Diet and Nutrition; Prevention

Why it’s so hard to keep excess weight off and how long-term treatment can help

Diet and Nutrition; Prevention

Keeping excess weight off can be more challenging than losing it in the first place. Biological and environmental factors complicate weight management, but they can be managed with support and expert care.

Anyone who has lost a significant amount of excess weight knows it doesn’t happen overnight. It takes knowledge, action, and dedication.

And once they reach their goal, the hard work isn’t over.

Obesity is a chronic condition, and data from designated NIH Nutrition Obesity Research Centers such as UT Southwestern are proving that losing weight and maintaining weight loss are two distinct biological processes that require different treatment approaches.

For example, if a patient with high blood pressure achieves a blood pressure reading of 120/80 once that does not mean the hypertension, which is a chronic condition, has been cured. The same holds true with obesity – reaching a healthier weight does not mean the condition is cured, as the weight may come back.

When it comes to maintaining a weight-reduced state, the challenge shifts to a range of biological factors – many of which are too complex to manage solely with grit and discipline.

A meta-analysis of 29 studies of weight loss showed that after five years, obesity recurrence led to more than 80% of lost weight to be regained. Even people who stick to healthy exercise and nutrition habits may struggle with weight recurrence due to brain activities outside our control that must be managed with a multimodal approach.

At UTSW’s Weight Wellness Program, our team of obesity specialists, with expertise in nutrition and weight loss through advanced medication therapies and bariatric surgery, supports patients during weight loss and maintenance. Understanding the challenges of both is the key to achieving successful, long-term weight maintenance and metabolic health.

How the brain can thwart weight maintenance

Our brains are hardwired to avoid starvation, so when we consume less food and lose weight, our brains and bodies instinctively react to stop us from losing weight and to restore the weight we have lost.

The brain is always trying to achieve homeostasis – a balanced state of normalcy. For people with chronic obesity, that translates into the body trying to push them back toward their heavier weight, despite the many health benefits of keeping the weight off.

Obesity is a chronic condition, even after significant weight loss. Weight maintenance is biologically complex and much more nuanced than telling someone to eat less, move more.

Jaime Almandoz, M.D., Medical Director of UTSW's Weight Wellness Program

When we lose weight, we lose fat and muscle. The more muscle we lose, the lower our metabolic rate – the amount of energy the body must burn to achieve homeostasis. It is important to have adequate protein intake and physical activity as part of a weight management plan, as these offset muscle loss.

That same instinct causes us to unconsciously move less so we burn fewer calories. So, intentional exercise becomes even more vital for weight maintenance. The more physical activity a person gets, the lower their risk of regaining weight. Experts recommend at least 150 minutes per week of aerobic exercise and at least three strength-training sessions weekly to improve weight maintenance, enhance fat loss, and preserve muscle.

This is a lot for a person to manage on their own. The challenge of weight maintenance magnifies when it collides with family, work, and social responsibilities. That’s why so many people wind up with recurrence, sometimes regaining more weight than they originally lost.

Some studies suggest it takes 5-10 years for the body to achieve a new homeostasis with respect to body weight. Effective options are available that can help people achieve and maintain long-term weight wellness – including an ever-growing list of anti-obesity medications (AOMs) that have been proven to support long-term weight maintenance.

Role of medication in weight maintenance

AOMs have a successful track record for weight loss. Semaglutide (Wegovy), for example, is proven to support up to five times the average weight loss of diet and exercise alone.

AOMs are currently under-prescribed and viewed as short-term treatments. Only 1% of doctors are trained to treat obesity, and less than 2% of eligible patients get an AOM prescription – which is often discontinued when they achieve their weight wellness goal. A study published in Diabetes, Obesity and Metabolism in 2021 found that the mean time on AOM treatment was less than three months, which is not long enough to see the maximal weight loss effects of most medications.

GLP-1 receptor agonist medications make the stomach empty slower and signal the brain that you are full, reducing cravings. They can also help improve fatty liver.

Perhaps not surprisingly, when the prescription ends, the risk of weight recurrence increases sharply. Research has shown that people can regain two-thirds of the weight lost within 12 months of stopping an injectable AOM.

AOMs should not be prescribed as a short-term solution for a chronic problem. Instead, we should treat obesity the way we address health conditions such as high blood pressure or cholesterol, for which chronic medication therapy is acknowledged as acceptable. We must give people with obesity the chance to maintain a weight-reduced state for better health and quality of life outcomes.

Many medications that are approved by the U.S. Food and Drug Administration (FDA) to treat chronic conditions associated with obesity, such as diabetes or high cholesterol, also are effective as AOMs for weight loss or maintenance when combined with exercise and dietary modification. Some of these include:

  • Incretin receptor agonists for diabetes, such as semaglutide and tirzepatide
  • Anti-seizure medications such as topiramate
  • Appetite suppressants such as phentermine
  • Volume-enhancing superabsorbent oral hydrogel, gelesis-100
  • SGLT2 inhibitors for diabetes, such as canagliflozin, dapagliflozin, and empagliflozin
  • NDRI antidepressants such as bupropion
  • Lipase inhibitors such as orlistat

The type 2 diabetes medication tirzepatide is poised to become the newest AOM, with FDA approval anticipated later in 2023. Clinical trial data show that over half of participants who have obesity or overweight with a related complication lose 20% or more of their body weight. Many people see these newer, second generation AOMs as treatments that can close the weight-loss gap between traditional lifestyle modification and bariatric surgery. These AOMs can also be effective tools for maintaining weight loss achieved with either lifestyle modification, bariatric surgery, or other means.

Medications are not the end-all-be-all for weight maintenance, but they are an effective complement to physical activity, a healthy eating plan, and management of coexisting conditions.

Maintaining weight wellness is worth the work

There is no quick fix for weight maintenance. Diet and exercise alone don’t work for most people. Maintaining a weight-reduced state requires a combination treatment approach – and like many other chronic conditions, managing obesity can be lifesaving.

People who lose 10% or more of their excess body weight and keep it off enjoy health benefits such as:

  • Lower risk of cardiovascular problems: 20% lower rate of cardiovascular death and 21% lower major adverse cardiac events, such as stroke in people with Type 2 diabetes.
  • Remission or improvements in Type 2 diabetes, hypertension, and fatty liver disease
  • Less joint and back pain
  • Reduced risk of certain types of cancer like breast and colorectal
  • Improvements in energy levels and self confidence
The path to losing weight and maintaining it can seem long and difficult, but with expert support you can the manage the biological forces at work and achieve your health goals..

It is common for patients to regain some weight as the body adjusts to its new level of homeostasis. Moderate weight recurrence may cause some previous conditions, such as high blood pressure, to return – but if most of the weight loss is maintained, many chronic conditions will be easier to manage with less medication.

Related reading: Tackling the dual challenges of AFib and weight wellness

Due to the progressive nature of many chronic conditions, such as Type 2 diabetes, conditions can become more difficult to manage than before if significant weight recurrence occurs. A combination of factors associated with weight regain, such as having to restart medications that promote weight gain, fatigue, and joint pain, may also facilitate additional weight gain.

In our Weight Wellness Program, patients develop a firm understanding about the biological processes that affect weight gain, weight loss, and weight maintenance. Empowering people with information from the latest research – and from their own biometric measurements, such as activity trackers and food apps – helps give patients a baseline from which to participate in their own health future.

Through a combination of education, nutrition support, and anti-obesity medication, patients in our program are defying biological obstacles for losing significant amounts of weight and maintaining a weight-reduced state for years.

Lingering, outdated stigmas continue to cast obesity as a personal flaw instead of the chronic condition it has proven to be.

While discussing weight can be uncomfortable for patients and some doctors, it is a necessary conversation. You don’t have to struggle through weight management alone. Expert care is available to help you manage the biological challenges of weight loss and weight maintenance.