Struggling to Maintain Lost Weight

by Kathy Keenan Isoldi, MS, RD, CDE; and Louis J. Aronne, MD, FACP

Dr. Aronne is Former President of the North American Association for the Study of Obesity and a Fellow of the American College of Physicians. He has authored more than 40 papers and book chapters on obesity, and edited the National Institutes of Health Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. He is a consultant to the VA Weight Management/Physical Activity Executive Council; Ms. Isoldi is Coordinator of Nutrition Services at The Comprehensive Weight Control Program, New York, New York. Ms. Isoldi has been counseling adult and pediatric clients seeking weight management for the past 19 years. She is currently a doctoral candidate at New York University.

INTRODUCTION

Obesity has emerged as a major public health crisis and presents a challenge for healthcare providers to tackle effectively.[1] Increased fat mass accumulation is associated with increased risk of developing several chronic as well as lifethreatening diseases.[2] However, losing a modest 5 to 10 percent of body weight results in improved biomarkers for health and decreases risks of disease development in high-risk groups.[3,4] The many varied components influencing body weight status, including genetic,[5] physiological,[6] and environmental
triggers,[7] create a complex set of interventions to target for obesity
prevention and treatment. Intervention studies report that obtaining a modest loss of approximately 3 to 12kg of body weight can be achieved with lifestyle modification and weight loss medication or with lifestyle modification alone.[8–10] Surgical treatment of obesity, although reserved for the most severe cases, results in greater weight loss outcome. Typical weight losses reported following surgical intervention for obesity are in the range of 20 to 50kg.[11] Unfortunately, long-term maintenance of lost weight, regardless of the treatment
modality chosen, has been difficult to achieve.[12,13] Studies reveal that behavioral interventions aimed at reducing calorie intake and increasing calorie expenditure in daily physical activities can result in 9 to 10 percent total body weight loss during the first six months of treatment. However, data shows
that one-third to two-thirds of lost weight is regained within one-year following end of treatment and that almost all weight is regained within five years post-treatment.[8,14] Several biological mechanisms aimed at maintaining fat mass as a survival measure,[6] as well as a multitude of environmental factors that oppose healthy habits, present as the most likely causes of weight regain.[7]

Long-term data from obese patients who received bariatric surgery as their treatment modality also report difficulty in maintenance of lost weight. In the prospective Swedish Obese Subjects (SOS) study, data were collected from 625 bariatric surgical patients two years following surgery and from 641 patients at 10 years post-surgery. Compared to total weight loss at Year 1, weight regain was noted in those treated with gastric banding, vertical banded gastroplasty, as well as gastric bypass surgery, at both the two-year and 10-year post-surgical data collection points (Table 1).[13]

Dilatation of the gastric pouch, more frequently reported in those receiving lapraoscopic gastric banding, has been implicated as one reason for weight regain in bariatric surgical patients. However, this complication occurs too infrequently to be the sole cause of post-surgical weight regain. Data collected from the SOS study document a decline in daily physical activity calories expended as the years following bariatric surgery progress.[13] Additionally, the investigators report a 33-percent increase in calories consumed at 10 years post-surgery compared with caloric consumption at six months following surgery.[13]

Reports of weight loss maintenance are not all stories of gloom. McGuire and colleagues refuted earlier reports of only two-percent weight loss maintenance success, reporting an approximate 20-percent success rate of self-reported weight maintenance in a random-digit phone interview study.[16] Others have set out to find and investigate those who have been successful at maintaining lost weight. The National Weight Control Registry (NWCR), developed by Wing and Hill in 1994, now tracks over 5,000 adult men and women who have maintained a body weight loss of >30 pounds for >1 year.[17] Researchers have associated certain factors with the success of higher rates of weight maintenance. The NWCR participants who were more successful at maintaining their lost weight were those able to maintain their weight for >2 years versus <2 years, those who lost <30 percent of total body weight versus >30 percent, as well as those who reported fewer episodes of depression and food-related disinhibition.[18] Other behaviors noted to be associated with successful weight loss maintenance in NWCR participants include eating breakfast everyday, frequent monitoring of body weight, fewer hours of television viewing, and exercising for at least one hour daily.[17] Lasting healthy lifestyle behaviors appear to support long-term weight maintenance; however, many dieters report reclaiming old behaviors when treatment is completed and time passes.[19]

The need to help overweight and obese individuals achieve lasting weight loss is obvious. The many health benefits gleaned from weight loss can vanish when weight is regained. Some experts suggest that obesity is a disease that has no known cure,[20] and therefore can only be managed through commitment to lifelong healthy lifestyle behaviors.[21] There are several reports of successful behavioral interventions promoting lifestyle changes that help individuals obtain a healthy body weight.[8] However, providing ongoing intensive behavioral interventions supporting healthy lifestyle habits can be too expensive and too labor intensive to healthcare systems in order for this to be delivered to the vast amount of patients in need. Therefore, cost-effective treatment modalities that can reach many overweight and obese patients are of great interest to clinicians working with this population.[22] Some suggest maintaining communication with patients through mail, internet, and phone conversations as a means to offer continued professional support, as these modes of treatment delivery have the potential to reach many individuals.[19,23] Results of studies using these communication modes to influence health behaviors are emerging.

One example is the Weigh-To-Be (WTB) study,[22] which investigated three different modes of delivering lifestyle modification treatments for weight loss. Researchers randomized 1801 adult volunteers with a body mass index ≥27 from four managed healthcare clinics into a usual care group, mail group, or phone group to evaluate efficacy of these three different treatment modalities aimed at facilitating weight loss. The participants in the phone and mail groups were mailed 10 structured weight loss lessons immediately following randomization.
Participants in the mail treatment group were directed to work on the lessons at home at their own pace, although encouraged to complete one lesson per week. All communication between healthcare providers and participants in the mail group occurred through written documents mailed to and from the participant. Participants in the phone treatment group received weekly phone calls, lasting about 19 minutes per call from either a dietitian or exercise physiologist to discuss each of the 10 lessons with the study participant.[22]

Immediately following randomization, the participants in the usual care group were given a list of available resources provided by the managed care clinic, including general phone counseling, a structured weight management phone course, or a group class offered at several of the healthcare clinics. Participants in the usual care group were instructed to seek out any of these weight loss guidance options on their own.[22]

After completing the 10 structured lessons, participants in the phone and mail treatment groups were offered follow-up sessions. Follow-up included either individual follow-up, participation in a group course run by the managed care clinic, or a repeat of any or all of the 10 structured lessons previously offered. The usual care group continued to have the same weight management treatment options available to them from baseline randomization. No significant difference in weight loss results were found between the three treatment groups. At 18 months, weight loss results were 2.3, 2.4, and 1.9kg for the mail, phone, and usual care groups, respectively. At 24 months weight losses were reported at 0.7, 1.0, and 0.6kg for mail, phone, and usual care groups, respectively. Researchers noted that at the two-year mark, all three treatment options were more effective in supporting weight maintenance rather than promoting weight loss. However, researchers note that the results of this study support that phone and mail-based weight loss counseling are both viable treatment options. Research on ways to improve weight loss and weight maintenance efficacy, as well as data on cost analysis of varying treatment options are needed.[22]

The internet has become a powerful vehicle for communication, and therefore appeals to healthcare providers interested in reaching a large number of individuals in need of guidance. Researchers investigated the use of a web-based behavior change program aimed at helping web visitors achieve a healthy body weight, as well as the adoption of healthy lifestyle behaviors.[24] A web-based health behavior change program to promote exercise and prevent overweight and obesity was offered free of charge to residents in the Netherlands. In this trial, 9,774 participants completed baseline data; however, only 940 (9.6%) visited the site after their first encounter. A total of 6,272 website visitors provided complete data and were therefore included in the analysis. Increased rates of repeat visits to the site were associated with those who were older, non-smokers, consumed more vegetables, and were more physically active. It became apparent in this trial that those who already had healthy lifestyle behaviors were more likely to visit the website frequently. Not reaching those in greatest need of services was a disappointing outcome noted by the investigators. However, the researchers also reported that individuals who were overweight or obese participated with greater frequency than lean individuals. It was postulated that the non-stigmatizing web-based intervention may be preferred to a face-to-face counseling session.[24]
In a recent systematic review of 26 telephone interventions aimed at increasing physical activity and dietary behavior change, researchers found that 20 of the 26 studies analyzed reported significant, positive change in target behavior. Positive outcome was measured by reports of behavior that improved selection of healthy foods and increased minutes of daily physical activity. Telephone counseling sessions targeting dietary behavior were found to be especially strong. Best results were associated with telephone counseling sessions lasting between 6 to 12 months, and providing 12 or more telephone calls. However, results evaluating behavior change lasting beyond the end of intervention are mixed. Only two of the 26 studies reported the cost to deliver the intervention; therefore, conclusions on the cost-effectiveness of phone counseling cannot be made at this time. More data investigating the cost and efficacy of short and long-term outcomes from telephone counseling sessions are needed.[23]

Conclusion

Obesity remains a present day public health threat. Interventions have been successful at producing modest weight loss success resulting in reduced disease risk. However, regain of weight often begins to occur one year following the end of treatment. Obesity is described as a chronic disease that requires continued support and guidance from healthcare professionals to help individuals achieve long-term success. To help patients maintain lost weight, healthcare providers are urged to consider creative ways to continue support and guidance after interventions are typically completed.

Mail, web-based, and phone interventions have emerged as potential options to reach out to many individuals, and the potential for these treatment modalities to be cost-effective exists. Preliminary studies reveal that these communication modalities result in positive behavior change, especially in the area of healthy behaviors related to food intake. Additionally, obese and overweight individuals appear more likely than their lean counterparts to participate in a web-based behavior change program aimed at healthy lifestyle choices. Trials investigating long-term outcome measurements, as well as cost analyses of internet, mail, and phone interventions targeted at maintaining healthy behaviors that support weight loss and weight loss maintenance are needed for a better understanding of ongoing patient support options for the future.

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