**4. The patient perspective**

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

#### **4.1 Barriers**

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


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

#### **Table 1.**

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

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 unhealthy, modifiable behaviors [34].

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.

#### **4.2 Facilitators**

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

**313**

unmet needs.

circumstances.

*Long-Term Weight Loss Maintenance*

short- and long-term [33].

**4.3 Strategies**

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

some patients for a long time, whereas others are rather motivated by them in the

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

According to a recent psychological model that integrated findings from 26 qualitative studies on perceived barriers, facilitators, and strategies, the core issue for patients during weight loss maintenance is the experience of tension [31]. This tension is a conceptualization of the aforementioned burden that patients associate with adhering to the strategies required for long-term success. However, the novelty of this model is that it (a) assumes variability of the tension, (b) suggests that barriers, facilitators, and strategies are relevant to the degree they are affecting a patients' individual tension, and (c) classifies all of these factors with respect to one of four key concepts, that is, "sources of tension", "modifiers of tension", strategies

• "Sources of tension" are comprised of psychological factors such as old habits and impulses, beliefs about identity, beliefs about weight management, and

• "Modifiers of tensions" are comprised of barriers and facilitators such as environmental and social factors, as well as health, finances, and other personal

lack of behavior change, behavior maintenance, or self-efficacy?

for "managing tension", and strategies for "reducing the tension":

**4.4 The experience of tension as a psychological core issue**

some patients for a long time, whereas others are rather motivated by them in the short- and long-term [33].
