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Time for change

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Long-term weight management is the gold standard for weight loss interventions, and it's far more likely to be attainable if patients are encouraged to embrace behavioural change - not just physically, but psychologically.

In what the World Health Organization calls the global obesity epidemic, much attention is given to initial weight loss, but less tends to be paid to long-term weight maintenance.1 This may be a factor in the weight regain that typifies the "yo-yo" dieting pattern, with studies suggesting only 20-30% of successful dieters maintain their reduced body weight over three years or more.2

Research identifies some common strategies used by people who successfully manage their new weight post-diet. Twenty years ago, a ground-breaking study in the American Journal of Clinical Nutrition found most successful maintainers exercised regularly, were conscious of their behaviour around food, regularly checked their weight, used available social support, confronted problems directly, and used personally developed strategies to help themselves and manage stress.3

Other large-scale studies, including the National Weight Control Registry in the USA and the more recent Lean Habits study in Germany, have highlighted a similar set of "lean strategies" in successful weight maintainers, including:

  • Exhibiting flexible control over eating behaviour, enabling them to follow their eating plan most of the time, without the "all-or-nothing" approach of rigid dietary rules that can (given human nature) lead to lapsing, demotivation and weight regain.
  • Having regular meals, at regular times, with little or no snacking.
  • Choosing high-quality, low-fat foods, with plenty of fresh fruit and vegetables.
  • Practising mindful eating - sitting down to eat, taking time over and concentrating on their meals, and choosing appropriate portion sizes.
  • Adopting effective stress management techniques.
  • Increasing activity levels to around an hour of moderate activity a day, including "incidental" lifestyle activity such as walking, as well as more structured exercise such as team sports or aerobics.4,5

The key thread underpinning these strategies is the motivation to make long-term change, which is supported by a change in mindset. Without that psychological adjustment, sustainable behavioural change is unlikely to occur.

The psychological drivers of obesity were examined in the Foresight report, Tackling Obesities, which noted the importance of developing interventions "capable of affecting the non-conscious associations that plausibly direct many unhealthy behaviours".6,7

Foresight found that "interventions that … simultaneously inform, shift motivation and provide the necessary skills are more likely to lead to behaviour change … Social psychological research suggests public campaigns might benefit from an interactive open-ended style, where individuals are encouraged to reflect and come up with their own answers, as self-generated persuasive arguments tend to lead to greater change."6

Dietary intervention plus behavioural change, based on well researched techniques such as cognitive behavioural therapy (CBT), may encourage readiness to adopt change and confidence in maintaining change in the long term. Following weight loss, a long-term weight management programme should focus on helping patients establish a healthier lifestyle through the continued development of a healthier psychology.
If patients are empowered with coping mechanisms from the continuing use of behaviour change work, they might be more likely to maintain their lifestyle changes and hence ongoing weight management.

Commercial weight-management company LighterLife, which specialises in the treatment of obesity, offers a weight management programme that first progresses patients who have achieved their weight loss goals to a healthy, balanced and varied diet using a structured food reintroduction with group support. Patients are encouraged to use food and mood diaries to help them monitor food intake and reflect on their thoughts and feelings around food.

Published data show that, two years after a mean weight loss of 18.4 kg on the LighterLife Total very-low-calorie-diet (VLCD), patients who continue in the management programme maintain, on average, a significant 46% of initial weight loss.8

1. World Health Organization (WHO). Obesity. Preventing and Managing the Global Epidemic. Report on a WHO consultation on obesity. Geneva, 3-5 June 1997. Geneva: WHO; 1998.
2. Ayyad C, Andersen T. A comprehensive literature study of long-term efficacy of dietary treatment of obesity. International Journal of Obesity 1994;18(Suppl 2):78.
3. Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in women: behavioral aspects. Am J Clin Nutr 1990;52(5):800-7.
4. Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997;66(2):239-46.
5. Westenhoefer J, von Falck B, Stellfeldt A, Fintelmann S. Behavioural correlates of successful weight reduction over 3 y. Results from the Lean Habits Study. Int J Obes Relat Metab Disord 2004;28(2):334-5.
6. Foresight. Tackling Obesities: Future Choices - Project Report. London: Foresight; 2007.
7. GR Maio, Haddock GG, Jarman HL. Short science reviews: social psychological factors in tackling obesity. Obesity Reviews 2007;8(Suppl 1):123-5.
8. Salsbury J et al. Two-year outcome for weight maintenance following a cohort of 134 patients who lost weight on the LighterLife Programme [the Total VLCD]. International Journal of Obesity 2009; 2(suppl 2):242. Poster presented at 17th International Congress on Obesity, Amsterdam, May 2009.

Further reading
Costain L. Diet Trials. London: BBC Books; 2003.

Your comments (terms and conditions apply):

"For a long time I have been offering to support patients with a weight problem through the many excellent groups that our PCT offer. They are all free of charge some are run on a weight watchers system, etc, but still 99% ask for orlistat. It's very difficult to persuade patients tht this is not a magic pill and eating habits must be changed to maintain any weight loss. Unfortunately doctors are all too willing to hand out the script" - Marie, Lancs