The Key to Successful Weight Maintenance

Marcia Herrin, EdD, MPH RDN, LD, FAED

October 2019

Worldwide Trends in Body Mass Index (BMI)

Worldwide BMI Nearly Tripled since 1975

• Expansion of US food companies

• Developed countries decreasing % of income spent on food

• Decrease in home-cooked meals

• Increase in popular quick-weight loss diets

• Increase in research on what to do• Standard Behavioral Weight Loss (BWL)

• Slow, modest weight loss can be maintained

Standard Behavioral Weight Loss (BWL) Treatment

• Read food labels

• Increase low fat dairy products, decrease sodium

• Eat low calorie foods

• Eat enough protein and fiber. This can make you feel fuller

• Increase variety of foods

• Eat more fruits, vegetables, and whole grains

• Decreased refined carbohydrates and white potatoes

• Eat leaner cuts of meat and lower fat dairy products

• Limit your intake of fried foods and other foods high in fat

• Watch your portion sizes

• Drink water instead of other beverages that are high in calories. These include non-diet sodas and most juices

• Increase activity level, sweat, at least 30-60 minutes every day

Standard Behavioral Weight Loss (BWL) Treatment

• Works for weight loss• No particular weight loss diet is

more effective

• Difficult to adhere to

• Weight loss plateaus• Metabolism decreases to protect

from weight loss

• Patient blame self for lack of long term success

• Regain weight when no longer following diet

• May lead to diet/binge cycle

• Can trigger eating disorders

• Exercise requirements• Overwhelm

• Discourage

Why is there an Obesity Epidemic▪ Changes in Food Environment

▪ Availability of cheap, high calorie foods▪ Large portions at restaurants

▪ Genetics▪ 50% of variance

▪ Aging▪ Reduced calorie needs

▪ Exercise: insignificant weight loss▪ Increased physical activity reduces energy

spent on other physiological activities

▪ Diets: transient reduction in weight▪ Rebound weight gain▪ Adaptive thermogenesis (decreased resting

metabolic rate)▪ Settling Point: defense of highest weight▪ Increase in Binge Eating

• All Diets: transient reduction in weight• Low fat• Low carbohydrate

• No sugar• No white carbs• No flour

• High protein• Paleo diet• Ketogenic• Vegetarian/Vegan• Clean food

• Fasting: transient reduction in weight• Intermittent fasting• Ramadan fasting*

*Fernando HA et al. Effect of Ramadan Fasting on Weight and Body Composition in Healthy Non-Athlete Adults Nutrients. 2019 Feb; 11(2): 478.

https://www.self.com/story/i-lost-90-pounds-maintaining-that-weight-loss-was-harder

The Biggest Loser Reality US TV Show

Why? Adaptation to Famine

• Genetic tendency toward obesity in modern people• Resist weight loss

• Conserve energy

• Low metabolism

• Drive to feast (overeat, binge)

• Thrifty gene

• Behavioral adaptation• Obesity associated with wealth or

fertility

What Doesn’t Work

• Restrictive Diets• Fad diets• Advice to eat healthy

• Exercise• No effect on calorie

balance• Exercise requirements

lead to dropouts

• Rapid Weight Loss• Not maintained

• Weight loss medications without dietary changes

• Bariatric surgery without dietary changes

• Not Addressing Eating Disordered Behavior• Binge eating• Restricting

• Shaming

• Blaming

• Giving the same old advice• Eat healthy• Exercise more

What Does Work

National Weight Loss Registry, Medication +, Bariatric Surgery +, “BWL-E”

National Weight Loss

Registry*

Ate regularlyDid not skip

breakfast

50% used artificial

sweetners

Monitored weight weekly

Psychological stability

No binge eating

Walked Social support

*http://www.nwcr.ws/research/

Weight Loss Medication

• A number of medications are approved by the US Food and Drug Administration (FDA) for the treatment of overweight or obesity • Decrease appetite• Increase fullness

• Orlistat, Lorcaserin, Phentermine-topiramate, Bupropion-naltrexone, Liraglutide, Benzphetamin, Diethylpropion, Phentermine, Phendimetrazine

• All have significant side effects• High dropout rates

• Non effective if NOT combined with dietary changes• Little long-term evidence of efficacy

•

Bariatric Surgery

• Surgical management of severe obesity• Decrease appetite• Increase fullness

• Deficiencies of micronutrients• Treated with supplements

• To maintain weight loss (“not an easy way out”)• 3 meals/day• Moderate-sized meals• Little to no eating between meals• No emotional eating

• Average weight loss 100 to 120 lb (45 to 54 kg)

• Maintenance of 50-75% reduction in excess BMI

• Significant improvement in diabetes and cardiovascular disease, hypertension, cancer, sleep apnea, reflux

Behavioral Weight Loss-Enhanced (BWL-E)How to do it

• Start with current diet• Start high (calories)• Go slow (no decrease in calories if

losing a pound a month)• 10 lbs/year 5 kg/year

• Aim low to maximize health benefits• 5-10% of body weight

• Unless weight is dropping naturally and is consistent with weight/family history

• Stop• Maintain sustainable approach to

eating• Let weight be

• No pressure to exercise• Acknowledge

• Lack of effect on weight • Health benefits

• Eat in a pleasurable old fashioned way• Solid meals• Desserts with meal• Minimize snack (“gateway” for eating)

• Children need after school snack• Adults may not need snack

• Respect for patients in higher weight bodies• Acknowledge that genetics is the main

cause

BWL-E Approach

• Regular meals and snacks • Food plans• 3 meals• 0-3 “intuitive” snacks• No judgment about food choices• Fun Food (“Save room for dessert”)

• No bad/forbidden foods• Except moldy food

• Parents oversee feeding of children & adolescents • Until child/adolescent demonstrates

competency

• No weight checks until easily following the “Plan”• “Tweak” Plan for slow weight loss

guide to planning healthy meals(Normal serving size usually is one cup or twice the size indicated on food labels)

BreakfastCalcium

Complex Carbohydrates Fruit or Vegetable Protein (optional)

Fat (optional)

Snack

LunchCalcium

Complex Carbohydrates Fruit or Vegetable

ProteinFat

"Fun Food"

Snack

DinnerCalcium

Complex Carbohydrates Fruit or Vegetable

ProteinFat

"Fun Food"

Snack

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Calcium Suggestions

milk, yogurt, cheese, frozen yogurt, tofu

Complex carbohydrate suggestionscereal, bage ls, bread, crackers, rice, potatoes, pasta, corn

Fat Suggestionsbutter, margarine, peanu t butter, cheese, cream cheese, salad dressing, mayonn aise, sauces, muffins,

bacon, nut s, egg yolks, fried/sautéed foods, chips, ice cream, some meats

Fruit or Vegetable Suggestionsany fresh, cooked, d ried, canned, or juiced fruits or vegetables

"Fun Food" suggestionsany dessert, cookies, cake, ice cream, pudding, doughnut s, croissants, candy bars, chips, fries, non-diet soda

Protein Suggestionsmeat, fish, poultry, cottage cheese, cheese, legumes, tofu, tempeh, eggs, peanut butter

Snack Suggestions

What Works(BWL-E)

• Diet• Breakfast• Permissive Flexibility• Effect of indulgence• Not telling people to eat

healthy• Targeting emotional eating

• Exercise• Important for health• Subjects eat better if they

regularly exercise• May help with weight loss

maintenance• Exercise requirements lead

to dropouts

• Reasonable Goals• 5% weight loss improves

health outcomes

• Support• Non-stigmatizing approach• One-on-one

consultation/group?

• Accountability• Weight checks• Weight graphs• Food behavior self-monitoring

• Weight loss medications + BWL-E

• Bariatric surgery + BWL-E

BWL-E Treatment Approach

1. First treat eating disordered behaviors (restrictive eating, bingeing)

2. Start high• Doable diet • “Choose healthiest diet you enjoy, stick to it, let weight be as it may.”

3. Go slowTweak plan to achieve 1 lb /.5 kg per month weight loss

4. Stop• Maintain sustainable approach to eating• Let weight be as is (genetics, weight history, no eating disordered behaviors)• Plan that led to weight loss is plan will maintain weight loss

• Calorie needs go down with weight loss• Aging decreases calorie needs

• Body neutrality/acceptance/respect for patient and their struggles• Negative body image associated with emotional eating

Clinical Experience & Recommendations:Long-Term Weight Loss Maintenance (WLM)• Agnostic about cause of overeating

• Sympathetic about difficulty of eating moderately in current food environment• How to have one serving of carbs when 6 types are served

• No focus on weight loss first year or until abstaining from overeating• Stop dieting• No weight checks

• Dessert/Fun food is an essential food group• Must include pleasurable food with meals twice a day

• Problem-solving eating events • family, social, business, restaurants, festivals

Managing Weight for Weight Loss

• “The scale is how you body speaks to me”• Weights taken “facing forward”

• My preference • Recommended by CBT-E

• Some patients check weight at home and report it• Warn against checking weight more than once per week• Too much natural variance

• 5 lb over the course of a day• 5 lb range for weight maintenance

• Make changes to usual dietary intake• 1 lb or ½ kilo/month• “I want you to lose weight on the highest calories possible

because you will be healthier and happier”• Address “off plan eating” first• 100 calorie decreases/week if weight not increasing 19

BWL-EClinical Techniques

• Health at Every Size (HAES)/Respect at Every Size (RAES)

Body Acceptance

• Treat restrictive & binge eating

• Regular eating

• Collaborative weight checks

Cognitive Behavioral Therapy-Enhanced

• Treat emotional eating

• Mindfulness

• Non-judgmental about thoughts

• Distress tolerance

• Emotional regulation

Dialectical Behavior Therapy

• Acceptance of body and focus on other personal values

Acceptance and Commitment Therapy

• Agnostic about weight

• Parents in charge

Family-Based Treatment

• Parents in charge of what, where, when of food

Division of Responsibility

New Paradigm: Health at Every Size (HAES)

• Promotes improved health for people of all sizes without focus on weight

• Body positivity

• Promotes healthy eating, active lifestyle, weight neutral outcomes

• Diets don’t work: Results in stress, poor self-esteem, weight gain

• Weight fluctuations may cause harm• Increase cholesterol, blood pressure

• No health consequences associated with overweight or moderate obesity• US BMI categories lowered in 1998

My Paradigm: Respect at Every Size (RAES)

• Respect and acceptance of people of all sizes • Necessary for success with patients of all sizes

• Body acceptance

• Increase understanding of the many factors that interfere with weight loss• “Settling Point” defense of the body’s highest adult weight• Genetic factors Body size is largely genetically determined• Food behaviors have to be slowly changed to have a long-term effect on

weight

• Willingness to provide best treatment without causing harm to those who want to lose weight to improve their health

References (partial list)*

• The Balance protocol: a pragmatic weight gain prevention randomized controlled trial for medically vulnerable patients within primary care, 2019.

• Behavioural intervention for weight loss maintenance versus standard weight advice in adults with obesity, 2019.

• M. D. Jensen, D. H. Ryan, K. A. Donato et al., “Executive summary: guidelines (2013) for the management of overweight and obesity in adults,” Obesity, vol. 22, no. 2, pp. S5–S39, 2014.

• Petrin C, Kahan S, Turner M, Gallagher C, Dietz WH. Current attitudes and practices of obesity counselling by health care providers. Obes Res Clin Pract. 2017;11(3):352-359.

• Petrin C, Kahan S, Turner M, Gallagher C, Dietz WH. Current attitudes and practices of obesity counselling by health care providers. Obes Res Clin Pract. 2017;11(3):352-359.

*Full reference list on request: marcia.herrin@Dartmouth.edu

• Kruger J, Blanck HM, Gillespie C. Dietary and physical activity behaviors among adults successful at weight loss maintenance. Int J Behav Nutr Phys Act. 2006;3:17.

• Look AHEAD Research Group; Wadden TA, Bantle JP, Blackburn G, et al. Eight-year weight losses with an intensive lifestyle intervention: the Look AHEAD Study. Obesity 2014;22:5–13.

• Fernando HA et al. Effect of Ramadan Fasting on Weight and Body Composition in Healthy Non-Athlete Adults Nutrients. 2019 Feb; 11(2): 478.

• Annesi JJ, Mareno N. Improvement in emotional eating associated with an enhanced body image in obese women: mediation by weight-management treatments effects on self-efficacy to resist emotional cues to eating. J Adv Nurs. 2015;71(12):2923–2935.

• M. D. Jensen, D. H. Ryan, K. A. Donato et al., “Executive summary: guidelines (2013) for the management of overweight and obesity in adults,” Obesity, vol. 22, no. 2, pp. S5–S39, 2014.

• Annesi JJ, Mareno N. Improvement in emotional eating associated with an enhanced body image in obese women: mediation by weight-management treatments effects on self-efficacy to resist emotional cues to eating. J Adv Nurs. 2015;71(12):2923–2935.

• Fernando HA et al. Effect of Ramadan Fasting on Weight and Body Composition in Healthy Non-Athlete Adults Nutrients. 2019 Feb; 11(2): 478.

Presentation Reference

Herrin, M. (October 2019). The Key to Successful Weight Maintenance: Review of the Literature and Clinical Recommendations. Paper to be presented at the 5th Dubai International Nutrition Congress, Dubai, UAE.