HHS Public Access

Author manuscript
Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
Author Manuscript

Published in final edited form as:

Med Clin North Am. 2018 January ; 102(1): 183–197. doi:10.1016/j.mcna.2017.08.012.

Maintenance of lost weight and long-term management of

obesity
Kevin D. Hall, Ph.D.1 and Scott Kahan, M.D., MPH2,3
1National Institute of Diabetes & Digestive & Kidney Diseases
2Johns Hopkins Bloomberg School of Public Health
Author Manuscript

3George Washington University School of Medicine

Synopsis
Weight loss can be achieved through a variety of modalities, but long-term maintenance of lost
weight is much more challenging. Obesity interventions typically result in early rapid weight loss
followed by a weight plateau and progressive regain. This review describes our current
understanding of the biological, behavioral, and environmental factors driving this near-ubiquitous
body weight trajectory and the implications for long-term weight management. Treatment of
obesity requires ongoing clinical attention and weight maintenance-specific counseling to support
sustainable healthful behaviors and positive weight regulation.
Author Manuscript

Keywords
obesity treatment; weight loss; weight maintenance; behavioral counseling; appetite; physiology

Introduction
Robert is a 47 year old patient who initially weighed 270 pounds. He lost 85
pounds three years ago by carefully following your guidance to decrease his caloric
intake to 1500 calories per day and exercise six days weekly. Today he comes in for
his annual physical examination. You were excited to hear about his continued
progress and see how much more he’s lost, but you felt immediately dejected to see
that he had regained almost 60 pounds. “I don’t know what to do…the weight
keeps coming back on. I keep trying, but there must be something wrong. I’m sure
Author Manuscript

my metabolism is in the dumps. It feels like every moment of the day I can’t help
but think about food – it was never like this before I lost the weight. And no matter
how hard I try to stop eating after one serving, I just can’t seem to do it anymore.”

Corresponding Author: Kevin D. Hall, 12A South Drive, Room 4007, Bethesda, MD 20892, [email protected].
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of
the resulting proof before it is published in its final citable form. Please note that during the production process errors may be
discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Conflicts of Interest: SK has no relevant disclosures.
 Hall and Kahan Page 2

Feeling defeated, he says “I don’t even know what’s the point of doing this
Author Manuscript

anymore!”

Frustrated, you remind him that he was able to do it just fine when he was losing
weight initially, and he just needs to keep working hard at it. “I know it’s not easy,
but I can’t help you unless you’re willing to help yourself. You just need to work
harder and take control of this again.” You feel for him, but you know that you need
to be stern to get him past this backsliding. Hoping to motivate him, you remind
him how bad he will feel if he regains more weight, and you tell him to make a
follow-up appointment for six months and warn him that if he doesn’t turn things
around quickly he will have to restart his blood pressure medications.
Substantial weight loss is possible across a range of treatment modalities, but long-term
sustenance of lost weight is much more challenging, and weight regain is typical1–3. In a
meta-analysis of 29 long-term weight loss studies, more than half of the lost weight was
Author Manuscript

regained within two years, and by five years more than 80% of lost weight was regained
(Figure 1)4. Indeed, previous failed attempts at achieving durable weight loss may have
contributed to the recent decrease in the percentage of people with obesity who are trying to
lose weight5 and many now believe that weight loss is a futile endeavor6.

Here, we describe our current understanding of the factors contributing to weight gain,
physiological responses that resist weight loss, behavioral correlates of successful
maintenance of lost weight, as well as the implications and recommendations for long-term
clinical management of patients with obesity.

Why is it so difficult to lose weight and keep it off?

Author Manuscript

The obesogenic environment

Long term weight management is extremely challenging due to interactions between our
biology, behavior, and the obesogenic environment. The rise in obesity prevalence over the
past several decades has been mirrored by industrialization of the food system7 involving
increased production and marketing of inexpensive, highly-processed foods8–10 with
supernormal appetitive properties11,12. Ultraprocessed foods13 now contribute the majority
of calories consumed in America14 and their overconsumption has been implicated as a
causative factor in weight gain15. Such foods are typically more calorically dense and far
less healthy than unprocessed foods such as fruits, vegetables, and fish16. Food has
progressively become cheaper17, fewer people prepare meals at home18,19, and more food is
consumed in restaurants18. In addition, changes in the physical activity environment have
made it more challenging to be active throughout the day. Occupations have become more
Author Manuscript

sedentary20 and suburban sprawl necessitates vehicular transportation rather than walking to
work or school as had been common in the past. Taken together, changes in the food and
physical activity environments tend to drive individuals towards increased intake, decreased
activity, and ultimately weight gain.

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 3

Physiological responses to weight loss

Author Manuscript

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 at rate of one pound for every 3500 kcal of accumulated dietary calorie
deficit21–24. For example, cutting just a couple of cans of soda (~300 kcal) from one’s daily
diet was thought to lead to about 30 pounds of weight loss in a year, 60 pounds in 2 years,
etc. Failure to achieve and maintain substantial weight loss over the long term is then simply
attributed to poor adherence to the prescribed lifestyle changes, thereby potentially further
stigmatizing the patient as lacking in willpower, motivation, or fortitude to lose weight25.

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 loss26.
More realistic calculations of expected weight loss for a given change in energy intake or
Author Manuscript

physical activity are provided by a web-based tool called NIH Body Weight Planner (http://
BWplanner.niddk.nih.gov) that uses a mathematical model to account for dynamic changes
in human energy balance27.

In addition to adaptations in energy expenditure with weight loss, body weight is regulated
by negative feedback circuits that influence food intake28,29. Weight loss is accompanied by
persistent endocrine adaptations30 that increase appetite and decrease satiety31 thereby
resisting continued weight loss and conspiring against long-term weight maintenance.

Explaining the weight plateau

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,
Author Manuscript

followed by progressive weight regain32. Different interventions result in varying degrees of

weight loss and regain, but the overall time courses are similar. As people progressively lose
more and more weight, they fight an increasing battle against the biological responses that
oppose further weight loss.

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 by about 20–30 kcal/d whereas appetite increases by about 100 kcal/d above the
baseline level prior to weight loss31. Despite these predictable physiologic phenomena, the
typical response of the patient is to blame themselves as lazy or lacking in willpower,
sentiments that are often reinforced by healthcare providers, as in the example of Robert,
Author Manuscript

above.

Using a validated mathematical model of human energy balance dynamics27,31, Figure 2

illustrates the energy balance dynamics underlying the weight loss time courses of two
example 90 kg women who either regain (blue curves) or maintain (orange curves) much of
their lost weight after reaching a plateau within the first year of a diet intervention. In both
women, large decreases in calorie intake at the start of the intervention result in rapid loss of

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 4

weight and body fat leading to a modest decrease in calorie expenditure that contributes to
Author Manuscript

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. In contrast to the
modest drop in calorie expenditure of less than 200 kcal/d at the weight plateau, appetite has
risen by 400–600 kcal/d and energy intake has increased by 600–700 kcal/d since the start of
the intervention.

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 loss33. While self-reported diet measurements are notoriously inaccurate and
imprecise34–36, it may be possible to reconcile such data with objectively quantified
increases in calorie intake. It is entirely possible that patients truly believe they are sticking
with their diet despite not losing any more weight or even regaining weight.
Author Manuscript

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 awareness37. Thus, signals to the brain that increase appetite
with weight loss could introduce subconscious biases such as portion sizes creeping upwards
over time. Such a slow drift upwards in energy intake would be difficult to detect given the
large 20–30% fluctuations in energy intake from day to day38,39. Furthermore, a relatively
persistent effort is required to avoid overeating to match the increased appetite that grows in
proportion to the weight lost31. For example, the model-calculated intervention effort for the
simulated patient who experiences the weight plateau at six months followed by weight
regain (Figure 2, blue curves) maintains more than ~70% of their initial intervention effort
until the plateau. Perhaps self-reported diet maintenance before and after the weight plateau
is more representative of the patients’ relatively persistent effort to avoid overeating in
Author Manuscript

response to their increased appetite31. New technologies using repeated weight monitoring
can be used calculate changes in calorie intake and effort over time40 and help guide
individuals participating in a weight loss intervention41–44.

Weight regain versus maintenance

From a purely calorie balance perspective, a patient who maintains lost weight after the first
year of an intervention (Figure 2, orange curves) may be eating only about 100 kcal/d fewer
than a patient who experiences long-term weight regain (Figure 2, blue curves). However,
such a small difference in food intake behavior is somewhat misleading considering that
prevention of weight regain requires about 300–500 kcal/d of increased persistent effort to
counter the ongoing slowing of metabolism and increased appetite associated with the lost
weight. The more typical pattern of long-term weight regain is characterized by a waning
Author Manuscript

effort to sustain the intervention.

There are likely many factors that account for the ability of some patients to achieve and
maintain large weight losses over the long term whereas others experience substantial
weight regain. Unravelling the biological, psychosocial, educational, and environmental
determinants of such individual variability will be an active area of obesity research for the
foreseeable future45.

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 5

The role of diet composition

Author Manuscript

The laws of thermodynamics dictate that the energy derived from macronutrients being
oxidized via the intricate biochemical pathways of oxidative phosphorylation inside cells can
be equated to the values measured by combusting these fuels in a bomb calorimeter.
However, this equivalence does not necessarily imply that “a calorie is a calorie” when it
comes to diets with different macronutrient proportions differentially impacting weight loss.

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. These possibilities do not necessarily violate the laws of thermodynamics
since any change in the body’s overall energy stores (i.e. fat mass) must be accompanied by
Author Manuscript

changes in calorie intake or expenditure. Therefore, it is theoretically possible that a

particular diet could result in an advantageous endocrine or metabolic state that promotes
weight loss. This promise provides fodder for the diet industry and false hope to the patient
with obesity since it implies that if they simply choose the right diet then weight loss can be
easily achieved.

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. Specifically, the so-called
“carbohydrate-insulin model of obesity” posits that diets high in carbohydrates are
particularly fattening because they increase the secretion insulin and thereby drive fat
Author Manuscript

accumulation in adipose tissue and away from oxidation by metabolically active tissues, and
this altered fat partitioning results in a state of “cellular starvation” leading to adaptive
increases in hunger, and suppression of energy expenditure46. Therefore, the carbohydrate-
insulin model implies that reversing these processes by eating a low-carbohydrate, high-fat
diet should result in effortless weight loss47. Unfortunately, important aspects of the
carbohydrate-insulin model have failed experimental interrogation48 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 fat49.
Nevertheless, low-carbohydrate, high-fat diets may lead to spontaneous reduction in calorie
reduction and increased weight loss, especially over the short term50–52. Meta-analyses of
long-term weight loss have suggested that low-fat weight loss diets are slightly, if
statistically, inferior to low-carbohydrate diets53, but the average differences between diets is
too small to be clinically significant54. Furthermore, the similarity of the mean weight loss
Author Manuscript

patterns between diet groups in randomized weight loss trials strongly suggests that there is
no generalizable advantage of one diet over another when it comes to long-term calorie
intake or expenditure33.

In contrast to the near equivalency of dietary carbohydrate and fat, dietary protein is known
to positively influence body composition during weight loss55,56 and has a small positive
effect on resting metabolism57. Diets with higher protein may also offer benefits for

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 6

maintaining weight loss58, particularly when the overall diet has a low glycemic index59.
Author Manuscript

This might be partially mediated by dietary protein’s greater effect on satiety compared to
carbohydrate and fat55,56 along with the possibility of increased overall energy
expenditure60. More research is needed to better understand whether these potentially
positive attributes of higher protein diets outweigh concerns that such diets mitigate
improvements in insulin sensitivity that are typically achieved with weight loss using lower
protein diets61.

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
diets33. Some of this variability may be due to interactions between diet type and patient
genetics62,63 or baseline physiology such as insulin sensitivity64–67. Such interactions offer
the promise of personalized diets that optimize the patient’s chances for long-term weight
Author Manuscript

loss success45,63. Unfortunately, diet-biology interactions for weight loss have not always
been reproducible68,69 and likely explain only a fraction of the individual variability.

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. Such non-biological factors likely play a strong role in determining whether
diet adherence is sustainable.

Clinical recommendations for long term weight management counseling

Author Manuscript

Given the physiologic and environmental obstacles to long-term maintenance of lost weight
described above, we offer the following recommendations for clinical practice and then
present an alternative preferable depiction of the opening case example.

Long term benefits require long term attention

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
(Figure 3)70,71. The importance of long-term intervention has been codified in the obesity
Author Manuscript

treatment guidelines, which state that weight loss interventions should include long term
comprehensive weight loss maintenance programs that continue for at least 1 year72.

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. Rather than asking Robert to
turn things around on his own, the physician has an opportunity to reengage with Robert to
offer guidance and support in a more intensive and regular manner than sending him off on
his own for six months, or if this is not realistic in a busy primary care practice, he could

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 7

refer Robert to an obesity medicine specialist, registered dietitian, comprehensive weight

Author Manuscript

management clinic, or recommend that he engage in a community weight management

group, such as the Diabetes Prevention Program (now covered by Medicare for patients with
prediabetes), or a commercial program, such as Weight Watchers.

Use weight maintenance-specific counseling/strategies

Behavioral strategies for initiation of weight loss are described elsewhere in this volume [].
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 substitutes2,73–75. Weight maintenance-specific
behavioral skills and strategies help patients to build insight for long-term management,
Author Manuscript

anticipate struggles and prepare contingency plans, moderate behavioral fatigue, and put into
perspective the inevitable lapses and relapses of any long-term engagement.

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 training76–79. Strategies are discussed below for weight
maintenance-specific counseling.

Strengthen satisfaction with outcomes

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 (e.g., lipid levels) improve can increase motivation, the
extended period of weight maintenance has fewer of these explicit rewards. To support
Author Manuscript

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 (described
below), as well as clinical improvements in risk factors, such as blood pressure and glycemic
control. Additionally, showing patients “before and after” photographs of themselves and
other tangible evidence of progress helps them to build awareness of and appreciate the
benefits they have already achieved, which may improve long-term persistence with weight
maintenance efforts.

Relapse prevention training

Anticipating and managing high-risk situations for “slips” and lapses helps patients
Author Manuscript

minimize lapses, get back on track, and avoid giving up. This counseling often includes self-
weighing and identifying weight thresholds that signal the need for reengaging with a
support team or initiating contingency strategies; proactively developing plans and
practicing strategies for managing and coping with lapses; problem solving to identify
challenges, formulate solutions, and evaluate options; and building strategies for non-food
activities and coping mechanisms, such as engaging in hobbies or mindfulness activities, to
minimize counterproductive coping mechanisms, such as emotional eating.

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 8

Cognitive restructuring
Author Manuscript

Cycles of negative and maladaptive thoughts (e.g., “What’s the point…I failed again and I’ll
never lose weight!”) and coping patterns (e.g., binge eating in response to gaining a few
pounds) are counterproductive and demotivating. Helping patients to recognize and
restructure the core beliefs and thought processes that underlie these patterns helps minimize
behavioral fatigue and prevent or productively manage slips and lapses.

Developing cognitive flexibility

Many tendencies that promote initial weight loss are unrealistic over the long term. For
example, many patients aim to make large, absolute changes in an “all-or-none” fashion via
rigid rules, such as aiming for “no carbs” or very restrictive intake. Much as a sprinter can
run all-out for a short race, but not for the entirety of a marathon, expecting strict, all-out
efforts and clear-cut, black-and-white outcomes over the lifelong management of obesity is a
Author Manuscript

recipe for frustration and failure. Instead, learning to accept that rigid expectations and
“perfect” adherence to behavioral goals is unrealistic and building cognitive flexibility to
take in stride when one’s plans do not go according to plan is a core competency for long
term sustainable behavioral changes and weight management.

Appeal to patients’ deeper motivations

External, superficial rewards are unlikely to support the long term endurance needed for
weight maintenance. For example, studies of financial rewards to incentivize behavioral
changes, such as weight loss or tobacco cessation, yield initial benefits that invariably wane
precipitously over time80,81. Whereas “white knuckling” and external, controlled
motivations, such as directives from a spouse or healthcare provider, may lead to short-term
weight loss, longer term sustained motivation is more likely when patients take ownership of
Author Manuscript

their behavioral changes and goals, and engage in them because they are deeply meaningful
or enjoyable80,81. As an example, compared with difficulty of sticking to a strict low-fat or
low-carb diet, which are often arbitrarily prescribed and of little personal significance to the
patient, and therefore difficult to maintain, countless millions throughout the world
rigorously stick to comparably strict kosher, halal, or vegan eating patterns, which are
aligned with their religious, ethical, or other deeply held beliefs and values. Similarly,
prescribing daily gym visits to someone who hates the gym environment or gym activities is
unlikely to be fruitful, whereas supporting patients to find more enjoyable physical
activities, such as sports or group dance-exercise classes, increases the likelihood of
continuing over time.

Manage expectations – both for patients and providers

Author Manuscript

Both patients and healthcare providers have wildly unrealistic expectations for weight loss
outcomes. In one study, patients entering a diet and exercise program expected to lose 20–
40% of their starting body weight - amounts that can only realistically be achieved by
bariatric surgery82. Physician expectations are similarly inflated: in a survey of primary care
physicians, acceptable behavioral weight loss was considered to be a loss of 21% of initial
body weight83. In contrast, numerous studies show that diet, exercise, and behavioral
counseling, in the best of cases, only leads to 5–10% average weight loss, and few patients

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 9

with significantly elevated initial weights achieve and maintain an “ideal” body weight.
Author Manuscript

From a cognitive psychology perspective, a waning intervention effort may be due to

disappointment in the degree of weight loss actually achieved82 leading the patient to
conclude that the effort is not worth the achieved benefits84.

Although the published data is mixed on whether unrealistic outcomes will deter weight loss
success, it stands to reason that excessive discrepancies between expectations and actual
outcomes would be demoralizing and increase negative thoughts and self-blame (which
itself is associated with numerous negative health outcomes85), and may diminish long term
persistence for continued behavioral change and weight loss maintenance. We recommend
advising patients about the physiologic challenges of long term weight loss and the degree of
weight loss that can be realistically expected from behavioral interventions. At minimum,
there’s no known harm of offering this insight and being frank with patients about
expectations, and it may help them navigate the minefield of unscrupulous diet programs
Author Manuscript

and promises that promise miraculous outcomes.

Nonetheless, positive outcomes of behavioral counseling extend beyond weight loss. Despite
the modest weight losses associated with behavioral interventions, small weight losses can
lead to impressive health improvements and risk factor reductions. In the Diabetes
Prevention Program, 7% weight loss over six months led to 58% reduction in development
of diabetes, despite half the weight being regained over three years86. In the Look Ahead
trial, 6% weight loss over eight years yielded improvements in a range of cardiovascular risk
factors, including glycemic control and lipids, as well as less medication usage, and reduced
hospitalizations and healthcare costs87,88.

While losing weight is important for improved health, people’s motivations for seeing the
Author Manuscript

scale go down is all-too-often driven by cultural norms for thinness and healthcare provider-
imposed weight loss directives. These external motivations can move the weight loss needle
in the short-run, but they rarely lead to long-lasting determination. As described in the
section above, long term management is improved when motivations are aligned with
personal values and preferences. Helping patients shift their locus of motivation from weight
loss alone to intrinsically meaningful areas, such as health improvement, can improve long
term weight and behavioral outcomes89.

Escalate treatment as needed

For patients that do not achieve sufficient weight loss or health improvements with basic
counseling in primary care settings, there are several opportunities to intensify therapy.
Consider referral to a registered dietitian, obesity medicine physician, or comprehensive
Author Manuscript

weight management clinic, as well as targeted specialists (such as a behavioral psychologist

for patients with binge eating disorder or body dysmorphia). For patients with BMI greater
than 30 kg/m2 (or 27–30 kg/m2 with obesity-related comorbid conditions), obesity
pharmacotherapy leads to as much as 15% weight loss in responders, with weight loss being
maintained in several studies for several years90–92. For patients with BMI greater than 40
kg/m2 (or 35–40 kg/m2 with comorbidities), bariatric surgery is a well-studied and valuable
option that leads to large, sustainable weight losses in most patients93.

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 10

Using the principles discussed above, a more productive encounter in response to Robert’s
Author Manuscript

presentation might go like this:

Physician: “I understand, and I know it’s challenging. It sounds like you’re feeling
frustrated because you’ve worked so hard and you feel like you’ve got nothing to
show for it.”

He nods and says, “Exactly. What’s the point of doing this anymore.”

Physician: “From my view, the evidence we have shows something different:

You’re actually doing quite well in the scheme of things. I actually see quite a lot of
progress for your efforts. You’re down 25 lbs, right? That’s almost 10% down from
where you started…that’s impressive. Few people lose that much weight and keep
it off for three years. Studies show that even under the best of circumstances with
aggressive counseling, average weight loss is between 5–10% of starting body
Author Manuscript

weight – so you’re doing better than most! You’ve been able to get off several
blood pressure medications and you no longer take the pain medicine for your back
and knees. And, we know from studies that losing just 7%, even if part of it is
regained over the years, lowers the risk of diabetes by 60%!” His eyes widen.
“Weight goes up and down, and our bodies fight back against weight loss, so this is
never easy. Some regain and relapse is inevitable – just like in other areas of life.”
He takes a deep breath and clearly seems more engaged and hopeful. ”So let’s
figure out how we can move forward and keep getting the benefits, and I’ll be here
with you to help along the way. Let’s agree on a couple of next steps, and we’ll
meet again in a few weeks to see how it’s going. If we need, we can also consider
additional strategies or treatments.”
Author Manuscript

Conclusion
The degree of weight loss and its maintenance should not be the sole metric of obesity
treatment success. Rather, physicians should support and encourage patients to make
sustainable improvements in their diet quality and physical activities if these behaviors fail
to meet national guidelines94,95. Such lifestyle changes over the long-term will likely
improve the health of patients even in the absence of major weight loss96.

Acknowledgments
Funding: This research was supported by the Intramural Research Program of the NIH, National Institute of
Diabetes & Digestive & Kidney Diseases.

KDH has received funding from the Nutrition Science Initiative to investigate the effects of ketogenic diets on
Author Manuscript

human energy expenditure. KDH also has a patent on a method of personalized dynamic feedback control of body
weight (US Patent No 9,569,483; assigned to the National Institutes of Health).

References
1. Loveman E, Frampton GK, Shepherd J, et al. The clinical effectiveness and cost-effectiveness of
long-term weight management schemes for adults: a systematic review. Health technology
assessment (Winchester, England). 2011; 15(2):1–182.
2. Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005; 82(1 Suppl):222S–
225S. [PubMed: 16002825]

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 11

3. Wu T, Gao X, Chen M, van Dam RM. Long-term effectiveness of diet-plus-exercise interventions

vs. diet-only interventions for weight loss: a meta-analysis. Obes Rev. 2009; 10(3):313–323.
Author Manuscript

[PubMed: 19175510]
4. Anderson JW, Konz EC, Frederich RC, Wood CL. Long-term weight-loss maintenance: a meta-
analysis of US studies. Am J Clin Nutr. 2001; 74(5):579–584. [PubMed: 11684524]
5. Snook KR, Hansen AR, Duke CH, Finch KC, Hackney AA, Zhang J. Change in Percentages of
Adults With Overweight or Obesity Trying to Lose Weight, 1988–2014. JAMA. 2017; 317(9):971–
973. [PubMed: 28267846]
6. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare's search for
effective obesity treatments: diets are not the answer. The American psychologist. 2007; 62(3):220–
233. [PubMed: 17469900]
7. Stuckler D, McKee M, Ebrahim S, Basu S. Manufacturing epidemics: the role of global producers in
increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco.
PLoS medicine. 2012; 9(6):e1001235. [PubMed: 22745605]
8. Swinburn BA, Sacks G, Hall KD, et al. The global obesity pandemic: shaped by global drivers and
local environments. Lancet. 2011; 378(9793):804–814. [PubMed: 21872749]
Author Manuscript

9. Blatt, H. America's food: What you don't know about what you eat. Cambridge: The MIT press;
2008.
10. Roberts, P. The end of food. New York: Houghton Mifflin Harcourt Publishing Company; 2008.
11. Kessler, DA. The end of overeating: controling the insatiable American appetite. Rodale Inc.; 2009.
12. Moss, M. Salt, sugar, fat: how the food giants hooked us. New York: Random House; 2013.
13. Monteiro CA, Levy RB, Claro RM, Castro IR, Cannon G. A new classification of foods based on
the extent and purpose of their processing. Cadernos de saude publica. 2010; 26(11):2039–2049.
[PubMed: 21180977]
14. Martinez Steele E, Baraldi LG, Louzada ML, Moubarac JC, Mozaffarian D, Monteiro CA.
Ultraprocessed foods and added sugars in the US diet: evidence from a nationally representative
cross-sectional study. BMJ open. 2016; 6(3):e009892.
15. Mendonca RD, Pimenta AM, Gea A, et al. Ultraprocessed food consumption and risk of
overweight and obesity: the University of Navarra Follow-Up (SUN) cohort study. Am J Clin Nutr.
2016; 104(5):1433–1440. [PubMed: 27733404]
Author Manuscript

16. Kahan, S., Cheskin, LJ. Obesity and eating behaviors and behavior change. In: Kahan, S.Gielen,
AC.Fagen, PJ., Green, LW., editors. Health Behavior Change in Populations. Baltimore: Johns
Hopkins University Press; 2014.
17. Putnam J. Major trends in the U.S. food supply, 1909–99. Food Review. 2000; 23(1):8–15.
18. Lin, BH., Guthrie, J. Nutritional Quality of Food Prepared at Home and Away From Home. U.S.
Department of Agriculture; 2012. p. EIB-105. [December 2012]
19. Smith LP, Ng SW, Popkin BM. Trends in US home food preparation and consumption: analysis of
national nutrition surveys and time use studies from 1965–1966 to 2007–2008. Nutrition journal.
2013; 12:45. [PubMed: 23577692]
20. Church TS, Thomas DM, Tudor-Locke C, et al. Trends over 5 decades in U.S. occupation-related
physical activity and their associations with obesity. PLoS One. 2011; 6(5):e19657. [PubMed:
21647427]
21. Guth E. JAMA patient page. Healthy weight loss. JAMA. 2014; 312(9):974. [PubMed: 25182116]
22. NHLBI. Aim for a Healthy Weight. National Institutes of Health, National Heart, Lung and Blood
Author Manuscript

Institute; 2005. p. 05-5213. [August 2005]

23. NHLBI Obesity Education Initiative Expert Panel on the Identification E, Treatment of Overweight
and Obesity in Adults. The Practical Guide: Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults. National Heart, Lung, and Blood Institute; 2000.
24. NHS. Your Weight Your Health: How to take control of your weight. London: National Health
Service, Department of Health; 2006. p. 274537 [April 2006]
25. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring). 2009;
17(5):941–964. [PubMed: 19165161]

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 12

26. Rosenbaum M, Hirsch J, Gallagher DA, Leibel RL. Long-term persistence of adaptive
thermogenesis in subjects who have maintained a reduced body weight. Am J Clin Nutr. 2008;
Author Manuscript

88(4):906–912. [PubMed: 18842775]

27. Hall KD, Sacks G, Chandramohan D, et al. Quantification of the effect of energy imbalance on
bodyweight. Lancet. 2011; 378(9793):826–837. [PubMed: 21872751]
28. Greenway FL. Physiological adaptations to weight loss and factors favouring weight regain. Int J
Obes (Lond). 2015; 39(8):1188–1196. [PubMed: 25896063]
29. Ochner CN, Tsai AG, Kushner RF, Wadden TA. Treating obesity seriously: when
recommendations for lifestyle change confront biological adaptations. Lancet Diabetes
Endocrinol. 2015; 3(4):232–234. [PubMed: 25682354]
30. Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to
weight loss. N Engl J Med. 2011; 365(17):1597–1604. [PubMed: 22029981]
31. Polidori D, Sanghvi A, Seeley RJ, Hall KD. How Strongly Does Appetite Counter Weight Loss?
Quantification of the Feedback Control of Human Energy Intake. Obesity (Silver Spring). 2016;
24(11):2289–2295. [PubMed: 27804272]
32. Franz MJ, VanWormer JJ, Crain AL, et al. Weight-loss outcomes: a systematic review and meta-
Author Manuscript

analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc. 2007;
107(10):1755–1767. [PubMed: 17904936]
33. Freedhoff Y, Hall KD. Weight loss diet studies: we need help not hype. Lancet. 2016; 388(10047):
849–851. [PubMed: 27597452]
34. Dhurandhar NV, Schoeller DA, Brown AW, et al. Energy balance measurement: when something is
not better than nothing. Int J Obes. 2014
35. Schoeller DA. How accurate is self-reported dietary energy intake? Nutr Rev. 1990; 48(10):373–
379. [PubMed: 2082216]
36. Winkler JT. The fundamental flaw in obesity research. Obes Rev. 2005; 6(3):199–202. [PubMed:
16045634]
37. Berthoud HR, Munzberg H, Morrison CD. Blaming the Brain for Obesity: Integration of Hedonic
and Homeostatic Mechanisms. Gastroenterology. 2017; 152(7):1728–1738. [PubMed: 28192106]
38. Chow CC, Hall KD. Short and long-term energy intake patterns and their implications for human
body weight regulation. Physiol Behav. 2014; 134:60–65. [PubMed: 24582679]
Author Manuscript

39. Kim WW, Kelsay JL, Judd JT, Marshall MW, Mertz W, Prather ES. Evaluation of long-term
dietary intakes of adults consuming self-selected diets. Am J Clin Nutr. 1984; 40(6 Suppl):1327–
1332. [PubMed: 6507353]
40. Sanghvi A, Redman LA, Martin CK, Ravussin E, Hall KD. Validation of an inexpensive and
accurate mathematical method to measure long-term changes in free-living energy intake. Am J
Clin Nutr. 2015
41. Brady I, Hall KD. Dispatch from the field: is mathematical modeling applicable to obesity
treatment in the real world? Obesity (Silver Spring). 2014; 22(9):1939–1941. [PubMed: 24895253]
42. Hall, KD. Inventor; National Institutes of Health, assignee. Personalized dynamic feedback control
of body weight. US patent. 9,569,483. 2013.
43. Martin CK, Gilmore LA, Apolzan JW, Myers CA, Thomas DM, Redman LM. Smartloss: A
Personalized Mobile Health Intervention for Weight Management and Health Promotion. JMIR
mHealth and uHealth. 2016; 4(1):e18. [PubMed: 26983937]
44. Martin CK, Miller AC, Thomas DM, Champagne CM, Han H, Church T. Efficacy of SmartLoss, a
smartphone-based weight loss intervention: results from a randomized controlled trial. Obesity
Author Manuscript

(Silver Spring). 2015; 23(5):935–942. [PubMed: 25919921]

45. MacLean PS, Wing RR, Davidson T, et al. NIH working group report: Innovative research to
improve maintenance of weight loss. Obesity (Silver Spring). 2015; 23(1):7–15. [PubMed:
25469998]
46. Ludwig DS, Friedman MI. Increasing adiposity: consequence or cause of overeating? JAMA.
2014; 311(21):2167–2168. [PubMed: 24839118]
47. Ludwig, DS. Always hungry? Conquer cravings, retrain your fat cells and lose weight permanetly.
New York: Grand Central Life & Style; 2016.

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 13

48. Hall KD. A review of the carbohydrate-insulin model of obesity. European journal of clinical
investigation. 2017 In press.
Author Manuscript

49. Hall KD, Guo J. Obesity Energetics: Body Weight Regulation and the Effects of Diet Composition.
Gastroenterology. 2017; 152(7):1718–1727. e1713. [PubMed: 28193517]
50. Foster GD, Wyatt HR, Hill JO, et al. A randomized trial of a low-carbohydrate diet for obesity. N
Engl J Med. 2003; 348(21):2082–2090. [PubMed: 12761365]
51. Gardner CD, Kiazand A, Alhassan S, et al. Comparison of the Atkins, Zone, Ornish, and LEARN
diets for change in weight and related risk factors among overweight premenopausal women: the A
TO Z Weight Loss Study: a randomized trial. Jama. 2007; 297(9):969–977. [PubMed: 17341711]
52. Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared with a low-fat diet in
severe obesity. N Engl J Med. 2003; 348(21):2074–2081. [PubMed: 12761364]
53. Tobias DK, Chen M, Manson JE, Ludwig DS, Willett W, Hu FB. Effect of low-fat vs. other diet
interventions on long-term weight change in adults: A systematic review and meta-analysis. The
Lancet Diabetes & Endocrinology. 2015; 3(12):968–979. [PubMed: 26527511]
54. Hall KD. Prescribing low-fat diets: useless for long-term weight loss? Lancet Diabetes Endocrinol.
2015; 3(12):920–921. [PubMed: 26527510]
Author Manuscript

55. Leidy HJ, Clifton PM, Astrup A, et al. The role of protein in weight loss and maintenance. Am J
Clin Nutr. 2015; 101:1320S–1329S.
56. Westerterp-Plantenga MS, Nieuwenhuizen A, Tome D, Soenen S, Westerterp KR. Dietary protein,
weight loss, and weight maintenance. Annu Rev Nutr. 2009; 29:21–41. [PubMed: 19400750]
57. Wycherley TP, Moran LJ, Clifton PM, Noakes M, Brinkworth GD. Effects of energy-restricted
high-protein, low-fat compared with standard-protein, low-fat diets: a meta-analysis of randomized
controlled trials. Am J Clin Nutr. 2012; 96(6):1281–1298. [PubMed: 23097268]
58. Westerterp-Plantenga MS, Lejeune MP, Nijs I, van Ooijen M, Kovacs EM. High protein intake
sustains weight maintenance after body weight loss in humans. Int J Obes Relat Metab Disord.
2004; 28(1):57–64. [PubMed: 14710168]
59. Larsen TM, Dalskov SM, van Baak M, et al. Diets with high or low protein content and glycemic
index for weight-loss maintenance. N Engl J Med. 2010; 363(22):2102–2113. [PubMed:
21105792]
60. Ebbeling CB, Swain JF, Feldman HA, et al. Effects of dietary composition on energy expenditure
Author Manuscript

during weight-loss maintenance. Jama. 2012; 307(24):2627–2634. [PubMed: 22735432]

61. Smith GI, Yoshino J, Kelly SC, et al. High-Protein Intake during Weight Loss Therapy Eliminates
the Weight-Loss-Induced Improvement in Insulin Action in Obese Postmenopausal Women. Cell
reports. 2016; 17(3):849–861. [PubMed: 27732859]
62. Bray GA, Siri-Tarino PW. The Role of Macronutrient Content in the Diet for Weight Management.
Endocrinology and metabolism clinics of North America. 2016; 45(3):581–604. [PubMed:
27519132]
63. Bray MS, Loos RJ, McCaffery JM, et al. NIH working group report-using genomic information to
guide weight management: From universal to precision treatment. Obesity (Silver Spring). 2016;
24(1):14–22. [PubMed: 26692578]
64. Cornier MA, Donahoo WT, Pereira R, et al. Insulin sensitivity determines the effectiveness of
dietary macronutrient composition on weight loss in obese women. Obes Res. 2005; 13(4):703–
709. [PubMed: 15897479]
65. Ebbeling CB, Leidig MM, Feldman HA, Lovesky MM, Ludwig DS. Effects of a low-glycemic
load vs low-fat diet in obese young adults: a randomized trial. JAMA. 2007; 297(19):2092–2102.
Author Manuscript

[PubMed: 17507345]
66. McClain AD, Otten JJ, Hekler EB, Gardner CD. Adherence to a low-fat vs. low-carbohydrate diet
differs by insulin resistance status. Diabetes Obes Metab. 2013; 15(1):87–90. [PubMed: 22831182]
67. Pittas AG, Das SK, Hajduk CL, et al. A low-glycemic load diet facilitates greater weight loss in
overweight adults with high insulin secretion but not in overweight adults with low insulin
secretion in the CALERIE Trial. Diabetes Care. 2005; 28(12):2939–2941. [PubMed: 16306558]
68. Gardner, CD., Hauser, M., Del Gobbo, L., et al. EPI | Lifestyle Scientific Sessions. Portland, OR:
2017. Neither Insulin Secretion nor Genotype Pattern Modify 12-Month Weight Loss Effects of
Healthy Low-Fat vs. Healthy Low-Carbohydrate Diets Among Adults with Obesity.

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 14

69. Gardner CD, Offringa LC, Hartle JC, Kapphahn K, Cherin R. Weight loss on low-fat vs. low-
carbohydrate diets by insulin resistance status among overweight adults and adults with obesity: A
Author Manuscript

randomized pilot trial. Obesity (Silver Spring). 2016; 24(1):79–86. [PubMed: 26638192]
70. Perri MG, McAllister DA, Gange JJ, Jordan RC, McAdoo G, Nezu AM. Effects of four
maintenance programs on the long-term management of obesity. Journal of consulting and clinical
psychology. 1988; 56(4):529–534. [PubMed: 2848874]
71. Middleton KM, Patidar SM, Perri MG. The impact of extended care on the long-term maintenance
of weight loss: a systematic review and meta-analysis. Obes Rev. 2012; 13(6):509–517. [PubMed:
22212682]
72. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of
overweight and obesity in adults: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014; 129(25
Suppl 2):S102–138. [PubMed: 24222017]
73. Pi-Sunyer X, Blackburn G, Brancati FL, et al. Reduction in weight and cardiovascular disease risk
factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes
Care. 2007; 30(6):1374–1383. [PubMed: 17363746]
Author Manuscript

74. Thomas JG, Bond DS, Phelan S, Hill JO, Wing RR. Weight-loss maintenance for 10 years in the
National Weight Control Registry. American journal of preventive medicine. 2014; 46(1):17–23.
[PubMed: 24355667]
75. Wing RR, Hill JO. Successful weight loss maintenance. Annu Rev Nutr. 2001; 21:323–341.
[PubMed: 11375440]
76. Perri MG, Limacher MC, Durning PE, et al. Extended-care programs for weight management in
rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized
trial. Archives of internal medicine. 2008; 168(21):2347–2354. [PubMed: 19029500]
77. Svetkey LP, Stevens VJ, Brantley PJ, et al. Comparison of strategies for sustaining weight loss: the
weight loss maintenance randomized controlled trial. Jama. 2008; 299(10):1139–1148. [PubMed:
18334689]
78. Voils CI, Olsen MK, Gierisch JM, et al. Maintenance of Weight Loss After Initiation of Nutrition
Training: A Randomized Trial. Ann Intern Med. 2017; 166(7):463–471. [PubMed: 28241185]
79. Wing RR, Tate DF, Gorin AA, Raynor HA, Fava JL. A self-regulation program for maintenance of
weight loss. N Engl J Med. 2006; 355(15):1563–1571. [PubMed: 17035649]
Author Manuscript

80. Halpern SD, French B, Small DS, et al. Randomized trial of four financial-incentive programs for
smoking cessation. N Engl J Med. 2015; 372(22):2108–2117. [PubMed: 25970009]
81. Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G. Financial incentive-
based approaches for weight loss: a randomized trial. JAMA. 2008; 300(22):2631–2637. [PubMed:
19066383]
82. Foster GD, Wadden TA, Vogt RA, Brewer G. What is a reasonable weight loss? Patients'
expectations and evaluations of obesity treatment outcomes. Journal of consulting and clinical
psychology. 1997; 65(1):79–85. [PubMed: 9103737]
83. Phelan S, Nallari M, Darroch FE, Wing RR. What do physicians recommend to their overweight
and obese patients? Journal of the American Board of Family Medicine : JABFM. 2009; 22(2):
115–122. [PubMed: 19264934]
84. Rothman AJ. Toward a theory-based analysis of behavioral maintenance. Health psychology :
official journal of the Division of Health Psychology, American Psychological Association. 2000;
19(1S):64–69.
Author Manuscript

85. Kahan S, Puhl RM. The damaging effects of weight bias internalization. Obesity (Silver Spring).
2017; 25(2):280–281. [PubMed: 28124505]
86. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metformin. N Engl J Med. 2002; 346(6):393–403. [PubMed:
11832527]
87. Espeland MA, Glick HA, Bertoni A, et al. Impact of an intensive lifestyle intervention on use and
cost of medical services among overweight and obese adults with type 2 diabetes: the action for
health in diabetes. Diabetes Care. 2014; 37(9):2548–2556. [PubMed: 25147253]

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 15

88. Wing RR, Bolin P, Brancati FL, et al. Cardiovascular effects of intensive lifestyle intervention in
type 2 diabetes. N Engl J Med. 2013; 369(2):145–154. [PubMed: 23796131]
Author Manuscript

89. Silva MN, Vieira PN, Coutinho SR, et al. Using self-determination theory to promote physical
activity and weight control: a randomized controlled trial in women. Journal of behavioral
medicine. 2010; 33(2):110–122. [PubMed: 20012179]
90. Allison DB, Gadde KM, Garvey WT, et al. Controlled-release phentermine/topiramate in severely
obese adults: a randomized controlled trial (EQUIP). Obesity (Silver Spring). 2012; 20(2):330–
342. [PubMed: 22051941]
91. le Roux CW, Astrup A, Fujioka K, et al. 3 years of liraglutide versus placebo for type 2 diabetes
risk reduction and weight management in individuals with prediabetes: a randomised, double-blind
trial. Lancet. 2017; 389(10077):1399–1409. [PubMed: 28237263]
92. Torgerson JS, Hauptman J, Boldrin MN, Sjostrom L. XENical in the prevention of diabetes in
obese subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes
for the prevention of type 2 diabetes in obese patients. Diabetes Care. 2004; 27(1):155–161.
[PubMed: 14693982]
93. Sjostrom L, Peltonen M, Jacobson P, et al. Bariatric surgery and long-term cardiovascular events.
Author Manuscript

JAMA. 2012; 307(1):56–65. [PubMed: 22215166]

94. Promotiion CfNPa. [Accessed 07/14/2017] Dietary Guidelines for Americans. 2015. 2017. https://
www.cnpp.usda.gov/2015-2020-dietary-guidelines-americans
95. Promotion OoDPaH. [Accessed 7/14/2017] Physical Activity Guidelines for Americans. 2008.
2017. https://health.gov/paguidelines/guidelines
96. Matheson EM, King DE, Everett CJ. Healthy lifestyle habits and mortality in overweight and obese
individuals. Journal of the American Board of Family Medicine : JABFM. 2012; 25(1):9–15.
[PubMed: 22218619]
Author Manuscript
Author Manuscript

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 16

Key points
Author Manuscript

• Long-term maintenance of lost weight is the primary challenge of obesity

treatment.

• Biological, behavioral, and environmental factors conspire to resist weight

loss and promote regain.

• Treatment of obesity requires ongoing attention and support, and weight

maintenance-specific counseling, to improve long-term weight management.

• Realistic long-term weight loss magnitude is significantly lower than patient

and healthcare provider expectations. However, even small amounts of
sustained weight loss lead to clinical health improvements and risk factor
reductions.
Author Manuscript
Author Manuscript
Author Manuscript

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 17
Author Manuscript
Author Manuscript

Figure 1.
Average time course of weight regain after a weight loss intervention.
Data from Anderson JW, Konz EC, Frederich RC, et al. Long-term weight-loss maintenance:
a meta-analysis of US studies. Am J Clin Nutr 2001;74(5):579–584.
Author Manuscript
Author Manuscript

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 18
Author Manuscript
Author Manuscript
Author Manuscript

Figure 2.
Mathematical model simulations of body weight, fat mass, energy intake, energy
Author Manuscript

expenditure, appetite, and effort for two hypothetical women participating in a weight loss
program. The curves in blue depict the typical weight loss, plateau and regain trajectory
whereas the orange curves show successful weight loss maintenance.

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.
 Hall and Kahan Page 19
Author Manuscript
Author Manuscript

Figure 3.
Weight management programs with a focus on maintenance of lost weight demonstrate
improved long-term weight loss (red curve) compared to programs without maintenance
visits (blue curve).
Adapted from Perri MG, McAllister DA, Gange JJ, et al. Effects of four maintenance
Author Manuscript

programs on the long-term management of obesity. J Consult Clin Psychol 1988;56(4):529–

534; with permission.
Author Manuscript

Med Clin North Am. Author manuscript; available in PMC 2019 January 01.