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

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


Most of the patient experience revealed by qualitative studies can be explained by using this framework, and therefore, the introduction of this model could be an important step to shift the research focus forward. Particularly, there is a need for prospective studies to evaluate the predictive value of patient perspective ensuring that it does not reflect merely post-hoc rationalizations. Furthermore, the contribution of physiological adaptations, probably as a "source of tension", to the psychological dynamics of weight maintenance should be evaluated.
