Weight Management

The Rocky Road of Weight Loss Maintenance

If you think losing weight is hard, try keeping it off. Without bariatric surgery, only 15% to 20% of people lose 10% of their weight and maintain it for at least a year.

Why Is It so Hard? 

It’s easy to forget that genetics play a tremendous role in body weight. When we conclude that weight regain is primarily a problem with willpower, we ignore the facts related to biological processes. Although our food and physical activity choices generally are under our control, many other weight-related factors aren’t. Understanding these contributors can build empathy towards our clients and help us become more effective weight management counselors.

  • Metabolic adaptation: Calorie restriction and weight loss cause a drop in resting metabolic rate. Even with weight regain, metabolism may not rebound as expected. Erin Fothergill and colleagues recently published long-term results from contestants who lost weight on The Biggest LoserSix years after the show, participants had regained about 70% of their weight. Remarkably, resting metabolism was still approximately 500 kcal below what we would expect from individuals with similar body compositions. Although metabolic adaptation isn’t fully understood, it appears to begin soon after calories are reduced and may be sustained indefinitely.
  • Increased appetite: You’ve probably experienced times when, despite eating what should be enough to fuel your body, you still don’t feel satisfied. Imagine if you felt this way all the time. Weight loss leads to changes in hormones that increase appetite and decrease satiety. Leptin and ghrelin are involved as well as many other factors including glucagonlike peptide-1, peptide YY, and cholecystokinin.
  • Restraint fatigue: Roy Baumeister, PhD, has conducted several experiments on self-control—one of which included placing participants in a room with radishes and chocolate chip cookies. He asked some to eat only the radishes and others to indulge in the chocolate chip cookies. After a short time, he measured their persistence on puzzles without solutions. The “cookie restrainers” gave up much sooner on trying to solve the puzzles. He has theorized that self-control is like a muscle that can be fatigued. Not everyone agrees with his theory, but it’s common for individuals who have practiced restricted diets to become “burned out” with following a rigid plan.
  • Diminishing motivation: When people are losing weight, their behaviors are frequently encouraged and reinforced. The scale moves; they feel better, wear smaller sizes, and receive compliments. When weight plateaus or begins to creep up again, these motivations disappear, and the compliments eventually fade away.

What’s a Dietitian to Do? 

  • Dance near the psychological sweet spot. If your intervention goals are too lofty, both you and your patient can become frustrated. Maintain a hopeful tone while discussing realistic long-term expectations. Your interactions should be more of a “dance” than a wrestling match, and the psychological sweet spot is one that appreciates self-control as well as genetic and biological factors.
  • Broaden your knowledge. Patients seek help from RDs because of our expertise. Stay up to date on obesity research as well as the periphery of weight management—approved medications, bariatric surgery and endoscopic procedures, wearable fitness devices, and useful apps.
  • Know what works but keep an open mind. Frequent provider contact, self-weighing, food journaling, and more than 200 minutes of exercise per week help prevent weight regain. But there’s no simple solution that works for everyone. No matter our personal beliefs about the best approach, it’s important to remain flexible based on what’s realistic, desirable, and safe for clients. Some may benefit from medical interventions, prepacked meals, lower-carbohydrate approaches, or intermittent fasting. Be willing to accept improvements over ideal plans.

— David B. Creel, PhD, RD, HSPP, is a psychologist and ACSM-certified clinical exercise physiologist. He works as a clinician and researcher at the St. Vincent Carmel Bariatric Center of Excellence in Carmel, Indiana. Visit his blog at drdavidcreel.com.

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