The Skinny on Losing Weight and Keeping It Off

Despite years of talk about the obesity epidemic and the emergence of countless government programs and weight loss crusades, only a select few people manage to lose significant amounts of weight and maintain that weight loss. At any given time, approximately 40% of women and 25% of men in the U.S. are trying to lose weight (Kruger et al. 2004). Sadly, most of their efforts will go unrewarded, especially in terms of permanently keeping any weight off. Yet some clients do succeed in achieving their weight loss and weight maintenance goals. How do they do it?

Their secrets, along with the latest research findings, treatment guidelines, weight loss options and large-scale policy ideas are discussed here.

Current Obesity Guidelines & Treatment Recommendations

Being “obese” is defined as having a body mass index (BMI) of ≥ 30 kg/m2, a measurement based solely on a person’s height and weight. While not a perfect measure of the percent of fat mass, this formula does accurately categorize most people.

Obesity results from an imbalance of caloric intake and caloric expenditure. It makes sense that today’s obesity treatments target either decreased caloric intake (or in some cases, decreased absorption of calories consumed) or increased caloric expenditure either via increased exercise or by revving up the body’s metabolism. In all, there are four potential obesity treatment options available to your clients, as follows:

• dietary changes
• lifestyle changes (including exercise and behavioral modification)
• medications
• surgery

In most cases, clients are advised to combine dietary and lifestyle changes in order to achieve the desired weight loss.

Dietary & Lifestyle Approaches
The best “diet” for weight loss continues to be a source of contentious debate. From drastically low fat and severely carbohydrate-restricted diets to meal replacements and strict calorie counting, every method has its followers. More to the point, every diet also has people who have failed to achieve their weight loss goals.

Recently a randomized trial, considered the “gold standard” in research design, compared some of the most popular diets: the Atkins™ diet (very low carbohydrate); the LEARN program (Lifestyle, Exercise, Attitudes, Relationships and Nutrition); the low-fat, high-carbohydrate diet recommended in national guidelines; the Ornish diet (very high carbohydrate, low fat); and the Zone™ diet (low carbohydrate). The study’s participants included more than 300 premenopausal women who were either overweight or obese (Gardner et al. 2007). At the end of 12 months, the Atkins dieters came out ahead of the other diets, but even in the Atkins group the maximum total weight loss was only 10 pounds (Gardner et al. 2007). This modest amount of weight loss underscores how hard it can be for our clients to adapt and stick to rigid dietary restrictions. However, it is worth noting that even a 5%–10% weight loss confers significant health benefits (NHLBI 1998).

Some studies have seen greater weight loss among participants. For example, a study of 60,000 men and women followers of the Jenny Craig® diet, a commercial weight loss program, found that those who followed the program for 1 year lost 16% of their body weight (Finley et al. 2007). Unfortunately, only 6.6% of the original dieters stuck with the program for that long (Finley et al. 2007). Another study found that people who ate a 100- to 300-calorie meal replacement (such as a nutrition bar or formulated milk shake meal) per day maintained a substantial (8.4% ± 0.8%) weight loss at 4 years (Flechtner-Mors et al. 2000).

The take-home message here may be best summarized by researchers who assessed the adherence rate and effectiveness of the Atkins, Ornish, Weight Watchers® and Zone diets in a 1-year randomized trial (Dansinger et al. 2005): it doesn’t matter which diet a person chooses as long as he or she can stick to it—which is a whole lot harder than it sounds.

Pharmacological Approaches

Although diet pills are never a “quick fix” for an unhealthy lifestyle, in some cases medications may be beneficial. Research suggests that people who eat healthfully, exercise regularly and take a weight loss medication do lose more weight in 1 year than those who use either the drug alone or the lifestyle treatment alone (Wadden et al. 2005).

In general, an effective weight loss medication will lead to a 4-pound loss within a month’s time, according to comments made by Ken Fujioka, MD, director of the Scripps Clinic Center for Weight Management in San Diego, during a recent presentation at the American College of Physicians Internal Medicine 2007 annual meeting (Fujioka 2007).

Surgical Approaches
Gastric bypass, a procedure in which surgeons reduce the stomach to about the size of an egg and then reattach it to the small intestine, is the most common weight loss surgery.

Only those who are committed to permanent lifestyle changes—including regular physical activity and a healthy diet—are candidates for the surgery (Consensus Development Conference Panel 1991). Of course, surgery is never without risks. Many people who have bypass surgery die or suffer serious symptoms as a result of the procedure (Buchwald et al. 2004; Steinbrook 2004).

11 Secrets of Successful Dieters

Perhaps the most practical way to learn what works in terms of weight loss options is to ask people who have overcome the odds and successfully lost—and more important, kept off—large amounts of weight. The National Weight Control Registry (NWCR) (www.nwcr.ws) is a database that tracks more than 5,000 people who have lost at least 30 pounds and maintained the loss for at least 1 year.

Here are 11 insights that you can offer clients who are trying to lose and maintain their weight:

Secret 1: Control Portions
Less than 20 years ago, a standard cup of coffee with whole milk and sugar measured in at 8 ounces and 45 calories. Today, many java junkies have replaced that cup with a Starbucks 16-ounce Grande Mocha Frappuccino, which weighs in at a whopping 380 calories (www.starbucks.com). To burn all those extra calories, your client would have to walk for at least an hour.

Successful weight “losers” control their food portions. In fact, research suggests portion control is the greatest predictor of successful weight loss (Logue et al. 2004). Help clients control portions by teaching them to read nutrition labels; carefully measure out servings; eat only a single helping; use smaller serving dishes; and resist the urge to “clean their plates.”

Secret 2: Be Mindful When Eating
Many people turn to food when they are bored or stressed out. Encourage clients to eat when they’re hungry and stop when they’re full. That means paying attention to everything they eat.

Teach clients to ask themselves why they are heading to the fridge or pantry. Are they really motivated by hunger, or are they really just bored, stressed, sad, tired and maybe even full from their last meal or snack! Emotional eating can wreak havoc on a well-planned weight management program.

Secret 3: Exercise Regularly
Fitness is key in losing weight and keeping those pounds off. More than 94% of participants who succeeded in their goals in the NWCR increased their rate of physical activity (NWCR 2007). In fact, many who lost weight reported walking for at least 1 hour per day.

And for those who kept the weight off, exercise was also crucial. This was evident because the registry participants who dropped out of fitness programs ended up putting the pounds back on (NWCR 2007). Remember, as people lose weight, a proportion of each pound comes from muscle; that, in turn, slows down the metabolism and makes it difficult to keep the weight off. Although walking and other cardiovascular exercise is important for burning calories, be sure to recommend a resistance training program to help clients preserve their lean tissue and keep up their metabolic rate.

Secret 4: Check the Scale
While it is not advisable to become obsessive about weight to the nearest 0.01 pound, people who maintain their weight loss do so by keeping periodic tabs on the scale, weighing themselves at least once per week. This way they are able to identify small weight increases in time to take appropriate corrective action (NWCR 2007).

Secret 5: Eat Breakfast
More than 75% of the NWCR participants eat breakfast daily; only 4% never do (Wyatt et al. 2002). And research suggests that breakfast eaters weigh less and suffer from fewer chronic diseases than people who skip breakfast (Timlin & Pereira 2007).

Secret 6: Monitor Intake
One of the strongest predictors of successful and maintained lifestyle change is monitoring dietary intake (Tinker et al. 2007). While it can be tedious to keep a daily food log, research has shown that this practice is a highly effective and proven strategy.

Secret 7: Turn Off the Tube
Time spent watching TV is time spent being completely sedentary (and thus expending minimal amounts of calories) and often eating as well. Most people mindlessly consume snacks while mesmerized in front of the television, not noticing the rapidly multiplying calorie intake. Case in point: The successful NWCR “losers” watched less than 10 hours of television per week (Raynor et al. 2006).

Secret 8: Retrain Your Brain
Interestingly, most people who have lost and kept off the most weight tend to be “lower left” brained, meaning they are organized, controlled, methodical and disciplined (Mithers 2005). This is not to say that those of us who thrive on spontaneity or embrace clutter are doomed—it’s just a matter of retraining our brains.

Encourage clients to become better organized by writing a grocery shopping list and sticking to it! During your next sessions, ask your clients to plan their workout schedule for the next week and make a promise to stick to it. These efforts will help solidify their lifestyle change and make permanent weight loss more of a reality.

Secret 9: Start Today and Don’t Cheat
It’s easy to put off starting a serious lifestyle change to a later date. Likewise, it’s easy to “cheat” and eat an extra piece of cake here, a pepperoni pizza there. It’s important to be diligent when attempting to lose weight, because people who don’t cheat on a regular basis are 150% more likely to maintain their weight loss (Gorin et al. 2004). Encourage clients to adopt a “doable” healthy lifestyle they can stick with; this will reduce those compelling urges to unwittingly sabotage their weight management success.

Secret 10: Know That Birds of a Feather Stick Together
A study of 12,067 people followed over 32 years concluded that obesity spreads through social ties (Christakis & Fowler 2007). That is, obese people tend to have obese friends. Pairs of friends and siblings of the same sex seem to have the most profound effect on each other’s weight loss. Some researchers suspect that the spread of obesity has a lot to do with an individual’s general perception of the social norms regarding the acceptability of obesity (Christakis & Fowler 2007). The logic works like this: If my best friend and my sister are both obese and I love and admire them all the same, then maybe it’s not so bad that I gain a few pounds. Clients can reverse this psychological phenomenon by inviting pals to work out at the gym or go for a bike ride with them to stay or get fit.

Secret 11: Remain Optimistic
Research suggests that people who are optimistic (i.e., they have perceived control, positive expectations, empowerment, a fighting spirit and lack of helplessness) are more successful at changing behaviors and losing weight (Tinkler et al. 2007).

Public Health Measures to Combat Obesity

Recently, there has been much discussion about potential regulatory and public health measures to decrease the prevalence of obesity. Following is a brief introduction to a few possible strategies, including their benefits and shortcomings, as detailed by Lawrence O. Gostin, JD, in the Journal of the American Medical Association (JAMA 2007). There are also tips on how you can help.

Label & Menu Disclosures
Restaurants and manufacturers would be required to disclose nutritional content and health warnings so that consumers could make more informed decisions. The effort to inform personal choices rather than restrict them is more palatable for most, but this proposition may be impractical for restaurants that continually change their menus. Plus, food labels often are misleading and inconsistent.

Tip: Encourage clients to seek out nutritional information at restaurants. Teach them to identify words that are euphemisms for “high in calories,” such as breaded, sautéed or creamy.

Tort Liability
Lawsuits levied against companies like fast-food giants for selling “unreasonably hazardous” products might force these outlets to offer healthier alternatives and provide accurate label or menu information. Of course, many public health experts believe that it is common knowledge that French fries are unhealthy, and that people must take some amount of personal responsibility for their dietary choices.

Tip: Acknowledge the many barriers and forces working against effective weight management. Then remind clients that, ultimately, they alone are the ones who can control their weight.

Surveillance
In the same manner that health departments currently monitor infectious diseases, states could monitor chronic diseases, such as diabetes. This might entail mandatory laboratory reporting of blood sugar measures, physician guidelines for treatment and/or health counseling. Surveillance would help consumers be better informed about their disease and make healthier choices. However, opponents counter this argument by saying that oversight would interfere with physician autonomy and be expensive and time-consuming, to boot.

Tip: Encourage clients to establish an open and ongoing dialogue with their physicians regarding excess weight, chronic diseases that can result from it and how to best manage both issues.

Regulation of Food Marketing to Kids
These strategies would entail restricting food advertising during children’s programs; using “counteradvertising” to promote good nutrition and physical activity; limiting use of cartoon characters on products; and other regulations designed to protect children who are too young to critically evaluate advertisements. While reasonable, this impingement on freedom of commercial speech could be unconstitutional.

Tip: Tell your clients to observe the advertisements their children are exposed to on a regular basis. Suggest they go one step further by encouraging their kids to question claims and to recognize various marketing strategies, such as free toy giveaways in sugary cereals and the use of cartoon characters.

Taxation
Imposing a higher tax on calorie-dense and nutrient-poor foods (sometimes called a “Twinkie tax”) might lower consumption of unhealthy foods and generate revenue to subsidize healthful foods. Beyond being paternalistic and regressive (poor people are more likely to eat high-fat foods), this plan would involve the challenging step of determining which foods to tax.

Tip: Tell clients to create a version of the tax within their own family. Suggest that any family member who eats an unhealthy food or remains stationary be charged a small sum (enough to buy the product and have some left over to save for an active adventure or a healthier meal).

School Policies
Many states have already removed school vending machines, provided healthier menus and offered more physical activity opportunities for their students. Although this can be helpful, the impact is lessened if no substantial changes are made at home.

Tip: Bone up on the types of changes the schools are making in your community. Also, empower clients to make changes at home. Encourage them to start by eating more meals at home and by eliminating the “clean your plate” rule with their kids.

The “Built” Environment
Some communities are considering zoning laws that would limit the number of fast-food restaurants, expand recreational facilities and encourage healthier lifestyles so that people would have more opportunities to live and play healthfully. Proponents say this type of zoning is especially important in poor neighborhoods where access to parks and healthy foods is severely limited. However, critics argue that the government should not impose its values on the public and should allow a free marketplace.

Tip: Learn about your own community. Where are the parks, recreational facilities and restaurants that offer healthy foods? Prepare a community packet for your clients, showing them where and how they can stay healthy and active in your community.

Food Prohibitions
New York City was the first to impose a trans-fat ban in all restaurants, effective July 2008. While expensive and a restriction on trade, eliminating this dangerous fat can profoundly affect the health of the city’s residents.

Tip: Teach clients how to read nutrition labels and identify foods containing hazardous ingredients, such as trans fat and high-fructose corn syrup.

SIDEBAR: What You Can Do

If you’re frustrated at the staggering epidemic of obesity in the United States, here’s how you can make a large-scale difference on a grass-roots level:

Live It. Model a healthy and fit lifestyle.

Talk About It. The National Heart, Lung, and Blood Institute (NHLBI) recommends several ways to effectively address weight management with a client: (1) set an effective tone for communication; (2) assess the client’s motivation to lose weight; and (3) build a partnership with the client (NHLBI 2002). Refer to www.nhlbi.nih.gov/health/prof/heart/obesity/aim_kit/steps.pdf for more detailed information on these methods.

Share Information and Education. Stay up-to-date on the latest advances and recommendations, and then share your newfound knowledge with anyone who will listen.

Get Out There. Be a loud proponent for healthy and active policies and activities in your community. Join community advocacy groups, such as your local school’s health or fitness committee.

Support and Encourage Clients. As an ally and mentor, offer support and encouragement to help clients clear the hurdles.

Be Innovative. Brainstorm fresh and creative ways with clients to inspire fitness and health.

Their excess pounds may not melt away overnight, but armed with knowledge, unwavering commitment and creative solutions, we can fight obesity—and win!

SIDEBAR: Resources

National Weight Control Registry, www.nwcr.ws. Find out how to join the registry, and read weight loss success stories and statistics.
Weight Control Information Network, win.niddki.nih.gov. Get science-based information on weight control, obesity, physical activity and nutrition.
Mayo Clinic Weight-Loss Center, www.mayoclinic.com. Answer your various weight loss questions through the Mayo Clinic’s extensive online library.
Yale Rudd Center for Food Policy & Obesity, www.yaleruddcenter.org. Stay up-to-date on the latest policy advances in the fight against obesity.
Smallstep.gov, www.smallstep.gov. Be inspired by success stories and simple tips on how to enhance health and fitness.
Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity, and Obesity, www.cdc.gov/nccdphp/dnpa/obesity/index.htm. Look up information on obesity statistics, trends, consequences and state-based programs.

Natalie Digate Muth, MPH, RD, CSCS, is a registered dietitian and a medical student at the University of North Carolina, Chapel Hill. As part of her training, she is currently conducting research on cholesterol and cardiovascular disease risk at the University of California, San Diego. She is also a master trainer for the American Council on Exercise.

References

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Consensus Development Conference Panel. 1991. Gastrointestinal surgery for severe obesity. Annals of Internal Medicine, 115, 956–61.
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National Heart, Lung, and Blood Institute (NHLBI). 2002. Three steps to initiate discussion about weight management with your patients. www.nhlbi.nih.gov/health/prof/heart/obesity/aim_kit/steps.pdf; retrieved Sept. 14, 2007.
National Heart, Lung, and Blood Institute (NHLBI). 1998. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf; retrieved Sept. 15, 2007.
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