Patients often think that because they were able to maintain their original weight with little or no effort, then this should also be the case after weight loss. To maintain their new lower weight they need to be eating less or doing more exercise than they were at their original weight. This is why the most important factor determining the success of any weight loss attempt is the ability to maintain long-term adherence to new lifestyle changes. Temporary changes will lead to temporary weight loss; if the predisposing factors remain, so too does the propensity for weight regain (Figure 2).14 Therefore patients should be encouraged to make lifestyle changes that are sustainable.
Patients often become frustrated and give up on lifestyle changes when their weight starts to plateau. The WHO recognises that no weight gain is a good outcome in weight loss interventions, particularly in patients who have previously been gaining weight. Helping patients identify benefits of their new lower weight or of not gaining weight may help them to feel less frustrated when their weight plateaus. Many dieters believe that if they restrict their intake further then they will lose weight no matter what their bodies are trying to do. The physiological adaptations to losing weight will make people feel more hungry and seek higher energy food more often.10-13 Therefore this can be a good time to introduce another strategy such as meal replacement products in particularly very low energy diets (VLED), which can control hunger while reducing weight, use of pharmacotherapy or bariatric surgery.15
The National Weight Control Registry in the USA (www.nwcr.ws), which is following more than 10,000 people who had lost 13.6 kg or more using any method and kept it off for at least a year, has shown that successful people had the following characteristics: they ate a low-energy and low-fat diet; consistently self-monitored their weight; ate breakfast regularly; engaged in 60 minutes of physical activity each day; watched very little television (screen time) and had minimal variation to diet on weekends or when on holidays.16
A practical approach
There are numerous dietary approaches for weight management. A simple starting point can be discussing vegetable consumption and discretionary food intake.
Increase vegetable consumption
Only 8% of Australian adults meet the guidelines of serves of vegetables per day. This is even less (5%) for both vegetables and fruit.17 A possible goal is to encourage patients to ensure that half of what they eat is vegetables for at least two meals each day.
Decrease discretionary food items: discuss alcohol and ultra-processed food intake
Discretionary foods make up more than one-third (36%) of Australian adults’ total daily intake. Of this, for adults aged 51 to 70 years, alcoholic beverages account for over one-fifth (22%) of discretionary food intake.18
Ultra-processed foods are those that undergo a multitude of processes including many that could not be recreated in the home. They have been found to have a detrimental effect on health particularly weight regulation. It has been reported, eating ad libitum only ultra-processed food for two weeks can lead to a 0.9 kilogram increase compared with a 0.9 kg weight loss after eating unprocessed food under the same circumstances.19
A possible goal is to encourage patients to swap discretionary foods for other (unprocessed) foods and/or minimise the amount consumed. It is not essential to eliminate a particular food.