Severe overweight is associated with a vast array of health problems, including chronic pain, diabetes, etc. Over the past 75 years or so, several behavioral themes have dominated approaches to losing weight. The most common but erroneous theme continues to be that finding the “best” commercial diet can provide a path to permanent weight loss for most people. Another false theme is that the quantity of food one eats, whatever it is, accounts for weight gain. The fact is that over 80% of people who attempt to lose weight gradually gain it back, and then some. I would like to highlight some of the valid themes and facts about weight loss and its relation to eating behavior and activity choices. My claims here are based on my understanding of the large research literature that exists on weight loss and especially, weight loss failure and success.
First, it is critical to reject the idea that most people can lose weight through a diet, and that following weight loss, one can then return to their prior eating and activity levels with no consequence. This theme or belief is utterly false because your body engages a large number of physiological mechanisms that are specifically designed to retain body fat. Literally, your body is built to fight your efforts to lose weight. You have probably heard of “yo-yo” dieting, in which people regularly spend years losing weight, gaining it back, attempting to lose it again, regaining, etc. Nearly all people who attempt weight loss find that in the end their body is more persistent in retaining fat than dieters are in losing it. The first general behavioral principle suggests that successful long-term weight loss involves an array of interactive permanent lifestyle changes, usually adopted in “baby steps”. Relatedly, the individual has to find them generally pleasant and rewarding to do.
A second, quite valid behavioral aspect of weight loss is that most people can in fact, lose weight (short term) by adopting any of the generally popular programs that are available, such as Weight Watchers, Jenny Craig, a “paleo” eating regimen, etc. Studies that compare the effectiveness of different programs fail to show truly meaningful differences in long term outcomes. One program is not hugely better than another. However, successful outcomes are on average, modest (up to about an average of seven pounds lost); and are nearly always short-lived. People nearly always gain the weight back when they leave the program. I believe that one of the key elements to permanently altering your eating behavior lies in finding one of the effective programs that you really like and that you believe you can “live with” the rest of your life. The principle says stop dieting and start identifying eating, food shopping, and physical activities you can enjoy doing every day, permanently.
Based on the above, note that I am not interested in debates about whether one diet program is superior to another. However, some general food choices are extremely important to permanent weight loss, and they include the following. Our third behavioral theme suggests that we shop only in the simple food areas of the grocery store, avoiding the “prepared foods” (which incidentally, tend to take up over 50% of commercial grocery isle space; think about how much space is devoted to candy, chips, snack foods, bakery goods, etc). The simple food areas include vegetables, meat and to a modestly lesser extent, fruit and dairy. The goal is to restrict purchases of products that contain added sugar and high levels of carbohydrates. I think our high intake of processed sugar and carbs and our tendency to allow others to prepare the food we eat (e.g., “fast food”) contributes heavily to the obesity epidemic in the U.S. Drastically reducing daily intake of carbohydrates and sugar will help your weight loss efforts tremendously. In summary, significant increases in the proportion of food containing fats, protein, vegetables, with severe reductions in carbohydrates and sugars, is an important weight loss guideline.
Second, most people I have worked with over the years have found that a permanent lifestyle change in eating behavior requires serious conscious attention to portion control. I generally coach people who want to lose weight permanently that if they do nothing else, they will benefit from simply reducing food portions of meals by roughly 30%, to start with. In conjunction with consuming smaller portions, it is also helpful to allow enough time (maybe, 10-20 seconds) to mentally assess whether you are minimally, feeling comfortably “full”. In fact, slowing the pace of your eating and strictly reducing portions, plus, taking 10 seconds to assess whether your are comfortably full are a series of fairly easy “first steps” to helping lose weight.
Third, we know that taking smaller, gradual steps e.g, incorporating new foods into one’s diet, a little at time, works better than making a radical change from a primarily high carb diet (to one that is sparse on carbs and sugar). An interesting case study involving Type 2 diabetes illustrates this point. A group of volunteers started a month-long eating and activity regimen change at an Arizona retreat center. All were immediately placed on a strict, “raw foods” diet, emphasizing vegetables and some whole grains, with no added sugars or carbs. Several individuals dropped out rather quickly because they felt they could not adjust to such a radical change to their American Diet (e.g., OJ for breakfast, bread, hamburgers with French fries, etc.). The best approach is to make sure that your dietary change is gradual, and that you like eating what you are transitioning to. An example would be eating a hamburger with only ½ of the bun, later fading this to eating hamburgers with no bun over time. Or easing into portion control by determining that every time you visit a restaurant, you’ve planned in advance how you will divide the meal in half and enjoy the other half the next day for lunch or dinner. After doing this a few times, many will report they start to look forward to having a favorite meal “twice”, because they exercised portion control.
Fourth, two other well-known lifestyle changes that aide permanent weight loss are getting enough total sleep at night, and increasing one’s activity level. A number of credible research studies suggest that quality sleep helps a person lose weight. Most adults probably need 7-8 hours per night of quality sleep but achieve only about 6-7. The positive impact of sleep on weight loss is due to factors scientists do not yet understand. However, it is well known that if we get enough sleep, we are much more likely to engage in higher levels of physical activity the next day (because we are not chronically tired). And, with regard to physical activity level—-there is simply no doubt that strength training and aerobic conditioning play a role in helping a person lose weight and keep it off. Increasing physical activity seems to be one of the lifestyle changes persons who lose weight long term adopt.
Fifth, there is a universal behavioral health theme that is supported by thousands of psychological research studies involving many different types of behavior change goals. Not surprisingly, the theme has huge implications for long-term, permanent weight loss and maintenance. The theme is that all behavior change occurs more easily and is more easily sustained if one has high social support for the behavior.. This means a friend or loved one who positively encourages, supports, or engages with you in the behavior change activity. For instance, an obese child almost certainly will never lose weight on their own. The entire family needs to change its food-shopping, meal planning, eating habits and activity level. Similarly, going on walks or visiting the gym is vastly more likely to occur for most people if they have a work-out partner. One’s meal changes are more likely to become permanent if his or her partner or family also engages in meal planning and cooking.
Why do over 80% of people who successfully lose weight regain it? I now want to introduce a simple hypothesis about what I think accounts for most weight regain following successful “dieting”. This is an educated speculation that is consistent with all of the best long-term studies examining successful versus unsuccessful weight loss patients. The primary reason people gradually regain weight is because they ever-so-gradually abandon the eating and activity behaviors that helped them lose weight in the first place. While vigilant and consistent for many months, they may eventually begin to experience very slight, minor “slips” in their weekly sugar or carb intake. Sooner or later, life circumstances may start to interfere with their usual exercise regimen. They start to become just a bit less vigilant about portion control and begin to experience “portion creep”. They may relapse a bit in the habit of slowing the pace of their eating. They grab a quick fast food meal during busy week more and more often. Or, recently, if under stress, they may begin to fall back on the old habit of de-stressing by eating “comfort foods”. They may allow themselves to “overindulge” on more frequent occasions than they did during their weight loss period. Researchers find that the most successful, long-term weight loss patients are highly persistent and consistent. To sustain weight loss over the very long term, the successful group tends to eat a small, healthy breakfast every day. They weigh themselves regularly, (about once a week). They have meal plans that they truly “stick with”, enjoy, and which are healthy. They watch fewer than 10 hours of TV per week (avoid being sedentary). They have permanently and consistently cut back on how much they eat in a given day and do not stop monitoring what and how much they eat. Nearly all make sure they maintain an exercise program, generally, this is simply walking many times each week. In general, their frame of thinking has shifted from “trying to be thin”, to being as strong, well-rested and as “healthy” as they can be. In summary, my speculation about weight regain after dieting emphasizes the idea that over time, patients ever so slowly fall back into patterns of eating, activity, sleep etc., that promoted their weight gain in the first place. They tend to not realize it is happening. Given the fact that your body is 100% committed to restoring its fat stores, the successful weight loser in the long term cannot afford to relapse much in terms of their lifestyle changes. He or she will catch themselves very quickly when the first few pounds return. They reassess where they are reverting to old patterns or habits with eating, grocery shopping, activity, sleep, etc.
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