weight-control benefits in less-selected US adults: eating a lower-fat diet somewhat higher in fruit, vegetables, and fiber and engaging in as little as 4 h of moderate physical activity

unusually high levels of physical activity (equivalent to walking 45 km/wk). But proportional reductions in these recommended lifestyle choices still produce measurable long-term weight-control benefits in less-selected US adults: eating a lower-fat diet somewhat higher in fruit, vegetables, and fiber and engaging in as little as 4 h of moderate physical activity per week (6). The second conceptual advance is the illustration that effective, short-term, temporary shaping of qualitative food choices can influence long-term behavioral success at reducing excess energy intake. Hill et al observed that patients taking orlistat early in the trial quickly learned not to exceed the recommended fat intake if they wanted to avoid unpleasant gastrointestinal events. Nearly all (95%) patients assigned to the orlistat condition reported unpleasant gastrointestinal events early in the trial but quickly learned how to avoid such events. Hill et al’s Figure 3 appears to show that the orlistat group decreased their dietary fat intake 5-fold more than did the placebo group, from week 2 of orlistat therapy to 1 y of follow-up. Is this sharper decline significant? If so, might it not be reasonably conjectured that orlistat serves as a behavioral analogue to antabuse by making dietary relapses back to high-fat meals unpleasant? This inadvertent aversive therapy effect could help to explain why, in the European orlistat trial (7), taking patients off orlistat during the second year did not impair the weight-control advantage obtained while receiving orlistat during year 1. This result suggests that orlistat therapy could be withdrawn after 1 y with only a partial return of the fat absorption level observed at baseline. These important conceptual advances, if confirmed, should stimulate increased behavioral research on how qualitative differences in foods relate to variations in satiety and how best to motivate the eating of high-satiety foods. When obtained in minimally processed, natural foods, the constituents water and fiber hold particular promise for contributing to satiety (8). Such issues as meal frequency and starch resistance (9) have been examined with respect to their effect on blood glucose but have yet to be investigated thoroughly with respect to long-term weight control. Finally, there has been remarkably little research on the potential for daily physical activity to influence adherence to a diet of high-satiety foods, especially fruit and vegetables, despite some cross-sectional evidence of doseresponse relations (10). While these theoretical issues are being sorted out by the researchers, the clinician would do well to recommend a sustainable version of the nutrient-rich, high-activity NWCR weight-control strategy before considering the use of orlistat. Not only does the NWCR strategy yield maintenance of far greater excess weight loss long-term than was shown so far for orlistat, but it also yields salubrious increases in micronutrients. The use of orlistat, by contrast, is associated with significant, unavoidable losses of fat-soluble micronutrients, with unknown long-term consequences for health.