Strength in Numbers
Predictors and Behaviors of Maintenance
What are successful maintainers actually doing? Scientists are actively researching these questions and publishing their findings. Our resident fat ass-now-bad ass, computational biologist Angela Baldo, reviews those findings and distills their wisdom for you.
Explaining the Science
This week’s article
“Maintenance of Long-Term Weight Loss”
By J. Graham Thomas, MS, and Rena R. Wing, PhD
Published In: Medicine and Health Rhode Island, February 2009
Full text available: http://www.rimed.org/medhealthri/2009-02/2009-02-53.pdf
If I hear one more person say, “just keep doing what you did to lose the weight,” I think I will scream. I have gained and lost 100+ pounds twice — losing weight wasn’t the problem, but keeping it off sure was.
Because while similar to weight loss, maintenance has subtle, important differences, both in procedure and in psychology. This is the whole point of the Second Helping Online, and today I will focus on some specific strategies that have been shown to be statistically associated with successful weight management after loss.
One of the most exciting aspects of emerging weight loss maintenance research is that it can help us understand what kinds of things we need to do in order to keep the weight off. The big difference between this approach and others I have seen is that there is actual scientific research backing up the claims, rather than some “expert” speaking about his or her individual personal experience or philosophy.
National Weight Control Registry team member J. Graham Thomas (interviewed recently by our own Russ Lane) published an article last year with Rena Wing in Medicine and Health Rhode Island, the official member newsletter of Rhode Island Medical Society. In this paper Thomas outlined the strategies that are most statistically associated with weight management.
“Maintenance Predictors” Examined
Part 1: Predictors of Maintenance: An Overview
Part 2: Longevity and Consistency
Part 3: Lessening TV and Fast Food
Part 4: Including Breakfast and Not Letting “Now what?” Get you Down
Here are the best predictors of keeping weight off:
1. Longer duration of weight loss maintenance (more than 2 years)
2. Dietary consistency
3. Less fast food consumption
4. Less TV viewing
5. More frequent breakfast consumption
6. Lower levels of depressive symptoms and dis-inhibited eating
Key behaviors associated with weight maintenance are:
1. Activity levels of over 200 minutes per week (at least for women in the cited study)
2. High levels of dietary restraint, such as:
- Deliberately taking small helpings
- Avoiding certain foods
- Counting calories
3. Having lower levels of depressive symptomology
4. Controlling overeating
Yes, this means that it’s important to continue logging and/or controlling eating. It’s important to keep exercising. A lot. If you want to keep the weight off, these behaviors need to continue.
One of the more interesting behaviors listed was controlling depression. This means getting help in the form of therapy and/or antidepressants, if necessary. It is not a factor one usually hears about in terms of controlling weight, but it makes sense: how is a person going to make rational, healthy decisions while suffering from mental illness?
Along with summarizing the strategies taken by successful maintainers, the article discusses how to teach these strategies. One of the most important factors associated with weight management was frequent weighing and using that information to regulate behavior.
Thus, as with any feedback system, the best control is achieved by:
1. Frequent monitoring
2. Immediate correction
Given these research findings, I find it stunning that there are no dedicated evidence-based weight management programs. Most programs focus on the weight loss, and tack on a slipshod “management” guide at the end as an afterthought. At best they tend to be based on the personal philosophies of “experts.”
I would love to see a program that leads people through the transition from loss to management, walking that delicate tightrope between exploring the wonderful new options that a healthy size offers in life while staying grounded and accountable to maintenance. There are plenty of weight loss programs out there, but why are there none oriented specifically toward weight management after loss?
Is it because weight management doesn’t pay as well as loss? Management isn’t as exciting as loss? So few people focus on management that there isn’t a market for it? A combination of these reasons?
People do successfully lose weight using weight loss programs. But unfortunately they also tend to usually gain back the weight. Is it any wonder? I would like to see this changed. Please, someone, develop an evidence-based program. But please, develop it!
Not only for me, but for the thousands upon thousands of us who spent so much time and energy (and even money) on getting the weight off. It is too important in terms of our health and our quality of life, just to let the pounds slip back on.
If they do come back, I won’t be able to continue enjoying things like this:
I have a lot of comments and questions. 1 and 2 seem like results, rather than actions. 3 and 4 seem to be behavioral, not dietary, per se. 5 and 6 are likely true during the weight loss period as well. So those factors don't (or should not) change.
So far, I'm a "lucky" one. I decided to lose weight, it's done, I've been at a goal weight for almost a year, with no sign of turning back. But that's because I still take my weight and consumption seriously. I would also seriously contend your point about exercising, a lot. Over the last 6 months, my cardio has been nearly absent. Yet my calories have gone up.
The only thing that has remained the same between my losing weight is knowing/discovering my body's daily calorie requirements and tracking good enough to stay within those requirements.
I think you, and John Walker have nailed it. Constant monitoring and applying CORRECT action. I think the second part of that equation is key to maintaining. Everyone has a pretty good idea on how to create a caloric deficit. When I hit my goal weight, I really didn't have any idea what my true maintenance level was. I'm not even sure I knew it was called a maintenance level.
While there are a number of decent formulas, activity levels are highly subjective, so they cannot possibly be super accurate. This is where the near constant monitoring comes into play. The slow upward calorie adjustment followed by measuring your weight. It took me months to figure out my daily expenditure. I'm probably slower than most.
So some questions, seeking honest answers … when you regained weight, did you put the diet on a shelf and revert back mostly to your old habits? Did you stop tracking entirely? Were there outside factors that contributed to each respective gain (stress, depression, traumatic experience(s)?)
I guess the "system" should be slowly increase calories, continue to monitor and track. The old glasses metaphor is appropriate, even if tired. Just because you wore glasses for 6 months, doesn't mean your vision improved and you can chuck them aside. For some reason, I think that's the general behavior when people hit a goal weight. I have no science behind it, only experience from those around me that yo-yo.
Thanks for your feedback, Bill!
That first list is a set of factors correlated with successful weight management but causation is not established, so your comment is right on.
When I gained back the weight in my 20s nutrition and exercise took a back seat to spending time with the new boyfriend and throwing myself into completing the PhD. Without vigilance the pounds crept back on, because that's what they do on me when nutrition and exercise go unmonitored.
I think daily monitoring is the only way to go and being aware of how much exercise you're getting, even when it's not in the form of "proper" exercise. For example, on my non-gym days, I can get in over 20,000 steps by walking to shops and pacing around the house when on conference calls. My body doesn't really know the difference between that and gym workouts, as long as I get my heartrate up.
I think it's a shame more weight loss programs don't take maintenance seriously. I still wake up every morning and have to check to make sure the weight hasn't all returned over night.
Awesome comments.
@Carrie — Absolutely — the more you fit the "weight management" part of life into everything else you do, the better off you are. There are some differences between weight loss and maintenance, and I find they're difficult to explain mainly because they're so contextual. It's in the thinking. I love that you add it into your mix while you're living your life, on your terms.
And I'm a weight daily kind of guy m'self, but I think daily monitoring's effectiveness depends on how you approach your calorie intake. That's not something we've addressed yet.
Having a range and tweaking is one thing: if you're a mathematical sort and you add/subtract calories very incrementally, logically it'd follow that weekly monitoring would provide a better sense of your maintenance than daily. A week-to-week approach, in that case, would provide a stronger idea of if the calories you're adding/subtracting are effective. Again, that's better for a vastly different personality and lifestyle than my own, but the option/consideration's there.
@Bill — Lord, I love your posts. And I agree largely. I'd love for you to weigh in (hardee har har) on my breakdowns of these. Otherwise I'll reread your comments tonight and respond more thoroughly. Thanks so much!
Of all the people I know, Carrie, I think you've got the personal monitoring down to an exact science. You use that BodyBugg within an inch of its little electronic life! LOL
If they made waterproof ones I'd so be on board with you on that…
[...] Comments Carrie Shearer on Strength in Numbers Predictors and Behaviors of MaintenanceBill on Strength in Numbers Predictors and Behaviors of MaintenanceShira Miller on Historyangela on [...]
I think I've heard of a few programs that do more than tack on a slipshod guide. One being Nutrisystem, which I looked into because a friend is doing it, which attempts to provide you with tools and training to enable you to maintain your weight loss after the program (at least if you are making full use of the program — and compliance is of course a potential issue with any program). The other is Optifast, which I know trains people in healthy food preparation and teaches them to chart various factors. I can't say I know much about a lot of others. But I bet most in the medical community would say that this "maintenance plan" is supposed to be something provided by regular visits to your primary doctor. I'd agree if it didn't cost me $25+ for a 10-minute visit (if I'm lucky) and they had ever had more than two words to say about it.
One problem I have, Russ, with a "week to week" approach is that I believe that the noise of daily up-and-downs can in many cases still be overly "noise-filled" which can make true shifts difficult to see. I can have weight swings of up to +/-2 lbs sometimes when I travel, cut wood for 8 hours, or really anything that is drastically out of my routine as far as exercise or anything that affects water balance. If I'm losing a pound a week that swing can make progress hard to gauge, and if I'm maintaining (which I am at the moment) it can make my weighings extremely questionable. I think that weighings must be at a significantly higher frequency than the data is used to make adjustments – hey wait there's something about Nyquist in here somewhere I'm sure.
Bill's suggestion to slowly increase calories is pretty much exactly what I've said before, which is to gradually reduce one's deficit in order to reduce bounce-back and gradually get one used to the proper amount to eat for maintenance.
One issue with having a program that "leads people through the transition" is that people would be starting from such a variety of different weight-loss programs. I'd think each might need a bit of a different spin on leading the people into maintenance.
Really, AB (wait, you have the same initials as Alton LOL), I'd suggest that rather than asking people to develop such a program, outline your thoughts in terms of the program and get some other geeky people (nudge nudge, wink wink) to make it with. You, we, can do better than "Please, someone, develop an evidence-based program. But please, develop it!". I doubt there are many people more highly qualified, and probably none more adamant about it, than you.
Keep the comments discussion focused on the material itself, please. Second Helping isn't a depository for everyone's diet or diet company angst. Comparing/analyzing? Great, go for it. Complaining is inappropriate. Food for thought: In losing weight, complaining never got me very far, but initiative makes it easier for others to jump on board. Something to consider.
Moving on…
Re: weekly vs. daily weigh in | I personally do daily — when my back isn't thrown out, that is — but if you're being so specific about calorie adding/subtraction, being able to spot larger trends to see how you fare longterm would be more helpful. Since my eating/life is so chaotic, daily works better for me so I can adjust better. But I can conceive a weekly approach proving helpful.
Re: Leading through the transition | All diets ultimately do is provide a structure for eating and maybe exercise that help reduce weight loss for a specific period. That's what they do. *Laughs* Frankly, there's so many other aspects to maintenance beyond exactly what people eat.
And beyond that — honestly, do we need more advice on how to eat? Isn't there too much already? Has all that "eat this?" discussion impacted CDC rates? And if you found a method that works for you, why would you need a maintenance-based plan telling you how to eat AGAIN? In which case, it's just another thinly disguised weight loss book. That's not maintenance.
As the NWCR is proving, there's some larger trends in maintenance that are so regardless of HOW you lose weight. and balancing the breadth and depth isn't that hard to accomplish.
@ Bill — I also found it interesting how the six predictors paired up with each other and what they are communicating. We'll have more on that in a bit.
Thanks guys and onward!
Best,
Russ
Another excellent article Angela! I believe that the majority of regain is due to emotional eating/depression. Some regain is just due to lack of follow through and the diet mentality, but I believe this is the minority. There has been some increased focus on dealing with the emotional side of overeating which is positive, but I don't know how much the layperson buys into it. I think most people feel that "willpower" is all you need….even if you can't find a job or are trapped in a horrible marriage, etc. The key to maintenance for me so far has been to keep my stress levels to a minimum. If I'm extremely stressed or angry you better lock up the food. Keep it up Angela! We will beat the statistics! Birdie.
I'm with you on the limitations of willpower. It only works in the short-term, at least for me. I have unhealthy habits with a long long history and when stressed or upset they're the mode I default back to unless something intervenes.
One thing that I'm starting to realize I need is external structure, especially for exercise. When this swim-bike portion of the triathlon is done I'm looking forward to going back to the exercise classes I used to do.
@Birdie The depression — or even just emotional reactions, to put it in neutral terms — is a big part of why we focus so much on the murkier effects of weight loss here at SH; dealing with loose skin, the comments people make, etc. That has little to do with maintenance/eating/exercise per se, but I remember being floored by these things as I hit goal. And when I say floored, I mean binging like crazy and then relosing the weight.
Besides, the whole "willpower" things is highly overrated. *Laughs* Personally, I lose more "willpower" fights than not. It's helpful in breaking a binge cycle, sure, but as a lifelong MO? No thanks. Structure and realizing a variety of goals — not just related to your body — help keep me going. And both of those are fueled by a motivation to prove my low expectations of myself — not to mention society's low expectations of everyone — wrong.
Cultivating my foodie sense also helped immeasurably on the willpower front … even in emotional situations and I start wanting some bad French Quarter pizza, what stops me isn't "Oh, I must maintain my vigilance and abstinence in the face of most vile sin." It's "Jesus God, that's just horrible food! If I really want to cut loose, why not one of the finer restaurants in the city? I'd rather wait out and go to Slice."
Totally agree on the foodie angle. Since I started to learn to cook better and really pay attention to food, there are an awful lot of things that just don't seem worth eating anymore. We have a place called Silvio's Organic Pizza here that has spoiled me against ordinary pies… and once I'd had the duck confit poutine burger at a local chef-owned restaurant, honestly burgers elsewhere pale in comparison now too. Many times I find myself going,"Wait a minute, do I REALLY want that??" Not always because of health concerns so much as the fact that after some really amazing food experiences, the bar separating food as fuel from food as experience has been raised.
Unfortunately, despite the fairly-recent trend of TV chef weight loss (Gooooo Alton!!!), most people on Food Network don't exactly say "fit, healthy person" by their outward appearances.
Beautifully put, John.
Well, I learned this the hard way personally; since I began Second Helping, I REALLY learned it. Maintainers, unless folks who've bucked the trends push and push hard, are more or less on their own so far as society and the diet industry is concerned. It's not a matter of any individual element of the diet industry; from the lack of research, not having lived through it, or outright fear of stepping beyond the normal "fat pant" conversation, EVERYONE'S afraid to broach the subject.
Obviously, that's something I'm trying to change, both in this site and in behind-the-scenes stuff.
But food is no different; to pull off what I have in my own life, I had to completely dismiss the idea of target marketing because no one is targeting folks interested in maintaining their successes. So I looked at the gourmands, the chefs, the food network folks and thought: how can I apply what they're teaching? Even if they looked like I did, how I can they be useful to me? What do I ignore or adopt? So I looked at the principles of their teaching knowledge and then figured out ways. Suddenly, I became a "healthy gourmand" or foodie. That was never my intent. Little old me? I was just trying to find food that wouldn't bore me out of my mind or make me want two pizza and a fast food parade.
I was just trying to meet my goals and survive while doing it; I never counted on rediscovering food in a manner I couldn't have EVER imagined in my 350 days.
That's what kills me about the catch 22 of weight loss marketing and the folks suffering or ignored because of it: the point's not being a "bitter weight loser," it's that there's an amazing life available to people that has NOTHING to do showing off how great you look. It's not about how you look, but about what you do, and finding an entirely different relationship to food is such an integral part of that for me.
I'm a lurker, don't like to post or blog. I've been maintaining an 80 lb. loss for three years now. I weigh every day, too. Also I was totally struggling with being hungry all the time. Then I read Barbara Berkley's blog and got her book. I LIKE it. If I leave out the carbs (or that kind of carb) I am not hungry all the time and can actually go for several days as I did just lately visiting my daughter and not gain weight and just totally eat when I was hungry!! It's a miracle for me. The eating regime is limited but that works for me. I suppose others might get different results but I think it would be worth a try.
Congratulations on your success maintaining such a significant weight reduction for so long!
I agree about the carbs. They make me want more food. Even complex ones are tricky. My body just runs better on a lean protein diet.
I try to get at least 140g of protein per day to support my strength training and to lessen cravings. On the days I don't manage it, I sure can tell! LOL
Plus it helps to remove eating triggers like TV, etc.