If losing weight were easy, two out of three Americans would not be overweight, and one out of three would not be obese. The only thing more difficult than losing weight, though, is not regaining some or all of the weight lost and maybe even more than that.
    Why is Maintaining Weight Loss Important?
    Of course, losing weight in the first place and keeping it off will tend to reduce all the health risks associated with being overweight and obese, including hypertension, hyperlipidemia, type 2 diabetes, coronary artery disease and strokes, metabolic syndrome, cancer, obstructive sleep apnea, osteoarthritis, orthopedic injuries, liver and gall bladder disease and, well, premature death.
    Additionally, according to a fairly recent study in the International Journal of Obesity, weight cycling (losing and gaining weight, etc.) may cause a redistribution of body fat to the "upper body fat compartments" (or, in the context of the study, your tummy). Tummy fat, especially visceral tummy fat (fat in and around your internal organs), has often been associated with hypertension, hyperlipidemia, type 2 diabetes, coronary artery disease and premature death. Also, weight cycling results in adaptive thermogenesis, a physiological phenomenon of some complexity but, for our purposes, is simply a reduced resting metabolism. Simply put, the more one loses weight and regains it, the lower his or her calorie burn at rest (over 24 hours) compared to where it was, pound-for-pound, before the loss and gain. And the lower one's metabolism is, the lower number of calories one can take in without putting on extra pounds.
    Many of my clients have achieved great success in their weight loss efforts. We've achieved those successes primarily through a combination of exercise and proper food intake. When my clients get to their goal weight, that's when the chore really begins. Your clients, too, may have lost weight, only to regain it.
    My clients, and perhaps you, want to know what's necessary to keep the weight off. To supply my clients a scientifically based answer, I hit the books. I recently reviewed approximately 25 peer-reviewed studies from the world's leading science and medical journals that have been published over the last five years. Those journals included, among others, New England Journal of Medicine; Obesity Reviews; American Journal of Preventive Medicine; International Journal of Obesity; Obesity Research; American Journal of Clinical Nutrition; Journal of Nutrition; Obesity; Journal of Clinical and Consulting Psychology; and Medicine and Science in Sports and Exercise.
    What I found is that there are a very large number of factors associated with successful weight maintenance — 39, in fact. Some are intuitive, and some would not have come to mind, but all are "positively" associated with maintenance:
    1.       Quality of intake — The better the quality of one's intake, the more likely one is to maintain lost weight. And by "quality of intake," we know all about veggies, fruits, whole grains, lean protein and low-fat (or no-fat) dairy.
    2.       Low variety of calorically dense food — A calorically dense food (sounds like a good thing, but it's a bad thing) is a food that, ounce for ounce, packs a large number of calories. Visualize, for example, raisins versus grapes. Ounce for ounce, raisins will pack more of a calorie punch than will an identical weight of grapes. So, consuming a small variety of dense foods is positively associated with maintenance.
    3.       Face-to-face accountability — When my clients saw this one on the list of factors associated with maintenance, they probably figured I made this one up. I didn't. It appears that folks attempting to maintain weight do better when they have face-to-face accountability. The "accountant," though, doesn't have to be a fitness trainer, I'd argue, but it does need to be someone to whom the "maintainer" will be accountable.
    4.       Low variety of all food groups — Yes, to maintain weight loss, not only does it help that you have a low variety of calorically dense foods, but it helps to have a low variety of all foods. Practically speaking, I find that my clients who are successful in their maintenance tend to eat a limited, but nutritious, variety of foods. Part of what's going on here is that eating the same foods makes calorie counting much easier.
    5.       Low television viewing — Television is a wonderful invention, and its offerings over the years have enriched our lives. Relative to maintaining weight, though, TV is counterproductive in that we are probably sedentary when we are watching it, our brains are passive (more so than when reading a book or a magazine, which also involves turning pages), we are likely "mindlessly" eating, and our TV watching is crowding out the hours during which we might otherwise be moving our bodies in chores or exercise.
    6.       Daily weighing — That is, daily weighing is positively associated with weight maintenance. That stands to reason in that one is more likely to "catch" a weight gain if one weighs daily rather than infrequently.
    7.       Greater weight loss — One is more likely to keep the weight off if the amount lost was a sizeable number. There will be exceptions, of course. 
    8.       Physically active lifestyle — 
    This stands to reason, since weight lost and maintained boils down to "calories in and calories out." The more active a maintainer is, the more likely he or she is going to burn more calories to offset intake.
    9.       Eating breakfast — Eating breakfast "revs up" our metabolism, lessens the possibility we'll snack mid-morning and/or gorge at lunch, and it gives us energy to keep active during the morning hours.
    10.   Regular meal rhythm — This is a fancy way of saying that eating three square meals a day is more likely to keep us from being famished and, as a result, overeat when we do sit down to eat after a missed meal or two.
    11.   Control of overeating — This is another way to say "eating mindfully" and without distraction, and it's another way to say being "tuned in" to one's satiety, or fullness. If one is tuned in to each bite, it is less likely that one will overeat.
    12.   Internal motivation to lose weight — Yes, it was you who decided to lose the weight. It was not your spouse, your parent or even the doctor. It was you. You were motivated to lose the weight. You didn't lose the weight because someone else wanted you to.
    13.   Social support — Those who helped you in your weight loss continue to support you in your maintenance efforts (and kick you in the rear, when necessary).
    14.   Ability to handle stress — Either because you are genetically wired to handle stress, or you've learned the tools to do so (or, less likely, your life is stress-free), you're more apt to keep the weight off. More on this under the "BALDS" memory device paragraph.
    15.   Low daily screen time — This is related, of course, to the television paragraph above, but by "screen" here we mean not just the television screen, but computer screens, movie screens, portable phone screens, video game screens and other high-tech devices unknown to me. It's the same logic, though: When you're in front of the screen, you are probably not moving, and you may be eating mindlessly.
    16.   Meeting public health recommendations regarding physical activity — The most current I've seen (from the American Heart Association and from the American College of Sports Medicine) is five days per week of moderate — or three days per week of vigorous — aerobic exercise and two days per week of resistance training. This stands to reason: you're moving, so you're burning calories and probably not eating.
    17.   Monitored intake of food — Yes, in one form or another, you are monitoring your eating. You're counting calories or servings, measuring portion sizes, eating commercially prepared meals (with certain calories), measuring a food's glycemic load or calculating a food's energy density. This is probably how you lost the weight, so don't quit now!
    18.   Monitored Intake of Fat — In addition to counting calories, you're also keeping track of your fat intake. Why? Because you remember that, gram-for-gram, fat has more than twice as many calories as carbohydrates or proteins.
    19.   Physically active for more than one hour per day — This is consistent with the findings from similar studies cited above.
    20.   low calorie intake — Duh! Remember the "calories in, calories out" notion in your weight loss? It still applies. Don't consume such a low level that your nutrition suffers, though; consult a good registered dietician.
    21.   Consistent eating pattern across weekdays and weekends — Don't eat celery Monday through Friday and then party hardy on Saturday and Sunday with pizzas, doughnuts, fast food, fried foods, ice cream, cakes, cookies, etc.
    22.   Low levels of depression — This one reminds me of the "handle stress" factor. If you're lucky enough not to have depression (a number of overweight people aren't), you have a better chance of maintaining your lost weight. If you are clinically depressed, you'd better find some relief in physician-prescribed medication, psychotherapy or both.
    23.   Medical trigger for weight loss — If your weight loss was triggered by a medically significant occurrence, you are more likely to keep the weight off. I guess it goes to the issue of motivation.
    24.   Eating similar amounts of dense food — This just means that you'll be more likely to keep the weight off if your intake is controlled by the energy density of foods. It is, the argument goes, the caloric density of the food we eat that makes us gain (or not keep off) the weight. We tend to eat the same amount from day to day, in volume. Therefore, if we eat "X" pounds of nutrient-dense, energy-diluted food, we'll keep the weight off, while if we do just the opposite, eating "X" pounds of energy-dense, nutrient-diluted foods, we'll gain weight.
    25.   Smaller portions of high energy-dense foods — Yes, it's okay to eat any food out there, but limit the portion size. Eat those foods; don't deprive yourself. Otherwise, you'll give in later and consume a quart of ice cream. So, when you want that junk food, eat it, but make sure to eat just a bit of it.
    26.   High resting metabolism — Well, this is one you have very little control over. Yes, your "slow" metabolism is somewhat "fixable," but only in very insignificant numbers — and only with an incredible amount of resistance training. Don't count on your metabolism being increased in any significant amount. I have clients whose metabolism is, per day per pound, from only five or six calories to those whose metabolism is 12-13 calories. "Big deal," you say, "a six-calories-per-day difference?" A 200-pound person who burns 12 calories per day per pound has a metabolism of 2,400. A 200-pound person who burns five calories per day per pound has a metabolism of 1,000. Yup, a 1,200 calories-per-day difference.
    27.   Fat-free-mass-sparing during weight loss — What? "Fat-Free-Mass-Sparing" is one word. All this means is that those clients who have lost in their weight loss effort mostly fat mass and not much lean mass are more likely to keep the weight off. The reason for this is clear: Lost lean mass results in a severe drop in metabolism, which results in a low daily caloric need, which more likely results in consumption exceeding caloric need, which results in weight gain.
    28.   Low frequency of dieting — Frequent dieting only indicates that a client has gained, lost, gained, lost, etc. And this indicates that he or she has probably severely lowered his/her metabolism (the adaptive thermogenesis concept). With every weight loss effort, some lean mass is lost. Weight loss leads to loss of lean (fat-free) mass to compensate for inadequate energy intake by lowering the tissue mass that uses energy. Our bodies, in a calorie-deficit mode, shed some of the metabolically-active lean mass (metabolically-active meaning high energy-needing) in order to lower metabolism and ensure survival. It is this relative increase in fat mass, coupled with a decrease in lean mass, that is seen as the outcome of adaptive thermogenesis — a stable or higher weight with a lower energy intake.
    29.   Generous consumption of fruits and veggies — Fruits and veggies, pound-for-pound, contain substantially more nutrients and substantially fewer calories (with a few exceptions) than an equal amount of fats, refined carbohydrates, many proteins and probably every junk food. Therefore, if you have a generous amount of fruits and veggies (while conscious of your calorie ceiling), you'll maintain weight loss.
    30.   High consumption of whole grains — Whole grains, aside from all their other health-protective benefits, seem to be related to long-term weight maintenance. Think of whole grains as you do fruits and veggies, and remember that the word "whole" must be described in the list of nutrients. If it really is whole grain, the first listed item will be "whole (wheat, oat, rye, etc)." Food manufacturers of non-whole grain products have gotten clever in making something seem to be a whole grain when it really is not.
    31.   Low consumption of meats, processed meats, butter, high-fat cheese and margarine — All these things in proper amounts are acceptable, but, relative to maintaining your weight loss, steer more away than toward.
    32.   Regular use of meal replacements — I'm a little concerned about the sodium levels in a number of commercially prepared meals (as opposed to many whole foods — fruits, whole grains and veggies), but meal replacements do provide easy accountability in calorie records, are easy to prepare and save time. So it seems that regular use of meal replacements is positively associated with successful weight maintenance.
    33.   Ongoing coaching — Similar to face-to-face accountability, coaching, in our context, means consulting, counseling and conferring with a qualified individual who has education, credentials and experience in weight loss and maintenance.
    34.   Increased dietary restraint — Also known as "conscious thoughts and behaviors to control calorie intake." Hundreds of books have been written about this topic, though more likely in the context of weight loss. However, it is as applicable, if not more so, in weight maintenance.
    35.   Absence of weight cycling — If you've gained and lost more than a couple times, you're more likely to encounter difficulties keeping the weight off. It can be done, but it will be more difficult for you than for your neighbor who has lost weight for the first time.
    36.   Hunger control — Be mindful of your hunger and your satiety. Eat before you are famished, and stop eating when you are full.
    37.   Restraint in the face of "BALDS" — Restrain yourself when you are Bored, Anxious, Lonely, Depressed and/or Stressed. Those who have tools and employ them to restrain themselves from eating to fix their boredom, anxiety, loneliness, depression or stress are more successful at maintaining their weight loss.
    38.   Weight loss via diet and exercise — Lose weight with a minor reduction in intake and a major amount of exercise. Determine your daily caloric need only after you've measured your metabolism (I don't recommend the prediction equations, as they can be off substantially) and after you've measured your activities of daily living with accelerometers and determined an achievable amount of exercise. Then, with a weight loss via diet and exercise, you will have lost less lean mass than had you lost weight only with diet. Besides, exercise is a magic pill. From the March-April issue ofHarvard Magazine: "In the bottle before you is a pill, a marvel of modern medicine that will regulate gene transcription throughout your body, helping prevent heart disease, stroke, diabetes, obesity and 12 kinds of cancer — plus gallstones and diverticulitis. Expect the pill to improve your strength and balance as well as your blood lipid profile. Your bones will become stronger. You'll grow new capillaries in your heart, your skeletal muscles and your brain, improving blood flow and the delivery of oxygen and nutrients. Your attention span will increase. If you have arthritis, your symptoms will improve. The pill will help you regulate your appetite, and you'll probably find you prefer healthier foods. You'll feel better, younger even, and you will test younger according to a variety of physiologic measures. Your blood volume will increase, and you'll burn fats better. Even your immune system will be stimulated. There is just one catch. There's no such pill. The prescription is exercise."
    39.   More exercise and intensity than "always normal" — It seems that those who have lost weight and want to keep it off need to exercise more of the time and at higher intensities for part of the time than people who have been "always normal" weight. Sorry. This stands to reason, though, as those who have lost weight tend to have lower metabolisms than "always normal" weighted persons, have probably lost lean mass and, as a result, will need to burn more calories just to eat an equal load of calories as the "always normal" weighted person.
    Okay, that's it. These are the 39 factors associated with successful weight maintenance. This is not to say that, if you don't meet even one of them, you will gain the weight back. I'm simply telling you that there is a positive association between these factors and successful weight maintenance. Likewise, I'm not telling you that if you meet every one of them, you won't gain the weight back. More than likely, though, you won't gain the weight back if you meet many of these. Only recently did I visit with a successful maintainer, one of my clients, and she met all but six of them. Yes, that's just anecdotal, but it's convincing to me.
    Warren E. Jones, JD, ACSM H/FI, NSCA CSCS, ACSM CEQ, is a personal trainer whose clients' ages and status range, respectively, from "ninth grade to the ninth decade" and "the serious triathlete to the morbidly obese." He can be reached atwej@cox.net.