was zero. Body weight. The total weight loss during the. 12-wk program was .... food intake in the alternating-calorie group was estimated from a randomly.
Evaluation of an alternating-calorie diet with exercise in the treatment of obesity13 James Barbara
0 Hill,
David
Stetson,
G Schlundt,
Mary
Kaler,
Tracy and
Sbrocco,
Craig
This study
loss.
obese
an alternating-
an average
examined
women
in weight-loss
detrimental
or without
period;
development
metabolic
of obesity
alterations
that
may
make
metabolic
rate,
be associated
the
obese
body
state
with difficult
to reverse (1-4). It appears to be easier for obese individuals to lose weight than to maintain a weight loss. This may in part be due to changes in body composition and resting
metabolic
rate
(RMR)
that
accompany
weight
loss and reduce energy requirements (4). It is important to identify variables that affect food intake, body composition,
and
energy
expenditure
and
to learn
of subjects
rate did not differ among
Introduction
The
daily intake
in the alternating-diet
groups.
Alternating
as a weight-loss strategy whereas Am J C/in Nutr l989;50:248-54.
therapy.
KEY WORDS Resting modification, weight loss
alternation and exercise on weight weight) were randomly assigned to aerobic exercise. Both diets provided
body
how
to ma-
nipulate these variables in weight-reduction programs. The ideal treatment program may be one that promotes lifestyle change, reduces total body fat, preserves lean tissue, and does not lead to dramatic reductions in RMR. The type of caloric restriction and the presence or absence ofaerobic exercise are two variables that have been suggested as influencing the composition of weight loss (5, 6) and reduction in RMR during dieting (5, 7). Katahn (5) suggested that a dietary regimen involving alternation between very low and moderate calorie restriction might enhance weight loss while preventing a reduction
composition,
body-fat
exercise
calories was clearly
distribution,
behavior
through newspaper advertisement. the Commiuee for the Protection derbilt University. Subjects were
had major health
problems
The study was approved by of Human Subjects of Vanexcluded if they smoked or
other than obesity
lar disease or diabetes). Subjects were complete a 2-wk baseline eating diary tion in the study. Baseline characteristics
ofthe
four experimental
jects participated program designed ercise conditions mote
long-term
to enhance and
were total weight
diet
to result
with the diet and cx-
in eating-habit
maintenance. body composition,
in each
1. All sub-
lifestyle-modification
compliance
was randomly
The
assigned
or an alternating-calorie
changes
outcome and RMR.
to provariables
of 1200
condition 600 kcal/d
had
and
kcal/d.
Subjects
diets
were
based
in the alternating-calorie intakes
kcal/d
Both
system and were implemented diet provided a target calorie
target-calorie
1800
to either a constant-cal-
diet.
on a six-food-group exchange for l2-wk. The constant-calorie intake
12-wk
subjects
in Table
diets
Each subject orie
loss,
ofthe
are shown
in an identical
weight
Experimental
groups
(eg, cardiovascu-
required to successfully to qualify for participa-
that
in the pattern
alternated
shown
diet between
in Table
2.
in RMR.
The purpose of the present study was to compare the effects on weight loss ofan alternating-calorie diet with a constant-calorie diet while controlling for aerobic exercise.
Subjects Forty moderately
248
From
the Departments
of Pediatrics,
Psychology,
University, Nashville, TN. 2 Supported by National Institutes of Health
grants
RR0009S. 3 Address reprint requests to JO Hill, Department 4130 Medical Center North, Vanderbilt University,
Methods
women
I
were recruited
and Medicine,
Vanderbilt
DK26657
and
of Pediatrics, Nashville,
DTN
37232.
obese
(1 30-160%
of ideal
from the population
body
of Nashville, Am J Clin Nuir
weight)
TN, 1989;50:248-54.
Received Accepted Printed
June 6, 1988. for publication in USA.
October
20, 1988.
© 1989 American
Society
for Clinical
Nutrition
Downloaded from www.ajcn.org by guest on July 10, 2011
beneficial
Pope-Cordle,
pattern from 600 to 1800 kcal/d. Exercising subjects walked in an intensive outpatient behavior-modification program. subjects had greater reductions in body weight and body fat subjects. The type ofcaloric restriction did not affect weight
percentage than did nonexercised or fat loss. Changes in resting metabolic nor
ofcalorie
of ideal
diet with
over a l2-wk
condition varied in a prescribed 5 d/wk. All subjects participated At the end ofthe study, exercised
beneficial
Jamie
the effects
(130-160%
or constant-calorie
of 1200 kcal/d
was neither
Sharp,
Heim
ABSTRACT Moderately
Teresa
and without
ALTERNATING TABLE Initial
1 characteristics
ofsubjects
in each group
Groupt
ofthe
Age
10)
=
A-NoE(n C-E (n
6)
=
8)
=
C-NoE
(n
6 5
37 ±
8
37
8)
=
33 ± 40 ±
EXERCISE
BMI
RMR
cm
kg/m2
kcal/h
± 7.3 ± ±
9.3 6.2
± 8.2
t A, alternating
diet; C, constant
Subjects were encouraged vestigators initially and tastes and lifestyles later.
bohydrates,
25%
fat, and
diet; E, exercise;
66 ±
.03
42.8
± 3.2
62 ± 10
0.86 0.89
±
31 30
±
.05
43.4
±
5.1
59 68
0.88 0.87
±
.03 .03
43.2 44.5
±
6.2
±
3.1
± 2 ±
3 1 ±
3 3
to follow
menus
to adapt
provided
these
menus
by the
to their
Both target diets consisted 20%
protein.
Subjects
of55% were
in-
own
car-
encour-
±
±
nutri-
consolidate
learning
each diet condition
subjects
were randomly
placed
ofeating
an exercise or a no-exercise group. Exercise subjects in a moderate aerobic training program consisting walking five times per week at a target heart rate of 60-
ofbrisk 70% of maximum
heart
test of maximum
aerobic
rate,
determined
capacity.
by a treadmill
Exercise
sessions
fitness
consisted
10-mm warm-up followed by a period ofbrisk walking progressively increased from 20 mm per session during
that the
first week to 50 mm per session by the eighth week. Three supervised exercise sessions per week were held for weeks I -4,
two per week during weeks 5-8, and one per week during weeks 9- 12. Subjects in the no-exercise condition were instructed to from
engaging
in any regular
exercise
during
the
12-wk
period.
Behavior-mod/1cation
program
chology and nutrition. Subjects group leaders before each session. was to help participants identify
were weighed by one of the The objective ofthe program day-to-day situations related
Subjects
asked
failing
Alternating-ca Number days
brie
diet
diet4 Constant-cal
of
Number days
Intake kca/
1
4
3 4 7 3 4 7
S
7
2 3
The pattern
was repeated
information
of Intake
weeks
7-12.
7
1200
7 7
1200 1200
7 7
1200 1200
and exercise
diary
in a diary
during
the 2-wk
ship
between
at each
group
to the investigators
in the diaries
entered
was
individual
baseline
behaviors and JO Hill, T Sbrocco,
into
meeting
within
the
were
2 d. The
a microcomputer
feedback
eating
on the relation-
psychosocial
variables
and T Kassar, unpublished observations, 1988). Thus, the diaries were used to collect data on eating-behavior pattern, to provide mdi(DG
Schlundt,
vidualized behavioral-assessment enhance compliance and increase weight
and body
Body weight
J Pope-Cordle,
information, total weight
and as a way to loss.
composition
was recorded
at baseline,
at each weekly
group
meeting, and at follow-up. Weights were always taken by one of the investigators on a calibrated balance-beam scale. Body composition was determined at the beginning and end of the study from body density. Body density was determined by underwater weighing to determine body volume (9). Body weights underwater
platform
sidual lung volume derwater weighing
method
(9).
were
measured
and Chatillon was
spring
determined
using N concentration
sured
kcal
600 900 1200 600 900 1200 1500 during
orie diet
to turn
the diary
that was used to generate
Heath intake on each experimental
a behavioral
to bring
in air and
TABLE 2 Weekly target-calorie
behavior
(8).
period and the 12-wk treatment program. The diary was used to record all meals and snacks along with the social, environmental, and emotional context in which the eating occurred. Each bout ofphysical activity was also recorded in the diaries.
Body
The lifestyle-change program consisted of 12 weekly group meetings conducted by two leaders with backgrounds in psy-
kept
sessions
between
a
to the
scales,
nearest
25 g using
respectively.
simultaneously
with
Reun-
close-circuit nitrogen-dilution during rebreathing was mea-
with a 505-D Nitralizer#{174} (Med-Science, St Louis, Percent body fat was estimated from body density by use
MO).
of the
revised equation ofBrozek et al (10). The waist-to-hip ratio (WHR) was determined from circumference measurements and was recorded at the beginning and end of the 12-wk weight-loss-program. Waist circumference was measured at one-third ofthe distance between the xiphoid process and the umbilicus, and hip circumference was measured 4 cm below the iliac crest. Energy RMR termined resting
expenditure was measured before and after weight loss. It was deby indirect calorimetry after an overnight fast. After quietly for 45 mm, subjects breathed through a face
Downloaded from www.ajcn.org by guest on July 10, 2011
to prevent
into either participated
4
8 8
eating behaviors and to learn more effective with these situations. The sessions consisted of group discussions, problem solving, and behavand rehearsal with homework assignments to
to inappropriate ways to cope presentations, ior modeling
Subjects
Within
Week
9
±
Self-monitoring
refrain
%
31 ± 3
Exercise
treatment
fat
NoE, no exercise.
aged to take vitamin and mineral supplements ent deficiencies during caloric restriction.
was
Body
SD.
4 j;
ofa
249
Waist-tohip ratio
Height
166.0 166.4 163.9 166.8
I1
±
AND
study4
y
A-E (n
CALORIES
250
HILL
mask for 3-5 mm. Respired was continuously monitored using
Ametek
values
were converted
S-3A
air entered a mixing chamber and for oxygen and carbon dioxide
and
CD-3A
to energy
analyzers.
O2-consumption
expenditure
by use ofthe
Weir
(1 1).
equation
Treadmill
(I)
U)
tests ofmaximum
Each
subject’s
aerobic
maximum
capacity
aerobic
capacity
fore and after the study by a treadmill
I-
was measured
be-
test using a Bruce proto-
(I 2).
col
02 and CO2 content ofexpired air during exercise was measured with an oxygen-uptake system (Sensormedics, Anaheim, CA). Maximum aerobic capacity (VO2max) was taken
to be the average of the two or three highest values of sumption. To ensure that a true maximum had been a respiratory quotient of > 1 I , a heart rate near the dicted maximum, and an increase in 02 consumption .
ml/kg mum
in response heart rates
set exercise
for subjects
in the aerobic-exercise
using
pressure
was measured
a random-zero
pressure was taken it was based on the average Hormones
at baseline
sphygmomanometer. as they sat upright after
oftwo
readings
of
-
.
.
fat-free
mass
(FFM).
For
nonexercisers, 73% ofthe weight loss came from fat and 27% from FFM. FFM declined by 5% in the group as a whole (47.6 ± 1 . 1 to 46.0 ± 1.0 kg, p < 0.05), with no difference as a function ofdiet or exercise condition. The caloric value ofthe weight loss was estimated with a value of900 kcal/kg for FFM (1 7) and 9000 kcal/kg for fat (assuming that fat measured by hydrostatic weighing consists almost entirely of triglyceride). The diet condition had no effect on the amount of energy lost (55 430 ± 4965 kcal for constant-diet subjects vs 54 427 ± 7445
Li. >-
0
for
alternating-diet
subjects).
Subjects
in the
exercise
more energy (63 125 ± 5090 kcal) than nonexercisers (43 875 ± 8398 kcal); this difference approached statistical significance (p < 0.08). condition
lost
Waist-to-hip
Li. >-
WHR
0
EXERCISE
NO EXERCISE
FIG 2. Body-fat
percent is shown for the entire group (top), as a condition (middle), and as a function ofexercise group (bottom) (j + SEM). The percent change from baseline to posttreatment is displayed above the bars. function
ofdiet
44%
ratio not
change
group
as a whole
did
(0.873
with weight reduction in the ± 0.006 to 0.872 ± 0.006) and there were no differences as a function ofdiet or exercise condition. The initial WHR was significantly correlated with total weight loss (r = -0.35, p < 0.05) and total fat loss (r = -0.4 1, p < 0.05). Subjects with lower-body obesity (ie, a lower WHR) tended to lose more fat and total weight than subjects with upper-body obesity. Resting
metabolic
rate
Figure
3 presents
RMR
expressed
both
as kcal/h
(top)
as kcal . kg FFM ‘ . h ‘ (bottom). RMR in kcal/h dedined 5% in the group as a whole (63.5 ± 1 .5 to 60.4 ± 1 . 1 kcal/h, p < 0.05), with no diet or exercise effects. and
Actual food intake in the alternating-calorie group was estimated from a randomly selected day during each of the specific calorie levels. Estimated intake, in kcal, was 902 ± 29 during the 600-kcal days, 1006 ± 26 during the 900-kcal days, 1 1 20 ± 25 during the 1 200-kcal days, 1212 ± 30 during the l500-kcal days, and 1303 ± 43 during the 1 800-kcal days. Thus, subjects ate more cabries than specified on the low-calorie days and fewer than prescribed on the high-calorie days. There was clearly an alternation of calories but the range was from 900 to 1 300 kcal/d rather than 600 to 1 800 kcal/d, as prescribed.
When
RMR
was adjusted
for changes
in FFM,
there
was
no
significant change with weight loss (1 .34 ± 0.03 to 1.31 ± 0.02 kcal.kg FFM’ .h’, NS). Although not statistically significant, initial RMR did show a positive correlation with total weight loss (r = 0.3 1, p < 0.08). Although there was only a slight decline in mean RMR, there was variability in RMR response, with some subjects showing an increase after weight loss and others a decrease. tracting the
Change posttreatment
in
RMR RMR
was computed in kcab/h from
by subthe base-
relative
of caloric
line RMR.
Body
The
composition
subjects
To investigate lost
an average
of 6.0
± 0.6
kg of body
fat during the study. There was no difference in fat loss between diets (6. 1 ± 0.6 vs 6.0 ± 0.8 kg for constant and alternating diets, respectively). Exercisers lost an average of 7 ± 0.6 kg from fat as opposed to 4.7 ± 1.0 kg for nonexercisers. The difference approached statistical significance (p < 0.07). Changes in body composition were also analyzed as change in percent body fat. Figure 2 presents
those
results.
The
overall
decline
in
percent
the effect
ofthe
restriction on changes in RMR, puted and divided by 1200 kcal, during weight loss. This would severity
of caloric
quirements. striction
showing changes caloric
The and
that could restriction.
restriction
correlation
degree
24-h RMR was comthe average daily intake be an indication of the
compared
with
energy
re-
relative caloric rechange in RMR was 0.788 (p < 0.001), 62% of the variance in metabolic-rate be accounted for by the relative degree of However,
between
the
direction
ofthis
associa-
Downloaded from www.ajcn.org by guest on July 10, 2011
kcal
HILL
252
ET AL to 4.8 1 ± 0.26 also ±
mmol/L, p < 0.05). Total triglycerides significantly with weight reduction (1.21 1.02 ± 0. 1 1 mmol/L, p < 0.05), with no diet effects.
decreased
0. 1 1 to
or exercise
L
Six-m
follow-up
Twenty-three ofthe 32 subjects (72%) returned for foblow-up measures 6 mo after the weight-loss program began. There was a marginally significant association between treatment group and follow-up adherence (X2 = 7.27, p < 0. 10) with 10 of 10 returning in the alternating-diet-exercise group, 6 of8 returning in the constantdiet-exercise group, 4 of 8 returning in the alternating-
U
z Ld
diet-no-exercise
group,
and
3 of 6 returning
in the con-
stant-diet-no-exercise group. Table 3 presents the results for the diet and exercise conditions. The group differences were not significant but total weight loss at 6 mo was twice as great for exercisers as for nonexercisers.
Similarly,
exercisers
fat at 6 mo
tended
than
did
to have
greater
reduction
in
nonexercisers.
0
Discussion The ing)
zo
did
pattern not
of food affect
amount
restriction
(constant
or composition
vs alternatofweight
loss
w
z 555
U
FIG 3. Resting
metabolic
h’ (bottom) before and difference between groups
tion
suggests
that
rate in kcal/h (top) after weight loss (i (p < 0.05).
those
subjects
with
and kcal.
SEM).
+
the
highest
kg FFM. 4Significant
.
initial
RMRs are the ones most likely to experience the greatest drop in RMR during weight loss. In fact, two subjects had a measured RMR of < 1 200 kcal/d and RMR increased
with
Maximum
weight aerobic
Figure 4 shows to posttreatment. whole with weight affected by the diet tion. Bloodpressure,
Weight
loss
“55
U
subjects.
capacity
the change in VO2max from baseline VO2max increased in the group as a loss. The increase in VO2max was not condition nor by the exercise condiONTM4T
lipids,
reduction
in these
z
insulin,
and
z
glucose
was accompanied
*LWflNG
by an increase
in
555
U
fasting glucose (4.9 ± 0.05 to 5. 1 ± 0.05 mmol/L, p < 0.05) without any change in fasting insulin (95 ± 8 to 108 ± 10 pmol/L, NS). Systolic(l 15 ± 2 to 108 ± 2mm Hg, p < 0.05) and diastolic (80 ± 1 to 74 ± 1 mm Hg, p < 0.05) blood pressure decreased with weight loss, with
no diet or exercise
effects.
Losing
weight
also led to a sig-
nificant reduction in total cholesterol (5.30 ± 0. 18 to 4.73 ± 0. 1 8 mmol/L, p < 0.05). Subjects in the alternating-diet condition showed greater reductions in total cholesterol than did subjects in the constant-diet condition (5.46 ± 0.26 to 4.68 ± 0.23 mmol/L vs 5.09 ± 0.23
DtER
NO DIEROSE
FIG 4. Maximum aerobic capacity (VO2max) is shown before and after weight loss for the entire group (top), as a function ofdiet condition (middle), and as a function of exercise condition (bottom) (1 + SEM).
Downloaded from www.ajcn.org by guest on July 10, 2011
body
ALTERNATING TABLE 3 Changes in body weight,
percent
body
fat, resting
metabolic
CALORIES
AND
rate, and VO2max
from
253
EXERCISE
baseline
values
Treat ment
to values
at 6-mo
follow-up4
group Diet
Exercise
9.6 6.2 4.6
Loss ofbody weight (kg) Reductioninpercentbodyfat Reduction ii RMR (kcal/h)
Increase
1
±
(1 1%)
1.1 (14%)
± 2.0
(7%)
9.5
4.7
± 3.5
4.3
±2.0(10%)
(5%)
5. 1
±
3.0 (8%)
2.7
1.7
±
2.2(8%)
3.4±
±
5.6± ±
calorie 14)
2.9 ( 12%)
7.2
1.2(13%)
5.6
±
1.5(13%)
3. 1 (6%)
6.3
±
1.9(9%)
1.2(13%)
1.2
± 2.0(4%)
± 2.7(8%)
in VO2max 2.4±
(mL.kg.min’) 4
± 2.4
Alternating (n=
Constant calorie (n=9)
No exercise (n=7)
Exercise (n= 16)
±
SEM.
Numbers
in parenthesis
1.4(10%)
are proportions
of before-weight-loss
values.
None
of the differences
within
treatment
groups
were signifi-
cant.
exercise led to greater total weight loss and a reduction in body fat percentage than did no exercise. RMR was reduced by “‘-5% in all subjects, with neither pattern of food restriction nor exercise having any differential effect. The only observed advantage to the alternating-calorie regimen was a significantly greater reduction in total cholesterol. A pattern of alternating-calorie intake provided neither an advantage nor a disadvantage in weight reduction in this study. These data did not support the suggestion that rotating one’s caloric intake differentially affects RMR (5). However, both diets in the present study represent moderate caloric restriction and the drop in RMR was totally explained by the drop in FFM. It is possible that pattern of caloric intake may be more important in very-low-calorie diets, in which the drop in RMR may be greater than the decline in FFM. In the present study subjects with higher baseline RMR values, and thus on a less extreme caloric restriction, were more likely to experience RMR reductions. The relationship between relative and absolute degree of caloric restriction and changes
in RMR
deserves
further
investigation
with
con-
Our
subjects
consumed
bohydrate, moderate-protein, loss. Low-calorie diets often carbohydrate,
moderate-fat
a relatively
low-fat diet during have a high-protein, composition.
Dietary
ing
subjects
leading
or to exercise’s
to a greater
despite
a failure
to find
a significantly
VO2max in the exercise subjects. proved VO2max and although tended to show a greater increase ing, the difference cally significant.
was highly It is possible
greater
increase
in
Weight loss alone imthe exercise subjects in VO2max with trainvariable and that exercise
not statisticompliance
the
case
because
exercising
subjects
reported
more
than five exercise bouts per week. Additionally, self-reports ofexercising subjects in the weekly group meetings suggested subjects enjoyed the exercise sessions and believed exercise to be a major factor in their success in weight reduction. These results suggest that the benefits of exercise occur with a moderate walking program and that part ofthe difference in weight loss can be accounted for by increased energy expenditure caused by increased activity. Exercise apparently has some effects on adherence to the. weight-loss program because the drop-out rate was lower in the exercise than in the no-exercise groups. We do not believe the different drop-out rate was due to
high-car-
weight lowcarbo-
effects on substrate oxidation total energy expenditure and
sub(7).
The reasons why the effects of exercise on body weight during dieting are discrepant are not well understood. The discrepancy may be due to the interaction oftype of exercise with type ofcaloric restriction. The effects of exercise were apparent in this study
was
hydrate content may influence RMR through its proteinsparing effect or through its impact on substrate utilization (19). The effect of macronutrient content on RMR changes deserves further controlled investigation. In spite of the fact that exercise did not differentially affect RMR, it was undoubtedly a beneficial component ofthe weight-loss program, leading to greater total weight loss and more reductions in percent body fat. The effects of exercise on body weight and body fat in this study could be due to greater adherence to the diet by exercis(19),
study, with some reporting greater weight loss ifthe jects exercise (2 1) and others reporting no difference
decreased as exercising subjects were required to attend fewer supervised exercise sessions. We do not believe this
trolled research designs and larger samples of subjects. The dietary regimens in this study differ in composition as well as in overall energy content from those used in other studies (1 8) in which large reductions in RMR occurred.
greater oxidation of fat. We did not find any evidence that exercise led to differential amounts or composition ofdietary intake and we did find that exercise altered the composition of the weight loss. This suggests the effects ofexercise were more due to increased oxidation of lipid than to greater adherence to the diet. Other studies have shown that exercise is a valuable addition to food-restriction programs for the treatment ofobesity (6, 20). However, the specific benefits of exercise vary from study to
differences in the were experienced bowed a prescribed a
We
found
behavioral groups. The group leaders in leading weight-loss groups and fobagenda for each group meeting.
a significant
negative
correlation
between
Downloaded from www.ajcn.org by guest on July 10, 2011
whereas greater
254
HILL
the subject’s
initial
weight
and body
er-body
obesity
WHR lost
of Wadden
weight they
with
more
weight
equally
from
weight
than
et al (22)
with
body
The exercising the 6-mo follow-up
did
with
women
with
lower-body their
Thus, and
obesity;
WHRs
they
did
lost
fat
for testing
We believe that greater than re-
reduction Sixteen
for fobunsuc-
than were subofthe 18 exercise
as compared
with
of the
intakes
seen
in subjects
jects in a supervised program, obese individuals in the general ticipating in the Rotation Diet
participating
9.
10.
1 1.
12.
in the
we do not believe that population who are parmeet the prescribed range
A true test ofthe caloric rotation suggested in the Rotation Diet (5) would almost certainly require an in-patient study in which caloric intake can be carefully controlled. In summary, these results offer more support that a program of moderate exercise is a beneficial addition to a weight-reduction program. Exercise led to greater total weight
l988;9:39-47. 8.
7 of the
Rotation Diet. We cannot state that a wider range of alternating caloric intake, such as 600-b 800 kcab/d, would not produce different results from those obtained in the present study. However, based on our results from sub-
ofcabone
7.
subjects.
It could be argued that this study does not provide a true test of the popular Rotation Diet (5) because the range ofcaboric intake was less than that specified in that diet. However, we provided the same target caloric intakes as are specified in that diet and we believe that the range ofcaboric intake in the present study are representative
6.
depots.
13.
14.
15.
rotation.
loss
The data and after a reduced
and
a greater
reduction
in percent
body
16. 17.
18.
fat.
also suggest that subjects who exercise during weight reduction are better able to maintain body weight than are those who do not exer-
19.
20. #{163}3
cise.
2 1.
References 1. Bray G. Management lO4A-l 121. 2. Bessard T, Schutz
options Y,
Jequier
in obesity. E.
Hosp
Energy
Pract expenditure
1982; 17: and
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returned
14 nonexercise
a weight for testing.
4. 5.
subjects seemed to be doing better at than the nonexercisers, although sig-
cessful at maintaining jects who did return
3.
change
apparently
lower-body
of
although not
because the subjects who refused to return assessment were more likely to have been
subjects
bow-
distribution
nificant differences were not obtained. the magnitude of the difference is even
ported low-up
in body
women
concerning
weight,
reduction. upper-
reduction
that
and is consistent with results reet al (22). Our results also support
boss in women lost
the total
suggests
more
upper-body obesity ported by Wadden those
and
fat. This
ET AL
