By Charissa Dejardins & Emily Stone
Research supports the following components of a weight maintenance program:
Weight loss is accompanied by physiological changes in hormone signalling and appetite regulation that act to counter weight loss. Therefore, weight maintenance strategies should be focused on interventions that mitigate these changes. Several notable psychological factors associated with successful weight loss, including but not limited to self-efficacy, self-regulation and motivation, identifying and understanding weight loss barriers, and minimizing dichotomous thinking. Increasingly, evidence is suggesting that behavioral interventions are a key determinant in the success of maintaining weight loss long term. Studies have found that the most successful behavioral interventions include education about weight loss and address skills required for success. Interventions are more likely to be carried out in the presence of social support and clinical care that extends beyond the initial weight loss period. Mindfulness is a type of behavioral intervention which focuses on relationships with food and eating habits. It has been found to be a successful form of intervention for weight loss, shows promising long-term results and sustainability.
Biological Adaptations in Weight Loss
It has been reported that 50% of weight lost is likely to be regained after two years and 80% within five years .1 The majority of obesity treatment focuses on the initial weight loss period, however, it is also important to consider long term weight management strategies. Often when weight is regained patients are held responsible for not adhering to a prescribed diet and exercise regimen. However, research increasingly suggests that many factors beyond an individual's control results in a relapse of weight gain .1
Appetite is controlled and regulated in the hypothalamus of the brain .2 Two classes of hormones regulate appetite and hunger cues: orexigenic hormones, including ghrelin and gastric inhibitory peptide (GIP), which stimulate food intake; and anorexigenic hormones including glucagon like peptide 1 (GLP-1), peptide YY (PYY), and cholecystokinin (CCK), which suppress food intake and increase satiety .2 The hypothalamus integrates both appetite regulating hormones as well as cues from the hedonic system  and from peripheral hormones including leptin, a hormone produced by adipose tissue, responsible for inhibition of hunger . 2, 3
Evidence shows that diet induced weight loss in obese individuals is accompanied by an increase in appetite mediated by biological signals. One study found that in obese or overweight individuals who had lost weight, anorexigenic hormones (leptin, PYY, CCK, insulin) were significantly reduced 10 weeks following weight loss, whereas orexigenic hormones (ghrelin, GIP) showed increased levels . At one year following the intervention significant decreases in anorexigenic hormones were still observed . 2 This highlights the persistent state of hormone signalling which supports a state of hunger following weight loss .3
The hedonic properties of food carry considerable weight in the hypothalamic integration of information that will ultimately lead to eating .3 The hedonic system is an integrated network of cues responsible for palatability. This includes information about food such as sight, smell and taste .2 In some cases, the hedonic system can override hormonal appetite cues to stimulate the desire to eat energy rich foods despite physiological satiation. For example a 2008 study reported that the palatability of reward increased significantly after an 8-week weight loss program in obese adults.3
It has also been found that in overweight and obese individuals that there is a significant reduction in the number of dopamine (D2) receptors in the brain .2 This factor may then account for over consumption of food as a result of decreased dopaminergic activation, as dopamine is a key regulator of food motivation and reward .2 In a 56-week randomized controlled trial, obese and overweight individuals who were treated with opioid agonists (naltrexone) and dopamine reuptake inhibitors (bupropion) were more likely to have improvements in their ability to resist food cravings .2 The overall result of weight loss seems to be an increased appetite that is disproportionate to the amount of weight lost .3
It is important to make individuals who are trying to lose weight or who have lost weight aware of physiological changes that might counter their efforts, like the above. To help individuals maintain weight loss, ongoing counselling during maintenance can focus on behavioral interventions that counteract physiological adaptations and other factors favouring weight regain [9, 10]. 1, 2
Psychological Factors in Weight Loss
Key psychological factors have been associated with successful weight loss including self-efficacy, self- regulation and motivation, identification of weight loss barriers, and minimizing dichotomous thinking .5
Self-efficacy refers to an individual's judgment in regard to their personal abilities .6 These beliefs regarding personal accomplishment or mastery and one’s desired outcomes will determine how an individual carries out a behavior. This includes if they will initiate a behavior, what they will try to attain and the degree of effort they will exert .6 Self-efficacy is critical in the estimation of one’s own abilities and is a major determinant of performance in a behavior regardless of underlying skill level .6 The strength of one’s perceived self-efficacy is particularly important in determining if an individual is likely to continue their efforts for the long term - higher self-efficacy leads to higher likelihood of continuation.
Self-efficacy has been found to positively predict success of weight loss and weight loss maintenance [2,22].7, 8 It has been found that higher weight loss specific self-efficacy is linked to higher success in weight loss, and increased general self-efficacy is related to higher performance of behaviors associated with weight loss .7
There are four major determinants of self-efficacy: enactive attainment (actual performance of the task), vicarious experience (witnessing comparable people perform the task), verbal persuasion (informing a person that they have the ability to perform a task), and physiological feedback (physical cues to one’s progress) .8
Physical activity has been shown to be associated with sustained weight loss, along with improvements in mood, self-efficacy and self-esteem [2, 14].7, 9 In one study 32 obese women were assessed changes in self-efficacy before and after 12 weeks of treatment which included behavioral therapy and a low-calorie diet found a positive correlation between an increase in self-efficacy and exercise behaviors .10 Particularly changes in self-efficacy regarding exercise may be more important than baseline self-efficacy when trying to achieve and maintain weight loss .11 This could include treatment focused on reinforcement of progress toward exercise, making plans for exercise, and providing education about exercise .11
Self-Regulation & Motivation
Goal management strategies can have a notable impact on success of long-term weight loss .9 Realistic, well-planned weight loss goals can help to maintain focus and motivation and provide a plan for progression toward a healthier lifestyle .12
In weight loss it is important to have long-term goals which help to maintain lifestyle changes .13 However, long term goals can seem overwhelming and unachievable. As a result, many people will benefit from breaking a long-term goal down into a series of smaller short- term goals .13 Research shows manageable short-term goals that are established, achieved and acknowledged result in greater feelings of competency as well as increased body satisfaction .14
One example is the “SMART” goal format:
- Specific – A goal should have specific details. For example, a goal to increase exercise is non-specific, whereas a goal to walk each day is specific.
- Measurable – A goal should be able to be measured objectively, most often quantitatively, such as walking for 30 minutes.
- Achievable – A goal should be reasonable in terms of the individual’s resources and means to perform. For some individuals setting the goal of walking to work may be unreasonable given distance, weather, or other factors.
- Realistic – A goal should be meaningful to the individual and be something the individual is willing and able to do.
- Time-limited – A goal should have a set deadline. Giving a time limit helps build motivation and stay on track.
These guidelines are useful for developing both long- and short-term goals and can help ensure the completion of desired goals.
Goals need to be flexible based on individual needs. If a certain goal is being met faster than expected, a new larger goal may be warranted. Likewise, if a goal cannot be met within the allotted time frame, it may have to be broken down to be more achievable .13
It is also important to focus on process goals as well as outcomes. A process is defined as a step required to achieve a desired outcome. An example of a process goal may be to begin drinking water with every meal. Rewarding this goal will help reinforce the behavior which in turn aides in the desired outcome .13
While during the weight loss phase there are many sources of external reward (e.g. weighing on a scale) which in turn improves motivation, the period of weight loss maintenance has fewer explicit rewards. To sustain motivation during this phase, the patient can be reminded of their previous accomplishments and improvements in overall health, shown by clinical improvements (e.g. lower blood pressure) .14 Additionally, visual comparisons through use of before and after images can be used to provide tangible evidence of improvement and progress .14
Identification of Barriers
It is also important to consider setbacks that may occur. This is a normal part of the process when making large scale behavioral changes, therefore it is better to expect and plan for these than be caught off guard and relapse into old habits . 15 This can be done by identifying potential barriers when it comes to maintaining weight and devising strategies for when setbacks occur .15
Four key barriers to weight loss have been established :16
Dichotomous thinking refers to a “black and white” thinking style. Dichotomous thinking has been associated with lower success in weight loss and weight loss maintenance [4, 16].17, 18 It is more commonly observed in those who regain weight than in healthy individuals or those who maintain weight loss. Specifically those who regain weight have been found to refer to eating, weight, and body size in dichotomous terms [4, 16], whereas those who are successful in weight loss hold a less polarized view of weight loss and individual control .17, 18 Dichotomous thinking has also been found to be a strong predictor of weight regain 1 year following weight loss intervention .18 Those with dichotomous thinking styles who do not achieve weight loss objectives most likely consider any weight loss to be inadequate and unsatisfactory. These individuals are less likely to then be motivated to maintain a weight they do not consider worthwhile, abandoning their weight loss goals .18
Behavioral interventions for weight loss usually last one to two years, including both the weight loss and weight maintenance phases, with about 1-4 sessions per month and can be implemented on an individual or group level, in person or virtual, and use print or online materials .11 Interventions can include counselling about nutrition and exercise as well as education about how to self-monitor weight loss maintenance .11 Additionally, interventions may address how to identify barriers to weight loss and weight loss maintenance, include techniques for problem solving, and facilitating social support networks .11
The key to a successful behavioural intervention is simplicity. When the behavior trying to be altered can be directly related to a cause and effect, it allows for a simple solution .19 For example the intervention that “smoking causes lung cancer” is easily understood and also provides a clear solution: stop smoking .19
Supervised interventions appear to have the highest adherence rate (~68%), while self- monitoring programs have the lowest (~40%) .20 Participants are also more likely to adhere to diet only interventions rather than exercise only interventions, or self-monitoring only interventions .20 Higher adherence rates are also reported for programs which integrate areas of social support. Social support can include group sessions, peer coaches and buddy programs. Multiple studies have indicated that social support whether through friends and family or providers is important for successful behavioral change, with one study finding a 37% higher likelihood of maintaining weight loss when guided support was received compared to self-directed strategies .20
Effective behavioral interventions have been found to include interventionist contact group time spent reinforcing behavioural changes made during the initial intervention, including continued support for meeting eating and exercise goals, utilizing problem solving skills to address barriers to maintaining behavior changes and training in relapse prevention .21 Most importantly those who attend extended care groups appear to have higher adherence to caloric and exercise goals, resulting in less weight regain .21
In summary, behavioural interventions appear to be a highly effective form of weight loss maintenance. These interventions should address education around nutrition and exercise, self-monitoring practices, barriers to weight loss, and social support. Individuals are more likely to adhere to diet or diet and exercise interventions and incorporate facilitation of social support networks. Interventions which incorporate extended care (long term care either in an individual or group setting) also show higher adherence and weight loss success than interventions that did not include follow up after the initial weight loss phase.
Mindfulness & Mindful Eating
In recent years there has been an increased interest in using mindfulness and mindful eating techniques as an intervention in obesity. The sustainability of these skills may be the most promising aspect of employing these strategies in weight management interventions.
Mindful eating consists of making conscious food choices, developing awareness of physical versus psychological hunger and satiety cues and eating healthily in response to those cues .22 It is conceptualized as being aware of the present moment when one is eating, paying close attention to the effect of the food on the senses, and noting the physical and emotional sensations in response to eating .22 Some common thought processes that are employed in mindful eating include :15
· Taking notice of how one is feeling in the present moment, and what food would satiate them.
A goal of mindful eating is to minimize automatic/inattentive eating .15 For most people, inattentive eating is an unavoidable learned behavior, where eating becomes secondary to other tasks. Automatic eating is common, one eats simply because it is a mealtime and not because of awareness of hunger .15 There are four characteristics of inattentive eating described as: taking place without awareness, they begin without attention, they carry on once started without control, and they function with little effort .15 The goal of mindful eating is to bring awareness back to eating, and de-automatize eating behaviors.
Impulsivity is also related to regulation of eating behaviors. Those who are more impulsive may have trouble controlling attention and can be powerless in delaying gratification. Using mindfulness techniques can decrease impulsivity and aid in lowering food consumption .15
Inattentive eating can also be the result of emotional eating, which results from the use of food as a coping mechanism when one experiences negative emotions . Emotional eating habits are associated with weight gain, anxiety and depression, whereas mindfulness shows a strong negative correlation with these factors . Therefore, mindfulness may be useful in moderating the effects of negative emotions on eating behavior, where mindfulness replaces eating as a coping mechanism .15
Preliminary research shows that mindfulness-based interventions reduce weight, emotional, and automatic eating. However, like any weight management technique it must be continued long term in order to achieve effective weight management . Mindful eating is a practice that requires a commitment to behavioral change, similar to any diet plan . However, there is promise that those who are successful in adopting a mindful eating lifestyle will be able to improve their weight management . In studies, mindful eating has resulted in a positive shift in food habits and quantity of food consumed. Studies have shown that when mindful eating strategies were employed 80% of follow up studies showed continued or sustained weight loss.15
Obesity is a multifaceted disease, which should be reflected in its treatment. It is now understood that weight loss leads to hormonal changes which attempt to hinder further weight loss in individuals. It is important that patients be made aware of these biological changes in order to mitigate weight gain relapse. Many psychological factors have also been identified in success or failure of weight loss. Most prominently: self-efficacy, self-regulation & motivation, understanding barriers, and avoiding dichotomous thinking. These along with biological factors may be addressed through behavioural interventions. Successful behavioural interventions should incorporate education around nutrition and exercise, self- monitoring approaches, ways to mitigate barriers and social support. Interventions should also incorporate follow on care beyond the initial weight loss period in order to sustain newly learned behaviours. Mindfulness and mindful eating are behavioural intervention that focuses on the relationship an individual has with food and eating with show promising results for sustaining weight loss.