Healthy Heart

How do I lose weight and keep it off?

Being overweight causes many problems. Ninety him percent of adult onset diabetes is related to obesity, and being overweight also makes it more likely that you will have high blood pressure and abnormal cholesterol levels.  If you already have these conditions you will need more medication than if your weight was normal.   And of course, being overweight also puts more strain on the back, knees, and other joints, makes it harder to play sports and be active, and then apart from all of these health considerations many people would like to be thinner for purely cosmetic reasons.

If you go online to Amazon.com and search the book category for "weight loss" you will come up with 65,500 hits! And that is only in Amazon. So with all of the advice out there, why is it so difficult to lose weight?  There is a remarkable paradox here. It is actually easy to lose weight, and probably there has never been a diet that did not produce weight loss. Most overweight people have in fact lost weight in the past. But the paradox is that it is remarkably difficult to keep weight off and almost everyone who loses weight regains it (and often more) over the course of the next several years.

Yet there are those who lose weight and keep it off. It can be done. And we have learned a lot about how to maintain weight loss over many years.  Here is what we have learned:

  • It doesn't seem to matter what kind of diet you use. All diets are successful in some people and all diets are unsuccessful in the majority of people over the long term. Dansinger and colleagues carried out a study in which they compared four different diets: the low-fat Ornish diet; the carbohydrate-restricted high-fat Atkins diet; the calorie-restricted Weight Watchers diet; and the macronutrient-balanced Zone diet (Dansinger et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for Weight Loss and Heart Disease Risk Reduction: A Randomized Trial. JAMA 2005;293:43-53). These four diets are very different and yet the results were much the same.  By the end of one year 50% of the participants had dropped out of the Ornish and Atkins groups, and 35% of participants had dropped out of the Weight Watchers and Zone diet groups. Average weight loss in all four groups ranged between 2.1 and 3.3 kg (4.6 and 7.3 pounds), hardly the weight loss that participants were looking for. However, in all of the groups there were those who did better – in each diet group, approximately 25% of the initial participants sustained a 1-year weight loss of more than 5% of initial body weight and approximately 10% of participants lost more than 10% of body weight. In all of the diets, increasing weight loss was associated with greater improvement in cholesterol levels and in risk of diabetes. So what is it that characterizes those people who do successfully lose more weight?
  • There is a study called the National Weight Control Registry (Klem et al. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997;66:239-46). This registry studies individuals who have been successful at maintaining weight loss. The many hundreds of men and women in the registry had lost an average of 30 kg (66 pounds) and had kept off at least 13 1/2 kg (30 pounds) for over five years. How did they do this? The group had several common characteristics:
  • The overwhelming majority used both diet and exercise to lose weight. The diets tended to be of the low-fat variety, but the type of diet is probably less important than sticking to it.
  • The level of exercise was high. 72% of participants were burning over 1000 calories a week in physical activity and 52% over 2000 calories a week. It is very important to understand that exercise allows you to eat more. If you burn 200 calories a day in exercise, you can eat those 2000 calories without gaining weight. If you are very sedentary, you can only maintain weight loss by eating very little, and that becomes very hard to keep up as time passes.
  • These folks were weighing themselves very often. 38% weighed themselves every day and 75% weighed themselves at least once a week. If you weigh yourself frequently, then you know when you have gained a pound or two and losing that pound or two is easy (stop eating dessert!). But if you don't weigh yourself and you have gained 20 pounds by the time you figure out that you are getting heavier it is too late and too difficult.

Several other characteristics of the group are interesting. Three quarters reported an event that triggered their weight loss. For many this was a medical problem but for others it was an emotional event such as a separation or divorce. So clearly having a strong motivation to lose weight and maintain 
man on scalethat weight loss is important.  But equally important, almost all of the registry members reported that weight loss made them feel better - they had more energy, felt healthier, were more self-confident and reported their mood as being much improved.

So in summary, here are the most important ways to lose weight:

  • You need to be physically active. Without physical activity you need very few calories and to lose weight and maintain that weight loss means that you have to be continuously restraining yourself to eating very little. It can be done, but it is truly hard to keep up that kind of effort year in and year out.
  • Physical activity is a combination of both formal exercise and being active in many different ways that do not involve going to the gym. See the separate article here on physical activity. 
  • Following an appropriate diet is useful. The exact type of diet is probably not important, although we favor a diet low in simple carbohydrates and low in saturated fat - what is commonly called a "Mediterranean" diet. Here is a link to a good discussion of this eating pattern on the Mayo Clinic website.
  • There are a lot of on-line programs if you want to track what you eat. One such is at www.fitday.com.
  • You need to weigh yourself frequently. That keeps you honest.
  • If you are serious about keeping weight off, it requires a lifetime commitment. You can't go on a "diet" for a few months and then quit. That will just result in the yo-yo pattern that so many people go through. This also means - and you won't like this - that you can't let the "once in a whiles" add up.  I see altogether too many patients who work hard to lose 10 pounds and then gain it all back in one week on a cruise!  So you do need to be careful about birthdays, holidays, vacations, office parties, and all of the other events that entice us to give up. Another very useful web site is stickk.com, where you can make a committment to change and be supported by others.

One other point. It is very important to understand the difference between medical weight loss and cosmetic weight-loss.  Losing five or 10 pounds may not seem like much when you look in a mirror and you may be tempted to say "This is hardly worth the effort.".  But from a medical point of view, it doesn't take much to have a beneficial effect.  Five or 10 pounds of weight loss improves blood pressure, lowers cholesterol levels, and can have a very important effect in preventing diabetes or improving diabetes control if you already have it.

So can you do it? Yes you can! But it takes willpower and commitment.