Introduction. Approximately one-third of American adults are overweight. 1 Although behavioral weight loss programs

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1 International Journal of Obesity (1998) 22, 1103±1109 ß 1998 Stockton Press All rights reserved 0307±0565/98 $ retention through a correspondence intervention EA Leermakers 1, K Anglin 1 and RR Wing *1 1 Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, USA OBJECTIVE: Since post-pregnancy weight retention may contribute to the development of obesity, we sought to determine whether a behavioral weight loss intervention was effective in returning women to their pre-pregnancy weight. METHOD: Ninety women who had given birth in the past 3±12 months and whose weight exceeded their prepregnancy weight by at least 6.8 kg were randomly assigned to either: a) a six-month behavioral weight loss intervention, delivered via correspondence or b) a no-treatment control group. Assessments of body weight, physical activity and eating patterns were conducted at pre-treatment and six months (post-treatment). RESULTS: During the six month treatment, subjects in the correspondence condition lost signi cantly more weight than control subjects (7.8 kg vs 4.9 kg, P ˆ 0.03) and lost a greater percentage of their excess postpartum weight (79% vs 44%, P ˆ 0.01). Furthermore, a signi cantly greater percentage of correspondence subjects than controls returned to their pre-pregnancy weight (33% vs 11.5%, P < 0.05). Weight loss in the correspondence group was correlated with completion of self-monitoring records (r ˆ 0.50, P < 0.005). CONCLUSIONS: A behavioral weight loss intervention, delivered via correspondence, appears to be effective in reducing women's postpartum weight retention. Future studies should examine the acceptability and the long-term impact of a correspondence postpartum weight loss intervention. Keywords: postpartum; weight loss; correspondence Introduction Approximately one-third of American adults are overweight. 1 Although behavioral weight loss programs generate initial weight losses, they have not been successful at promoting long-term maintenance of weight loss. Therefore, a major research direction encouraged by the National Task Force on Prevention and Treatment of Obesity 2 is the prevention of weight gain. One approach to preventing weight gain is to identify time periods during which individuals are at high risk for gaining weight. For women, one such high risk period is the time surrounding childbirth (that is, during gestation and the postpartum year). One review 3 of the literature on postpartum weight changes indicated that, on average, women retain only a small amount of weight (approximately 1.5 kg) postpartum. However, there is a great degree of variability in the amount of weight retained after pregnancy. For example, 12% of a sample of 1599 women retained 4±6 kg at 10±18 months postpartum, and 14% of the women retained kg. 4 Excessive postpartum weight retention may be associated with the * Correspondence: Dr Rena R. Wing, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA 15213, USA. Received 4 August 1997; revised 14 May 1998; accepted 18 June 1998 development of obesity. Ohlin and Rossner 5 indicate that 40±50% of the severely obese women who seek treatment at their clinic, report that their obesity was initiated by previous pregnancies. The best predictor of postpartum weight retention is excessive weight gain during pregnancy. Gestational weight gain above the recommended range is associated with postpartum weight retention. 6 Thus one approach to the problem of postpartum weight retention is to intervene during pregnancy and try to help women gain an appropriate amount of weight. However, programs which focus on weight gain restrictions during pregnancy are controversial, because of the strong relationship between maternal weight gain and fetal birthweight. 7 Therefore, another approach is to intervene during the postpartum period, to help women lose the excess weight gained during pregnancy. Other factors that may in uence postpartum weight retention include breast-feeding and how quickly new mothers return to employment after giving birth. Although breast-feeding is commonly believed to in uence postpartum weight retention, research indicates that breast-feeding status does not have a longterm effect on postpartum weight. 5,8 However, some evidence suggests that the sooner new mothers return to work, the less weight they retain at six months postpartum. 9 New mothers who stay at home may have more access to food throughout the day and may spend more time cooking and feeding others.

2 1104 Other lifestyle factors, including increased calorie consumption and=or decreased physical activity, have also been associated with the retention of postpartum weight. 3,7 For example, Ohlin and Rossner 10 studying 1423 Swedish women, found that low levels of leisure time physical activity after delivery were associated with weight retention at one-year postpartum. Furthermore, greater weight retention at one-year postpartum occurred in women who reported increasing their caloric intake during and after pregnancy. 11 These results suggest that increased caloric intake and decreased exercise may play a role in postpartum weight retention. Therefore, a behavioral weight loss intervention, which focuses on decreasing intake and increasing physical activity, should be effective in helping women who have retained weight return to their pre-pregnancy weight. Behavioral lifestyle interventions, with weekly group treatment meetings, typically result in weight losses of 0.5 kg per week. 12 However, in a pilot study we conducted, we found that new mothers were not willing to attend weekly group behavioral treatment meetings, even when free child care was offered. Therefore, we chose a correspondence format for this study. We anticipated that a correspondence intervention would be more convenient for women at this very busy time in their lives. Correspondence interventions, including telephone and computer contact, have been used in managed care settings, where cost-effectiveness is important, 13,14 and with populations for whom it is impractical to recommend weekly group meetings. For example, community studies focusing on the prevention of weight gain have typically been delivered via correspondence. 15 Several studies have shown that correspondence interventions promote weight losses of approximately 1± 4 kg, 16 ±18 which are smaller than weight losses typically seen in group interventions, but superior to those in no-treatment control groups. Given that new mothers may be unwilling to participate in a groupbased intervention, a correspondence intervention with telephone contact may be a more effective way to promote weight loss in this population. This study was designed to examine whether a sixmonth correspondence behavioral weight control program delivered in the postpartum year can help women return to their pre-pregnancy weight. To our knowledge, this is the rst study to speci cally intervene with women during the postpartum year. It was hypothesized that women in the correspondence group would lose signi cantly more weight than women in the no-treatment control group. Methods Subjects Ninety women who had recently given birth at a local women's hospital were recruited for this study. To be eligible, women had to be at least 18 years old, to have delivered within the last 3±12 months and to currently exceed their pre-pregnancy weight by at least 6.8 kg. To reduce the likelihood of a woman becoming underweight if she lost 6.8 kg, only women with a current body mass index (BMI) 5 22 were included in this study. Women who were currently lactating were excluded from the study because of concerns that dieting and weight loss might affect lactation. All participants gave written informed consent prior to participation. Women entering this study had an average BMI of 29.8 and were 12.3 kg over their pre-pregnancy weight. The average age was 31 y and 97% of the participants were Caucasian. Treatment conditions Participants were randomly assigned to one of two conditions: No-treatment control condition. These participants (n ˆ 43) were given an informational brochure about healthy eating and exercise (C. Everett Koop's On Your Way to Fitness). They did not receive any treatment, but participated in assessments at pre-treatment and six months later. Correspondence condition. These participants (n ˆ 47) received a correspondence behavioral weight loss program, delivered over six months, which focused on low-fat=low-calorie eating habits and increasing physical activity. This intervention included three components: 1) two group sessions; 2) correspondence materials; and 3) telephone contact. First, participants were invited to attend two group sessions, held at the beginning of the intervention and at Month 2. At the rst session, women received group instruction in self-monitoring and getting started on the weight loss program. They were instructed to follow a diet consisting of 1000±1500 kcal=d, with fat restricted to 20% of caloric intake, as is typically used in behavioral weight loss programs. 19 Participants were also instructed to begin an aerobic exercise program, consisting primarily of walking, and to gradually increase the frequency and duration of their walking until they reached two miles per day on at least ve days per week. This prescription is consistent with the exercise guidelines for all adults, recommended by the American College of Sports Medicine (ACSM). 20 Women were asked to monitor their calorie and fat intake and their exercise on a daily basis throughout the sixmonth program and return their records by mail. At the second group session, there was a discussion of eating and exercise progress and problem-solving. The correspondence component consisted of 16 written lessons about nutrition, exercise and behavior change strategies, which were mailed to participants. These lessons were sent weekly for the rst 12 weeks,

3 biweekly for the next four weeks and monthly for the last eight weeks. Behavioral lessons, which focused on strategies to modify diet and exercise behaviors, were tailored to the special needs of new mothers. For example, to encourage participants to include their babies in their exercise, one exercise lesson contained information about appropriate strollers and special baby carriers. Each lesson included a 1±2 page homework assignment, which was to be completed and returned with the self-monitoring diaries. Finally, women in the intervention group were called by program staff on a regular basis during the six month intervention period. These brief telephone contacts (approx. 5±15 min) were made weekly or biweekly, depending on the participant's desires and needs. The discussions focused on eating and exercise progress, goal-setting and problem-solving. Participants were encouraged to weigh themselves at home on a weekly basis and report their weight during the phone contact. Assessments Pre-pregnancy weight and amount of weight gained during pregnancy were self-reported on a weight history questionnaire completed at pre-treatment. The following measures were completed at pretreatment and six months (post-treatment). Weight=height. Body weight was measured using a balance beam scale; participants were weighed in light street clothes without shoes. Height was measured with a stadiometer and used to calculate BMI (kg=m 2 ). Physical activity. Level of physical activity was assessed using the Paffenbarger Physical Activity Questionnaire, 21 a measure which estimates weekly energy expenditure from self-reports of stairs climbed, blocks walked and other recreational activities performed in the past week. Eating behavior. Daily caloric intake and percent intake from fat were assessed using the 60-item Block Food Frequency Questionnaire. 22 This questionnaire was modi ed to ask about intake over the past six months. Program Adherence. Three measures of adherence to the correspondence intervention were used: 1) number of self-monitoring records returned; 2) number of homework assignments returned; and 3) number of phone contacts completed. Statistical analysis One-way analyses of variance (ANOVAs) were used to compare the two conditions on continuous variables measured at baseline (for example, pre-treatment weight, physical activity, and eating habits) and chi square statistics were used to compare groups on categorical demographic variables. Repeated-measures analyses of covariance were used to compare the two conditions on changes in weight, calorie intake and percent fat intake over time, adjusting for baseline differences between conditions. Because the physical activity scores at pre-treatment and posttreatment were not normally distributed, physical activity scores were log transformed prior to conducting the repeated-measures ANOVA. Stepwise regression was used to determine which variables predicted how close women came to returning to their prepregnancy weight. Results Pre-treatment characteristics of the 90 women who began the study are presented in Table 1. Correspondence participants were signi cantly older than control participants (32.4 vs 30.3 y P < 0.05), and a greater percentage of correspondence women were married, compared to control women (93.5% vs 79.1%, respectively, P < 0.05). There were no other signi cant differences between the correspondence and control groups in the demographic or weight variables. Attrition Twenty-eight women (31%) did not provide posttreatment weight data, ve because of another pregnancy. Attrition did not vary by treatment group (w 2 ˆ 2.7, P ˆ 0.1); 11 women dropped out of the correspondence group (23%) and 17 dropped out of the control group (40%). There were no differences between drop-outs and completers in marital status, ethnicity, age, months since delivery or number of full-term deliveries (Ps > 0.1). However, dropouts were signi cantly heavier at pre-treatment ( kg) than completers ( kg) (P < 0.05) and retained signi cantly more weight (above their pre-pregnancy weight) at pre-treatment ( kg) than completers ( kg) (P < 0.005). Weight loss Weight and weight change data for all women who completed the post-treatment assessment (n ˆ 62) are presented in Table 2. For 12 subjects, post-treatment weight is based on self-report of weight measured on a balance beam scale by a doctor or other health professional. The correspondence group lost signi cantly more weight during the six-month treatment than the control group (7.8 kg vs 4.9 kg; P < 0.03), and lost a greater percentage of their pre-treatment body weight ( % vs %, P < 0.005). After adjusting for baseline differences in age and marital 1105

4 1106 Table 1 Pre-treatment demographic and weight characteristics [% or mean s.d. (range)] Correspondence Control Variable (n ˆ 47) (n ˆ 43) Ethnicity % Caucasian 98% 95% Marital Status* Married 93.5% 79.1% Single 2.2% 20.9% Separated=Divorced 4.3% 0% Employment status Currently employed 60.9% 62.8% Currently not employed 39.1% 37.2% Education High School 17.4% 16.7% Some College 13.1% 23.8% College Degree 39.1% 47.6% Graduate Degree 30.4% 11.9% Age* (24± 43) (18±40) Months since delivery (3.2± 12.2) (3.0± 11.8) Full-term deliveries (including current) (1± 4) (1± 4) Pre-pregnancy weight (kg) (52.3± 86.4) (52.3±109.1) Pre-pregnancy BMI (20.3± 33.2) (20.1±39.0) Pregnancy weight gain (kg) (4.6±29.6) (9.1± 36.4) Percent of subjects who exceeded IOM weight-gain 64% 77% recommendations Pre-treatment weight (kg) (9.1±117.2) (59.6±130.6) Pre-treatment BMI (23.4± 42.0) (23.4±43.5) Weight retained at study entry (kg) (Pre-treatment weight 7 pre-pregnancy weight) (5± 35.3) (5.6± 26.4) Physical activity (kcal=week) (84±4712) (28±38%) Caloric intake (kcal=d) (686±7418) ( ) Fat intake (% total calories) (23.3± 54.5) (20.1±54.5) *Signi cant between-group difference, P < There were no other signi cant between-group differences, Ps > BMI ˆ body mass index; IOM ˆ Institute of Medicine. Table 2 Weight change for subjects who provided post-treatment data [mean s.d. (range)] Correspondence Control Variable (n ˆ 36) (n ˆ 26) Baseline characteristics Pre-treatment weight (kg) (59.1± 105) (59.5±114.5) > 0.10 Weight retained at study entry (kg) (5.0±26.4) (5.6± 20.5) > 0.10 Months post pregnancy (3.2±12.2) (3.0± 11.8) > 0.10 Changes during intervention Weight loss (kg) (0± 20.3) ( ±21.4) 0.03 Weight loss (% of initial body weight) (0± 25.1) ( ±18.7) Weight retained at post-treatment (kg) (post-treatment ( ±16.8) ( ±18.3) 0.05 weight 7 pre-pregnancy weight) Retained weight lost (%) (0±211) ( 7 26 ± 214) 0.01 Women at or below pre-pregnancy weight at post-treatment [n (%)] 13 (36.1%) 3 (11.5%) 0.05 status, these differences remained signi cant (P < 0.05 and P < 0.009, respectively). Moreover, correspondence subjects lost 79% of their excess postpartum weight, whereas control participants lost only 44% of their excess postpartum weight, P ˆ A greater percentage of women in the correspondence group (33%) returned to, or below, their pre-pregnancy weight, compared with women in the control group (11.5%) (P < 0.05). Using an intent-to-treat approach, we imputed missing post-treatment weight data by assuming that women who did not complete the post-treatment assessment had no weight change from their pretreatment weight. The ve women who became pregnant during this study were excluded from this analysis. Using this strategy, the average weight losses in both groups were lessened, but all of the betweengroup differences were maintained. The correspondence group lost kg, while the control group lost only kg (P < 0.004). This difference remained signi cant after adjusting for age and marital status (P < 0.01). Of the correspondence group, 27% returned to their pre-pregnancy weight, while only 7% of the control group did (P < 0.04).

5 Physical activity and eating patterns. Information on weekly energy expenditure, daily calorie intake and percent intake from fat was available for 30 subjects in the correspondence group and 16 in the control group at post-treatment. Again, subjects with missing data were more overweight at baseline and had retained more of their pregnancy weight at entry into the study, than subjects who completed these data (Ps < 0.05). At baseline, the two treatment groups were similar on all of these measures (Ps > 0.1). Energy expenditure did not change over time in either the correspondence condition (924 kcal=week at baseline and 1000 kcal=week at six months) or in the control condition (1184 kcal=week at baseline and 1229 kcal=week at six months). In contrast, both groups signi cantly reduced their daily energy intake and percent of calories from fat over time (Ps < 0.001). The correspondence condition decreased their intake from 1794 kcal=d to 1331 kcal=d and their percentage of calories from fat were reduced from 34.6% to 29.4%. Changes in the control condition were of similar magnitude (1957 kcal=d at baseline and 1340 kcal=d at six months; 37.6% fat at baseline and 31.2% fat at six months). Weight loss was unrelated to these changes in diet or exercise (Ps > 0.1). Adherence Because the drop-outs discontinued their participation in the program within the rst few weeks, adherence data are presented only for correspondence participants who provided post-treatment data. Correspondence subjects (n ˆ 36) returned (of a possible 25) self-monitoring records and (of a possible 15) homework assignments. They received an average of telephone contacts during the six-month program. There was a signi cant correlation between number of self-monitoring records returned and weight loss (r ˆ 0.50, P < 0.005). There were no signi cant associations between homework completion or telephone contact and weight loss (Ps > 0.1). Regression A stepwise regression analysis was conducted to predict how close women came to returning to their pre-pregnancy weight. Variables that had been signi cant in univariate analyses were examined, including the amount of weight retained at pre-treatment, months since delivery, treatment group, age and marital status. Results indicated that the amount of weight retained at pre-treatment (kg above pre-pregnancy weight) was the strongest predictor of how close a woman came to returning to her pre-pregnancy weight (P < 0.001). The more weight a participant retained at pre-treatment, the farther she was from her pre-pregnancy weight at post-treatment. The only other variable signi cantly related to return to prepregnancy weight was treatment group membership (P < 0.03). Correspondence participants came closer to returning to their pre-pregnancy weight than control participants. The model including amount of weight retained at pre-treatment and treatment group accounted for 34% of the variance in return to prepregnancy weight. Discussion A correspondence weight loss intervention delivered during the postpartum year was effective in reducing postpartum weight reduction. Women in the correspondence group lost 7.8 kg or 79% of their excess postpartum weight, compared to the no-treatment control group, who lost only 4.9 kg or 44% of their excess weight. The correspondence intervention included several components which may have contributed to its effectiveness. The signi cant correlation between completion of self-monitoring records and weight loss suggests that encouraging women to self-monitor and providing feedback on these diaries may be the key component of the intervention, as has been reported in many other behavioral weight loss programs. 23 In contrast, the failure to nd a relationship between number of phone contacts and weight losses raises the possibility that this component of the intervention, which was the most expensive aspect of the program, may not be necessary. Although a 20% fat goal was recommended, subjects reduced their fat intake only to 30% of calories. These data and the failure to nd a signi cant correlation between eating or exercise behavior and weight loss may re ect poor adoption of the suggested behavior changes and problems with self-report of this information. 24 This study suggests some advantages and disadvantages to intervening in the postpartum period. The weight losses seen in the correspondence group compare favorably with weight losses seen in behavioral programs that include weekly treatment meetings. 12,25 Even the control group in the present study was successful at weight loss and achieved larger weight losses than usually seen in control conditions. 26 Although this may re ect the fact that weight loss occurs naturally during the postpartum year, previous studies suggest that most of the postpartum weight loss that occurs without intervention is seen during the rst nine months postpartum, 27,28 whereas women in the current study were, on average, already eight months postpartum. Alternatively, the large weight losses achieved in both the correspondence and control condition may re ect the fact that these women were particularly motivated to lose weight. Evidence supporting this comes from the fact that 23% of the controls who provided post-treatment data, reported joining Weight Watchers or another formal weight loss program during the six month intervention. 1107

6 1108 Disadvantages to intervening at this time were also apparent. The attrition rate (27%, excluding women who became pregnant again) is higher than that typically seen in behavioral weight loss interventions. 12 The women who dropped out, were the ones who most needed to lose weight; they were heavier at the start of the study and had retained more of their pregnancy weight gain than program completers. Because we were unable to reach many of the dropouts, we do not know why they dropped out. It may be that drop-outs were motivated to lose weight, but were dissatis ed with their group assignment (controls) or with the limited contact with treatment staff (correspondence). Another potential explanation for the high drop-out rate is that participating in a weight loss program, even one with limited time demands, is too big a burden for new mothers. The fact that women in the program were unable to signi cantly increase their physical activity, despite the emphasis on this aspect in the program, and the evidence that fat intake was not reduced to the 20% level recommended, suggest that it may be particularly dif cult to make such behavior changes at this time in a woman's life. Finally, the fact that ve of the women became pregnant again re ects another dif culty intervening in the postpartum period. Therefore, although the postpartum year may be an effective time period for a weight loss intervention, it may not be a convenient and appealing one for new mothers. Although the correspondence program improved weight loss, only 33% of women in this condition returned to their prepregnancy weight. Since selfmonitoring was associated with weight loss and participants completed only 40% of their self-monitoring records on average, better weight loss might be obtained by improving adherence to self-monitoring. Results of the regression analysis indicated that the strongest predictor of return to prepregnancy weight was the amount of weight retained at pretreatment. Since women on average had to lose > 12 kg (ranging up to 35 kg) in order to return to prepregnancy weight and behavioral weight loss programs achieve at best a 9 kg weight loss at six months, the duration of the current program may not have been suf cient to achieve this goal. Hopefully, this program may have given women the tools to continue losing weight in the future. Future studies should examine the longer term impact of this intervention on women's weight, although as noted above, such studies may be complicated by subsequent pregnancies in the participants. Conclusion A weight loss intervention delivered by correspondence during the postpartum year was effective in helping women reduce excess postpartum weight. To our knowledge, this study is the rst to intervene during this particular high-risk period for weight gain. Although the success of this intervention suggests that the postpartum year may be a good time to intervene, it remains to be seen whether such a program can in uence long-term weight and would be acceptable to the general population of women retaining weight post-pregnancy. Acknowledgements The authors thank Dr Cynthia Sims of Magee Womens Hospital for her assistance with subject recruitment. Supported by a Pilot=Feasibility Grant from the Obesity=Nutrition Research Center (DK46204). References 1 Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among US adults. J Am Med Assoc 1994; 272: 205± The National Task Force on Prevention and Treatment of Obesity. Towards prevention of obesity: Research directions. Obes Res 1994; 2: 571± Lederman SA. The effect of pregnancy weight gain on later obesity. Obstet Gynecol 1993; 82: 148 ± Keppel KG, Taffel SA. Pregnancy-related weight gain and retention: Implications of the 1990 Institute of Medicine guidelines. Am J Public Health 1993; 83: 1100± Ohlin A, Rossner S. Maternal body weight development after pregnancy. Int J Obes 1990; 14: 159± Green GW, Smiciklas-Wright H, Scholl TO, Karp RJ. Postpartum weight change: How much of the weight gained in pregnancy will be lost after delivery? Obstet Gynecol 1988; 71: 701± Abrams B. Prenatal weight gain and postpartum weight retention: A delicate balance. Am J Public Health 1993; 83: 1082 ± Parker JD, Abrams, B. Differences in postpartum weight retention between black and white mothers. Obstet Gynecol 1993; 81: 768± Schauberger CW, Rooney BL, Brimer LM. Factors that in uence weight loss in the puerperium. Obstet Gynecol 1992; 79: 424± Ohlin A, Rossner S. Factors related to body weight changes during and after pregnancy: The Stockholm Pregnancy and Weight Development Study. Obes Res 1996; 4: 271 ± Ohlin A, Rossner S. Trends in eating patterns, physical activity and sociodemographic factors in relation to postpartum body weight development. Br J Nutr 1994; 71: 457± Wadden TA. The treatment of obesity: An overview. In: Stunkard AJ, Wadden TA (eds). Obesity Theory and Therapy. Raven Press: New York, 1993, 197 ± Clark M, Ghandour G, Miller NH, Taylor CB, Bandura A, DeBusk RF. Development and evaluation of a computer-based system for dietary management of hyperlipidemia. J Am Diet Assoc 1997; 97: 146± Piette JD, Mah CA. The feasibility of automated voice messaging as an adjunct to diabetes outpatient care. Diabetes Care 1997; 20: 15± Jeffery RW, French SA. Preventing weight gain in adults: Design, methods, and one year results from the Pound of Prevention study. Int J Obes 1997; 21: 457± Black DR, Coe WC, Friesen JG, Wurzman AG. Minimal interventions for weight control: A cost-effective alternative. Addict Behav 1984; 9: 279±285.

7 17 Forster JL, Jeffery RW, Schmid TL, Kramer FM. Preventing weight gain in adults: a Pound of Prevention. Health Psychol 1988; 7: 515± Jeffery RW, Danaher BG, Killen J, Farquhar JW, Kinnier R. Self-administered programs for health behavior change: Smoking cessation and weight reduction by mail. Addict Behav 1982; 7: 57± Wing RR, Jeffery RW, Burton LR, Thorson C, Nissinoff KS, Baxter JC. Food provision versus structured meal plans in the behavioral treatment of obesity. Int J Obes 1996; 20: 56± Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King AC, Kriska A, Leon AS, Marcus BH, Morris J, Paffenbarger Jr RS, Patrick K, Pollock ML, Rippe JM, Sallis J, Wilmore JH. Physical activity and public health: A recommendation from The Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995; 273: 402± Paffenbarger RS, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol 1978; 108: 161± Block G, Hartman AM, Dresser CM, Carroll MD, Gannon J, Gardner L. A data-based approach to diet questionnaire design and testing. Am J Epidemiol 1986; 124: 453± Baker RC, Kirschenbaum DS. Self-monitoring may be necessary for successful weight control. Behav Ther 1993; 24: 377± Lichtman SW, Pisarska K, Berman ER, Pestone M, Dowling H, Offenbacher E, Weisel H, Heshka S, Matthews DE, Heyms eld SB. Discrepancy between self-reported and actual caloric intake and exercise in obese subjects. N Engl J Med 1992; 327: 1893± NIH Technology Assessment Conference Panel. Methods for voluntary weight loss and control. Ann Intern Med 1993; 119: 764± Jeffery RW, Wing RR, Thorson C, Burton LR, Raether C, Harvey J, Mullen M. Strengthening behavioral interventions for weight loss: A randomized trial of food provision and monetary incentives. J Consult Clin Psychol 1993; 61: 1038± Crowell DT. Weight change in the postpartum period: A review of the literature. J Nurse Midwifery 1995; 40: 418± Dewey KG, Heinig MJ, Nommsen LA. Maternal weight loss patterns during prolonged lactation. Am J Clin Nutr 1993; 58: 162±

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