**1. Introduction: is weight maintenance a losing battle?**

The importance of weight loss for people in the western world is reflected by a growing diet industry that is providing easier, faster, and more powerful products. In addition to public demand, the diet industry keeps growing because many of their products simply work, i.e., they do enable customers to reduce their body weight short-term. Socio-cultural ideals of beauty and attractiveness are major motivators for reducing body weight even if it already falls within a healthy norm. However, for approximately 20% of adults in western societies, losing weight has become a health-related issue as they are suffering from obesity. It has been shown that comorbidities of obesity such as cardiovascular diseases, joint damage, or diabetes as well as quality of life significantly improve when weight is reduced [1]. However, the same way it has been shown that short-term weight loss is achievable for many people, it has become clear that only few are successful in the long-term [2, 3]. The authors of a recent systematic review concluded that substantial weight loss cannot be sustained by the average person in the absence of a continued followup intervention [4]. Moreover, behavioral treatments have been questioned ethically with respect to the claim of permanent weight loss [5]. However, recent data suggest that treatment programs comprising of intensified lifestyle interventions with continued support can lead to longer-term weight loss [6]. Therefore, a better understanding of the interaction between physiological and psychological barriers to weight maintenance has been recommended as well as the development of more individualized and targeted strategies.

## **2. What makes weight loss maintenance challenging?**

A number of physiological and psychological factors have to be emphasized in order to understand the challenge of weight loss maintenance. Physiologically, weight loss induces metabolic adaptations that favor weight regain by creating an energy gap [7–9]. These comprise the hormonal regulation of appetite, satiety, and satiation as well as resting energy expenditure. Energy expenditure is lowered beyond what changes of body composition predict and this might be due to adaptive thermogenesis, that is, the capability of the human body to reduce energy expenditure by producing less body heat [10]. Moreover, there is evidence that at least some of these changes can last over several years, even after partial weight regain [11, 12].

Psychologically, it is known that the effect of health behavior interventions generally diminishes over time, and that behavior maintenance has to be regarded as a separate challenge [13]. Five overarching themes have been associated with behavior maintenance and may explain why it is difficult to achieve, i.e., maintenance motives [...], self-regulation, resources, habits, and contextual influences [13]. With respect to weight maintenance, it has to be considered that adherence not just to a single but to a whole set of behavior is required in order to balance and regulate energy intake and expenditure [14]. These changes comprise areas such as meal structure, eating behavior, food shopping, calorie counting, alcohol consumption, exercise, stress management, sleep, leisure activities, and vacation. Although they are referred to as a single change of lifestyle, the difficulties to maintain each associated behavior change may rather accumulate than complement. In accordance with this is the observation that even after several years of successful weight maintenance, its execution is still experienced as a burden [15].

Taken together, weight loss maintenance is a challenge because it requires actively counteracting a possibly infinite physiological resistance against weight reduction as well as the psychological tendency to relapse from health behavior changes of which many are necessary for long-term maintenance. Therefore, after successful weight loss, obese patients should not be treated as cured, normal-weight people, but rather as reduced obese individuals [16].

#### **3. Factors associated with weight loss maintenance**

Despite its physiological and psychological challenges, a considerable number of patients are able to minimize weight regain [17]. This has been attributed to personal characteristics such as internal motivation, social support, self-efficacy, novelty seeking, or sleep chronotype, as well as to a set of specific behaviors observed in successful maintainers such as high levels of physical activity, compliance to a low-energy diet with a regular meal rhythm, flexible eating restraint, portion control, control of over-eating, self-monitoring, immediate regulation of weight gain, and active problem solving [18–23].

Notably, successful maintenance practices seem to differ from successful weight loss practices [24]. In recent reviews, energy intake on one side and energy expenditure on the other have been used as a framework to explain how different determinants may affect weight maintenance [8, 20]. According to this view, any factor or strategy that enables a weight-reduced patient to permanently reduce calorie intake will support weight maintenance. Similarly, any strategy that enables a patient to permanently increase energy expenditure will support maintenance as well. It has to be noted that none of these determinants are believed to alter the physiological adaptations associated with weight loss but rather help to

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**4.1 Barriers**

*Long-Term Weight Loss Maintenance*

patient perspective [30].

**4. The patient perspective**

*DOI: http://dx.doi.org/10.5772/intechopen.92103*

energy regulation is an inevitable necessity.

minimize their impact. In other words, it is assumed that a cognitive control of

Although several determinants of successful weight loss maintenance have been observed, intervention studies reported mainly disappointing results [17, 25, 26]. An increase of physical activity and exercise, for example, is clearly predictive of weight loss maintenance, but when applied as a clinical intervention in randomized controlled trials, its effectiveness remains questionable, especially in the long-term [27, 28]. The reason for this is still not clear but an important factor could be adherence. Therefore, additional mediators need to be identified that may explain why some patients continue pursuing weight maintenance behaviors and some others are not [22]. For example, the contribution of novel neuropsychological factors such as executive functioning and neurocognitive control to weight loss maintenance have been recently discussed [16, 29]. Another important approach for improving long-term adherence might be the provision of more tailored and multidisciplinary weight loss maintenance strategies [14]. This requires a deeper understanding of the

In order to provide a tailored support after weight loss, it is crucial to understand the patient perspective on weight loss maintenance. What do patients experience during this time? How do the physiological and psychological challenges translate into the individual's perception and what measures do they undertake in response to that and with what kind of perceived success? These questions can be answered by identifying factors that patients perceive as threats and factors that they perceive as facilitators during weight loss maintenance. It might also be useful to identify the different maintenance strategies patients rely on and their experience with them. Most studies have used qualitative designs to explore how patients experience and explain their success or failure during weight maintenance, respectively. Although the transferability of a single qualitative study may be limited, a more valid view can be generated by thematically synthesizing many of them [31]. To expand insights gathered by qualitative studies, it could also be helpful to utilize quantita-

A great variety of barriers to weight maintenance have been revealed by reviews of qualitative studies on patient perspective (**Table 1**). For example, in one review, the identified barriers included bad weather conditions such as extreme winters, poor health and sickness, lack of motivation (e.g., due to previous failure, body image, or eating for reasons other than hunger), lack of time management, problems at home (e.g., due to the inability to afford a healthy lifestyle), festivities, and past stigmatizing experiences [33]. Additional barriers, identified in another review included maladaptive habits, poor self-regulation skills, emotional problems, social-cultural factors (e.g., pressure, saboteurs, and social commitments), and environmental limitations (e.g., feeling unsafe to exercise in the neighborhood) [34]. Identity conflicts and negative beliefs about weight management are two more barriers patients experience during weight loss maintenance [31]. It is possible that a considerable overlap between some of these barriers exists and that they can be reduced to a small number of main barriers [30]. It is also noteworthy that the perception of barriers and their relevance for actual weight regain could change over time and there might even be moments when some patients are not experiencing

tive designs in future studies of patient perspective [30, 32].

#### *Long-Term Weight Loss Maintenance DOI: http://dx.doi.org/10.5772/intechopen.92103*

*Weight Management*

regain [11, 12].

**2. What makes weight loss maintenance challenging?**

maintenance, its execution is still experienced as a burden [15].

people, but rather as reduced obese individuals [16].

weight gain, and active problem solving [18–23].

**3. Factors associated with weight loss maintenance**

A number of physiological and psychological factors have to be emphasized in order to understand the challenge of weight loss maintenance. Physiologically, weight loss induces metabolic adaptations that favor weight regain by creating an energy gap [7–9]. These comprise the hormonal regulation of appetite, satiety, and satiation as well as resting energy expenditure. Energy expenditure is lowered beyond what changes of body composition predict and this might be due to adaptive thermogenesis, that is, the capability of the human body to reduce energy expenditure by producing less body heat [10]. Moreover, there is evidence that at least some of these changes can last over several years, even after partial weight

Psychologically, it is known that the effect of health behavior interventions generally diminishes over time, and that behavior maintenance has to be regarded as a separate challenge [13]. Five overarching themes have been associated with behavior maintenance and may explain why it is difficult to achieve, i.e., maintenance motives [...], self-regulation, resources, habits, and contextual influences [13]. With respect to weight maintenance, it has to be considered that adherence not just to a single but to a whole set of behavior is required in order to balance and regulate energy intake and expenditure [14]. These changes comprise areas such as meal structure, eating behavior, food shopping, calorie counting, alcohol consumption, exercise, stress management, sleep, leisure activities, and vacation. Although they are referred to as a single change of lifestyle, the difficulties to maintain each associated behavior change may rather accumulate than complement. In accordance with this is the observation that even after several years of successful weight

Taken together, weight loss maintenance is a challenge because it requires actively counteracting a possibly infinite physiological resistance against weight reduction as well as the psychological tendency to relapse from health behavior changes of which many are necessary for long-term maintenance. Therefore, after successful weight loss, obese patients should not be treated as cured, normal-weight

Despite its physiological and psychological challenges, a considerable number of patients are able to minimize weight regain [17]. This has been attributed to personal characteristics such as internal motivation, social support, self-efficacy, novelty seeking, or sleep chronotype, as well as to a set of specific behaviors observed in successful maintainers such as high levels of physical activity, compliance to a low-energy diet with a regular meal rhythm, flexible eating restraint, portion control, control of over-eating, self-monitoring, immediate regulation of

Notably, successful maintenance practices seem to differ from successful weight loss practices [24]. In recent reviews, energy intake on one side and energy expenditure on the other have been used as a framework to explain how different determinants may affect weight maintenance [8, 20]. According to this view, any factor or strategy that enables a weight-reduced patient to permanently reduce calorie intake will support weight maintenance. Similarly, any strategy that enables a patient to permanently increase energy expenditure will support maintenance as well. It has to be noted that none of these determinants are believed to alter the physiological adaptations associated with weight loss but rather help to

**310**

minimize their impact. In other words, it is assumed that a cognitive control of energy regulation is an inevitable necessity.

Although several determinants of successful weight loss maintenance have been observed, intervention studies reported mainly disappointing results [17, 25, 26]. An increase of physical activity and exercise, for example, is clearly predictive of weight loss maintenance, but when applied as a clinical intervention in randomized controlled trials, its effectiveness remains questionable, especially in the long-term [27, 28]. The reason for this is still not clear but an important factor could be adherence. Therefore, additional mediators need to be identified that may explain why some patients continue pursuing weight maintenance behaviors and some others are not [22]. For example, the contribution of novel neuropsychological factors such as executive functioning and neurocognitive control to weight loss maintenance have been recently discussed [16, 29]. Another important approach for improving long-term adherence might be the provision of more tailored and multidisciplinary weight loss maintenance strategies [14]. This requires a deeper understanding of the patient perspective [30].
