Weight loss is achievable through various methods, but maintaining that weight loss long-term is significantly more challenging. Obesity interventions commonly result in initial rapid weight loss, followed by a plateau and subsequent regain. This article explores the biological, behavioral, and environmental factors that contribute to this common weight trajectory and their implications for long-term weight management.
The Challenge of Long-Term Weight Management
Substantial weight loss is possible through a range of treatment modalities, but sustaining that weight loss over the long term is considerably more challenging, and weight regain is typical. In a meta-analysis of long-term weight loss studies, a significant portion of lost weight was regained within a few years. Long-term weight management is extremely challenging due to interactions between our biology, behavior, and the obesogenic environment.
Consider the case of Robert, a 47-year-old patient who initially weighed 270 pounds. He successfully lost 85 pounds by adhering to a 1500-calorie-per-day diet and exercising six days a week. However, during his annual physical examination three years later, it was disheartening to find that he had regained almost 60 pounds. This scenario highlights the difficulties many individuals face in maintaining weight loss.
The Obesogenic Environment
The rise in obesity prevalence over the past several decades has been mirrored by the industrialization of the food system, involving increased production and marketing of inexpensive, highly-processed foods with supernormal appetitive properties. Ultraprocessed foods now contribute the majority of calories consumed in America, and their overconsumption has been implicated as a causative factor in weight gain. These foods are typically more calorically dense and far less healthy than unprocessed foods such as fruits, vegetables, and fish. Food has progressively become cheaper, fewer people prepare meals at home, and more food is consumed in restaurants.
Changes in the physical activity environment have also made it more challenging to be active throughout the day. Occupations have become more sedentary, and suburban sprawl necessitates vehicular transportation rather than walking to work or school as had been common in the past.
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The Flawed Logic of Simple Calorie Deficits
Outdated guidance to physicians and their patients gives the mistaken impression that relatively modest diet changes will consistently and progressively result in substantial weight loss. For example, cutting just a couple of cans of soda from one’s daily diet was thought to lead to significant weight loss over time. However, we now know that the simple calculations underlying the old weight loss guidelines are fatally flawed because they fail to consider declining energy expenditure with weight loss.
The Role of Biological Factors
In addition to adaptations in energy expenditure with weight loss, body weight is regulated by negative feedback circuits that influence food intake. The overlapping physiological changes that occur with weight loss help explain the near-ubiquitous weight loss time course: early rapid weight loss that stalls after several months, followed by progressive weight regain.
Appetite changes likely play a more important role than slowing metabolism in explaining the weight loss plateau since the feedback circuit controlling long-term calorie intake has greater overall strength than the feedback circuit controlling calorie expenditure. Specifically, it has been estimated that for each kilogram of lost weight, calorie expenditure decreases, whereas appetite increases above the baseline level prior to weight loss.
Mathematical model simulations illustrate the energy balance dynamics underlying the weight loss time courses of individuals who either regain or maintain much of their lost weight after reaching a plateau within the first year of a diet intervention. Large decreases in calorie intake at the start of the intervention result in rapid loss of weight and body fat leading to a modest decrease in calorie expenditure that contributes to slowing weight loss. However, the exponential rise in calorie intake from its initially reduced value is the primary factor that halts weight loss within the first year.
These mathematical model results contrast with patients’ reports of eating approximately the same diet after the weight plateau that was previously successful during the initial phases of weight loss. While self-reported diet measurements are notoriously inaccurate and imprecise, it may be possible to reconcile such data with objectively quantified increases in calorie intake. The patient’s perception of ongoing diet maintenance despite no further weight loss may arise because the physiological regulation of appetite occurs in brain regions that operate below the patient’s conscious awareness. Thus, signals to the brain that increase appetite with weight loss could introduce subconscious biases such as portion sizes creeping upwards over time. Furthermore, a relatively persistent effort is required to avoid overeating to match the increased appetite that grows in proportion to the weight lost.
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From a purely calorie balance perspective, a patient who maintains lost weight after the first year of an intervention may be eating only slightly fewer calories per day than a patient who experiences long-term weight regain. However, such a small difference in food intake behavior is somewhat misleading considering that prevention of weight regain requires increased persistent effort to counter the ongoing slowing of metabolism and increased appetite associated with the lost weight.
The Impact of Macronutrient Composition
Altering dietary macronutrient composition could theoretically influence overall calorie intake or expenditure resulting in a corresponding change in body weight. Alternatively, manipulation of diet composition can result in differences in the endocrine status in a way that could theoretically influence the propensity to accumulate body fat or affect subjective hunger or satiety. Therefore, it is theoretically possible that a particular diet could result in an advantageous endocrine or metabolic state that promotes weight loss.
In recent years, there has been a reemergence of low-carbohydrate, high-fat diets as popular weight loss interventions. Such diets have been claimed to reverse the metabolic and endocrine derangements resulting from following advice to consume low-fat, high-carbohydrate diets that allegedly caused the obesity epidemic. However, important aspects of the carbohydrate-insulin model have failed experimental interrogation, and, for all practical purposes, “a calorie is a calorie” when it comes to body fat and energy expenditure differences between controlled isocaloric diets varying in the ratio of carbohydrate to fat.
Nevertheless, low-carbohydrate, high-fat diets may lead to spontaneous reduction in calorie reduction and increased weight loss, especially over the short term. Meta-analyses of long-term weight loss have suggested that low-fat weight loss diets are slightly, if statistically, inferior to low-carbohydrate diets, but the average differences between diets is too small to be clinically significant.
In contrast to the near equivalency of dietary carbohydrate and fat, dietary protein is known to positively influence body composition during weight loss and has a small positive effect on resting metabolism. Diets with higher protein may also offer benefits for maintaining weight loss, particularly when the overall diet has a low glycemic index. This might be partially mediated by dietary protein’s greater effect on satiety compared to carbohydrate and fat along with the possibility of increased overall energy expenditure.
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The Importance of Individual Variability and Personalized Approaches
Whereas long-term diet trails have not resulted in clear superiority of one diet over another with respect to average weight loss, within each diet group there is a high degree of individual variability and anecdotal success stories abound for a wide range of weight loss diets. Some of this variability may be due to interactions between diet type and patient genetics or baseline physiology such as insulin sensitivity. Such interactions offer the promise of personalized diets that optimize the patient’s chances for long-term weight loss success.
It is certainly possible that the patients who successfully lost weight on one diet would have been equally successful had they been assigned to an alternative diet. In other words, long-term success with a weight loss diet may have less to do with biology than factors such as the patient’s food environment, socioeconomics, medical comorbidities, and social support, as well as practical factors, such as developing cooking skills and managing job requirements.
The Critical Role of Ongoing Support and Behavioral Changes
Long term behavioral changes and obesity management require ongoing attention. Even the highest quality short-term interventions are unlikely to yield continued positive outcomes without persisting intervention and support. Several studies show that ongoing interaction with healthcare providers or in group settings significantly improves weight maintenance and long-term outcomes, compared with treatments that end after a short period of time.
With respect to the case study at the start of this paper, the physician should not expect ongoing weight loss without ongoing support and interaction. Weight-loss specific behaviors associated with long term success include: frequent self-monitoring and self-weighing, reduced calorie intake, smaller and more frequent meals/snacks throughout the day, increased physical activity, consistently eating breakfast, more frequent at-home meals compared with restaurant and fast-food meals, reducing screen time, and use of portion-controlled meals or meal substitutes. Although the research is mixed, several studies show improved weight loss outcomes in patients receiving weight maintenance-specific training, compared with those who only receive traditional weight loss training.
Maintaining Motivation and Managing Setbacks
People tend to focus on what they haven’t achieved, rather than what they’ve already accomplished. Unlike with weight loss, during which the external reward of watching the scale decrease and clinical measures improve can increase motivation, the extended period of weight maintenance has fewer of these explicit rewards. To support motivation and make salient satisfaction with outcomes, call attention to patients’ progress, which often becomes overlooked. Providers can point to the magnitude of weight that has been kept off, putting it into context in terms of average expected weight loss, as well as clinical improvements in risk factors, such as blood pressure and glycemic control.
Anticipating and managing high-risk situations for “slips” and lapses helps patients minimize lapses, get back on track, and avoid giving up. Cycles of negative and maladaptive thoughts and coping patterns can derail progress.
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