A patient told us she had lost more than 800 pounds.

She was quick to add that it was the same 40 pounds she had lost at least 20 times.

Although her sense of humor is refreshing, she's talking about a pretty serious problem. The literature suggests that maintaining lost weight is much more difficult than losing it, with up to 95 percent of the "dieting" population returning to their prediet weight within five years.¹ This pattern of losing and regaining is called yo-yo dieting or weight cycling.

It's for this, and many other reasons, that problematic excess weight should be viewed as a chronic recurrent biopsychosocial condition that requires life-long intervention--well after people have achieved their weight goals. Successfully managing weight for the long term requires that patients expend, on average, at least as much energy as they consume.

But this concept is easier said than done. A patient's best weight loss efforts are often mitigated by numerous and varied biological, psychological and social factors. Eating patterns, food preferences, medical conditions, self-esteem, destructive self-talk, cultural norms, stress management skills and personal lifestyle are just a few of the seemingly infinite factors that can impede weight loss. As healthcare providers, we need to adequately identify and address these factors. We also need to help our patients develop specific skills to manage their weight.

What Is Success?
Traditional weight loss approaches suggest that "success" is defined as achieving and maintaining an ideal body weight. We prefer to define success as a sustained improvement in medical or psychological conditions and overall quality of life. The good news is that a weight loss of 10 percent of body weight improves numerous weight-related metabolic and mechanical health consequences, such as hypertension, hyperlipidemia, diabetes, sleep apnea and osteoarthritis.² Explain to patients that maintaining a relatively small weight loss can significantly improve quality of life and health status. The increased ability to perform activities of daily living can help alleviate a person's symptoms of anxiety and depression. It also can serve as a motivator.

The National Institutes of Health has defined weight maintenance as maintaining a 10 percent loss for more than one year. Encourage patients to celebrate every achievement. Maintaining a weight loss of a few pounds--which can improve quality of life and health status--is a worthy achievement. Even weight maintenance without weight loss may be viewed as a triumph, since this prevents further deterioration of one's physical and emotional well-being.

The National Weight Control Registry (NWCR) is the largest source of information for examining the habits of people who have successfully maintained their weight losses. Created in 1994, the NWCR tracks more than 5,000 people who have maintained a 30-pound weight loss for one year or more. Here's a snapshot of what the NWCR shows.

Regular Exercise
More than 90 percent of those being tracked reported exercising regularly, on average, for one hour a day.³ This is the first thing that strikes us about the NWCR population. When patients try to maintain weight loss, increasing the number of calories burned is the only way to loosen the chains of dietary restriction. Educate patients that exercise is not simply a tool to help them lose weight. It's a critical component of life-long weight maintenance. If someone is exercising solely for the purpose of losing weight, physical activity would be quickly abandoned if that weight loss didn't occur.

Shifting expectations of physical activity from weight loss to weight maintenance can improve compliance. As practitioners, we need to appreciate the biological, psychological and social obstacles that can make regular exercise difficult. If patients haven't complied with exercise recommendations (or any other recommendation), try to explore, in a nonjudgmental way, the real or perceived obstacles they face.

You can start by asking them about the activities they enjoy. Do they like to walk, swim, play music in a band or dance? If they have a hard time answering this question, ask about the activities they enjoyed as a kid. Then ask them to talk about what gets in the way of their doing the activities they enjoy? This can lead to a discussion about unmanaged physical pain, depressed mood and all-or-nothing thinking.

We must continually address the psychological and social obstacles patients present during our encounters with them. Doing this in group settings is often an effective strategy to accomplish this. Group members who have sensibly worked on these challenges themselves can help troubleshoot the quandaries of others. Encourage patients to participate in sensible programs, such as Weight Watchers. Such programs can help them learn weight management strategies. Reaching out to an online support group also can provide a similar benefit. But before referring your patients, be sure to investigate any programs that claim to offer "weight loss."

For those with physical limitations, a recommendation to physical therapy, when indicated, can be a good start to developing a safe exercise routine. Communicate to the therapist that the goal goes beyond rehabilitating the specific dysfunctional musculoskeletal issues to helping the patient create a realistic and individualized exercise program he can continue long after therapy ends.