**5. Providing support during weight loss maintenance**

With respect to the available findings on patient perspective as well as our own experience, we suggest that an ideal weight loss maintenance treatment program comprises of two components, one provided during and immediately after weight loss in a structured manner, and one provided and tailored as part of a longer-term follow-up care.

#### **5.1 Structured component of a weight loss maintenance program**

The structured component of a weight loss maintenance program should promote early (i.e., already at the weight loss stage) cognitive-behavioral changes such as habit formation that will later help reduce the tension of weight loss maintenance. Additionally, during the transition from weight loss to maintenance, this component should support the development of strategies for managing the tension (**Table 2**) [31]. An important cognitive goal of this component is to help patients accept the challenge of weight loss maintenance early, so they have time to make a psychological commitment and be prepared for integrating weight management strategies into everyday life (facilitator of WLM). Therefore, weight loss maintenance treatment ideally begins during the last weeks of the weight loss stage, when weight reduction is just starting to level off. Ways to support early acceptance include psychoeducation, cognitive restructuring (e.g., by increasing awareness of already achieved improvements), and introduction of former patients as role models. This acceptance also requires acceptance of the end of the current weight loss episode. The latter is not easy for many patients because they are experiencing weight loss as a rather euphoric state with rapid success and regular reinforcement due to social adoration, improved quality of life, and health. Also, they are feeling in control of their disease and some might even feel cured, expecting to continue until some far-away ideal weight is being reached. Therefore, it is essential for them to gain insight into the fact that weight loss is going to cease, largely due to physiological adaptations, and that it is psychologically healthier, easier, and more functional to start focusing on maintenance than further weight loss. For this purpose, it can be helpful to emphasize differences between the two (**Table 3**).

#### **5.2 Tailored longer-term follow-up care**

The second component of an ideal weight loss maintenance treatment program should provide tailored interventions as part of a longer-term follow-up care.

**315**

*a*

**Table 2.**

interventions may need to be offered.

Willpower or motivation Buddying

*Approach to a structured weight loss maintenance treatment.*

The time frame should be at least 3 years after weight loss, as these years are most critical with respect to weight regain [39]. During this time, a continuous assessment of body weight change, cognitive-behavioral changes, emergence of barriers, and loss of facilitators should be performed to allow immediate intervention. To get a more valid picture, data can be recorded by patients prior to a consultation [36]. With respect to the different barriers patients are experiencing, at least five tailored

A first intervention should be targeted towards patients who are primarily experiencing difficulties due to festivities, environmental factors such as food availability, social-cultural factors such as peer pressure, and old habits. Practicing

*Long-Term Weight Loss Maintenance*

Reducing the tension

Meeting needs more

Changing beliefs about weight management

Managing the tension Self-regulation, learning

Managing internal and external influences

and insight

healthily

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

Developing automaticity Stimulus control

**Strategya Interventional tools Examples**

Habit formation Nudging Model learning

reduction Social skills training Physical activity Exercise

Psychoeducation Cognitive restructuring Model learning

Psychoeducation Diaries, protocols, Apps

Psychoeducation Acceptance-based treatment

*Strategies adopted from a conceptual model of the dynamics of weight loss maintenance [31].*

Self-help

Cognitive restructuring Problem solving Mindfulness-based stress • Eating before food shopping • Parking further away from the office • Move the TV out of the living room • Joining a fitness tracker community

are not food related

• Learning to say 'no'

of success

want to be

• Self-monitoring

• Relapse recovery

situations

• Using social accountability

• Flexible eating restraint • Recognizing lapses and relapses • Owning up to and growing from lapses

• Defusing food cravings

• Patient-led workshops

• Sharing success with new patients

choices • Photo shoot

Changing identity Cognitive restructuring • Showing others who you were and who you

• Identify pleasant aspects of vacations that

• Using exercise performance as an indicator

• Associate personal values with healthy

• Appreciating the weight loss outcome • Accepting the weight maintenance challenge • Getting to know successful maintainers

• Becoming aware of personal risk factors

• Anticipating, planning, and avoiding at-risk

• Joining a Nordic walking group

• Feeling healthy by eating healthy food

*Weight Management*

motivation.

follow-up care.

• Strategies for "reducing the tension" are comprised of developing automaticity,

• Strategies for "managing the tension" are comprised of learning and insight, self-regulation, managing internal and external influences, and willpower or

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 psycho-

With respect to the available findings on patient perspective as well as our own experience, we suggest that an ideal weight loss maintenance treatment program comprises of two components, one provided during and immediately after weight loss in a structured manner, and one provided and tailored as part of a longer-term

meeting needs more healthily, and changing beliefs and self-concept.

logical dynamics of weight maintenance should be evaluated.

**5. Providing support during weight loss maintenance**

**5.1 Structured component of a weight loss maintenance program**

be helpful to emphasize differences between the two (**Table 3**).

The second component of an ideal weight loss maintenance treatment program

should provide tailored interventions as part of a longer-term follow-up care.

**5.2 Tailored longer-term follow-up care**

The structured component of a weight loss maintenance program should promote early (i.e., already at the weight loss stage) cognitive-behavioral changes such as habit formation that will later help reduce the tension of weight loss maintenance. Additionally, during the transition from weight loss to maintenance, this component should support the development of strategies for managing the tension (**Table 2**) [31]. An important cognitive goal of this component is to help patients accept the challenge of weight loss maintenance early, so they have time to make a psychological commitment and be prepared for integrating weight management strategies into everyday life (facilitator of WLM). Therefore, weight loss maintenance treatment ideally begins during the last weeks of the weight loss stage, when weight reduction is just starting to level off. Ways to support early acceptance include psychoeducation, cognitive restructuring (e.g., by increasing awareness of already achieved improvements), and introduction of former patients as role models. This acceptance also requires acceptance of the end of the current weight loss episode. The latter is not easy for many patients because they are experiencing weight loss as a rather euphoric state with rapid success and regular reinforcement due to social adoration, improved quality of life, and health. Also, they are feeling in control of their disease and some might even feel cured, expecting to continue until some far-away ideal weight is being reached. Therefore, it is essential for them to gain insight into the fact that weight loss is going to cease, largely due to physiological adaptations, and that it is psychologically healthier, easier, and more functional to start focusing on maintenance than further weight loss. For this purpose, it can

**314**


#### **Table 2.**

*Approach to a structured weight loss maintenance treatment.*

The time frame should be at least 3 years after weight loss, as these years are most critical with respect to weight regain [39]. During this time, a continuous assessment of body weight change, cognitive-behavioral changes, emergence of barriers, and loss of facilitators should be performed to allow immediate intervention. To get a more valid picture, data can be recorded by patients prior to a consultation [36]. With respect to the different barriers patients are experiencing, at least five tailored interventions may need to be offered.

A first intervention should be targeted towards patients who are primarily experiencing difficulties due to festivities, environmental factors such as food availability, social-cultural factors such as peer pressure, and old habits. Practicing


**Table 3.**

*Example for how weight loss maintenance can be emphasized as a separate challenge to patients.*

stimulus control techniques, social skills, and mindfulness eating might help these patients to gain back control over externally triggered hedonic eating motives.

A second intervention should be targeted towards patients who primarily report emotional problems, lack of time management, or negative beliefs about weight management. Stress prevention and reduction trainings might help these patients to free the resources necessary to pursue healthy behaviors again and to not rely on emotional eating as a coping mechanism. Of note, some of these patients may need to be referred to psychotherapy to treat an underlying affective disorder.

A third intervention should be made available to patients who primarily experience a lack of control over eating in the absence of clear external or emotional causes. A training comprising of acceptance-based and cognitive-behavioral techniques, proven effective for the treatment of binge eating disorder, might be helpful.

A fourth intervention should be made available for patients whose primary issue is a directly experienced lack of motivation or who are demoralized by the experience of barriers seemingly out of their control such as bad weather conditions, poor health and sickness, financial problems at home, a lack of social support, or poor body image. Training these patients in problem-solving might enable them to find solutions for their respective issues and more importantly, may increase their self-efficacy and beliefs in long-term success. Self-efficacy can be further promoted by applying methods such as mentoring, adequate goal setting, action planning, and motivational interviewing. With respect to body weight, it should be considered that stabilization of a partly regained weight is a more realistic goal for recovery than anew weight loss [40].

A fifth intervention should be made available for patients who are experiencing identity conflicts as their primary issue such as discomfort with the new body, social insecurities, or inhibition by past stigmatizing experiences. Cognitive-behavioral techniques can be used to dispute potentially idealizing of the former obese self or

**317**

**Author details**

Martin Fischer1

Germany

\*, Nadine Oberänder2

which may help improve weight loss maintenance.

\*Address all correspondence to: martin.fischer@sanktgeorg.de

2 Klinikum St. Georg, Leipzig, Germany

provided the original work is properly cited.

and Arved Weimann<sup>2</sup>

1 St. George Obesity Treatment Study Group, Klinikum St. Georg, Leipzig,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Long-Term Weight Loss Maintenance*

**6. Conclusion**

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

an exaggerated significance of body image to self-worth. They can also be used to help patients seek and build on self-esteem fostering situations. Psychoeducation

As described before, it is likely that patients are experiencing several of the barriers in parallel or intermittently during weight maintenance. However, we think it is still beneficial to treat one barrier at a time in order to focus on behavior and

Weight loss maintenance is a complex physiological and psychological challenge associated with a high risk of failure. Studies on patient perspective have revealed valuable information on how this process is experienced. Although generally experienced as an ongoing burden, the underlying psychological tension is variable and moderated by a number of now well-defined barriers, facilitators, and strategies. With this novel information, a more tailored long-term support can be provided

about optional plastic surgery after weight loss might be offered as well.

cognition instead of weight loss to achieve long-term improvements.

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

an exaggerated significance of body image to self-worth. They can also be used to help patients seek and build on self-esteem fostering situations. Psychoeducation about optional plastic surgery after weight loss might be offered as well.

As described before, it is likely that patients are experiencing several of the barriers in parallel or intermittently during weight maintenance. However, we think it is still beneficial to treat one barrier at a time in order to focus on behavior and cognition instead of weight loss to achieve long-term improvements.
