Despite the intensive behavioral counseling in our study, participants had difficulty achieving the goals for macronutrient intake of their assigned group. The mean differences among the groups in fat, carbohydrate, or protein intake at 6 months were nevertheless often greater than those in several previous trials comparing diets for weight loss. Substantially diminished adherence after the first few months is typical in weight-loss trials and occurred between 6 months and 2 years in our trial. Only two trials have reported dietary intake beyond 1 year, and one of them provided foods to the participants. In addition, trials of low-carbohydrate diets have reported a very low incidence of urinary ketosis after 6 months, suggesting that in most overweight people, it is futile to sustain a low intake of carbohydrates. Overall, these findings with respect to adherence to macronutrient goals suggest that participants in weight-loss programs revert to their customary macronutrient intakes over time but may nonetheless be able to maintain weight loss.


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