
media and community outreach).
Study design and randomization
The study design for the NEW trial is shown in Figure 1. Following
baseline data collection, eligible women were randomized into one of
four study arms: (i) dietary weight loss (D, N = 118); (ii) moderate-
to-vigorous intensity aerobic exercise (E, N = 117); (iii) both interven-
tions combined (D+E, N = 117); or (iv) no-lifestyle-change control (C,
N = 87). The random assignment was generated by a computerized
program, stratified according to BMI (<30 kg/m2 or ≥30 kg/m2) and
participants’ self-reported race/ethnicity (non-Hispanic white, black,
or other). In addition, to achieve a proportionally smaller number of
women assigned to the control group, a permuted blocks randomiza-
tion with blocks of four was used, wherein the control assignment was
randomly eliminated from each block with a probability of ~1 in 4.
Lifestyle-change interventions
The NEW dietary weight-loss intervention comprised our modifica-
tion of the dietary component of the DPP (9) and the Look Action
for Health in Diabetes (AHEAD) (13) lifestyle intervention programs,
with the following goals: total daily energy intake of 1,200–2,000 kcal/
day based on baseline weight, <30% daily energy intake from fat, and a
10% reduction in body weight by 6 months with maintenance thereaf-
ter to 12 months. Content of the dietary counseling sessions was modi-
fied to better fit our study population (less focus on diabetes or diabetes
risk), and the frequency and type of sessions (individual vs. group) also
varied from DPP and Look AHEAD. Women met individually with a
study dietitian for personalized goal-setting on at least two occasions,
followed by weekly meetings in groups of ~5–10 women, through the
first 6 months. Thereafter (months 7–12), dietitians had contact with
participants twice a month, including one face-to-face contact (indi-
vidual or group session) and one additional contact via phone or email.
Participants were permitted additional in-person sessions, phone, or
email contacts beyond the 32 expected, if they or the dietician felt these
would help to achieve intervention goals. This combination of individ-
ual and group-based approaches was used to maximize the benefits of
targeted, personalized recommendations along with the social support
and greater cost-effectiveness of a group setting. Women were asked to
record all food eaten daily for at least 6 months, or until they reached
their individual weight loss goal (10%). Food journals were collected by
the dietitian and returned with feedback. Journaling, weekly weigh-ins,
and session attendance were tracked to promote adherence to the diet
intervention.
Based on our previous exercise research in a similar population, the
goal of the NEW exercise intervention was ≥45 min of moderate-to-vigor-
ous intensity exercise, 5 days/week (225 min/week) for 12 months (14,15).
Participants attended at least three sessions/week at our study facility
where they were supervised by an exercise physiologist, and exercised for
their remaining sessions at home. The exercise training program began
with a 15 min session at 60–70% maximal heart rate (determined by
baseline exercise treadmill testing) and progressed to the target 70–85%
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Intervention and Prevention

Women sent mass mailings Women calling in response to

126,802 media and community outreach
2,048
Returned interest survey
5,621

Eligible after phone interview (N = 929)

Attended information session (N = 703)

Screened in clinic (N = 684)

Not randomized (N = 245)
Anthropometry = 506 eligible
Did not meet eligibility criteria = 191
Maximal treadmill test = 443 eligible Declined participation = 54
DXA = 439 eligible

Randomized (N = 439)

Control (delayed intervention) Calorie-reduced diet Aerobic exercise Aerobic exercise + calorie-
(N = 87) (N = 118) (N = 117) reduced diet (N = 117)

Did not receive intervention Did not receive intervention Did not receive intervention Did not receive intervention
as allocated (N = 7) as allocated (N = 13) as allocated (N = 11) as allocated (N = 9)
4 = Lost to follow-up 6 = Lost to follow-up 5 = Lost to follow-up 1 = missing baseline blood
3 = Withdrew (dissatisfied with 7 = Withdrew (4 = dissatisfied with 6 = Withdrew (2 = illness/medical 5 = Lost to follow-up
randomization) randomization; 2 = work or family reasons; 2 = transportation; 1 = 4 = Withdrew (2 = work or family
demands; 1 = illness/medical work or family demands; 1 = death demands; 1 = illness/medical
reasons) unrelated to intervention) reasons; 1 = relocation)

Completed trial Completed trial Completed trial Completed trial

(N = 80) (N = 105) (N = 106) (N = 108)
Anthropometry = 80 Anthropometry = 103 Anthropometry = 106 Anthropometry = 108
DXA = 80 DXA = 104 DXA = 105 DXA = 107
VO2max = 73 VO2max = 97 VO2max = 96 VO2max = 104

Figure 1  Flow diagram of the progress through the NEW trial. DXA, dual X-ray absorptiometry; VO2max, cardiorespiratory fitness test.

maximal heart rate for 45 min by the 7th week after enrollment where it
was maintained for the remainder of the study. Women wore Polar heart
rate monitors (Polar Electro, Lake Success, NY) during facility exercise
sessions to assist with attaining their target heart rate. In addition, during
both facility and home sessions they recorded the mode and duration
of exercise, and peak heart rate achieved. Facility-based exercise con-
sisted of treadmill walking, stationary bicycling, and use of other aerobic
machines; while a variety of home exercises were encouraged including
walking/hiking, aerobics, and bicycling. A small amount of resistance
training to strengthen joints and limit injury was recommended, though
not required. Activities of at least four metabolic equivalents according
to the Compendium of Physical Activities (16) such as brisk walking
were counted toward the prescribed aerobic exercise target. Activity logs
were reviewed weekly by study staff in order to monitor adherence. Par-
ticipants who were not meeting exercise targets were contacted by staff
to discuss barriers and approaches to increase activity. In addition, the
dietitians and exercise physiologists met regularly with a clinical health
psychologist experienced in lifestyle behavior change to discuss partici-
pant progress and refine behavior modification goals according to each
participant’s needs.
Women randomized to the diet + exercise group received both the
dietary weight loss and aerobic exercise interventions. They participated
in separate groups for the dietary weight-loss intervention from women
assigned to diet alone. Although the diet + exercise group could use the
exercise facility at the same time as participants assigned to the exercise-
only group, they were instructed not to discuss the diet intervention.
Women randomized to the control group were requested not to change
their diet or exercise habits for the duration of the trial. At the end of
12 months, participants in the control group were offered four group
nutrition classes and 8 weeks of facility exercise training with individual-
ized guidance from an exercise physiologist, as an incentive to undergo
randomization.
Study measures and data collection
All study measures were obtained by trained study personnel who were
blinded to the participants’ randomization status.
Participants completed a series of questionnaires at their baseline
screening visit before randomization, including demographic informa-
tion, medical history, health habits, reproductive and body weight history,
diet intake (via a validated 120-item self-administered Food Frequency
Questionnaire (FFQ)) (17), as well as frequency, duration, and intensity
of physical activity over the preceding 3-month period (via an interview-
administered Minnesota Physical Activity Questionnaire) (18). These
same questionnaires were completed at the end of the 12-month study
period.
Anthropometric measures were obtained at baseline and again at 12
months, whereas participants wore a hospital gown without shoes. Weight
and height were measured to the nearest 0.1 kg and 0.1 cm, respectively,
with a balance beam scale and stadiometer. Both measures were made
in duplicate and averaged. BMI was calculated as weight in kilograms
divided by the square of height in meters. Waist and hip circumferences
were measured in duplicate to the nearest 0.5 cm using a fiberglass tape,
and averaged. Waist circumference was obtained at the end of normal
expiration in the horizontal plane at the minimal waist, whereas the hip

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Intervention and Prevention

measure was obtained at the maximum point also in the horizontal plane.
Total and percentage body fat and lean mass were measured using a dual
X-ray absorptiometry whole-body scanner (GE Lunar, Madison, WI)
with participants in a supine position.
Adherence to the diet and exercise interventions was assessed via
multiple approaches. The dietary intervention was evaluated by weight
loss, and monitoring frequency of session attendance (19), food journal
completion and submission, and self-weighing. These measures were
reviewed weekly by study dieticians. Exercise participants tracked their
activities in a daily exercise log that was reviewed on a weekly basis by
the exercise physiologists. All participants completed certain measures
at baseline and 12 months to assess differences and change across study
arms. FFQs were completed primarily to assess dietary patterns and
change in fat intake. Participants wore pedometers (Accusplit, Silicon
Valley, CA) while awake for 7 consecutive days in order to determine
an average daily step count. Cardiorespiratory fitness (VO2max) was
assessed using a maximal graded treadmill test according to a modified
branching protocol starting at 3.0 mph and 0% grade with incremental
increases in speed or grade every 2 min (20,21). Heart rate and oxygen
uptake were continuously monitored with an automated metabolic cart
(MedGraphics, St Paul, MN).
body ­composition as well as additional anthropometric measures. With
439 women enrolled in the NEW trial, we had over 80% power to detect
a 3.16 kg difference between groups, using a Bonferroni adjustment
for the multiple comparisons (two-sided α = 0.05/6), and assuming a
10% drop-out rate/5% drop-in rate. We experienced 91% retention at
12 months, with 399 out of the 439 women randomized returning for
final assessments (Figure 1). All analyses were based on the assigned
intervention at the time of randomization regardless of adherence
(i.e., intention-to-treat), with a conservative no-change-from-baseline
imputation made for the missing values.
We computed the mean change in body weight, anthropometric, and
body composition measures from baseline to 12 months and assessed the
differences between each of the intervention and control groups. As these
outcome measures were normally distributed, data transformation was
not necessary. We used the generalized estimating equations modification
of linear regression to account for the longitudinal nature of the data and
correlation within individuals. As a secondary analysis, we compared the
mean 12-month changes in outcomes by tertiles of adherence measures.
Additional descriptive data are presented as mean ± s.d., unless otherwise
noted. All statistical analyses were performed using SAS software version
9.1 (SAS Institute, Cary, NC).

Statistical analyses
Our primary outcome was the comparison of change in body weight Results
by study group from baseline to 12 months. Secondary outcomes The baseline characteristics of the 439 participants randomized
included the comparison by study group of the 12-month change in to the NEW trial are shown in Table 1. Women were on average

Table 1  Baseline characteristics of NEW trial participants

All (N = 439) Control (N = 87) Diet (N = 118) Exercise (N = 117) Diet+Exercise (N = 117)
Mean (s.d.) Mean (s.d.) Mean (s.d.) Mean (s.d.) Mean (s.d.) P a
Age (years) 58.0 (5.0) 57.4 (4.4) 58.1 (6.0) 58.1 (5.0) 58.0 (4.5) 0.76
Weight (kg) 83.6 (11.8) 84.2 (12.5) 84.0 (11.8) 83.7 (12.3) 82.5 (10.8) 0.71
BMI (kg/m2) 30.9 (4.0) 30.7 (3.9) 31.1 (3.9) 30.7 (3.7) 31.0 (4.3) 0.83
Waist circumference 94.5 (10.1) 94.8 (10.2) 94.6 (10.2) 95.1 (10.1) 93.7 (9.9) 0.76
(cm)
Body fat mass (kg) 39.8 (8.1) 40.1 (8.5) 39.8 (8.1) 39.9 (8.2) 39.4 (7.9) 0.95
Body fat (%) 47.2 (4.3) 47.3 (4.4) 47.0 (4.3) 47.3 (4.1) 47.4 (4.5) 0.90
Lean mass (kg) 40.2 (5.0) 40.6 (5.3) 40.7 (5.1) 40.2 (5.3) 39.6 (4.3) 0.36
Lean mass (%) 48.5 (4.2) 48.5 (4.3) 48.7 (4.3) 48.3 (3.9) 48.3 (4.4) 0.87
VO2max (kg/ml/min) 22.9 (4.0) 23.1 (4.1) 22.7 (3.8) 22.5 (4.1) 23.5 (4.1) 0.17
Usual physical activity 32.8 (44.1) 23.8 (41.2) 33.6 (45.5) 37.7 (43.7) 33.6 (44.7) 0.16
(min/week)b
Total calories (kcal/day)c 1,934 (638) 1,988 (669) 1,884 (661) 1,986 (589) 1,890 (638) 0.46
Fat intake (percentage of 34.3 (6.9) 35.6 (6.9) 33.1 (6.3) 33.6 (6.9) 35.3 (7.3) 0.02
total kcal/day)c
N (%) N (%) N (%) N (%) N (%) Pd
Ethnicity
  Non-Hispanic white 373 (85.0) 74 (85.1) 101 (85.6) 98 (83.8) 100 (85.5) 0.15
  Non-Hispanic black 35 (8.0) 6 (6.9) 9 (7.6) 15 (12.8) 5 (4.3) 0.07
Education
  College graduate 287 (65.4) 59 (67.8) 76 (64.4) 70 (59.9) 82 (70.1) 0.26
Employment
  Part-time employed 123 (28.0) 25 (33.8) 34 (32.4) 34 (35.4) 30 (29.1) 0.62
  Full-time employed 222 (50.6) 47 (63.5) 58 (55.2) 53 (55.2) 64 (62.1) 0.42
a
ANOVA test, comparing baseline characteristics among four groups. bFrom Physical Activity Index Questionnaire. cN = 427 for total; N = 85 for control; N = 114 for diet,
exercise, and diet + exercise groups. dχ2-test or Fisher exact test, comparing baseline characteristics among four groups.

obesity | VOLUME 20 NUMBER 8 | august 2012 1631

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Table 2  Baseline and 12-month body weights, anthropometric measures, and body composition measures by intervention group
Control (N = 87) Diet (N = 118) Exercise (N = 117) Diet + exercise (N = 116)
articles

Baseline 12 months %Δ Baseline 12 months %Δ Baseline 12 months %Δ Baseline 12 months %Δ

Mean (s.d.) Mean (s.d.) Mean (s.d.) Mean (s.d.)
Weight (kg) 84.2 (12.5) 83.5 (12.3) –0.8 84.0 (11.8) 76.9 (13.4) –8.5 83.7 (12.3) 81.7 (12.4) –2.4 82.5 (10.8) 73.6 (11.5) –10.8
PC < 0.0001 PE < 0.0001 PD+E = 0.03 PC = 0.03 PD < 0.0001 PD+E < 0.0001 PC < 0.0001 PE < 0.0001 PD = 0.03
BMI (kg/m2) 30.7 (3.9) 30.5 (4.1) –0.7 31.0 (3.9) 28.4 (4.6) –8.6 30.7 (3.7) 29.9 (3.8) –2.4 31.0 (4.3) 27.6 (4.5) –10.8
PC < 0.0001 PE < 0.0001 PD+E = 0.02 PC = 0.017 PD < 0.0001 PD+E < 0.0001 PC < 0.0001 PE < 0.0001 PD = 0.02
Waist (cm) 94.8 (10.2) 95.7 (9.6) 1.0 94.6 (10.2) 90.2 (11.5) –4.7 95.1 (10.1) 93.1 (9.8) –2.1 93.7 (9.9) 86.7 (11.6) –7.5
Intervention and Prevention

PC < 0.0001 PE = 0.004 PD+E = 0.004 PC = 0.001 PD = 0.004 PD+E < 0.0001 PC < 0.0001 PE < 0.0001 PD = 0.004
Body fat (kg) 40.1 (8.5) 39.7 (8.7) –1.0 39.7 (8.1) 33.6 (10.0) –15.6 39.9 (8.2) 37.8 (8.7) –5.3 39.4 (7.9) 31.2 (9.5) –20.8
PC < 0.0001 PE < 0.0001 PD+E = 0.006 PC = 0.0006 PD < 0.0001 PD+E < 0.0001 PC < 0.0001 PE < 0.0001 PD = 0.006
Body fat (%) 47.3 (4.4) 47.1 (5.2) –0.3 47.0 (4.3) 42.8 (6.6) –8.9 47.3 (4.1) 45.7 (4.9) –3.3 47.4 (4.5) 41.5 (7.0) –12.4
PC < 0.0001 PE < 0.0001 PD+E = 0.005 PC = 0.0006 PD < 0.0001 PD+E < 0.0001 PC < 0.0001 PE < 0.0001 PD = 0.005
Lean mass (kg) 40.6 (5.3) 40.5 (5.0) –0.1 40.7 (5.1) 39.9 (4.8) –1.9 40.2 (5.3) 40.5 (5.1) 0.7 39.6 (4.3) 39.2 (3.9) –1.1
PC = 0.0048 PE < 0.0001 PD+E = 0.15 PC = 0.20 PD < 0.0001 PD+E = 0.003 PC = 0.15 PE = 0.003 PD = 0.15
Lean mass (%) 48.5 (4.3) 48.9 (4.8) 0.8 48.7 (4.3) 52.8 (6.5) 8.3 48.3 (3.9) 50.0 (4.8) 3.5 48.3 (4.4) 54.0 (7.0) 11.8
PC < 0.0001 PE < 0.0001 PD+E = 0.008 PC = 0.0005 PD < 0.0001 PD+E < 0.0001 PC < 0.0001 PE < 0.0001 PD = 0.008
Physical activity 23.8 (41.2) 63.8 (96.3) 168 33.6 (45.5) 57.7 (87.8) 72 37.7 (43.7) 223.0 (135) 491 33.6 (44.7) 238.0 (138) 609
(min/week)a
PC = 0.21 PE < 0.0001 PD+E < 0.0001 PC < 0.0001 PD < 0.0001 PD+E = 0.28 PC < 0.0001 PD < 0.0001 PE = 0.28
Pedometer 5,605 6,155 9.8 5,539 6,110 10.3 5,777 8,192 41.8 5,980 9,448 58.0
(steps/week)b (2,334) (2,811) (2,257) (2,865) (2,129) (3,373) (2,393) (3,316)
PC = 0.95 PE < 0.0001 PD+E < 0.0001 PC < 0.0001 PD < 0.0001 PD+E = 0.0056 PC < 0.0001 PD < 0.0001 PD+E = 0.0056
VO2max (l/min) 1.93 (0.37) 1.91 (0.33) –1.1 1.89 (0.31) 1.87 (0.31) –1.0 1.85 (0.31) 2.02 (0.34) 8.9 1.93 (0.34) 2.05 (0.41) 6.5
PC = 0.92 PE < 0.0001 PD+E < 0.0001 PC < 0.0001 PD < 0.0001 PD+E = 0.38 PC = 0.0007 PE = 0.38 PD < 0.0001
Total calories 1,988 (669) 1,768 (606) –11.0 1,884 (661) 1,637 (621) –13.0 1,986 (589) 1,801 (551) –9.3 1,890 (638) 1,617 (598) –14.0
(kcal/day)c
PC = 0.72 PE = 0.37 PD+E = 0.70 PC = 0.66 PD = 0.37 PD+E = 0.17 PC = 0.48 PE = 0.17 PD = 0.70
Fat intake 35.6 (6.9) 33.4 (6.8) –6.2 33.1 (6.3) 27.3 (7.2) –18.0 33.6 (6.9) 32.5 (7.3) –3.3 35.3 (7.3) 28.3 (7.6) –20.0
(percentage of 
PC < 0.0001 PE < 0.0001 PD+E = 0.18 PC = 0.12 PD < 0.0001 PD+E < 0.0001 PC < 0.0001 PE < 0.0001 PD = 0.18
kcal/day)c
Baseline observation carried forward for 12-month missing values, P < 0.05/6 = 0.0083 considered significant.
PC, comparing the change from baseline to 12-month follow-up between control and intervention group; PE, comparing the change from baseline to 12-month follow-up between exercise and other intervention group;
PD, comparing the change from baseline to 12-month follow-up between diet and other intervention group; PD+E, comparing the change from baseline to 12-month follow-up between diet + exercise and other intervention
group.
a
From Physical Activity Index Questionnaire. bN = 82 for control, N = 117 for diet, N = 114 for exercise, N = 115 for diet + exercise. cN = 85 for control, N = 114 for diet, exercise, and diet + exercise group.

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58.0 ± 5.0 years old, obese (BMI 30.9 ± 4.0 kg/m2) with a high
percent body fat (47.2 ± 4.3%), and had poor cardiorespiratory
fitness (VO2max 22.9 ± 4.0 kg/ml/min). Approximately 85% of
participants were non-Hispanic white, 65% were college grad-
uates, and about half were full-time employed. With the excep-
tion of percent fat intake in the diet estimated by FFQ, there
were no statistically significant differences in any demographic
or lifestyle variables between the study groups at baseline. Forty
women did not complete the study (D = 13, E = 11, D+E = 9, C
= 7), with the primary reasons for study discontinuation being:
dissatisfaction with randomization, work or family demands,
or injury or other medical issues unrelated to the intervention.
At 12 months, 399 participants completed follow-up visits for
body weight and anthropometric assessments, 396 underwent
a dual X-ray absorptiometry scan, and 370 participants com-
pleted a maximal treadmill test (Figure 1).
Overall, adherence to the dietary weight loss and aero-
bic exercise interventions was excellent (Table 2). Estimated
relative fat intake (percentage of total kcal/day) decreased by
18% in the diet-alone group and by 20% in the diet + exercise
group. Changes in total kcal intake among D and D+E groups
did not change significantly compared to controls, however the
FFQ is not as robust for estimating this parameter (17). In both
the diet-alone and diet + exercise groups, women attended an
average of 27-diet behavior change sessions (86%). Women
randomized to exercise alone achieved on average 80% of the
target 225 min/week aerobic exercise over the 12-month trial,
whereas women randomized to diet + exercise achieved 85%.
Both groups significantly increased their average pedometer
steps/day (E: 2,354 ± 2,749 steps/day, 42% increase; D+E: 3,408
± 3,001 steps/day, 58% increase) and VO2max (E: 0.16 ± 0.36 l/
min, 9% increase; D+E: 0.12 ± 0.34 l/min, 7% increase), com-
pared to baseline.
Body weight, anthropometric, and body composition
changes were evaluated at 12 months and are presented in
Table 2. Participants in the diet-alone group lost a mean 7.2 kg
(−8.5%, P < 0.0001), those in the exercise alone group lost a
mean 2.0 kg (−2.4%, P = 0.034), whereas those in the diet +
exercise group lost a mean 8.9 kg (−10.8%, P < 0.0001), each
compared to a 0.7 kg decrease among controls. The weight
reductions for the diet-alone and diet + exercise groups both
were significantly greater than that experienced by the exercise
alone group (both P < 0.0001), though the difference between
diet-alone and diet + exercise did not reach the adjusted level
of statistical significance (P = 0.02). Waist circumference
decreased significantly in all intervention groups compared to

Table 3  Baseline and 12-month weight, anthropometric, and body composition measures for diet group, stratified by adherence
Baseline 12 Months
N Mean STD N Mean STD % P valuea P valueb
Weight (kg) Control 87 84.2 12.5 80 83.7 12.3 –0.6 Ref.
<84.3% 41 87.3 12.7 28 81.8 12.0 –6.3 0.006 Ref.
84.3–106% 37 80.6 10.8 36 72.3 9.8 –10.4 <0.0001 <0.0001
≥106% 40 83.9 11.1 40 72.5 12.9 –13.5 <0.0001 <0.0001
(<0.0001 ) c
(<0.0001d)
BMI (kg/m ) 2
Control 87 30.7 3.9 80 30.4 4.1 –0.8 Ref.
<84.3% 41 32.4 4.1 28 30.6 4.1 –5.5 0.004 Ref.
84.3–106% 37 29.9 3.5 36 26.8 3.3 –10.3 <0.0001 <0.0001
≥106% 40 30.8 3.9 40 26.6 4.5 –13.6 <0.0001 <0.0001
(<0.0001c) (<0.0001d)
Waist (cm) Control 87 94.8 10.2 79 95.4 9.6 0.7 Ref.
<84.3% 41 96.3 10.6 28 93.9 9.8 –2.5 0.10 Ref.
84.3–106% 37 92.8 11.0 35 86.9 8.8 –6.4 <0.0001 <0.0001
≥106% 40 94.5 8.9 40 86.3 11.2 –8.7 <0.0001 <0.0001
(<0.0001c) (0.0001d)
Body fat (%) Control 87 47.3 4.4 80 47.2 5.3 –0.2 Ref.
<84.3% 41 47.7 4.8 28 45.8 4.5 –3.9 0.03 Ref.
84.3–106% 37 46.3 3.7 36 41.8 6.3 –9.8 <0.0001 <0.0001
≥106% 40 46.9 4.4 40 39.7 6.5 –15.3 <0.0001 <0.0001
(<0.0001c) (<0.0001d)
Adherence defined by percent of in-person nutrition session attendance, by tertiles.
a
Testing difference in change from baseline to 12 months in body composition measure compared to controls. bTesting difference in change from baseline to 12 months
in body composition measure compared to low adherence group, excluding controls. cTesting for a trend in change from baseline to 12 months in body composition
measures from controls through high adherence group. dTesting for a trend in change from baseline to 12 months in body composition measures from low adherence
group through high adherence group.

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the nonsignificant 0.9 cm increase among controls (D: −4.5 cm
P < 0.0001; E: −2.0 cm P = 0.001; D+E: −7.0 cm P < 0.0001).
Furthermore, the decrease in waist circumference was signifi-
cantly greater for the diet + exercise participants than for either
the diet-alone or exercise-alone participants (P = 0.004 D+E vs.
D and P < 0.0001 D+E vs. E), and women who were assigned to
diet alone also experienced significantly greater decrease com-
pared to those assigned to exercise alone (P = 0.004). Similarly,
% body fat decreased among all intervention groups compared
to controls, with an absolute percent change of −4.2% for diet
alone, −1.6% for exercise alone, and −5.9% for diet + exercise
(all P < 0.0001). Paralleling the findings for waist circumfer-
ence, comparing these reductions among intervention groups
revealed the rank-order for the reduction was also D+E > D
> E (all P < 0.005). Finally, lean mass increased only among
those participating in exercise alone (+0.3 kg). Although this
increase did not differ significantly from control women, it was
significantly greater compared to the reductions in lean mass
among women in the diet alone (−0.8 kg, P < 0.0001 E vs. D) or
diet + exercise (−0.4 kg, P = 0.003 E vs. D+E) groups.
We assessed measures of adherence for the combined diet +
exercise group separately from either intervention alone.
Changes in outcome measures at 12 months stratified by
tertiles of percentage of in-person diet intervention session
attendance are shown in Table 3 (D group) and Table 4 (D+E
group). Women from the diet-alone group who participated
in ≥106% of sessions (included optional visits) lost the most
weight, with an 11.4 kg (13.5%) decrease, compared to losses of
8.3 kg (10.4%) among women attending 84–106% of sessions,
5.5 kg (6.3%) among those attending <84%, or a 0.5 kg loss
(0.6%) among controls (all P trend <0.0001). Comparable find-
ings were noted for BMI, waist circumference, and % body fat
(all P trend ≤0.0001, Table 3). Similarly to the diet-alone par-
ticipants, women from the diet + exercise group who attended
the most in-person sessions also lost the most weight, with a
10.9 kg (13.4%) decrease, compared to losses of 9.4 kg (11.5%)
among women attending 84–106% of sessions, and 8.1 kg
(9.6%) among those attending <84% (all P trend <0.0001).
Equivalent changes were observed for other all outcome meas-
ures (Table 4).
Changes in outcome measures at 12 months stratified by
tertiles of reported exercise (exercise logbook min/week) are
shown in Table 5 (E group) and Table 6 (D+E group). Women
from the exercise-alone group who participated in ≥196 min/
week physical activity (highly active) lost the most weight, with
a 3.1 kg (3.9%) decrease, compared to losses of 2.0 kg (2.4%)

Table 4  Baseline and 12-month weight, anthropometric, and body composition measures for diet + exercise group, stratified by
adherence
Baseline 12 Months
N Mean STD N Mean STD % P valuea P valueb
Weight (kg) Control 87 84.2 12.5 80 83.7 12.3 –0.6 Ref.
<84.3% 33 84.4 10.6 25 76.3 9.5 –9.6 <0.0001 Ref.
84.3–106% 43 82.0 12.2 43 72.6 13.1 –11.5 <0.0001 <0.0001
≥106% 41 81.5 9.4 41 70.6 8.7 –13.4 <0.0001 <0.0001
(<0.0001 ) c
(0.03d)
BMI (kg/m2) Control 87 30.7 3.9 80 30.4 4.1 –0.8 Ref.
<84.3% 33 31.6 4.3 25 28.9 4.3 –8.5 <0.0001 Ref.
84.3–106% 43 30.9 4.8 43 27.3 5.2 –11.5 <0.0001 <0.0001
≥106% 41 30.7 3.8 41 26.6 3.4 –13.4 <0.0001 <0.0001
(<0.0001c) (0.02d)
Waist (cm) Control 87 94.8 10.2 79 95.4 9.6 0.7 Ref.
<84.3% 33 97.4 10.8 25 90.1 9.9 –7.5 <0.0001 Ref.
84.3–106% 43 92.4 10.3 43 85.1 11.8 –7.9 <0.0001 <0.0001
≥106% 41 92.1 7.9 41 83.4 9.1 –9.4 <0.0001 <0.0001
(<0.0001c) (0.24d)
Body fat (%) Control 87 47.3 4.4 80 47.2 5.3 –0.2 Ref.
<84.3% 33 47.7 4.6 25 44.4 6.1 –7.0 0.0003 Ref.
84.3–106% 43 47.0 4.5 43 40.4 7.4 –14.0 <0.0001 <0.0001
≥106% 41 47.6 4.4 41 39.8 6.6 –16.4 <0.0001 <0.0001
(<0.0001c) (0.0001d)
Adherence defined by percent of in-person nutrition session attendance, by tertiles.
a
Testing difference in change from baseline to 12 months in body composition measure compared to controls. bTesting difference in change from baseline to 12 months
in body composition measure compared to low adherence group, excluding controls. cTesting for a trend in change from baseline to 12 months in body composition
measures from controls through high adherence group. dTesting for a trend in change from baseline to 12 months in body composition measures from low adherence
group through high adherence group.

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Table 5  Baseline and 12-month weight, anthropometric, and body composition measures for exercise group, stratified by
adherence
Baseline 12 Months
N Mean STD N Mean STD % P valuea P valueb
Weight (kg) Control 87 84.2 12.5 80 83.7 12.3 –0.6 Ref.
<154 min/week 41 87.7 10.8 29 85.8 9.6 –2.2 0.40 Ref.
154–196 min/week 41 83.0 13.1 41 81.0 12.7 –2.4 0.09 0.11
≥196 min/week 35 79.8 11.9 35 76.7 12.2 –3.9 0.01 0.01
(0.009c) (0.12d)
BMI (kg/m2) Control 87 30.7 3.9 80 30.4 4.1 –0.8 Ref.
<154 min/week 41 31.9 3.8 29 31.8 3.8 –0.5 0.38 Ref.
154–196 min/week 41 30.5 3.6 41 29.8 3.6 –2.4 0.06 0.08
≥196 min/week 35 29.3 3.3 35 28.2 3.5 –3.9 0.007 0.009
(0.004 ) c
(0.10d)
Waist (cm) Control 87 94.8 10.2 79 95.4 9.6 0.7 Ref.
<154 min/week 41 98.2 10.3 30 98.3 8.3 0.1 0.18 Ref.
154–196 min/week 41 93.7 9.6 41 91.9 9.7 –1.9 0.03 0.06
≥196 min/week 35 92.9 9.9 35 89.4 9.9 –3.8 0.0009 0.002
(0.0005c) (0.10d)
Body fat (%) Control 87 47.3 4.4 80 47.2 5.3 –0.2 Ref.
<154 min/week 41 48.3 3.7 29 47.8 3.9 –0.9 0.23 Ref.
154–196 min/week 41 47.1 4.0 41 45.8 4.1 –2.9 0.009 0.01
≥196 min/week 35 46.3 4.6 35 43.4 5.8 –6.3 0.0001 0.0001
(<0.0001c) (0.003d)
Adherence defined by exercise logbook minutes per week, by tertiles.
a
Testing difference in change from baseline to 12 months in body composition measure compared to controls. bTesting difference in change from baseline to 12 months
in body composition measure compared to low adherence group, excluding controls. cTesting for a trend in change from baseline to 12 months in body composition
measures from controls through high adherence group. dTesting for a trend in change from baseline to 12 months in body composition measures from low adherence
group through high adherence group.

among intermediate-active women (154–196 min/week),
1.9 kg (2.2%) among low-active women (<154 min/week) or a
0.5 kg loss (0.6%) among controls (P trend <0.0001 in refer-
ence to controls, P = 0.12 in reference to low-active group).
Comparable findings were noted for BMI, waist circumfer-
ence, and % body fat (P trend all <0.01 in reference to controls,
Table 5); in addition these same trends were observed when
adherence was assessed by change in cardiorespiratory fitness
level or change in pedometer steps/week (data not shown).
Highly active women from the diet + exercise group lost 10.5 kg
(12.8%) decrease, similar to the weight loss achieved by active-
intermediate women (10.5 kg or 12.7%), whereas low-active
women lost 8.0 kg (9.6%; all P trend <0.0001 in reference to
controls, and P trend ≤0.01 in reference to low-active group).
Equivalent changes were observed for other outcome measures
(Table 6), and also when adherence was assessed by change in
cardiorespiratory fitness level or change in pedometer steps/
week (data not shown).
Discussion
We found that a year-long lifestyle-change program, incorpo-
rating either combined or separate dietary weight loss or mod-
erate-to-vigorous aerobic exercise interventions, produced
clinically important and significant reductions in body weight
and improvements in body composition among overweight-
to-obese postmenopausal women. Our dietary intervention
was adapted primarily from the DPP for group-based delivery,
whereas our exercise intervention was based on our previous
successful physical activity programs (14,15). With excellent
overall follow-up (>90%) and adherence to the interventions,
we observed an 8.5% weight loss among women participating
in diet alone, 2.4% weight loss among those participating in
exercise alone, and 10.8% weight loss among those in the com-
bined diet + exercise interventions. Furthermore, we observed
that the relative reductions in % body fat measured by dual
X-ray absorptiometry in each group differed significantly (at
a Bonferroni-adjusted level of P < 0.05/6 to account for the
multiple comparisons) with the following rank order: −12.4%
(D+E) > −8.9% (D) > −3.3% (E) > −0.3 (C).
Our combined diet + exercise group effectively put to the
test the recommendation of the NIH Obesity Education
Initiative Expert Panel, which suggested a caloric deficit of
500–1,000 kcal/day using an individualized dietary strategy,
along with 45 min of moderate-intensity physical activity 5
day/week. Most importantly, we tested this among postmeno-
pausal women, for whom well-designed studies examining the

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Table 6  Baseline and 12-month weight, anthropometric, and body composition measures for diet + exercise group, stratified by
adherence
Baseline 12 Months
N Mean STD N Mean STD % P valuea P valueb
Weight (kg) Control 87 84.2 12.5 80 83.7 12.3 –0.6 Ref.
<154 min/week 39 83.2 11.4 31 75.2 10.8 –9.6 <0.0001 Ref.
154–196 min/week 36 82.8 10.2 36 72.3 10.9 –12.7 <0.0001 <0.0001
≥196 min/week 42 81.7 10.8 42 71.2 11.0 –12.8 <0.0001 <0.0001
(<0.0001 ) c
(0.01d)
BMI (kg/m2) Control 87 30.7 3.9 80 30.4 4.1 –0.8 Ref.
<154 min/week 39 30.9 4.4 31 28.2 4.6 –8.8 <0.0001 Ref.
154–196 min/week 36 31.4 4.5 36 27.4 4.7 –12.7 <0.0001 <0.0001
≥196 min/week 42 30.7 4.1 42 26.7 4.1 –12.9 <0.0001 <0.0001
(<0.0001c) (0.006d)
Waist (cm) Control 87 94.8 10.2 79 95.4 9.6 0.7 Ref.
<154 min/week 39 94.6 12.0 31 88.0 11.2 –7.0 <0.0001 Ref.
154–196 min/week 36 93.3 9.4 36 86.0 11.0 –7.7 <0.0001 <0.0001
≥196 min/week 42 93.3 8.1 42 83.5 9.8 –10.5 <0.0001 <0.0001
(<0.0001c) (0.002d)
Body fat (%) Control 87 47.3 4.4 80 47.2 5.3 –0.2 Ref.
<154 min/week 39 47.3 4.4 31 43.1 6.8 –8.9 <0.0001 Ref.
154–196 min/week 36 47.8 4.6 36 41.4 6.4 −13.4 <0.0001 <0.0001
≥196 min/week 42 47.2 4.5 42 39.4 7.4 −16.5 <0.0001 <0.0001
(<0.0001c) (0.0003d)
Adherence defined by exercise logbook minutes per week, by tertiles.
a
Testing difference in change from baseline to 12 months in body composition measure compared to controls. bTesting difference in change from baseline to 12 months
in body composition measure compared to low adherence group, excluding controls. cTesting for a trend in change from baseline to 12 months in body composition
measures from controls through high adherence group. dTesting for a trend in change from baseline to 12 months in body composition measures from low adherence
group through high adherence group.

longer-term benefits of lifestyle change are needed (12). When
we examined the percentage of participants from our trial who
achieved various clinically relevant weight loss targets (<5%,
5–<10%, and ≥10%), the majority (60%) of women in the diet
+ exercise intervention achieved ≥10%, whereas only 42% of
those in diet alone, and 3% in exercise alone achieved that tar-
get (data not shown). Although adding 5 day/week of exercise
requires effort, 20% more women attained the very relevant
goal of 10% weight loss when they added exercise to diet modi-
fication. It is likely that the cost of exercise is offset by the cost
savings due to health benefits arising from increased physical
activity (22). Furthermore, following a recent review of stud-
ies examining exercise for weight loss the American College
of Sports Medicine has now increased its recommended dose
of exercise to 150–250 min/week, suggesting that particularly
when exercise is combined with moderate caloric restriction
these levels are necessary to augment weight loss (23). Similarly,
the US Department of Health and Human Services Physical
Activity Guidelines Committee found that optimal exercise
levels for weight loss and weight loss maintenance could be up
to 60 min/day (24).
Other research has demonstrated comparable degrees of
weight loss to those we found with our interventions, though
studies vary widely with respect to type of diet and exercise
interventions, the inclusion of a control group, their duration,
size, and measures of potential greater metabolic relevance such
as body fat and lean mass (25–30). The MONET study also tar-
geted postmenopausal women (N = 173), but only examined
diet vs. diet + resistance training over 6 months, and found
equivalent weight loss between these groups (31). We found
that exercise had an important effect of maintaining lean body
mass that did not occur with diet alone, and this effect could
certainly have important implications as older people are at
increased risk for sarcopenia (32). Although it would be diffi-
cult to determine the relative impact of different diets and doses
of exercise within a single study, it has been shown that most
diets are effective regardless of composition as long as partici-
pants are adherent (33,34). We found adherence, whether to
the diet or exercise intervention, had a dose-dependent impact
on weight loss and change in body composition among our
population of postmenopausal women.
The degree of adherence to lifestyle change has been clearly
shown to positively influence all weight and body compo-
sition-related outcomes. We found that greater adherence
to our exercise intervention, whether measured using a self-
reported variable of minutes exercised per week (in relation

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to the goal of 225), or more objective measures such as ped-
ometer-recorded steps per week or cardiorespiratory fitness
(measured by an exercise tolerance test), was associated with
greater weight reduction or improvement in body composi-
tion. Greater adherence to the exercise prescription in both the
DPP and the Look AHEAD trial also predicted greater rates of
achieving weight loss goals (19,35). The same relationship with
adherence and weight loss was found when we examined in-
person session attendance for our diet intervention. The level
of adherence overall was very high (over 90% attendance for
both D and D+E), but we were still able to see greater improve-
ment in body weight and composition outcomes among
women in the highest adherence groups. Alhassan et al. found
that adherence to diet was a key predictor of weight loss in
the “A to Z” study of different popular diets, similar findings
were also reported by Greenberg et al. for a randomized low
fat vs. low carbohydrate diet, and again for the DPP and Look
AHEAD (19,35–37). Further research is warranted to improve
our understanding of behavioral and biological determinants
of adherence, particularly those that could be modifiable.
One limitation of our study was that exercise performed
at home was self-reported, in comparison with that directly
observed at our facility. Although facility sessions allowed
for direct observation of participants’ activity, the applica-
bility of our findings to less-intensive or costly community
programs to promote physical activity is not as clear. Still,
the significant increases in VO2max observed only among
women randomized to the exercise groups (E and D+E) sup-
port the internal validity of our data, and that these women did
raise their physical activity level. Diet was also self-reported
by women in the dietary weight loss arms, and although the
FFQ is a valid measure for assessing diet, it has acknowledged
limitations. The significant weight loss experienced by women
in the diet interventions (nearly 9% and 11% in D and D+E,
respectively) again supports that these women did reduce their
caloric intake. Another potential factor which may have intro-
duced some additional variability to the weight loss achieved
by the study groups is contact time with study staff. Study con-
tact time may impact weight loss (38), and it varied to some
degree by intervention group and was the least, by design, for
women in the control group.
Strengths of our study included our large study size with suf-
ficient power to examine differences not only in comparison to a
no-lifestyle-change control group, but also relative to differences
among the elements of lifestyle change (diet and exercise, alone
and in combination). We examined the impacts of our interven-
tions on weight, but also on body fat measured by dual X-ray
absorptiometry. Body fat does not increase linearly with body
weight, and measuring body fat directly may allow for better esti-
mation of health impacts (39). Our study population consisted of
postmenopausal women, and our focus on this group was pur-
poseful, given their particularly high rates of weight gain and
obesity (1,40). Furthermore, we experienced excellent adherence
to the interventions, and low drop-out rates. Finally, in contrast to
numerous published short-term studies examining the impacts of
diet and exercise, our study was a full year in duration. Ongoing,
obesity | VOLUME 20 NUMBER 8 | august 2012
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Intervention and Prevention
long-term follow-up of participants is now underway, and factors
contributing to the successful maintenance of weight loss will be
examined in the future.
In conclusion, we have demonstrated a successful imple-
mentation of a group-based modification of the DPP dietary
weight loss intervention, along with moderate-vigorous aerobic
physical activity, among a population at high risk for ongoing
weight gain and the negative metabolic consequences thereof.
Although our diet and exercise interventions had beneficial
effects on weight loss and body composition when delivered
in isolation, the greatest effects were found in the combined
intervention group, where 60% of participants achieved ≥10%
weight loss at 1 year. Our combined diet + exercise interven-
tion group essentially followed the current recommendations
by the NIH Obesity Education Initiative Expert Panel (5),
providing the highest level of support for these recommenda-
tions: a randomized clinical trial that examined each element
singly and in combination vs. a no-lifestyle-change control.
Yet, despite the now overwhelming evidence for the benefits
of lifestyle-induced weight loss, there are still major barriers
to implementing these programs, particularly at the primary
care level where the most benefit stands to be made (41,42).
Providing group-based nutrition education along with exer-
cise likely outweighs the costs of health consequences that
come from untreated obesity, assuming these changes can
be sustained over the long-term (43,44). We are conducting
ongoing follow-up of our NEW trial participants to examine
the behavioral and physiologic predictors of long-term weight
loss maintenance in a free-living environment post-trial, with
the goal that identification of these factors will help to guide
the successful design and implementation of obesity treatment
programs with the greatest potential to impact public health.
Acknowledgments
This study was funded by National Cancer Institute (NCI) NIH grants
R01 CA102504 and U54-CA116847. K.E.F. received support from NIH
5KL2RR025015-03, A.K. was supported by NCI R25 CA94880. The authors
thank the study participants for their time and dedication to the study.
Disclosure
The authors declared no conflict of interest.
© 2011 The Obesity Society
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VOLUME 20 NUMBER 8 | august 2012 | www.obesityjournal.org