**4.3 Strategies**

*Weight Management*

• Bad weather conditions • Poor health and sickness • Lack of motivation • Lack of time management • Problems at home • Festivities

• Past stigmatizing experiences

• Negative beliefs about weight

• Maladaptive habits • Poor self-regulation skills • Emotional problems • Social-cultural factors • Environmental factors • Identity conflict

management

*a*

**Table 1.**

any barriers to weight loss maintenance [30, 35]. Also, despite the experience of external barriers and facilitators, many patients may still take mostly personal responsibility for weight maintenance as excess weight is oftentimes attributed to

*Main barriers, facilitators, and strategies of weight loss maintenance from patient perspective.a*

**Barriers Facilitators Strategies**

• Identity shift

into everyday life • Environmental factors • Socio-cultural factors • Improved self-perception

• Psychological commitment and preparedness to integrate weight management strategies • Self-motivation/ self-reinforcement • Self-monitoring

system

system • Habit formation

• Adoption of a food choice

• Establishing a non-food reward

• Restructuring the environment • Accepting and committing to weight loss maintenance as a

• Balancing eating restraint and

• Being open for building new

lifelong challenge

flexibility

relationships

In one of our studies, we found that patients who had been successfully treated for severe obesity were experiencing four main barriers to weight loss maintenance during the first 3 years after treatment completion [30]. The first barrier, 'Hedonic Hunger', reflected difficulties arising from food-related pleasure and the struggle with availability of highly palatable foods. The second barrier, 'mental distress', reflected difficulties arising from stress, emotional eating, and mental issues. The third barrier, 'Binge Eating', reflected difficulties arising from subclinical loss of control eating, binge episodes, boredom, and craving. The last barrier, 'Demoralization', reflected several difficulties arising from an implicit demoralized state, a low self-efficacy and helplessness such as lacking social support, finances, health, and motivation. Each barrier was found to be relevant for weight regain, but also that time could be a mediator. In particular, "Binge Eating" was found to be most critical at the beginning of weight loss maintenance and 'Mental Distress" at later stages.

Perceived facilitators of weight maintenance that have been revealed by reviews of qualitative studies include an identity shift (e.g., living healthily became a need), a psychological commitment, and preparedness to integrate weight management strategies into everyday life, environmental factors (e.g., healthy choices are visible, available and attractive), socio-cultural factors (e.g., support and engagement by friends, family, colleagues, and professionals), and an improved self-perception due to successful weight loss (**Table 1**) [8, 31, 33, 34]. However, the experience of facilitation can differ inter-individually. For example, for some patients, social support seems to be irrelevant [36], and past stigmatizing experiences seem to inhibit

unhealthy, modifiable behaviors [34].

*Main themes according to recent reviews of qualitative studies [31, 33, 34].*

**312**

**4.2 Facilitators**

Patients who are able to maintain weight loss report several strategies to explain their success including self-motivating and reinforcing strategies (e.g., consciously enjoying physical activity as a new quality of a weight-reduced life; intentionally turning dieting and exercise into meaningful hobbies), self-monitoring (e.g., appbased monitoring of food intake, physical activity, and body weight), adoption of a food choice system to reduce energy intake (e.g., preferring high-grade, unprocessed foods), establishing a nonfood reward system for weight maintenance (e.g., buying clothes), habit formation (e.g., avoiding the candy isle; parking faraway), restructuring the environment (e.g., food storage at home; avoiding high-risk situations), accepting and committing to weight loss maintenance as a lifelong challenge, balancing eating restraint and flexibility (e.g., having a slightly relaxed mind-set, faith in the process, testing limits, and consciously plan for occasional treats and even lapses), and being open for building new relationships (e.g., when former relationships loosen due to an incompatibility with the new lifestyle) (**Table 1**) [15, 36–38]. It should be noted though that successful weight maintainers may not use these strategies consistently, and the differences to unsuccessful patients could therefore be less pronounced than previously assumed [36]. Also, the burden patients associate with implementing weight maintenance strategies seems to remain much higher compared to lifetime weight stable persons who are relying on comparable strategies [15].

So far, mainly strategies that successful patients employ have been explored. In contrast, it is less clear which strategies less successful patients try to employ and how that relates to their weight regain and failed recovery attempts. For example, less successful patients oftentimes end up not eating breakfast, a strategy consistently reported by weight maintainers [23]. Is that because they have never managed to eat breakfast on a regular basis, because they discontinued it prior to regain, or because they discontinued it after weight began to regain? In other words, is it a lack of behavior change, behavior maintenance, or self-efficacy?
