So, you’ve lost 22% of your body weight in 3 months, now what? I am so happy when people ask me in their initial consultation, “What is your maintenance plan?” I had a conversation with a patient the other day about the name “Rainier Medical.” I did not choose it just because we are close to Mt. Rainier. In fact, after I opened, I realized how many businesses are named “Rainier” and wondered if it was the right choice. But, I have seen that it is perfect! Why? Because losing weight and keeping it off is like being a mountain climber! It takes courage to look at that peak and decide to start. It takes planning and training and physical and emotional pain to summit. It takes heart, grit, and the ability to envision the incredible view from the top when your knees hurt and your chest burns and you are grinding away at the switchbacks in a forest. Then, when you get to the top, you get to enjoy the view for about 5 minutes until you have to start the climb down to get to the car before the sun goes down. Lo and behold, the way down is harder than the way up! Your knees hurt even more, you are mentally and physically fatigued, and you do not have that victorious peak to look forward to. Then, once you revel in the glory for a few months and you have conquered that mountain, you may suffer from the apathy of not having a goal. You may feel lost and not no where to go next. With that picture of maintaining weight loss, let’s look at how I approach weight maintenance. I have used resources to clarify a few simple rules. I am not saying they are easy, but I am saying they are simple and effective. The good news? You already learned most of how to maintain weight during weight loss, and you may not have even realized it! Remember the movie “Karate Kid?” Remember when Daniel was waxing the car and painting the fence and did not even know he was creating muscle memory? Well, you create habits during the Rainier Medical weight loss program that are the cornerstone of weight maintenance. So, the transition phase from weight loss to weight maintenance is crucial because you have to know what to change and what to keep. People who regain weight and come back frequently say the transition was what was missing. It happens when people go on vacation at the end of their weight loss and then do not return to make the transition phase.
As with most of my blogs, there is an evidence basis for my recommendations. The basis for this blog comes from a few sources. One is the National Weight Control Registry.
Another basis is the literature search I performed for my talk on this program, available as a podcast if you would like (stay tuned for it posted on website).
Section One: Nutrition
Rule 1: Eat the Same Things most of the time.
Have you heard the nutrition advice to eat a variety of foods or to try a new food each week? In actuality, the science shows that a smaller variety of foods is associated with prevention of weight regain. Choose a few meals/food combinations for breakfast and lunch. You may read this with a sense of relief. You may recall with fondness how simple things were when you were on meal replacements and did not have to think about what you were going to eat. Keep that pattern when you substitute the meal replacements with grocery store food. The good news? You have just been on a meal replacement weight loss plan, so you have eliminated all food from your diet. Most people have to get to a small variety of foods by cutting out one food per week. You get to add back food to your diet, just don’t add back too many. But, to you, it will seem like a lot of variety right now. So, this is the first crucial part of transition. Go from no foods, to just the foods you want on your plan. It will seem like a large variety to you! Part of the value of the meal replacement plan is that taking away food is a powerful way to change your relationship with the food. Your hypothalamus is reconditioned. Your palate is cleansed. You can appreciate the subtle deliciousness of a ripe tomato and a crispy vegetable. Protect that! Refer to my previous blog on how quickly the hypothalamus can be reconditioned to crave high fat foods. You do not want to have to go through withdrawals again.
Rule 2: Make it Easy on Yourself.
Set yourself up for success and think long term. What sounds like a great plan at first may be too time consuming or labor intensive long term. Reduce as many barriers as possible when you make your nutrition plan. Develop a system and habits of how to have the foods in your plan available and prepared and with you when you need them. Create a shopping list in the correct volumes to last until your next shopping trip. Find the store to buy them and a system for buying them that is sustainable. For example, if you have to go to Trader Joe’s or Metropolitan Market for a special food item, but you get everything else at Fred Meyer, that is probably not sustainable. If your plan includes a seasonal item or something that spoils quickly, like fresh berries, or costs a premium that you will not want to keep paying month after month, then you are adding additional barriers to maintaining your plan. Additionally, following some rules like “no night shade vegetables” or an in vitro food sensitivity test that tells you that you “can’t” eat one of your favorite foods that you are for years before knowing you were “allergic” to it, then that is not likely the right plan. If you have to shop 3 times a week for your plan, you are less likely to be able to sustain that.
Rule 3: Make sure your food doesn’t taste “too good.”
There are certain foods that are considered “highly palatable.” In studies, when people eat these foods, they actually rate their hunger as increasing as they consume calories. This makes no sense, right? If my hunger was a “6 when I started eating and I just ate 200 calories, then why is my hunger a “7” now? The answer is probably the food industry! You know, the companies that make a fortune on super sizing and compete for market share. These are the companies that lobby the government when the dietary guidelines are issued to make sure that dairy (grown with growth hormones and antibiotics) and grains (now genetically engineered) stay in the food plate even though neither is required in the human diet. The food industry that creates ad campaigns when tax measures come onto the ballot to tax beverages with high fructose corn syrup the same way cigarettes were taxed by telling you it is just the start and all groceries might be taxed next. This is not about politics, but it is about awareness. After all, they put it in their tag line, “No one can eat just one.” Functional MRI scans show that these highly processed foods elicit the same brain chemistry response that addictive drugs like cocaine elicit. You can read a fabulous book on this by Dr. Lustig. I attended one of his lectures and it was an “Aha” moment that set me on the course I am on today. Binge eating is the most common cause of weight gain following bariatric surgery. Remember, cravings increase after weight loss. “Trigger foods” are more likely to be processed and trigger binge eating or over consuming calories. If you have a trigger food, for at least a period of time, have none of it for as long as possible. There are many analogies between these highly palatable trigger foods and alcohol for a person prone to over consuming alcohol. The difference, we can not eliminate food completely from our diet like people with alcoholism are advised to do with alcohol. So, if there are foods that are likely to get out of control, do not aim for moderation at first. That is definitely an advanced maneuver.
Rule 4: Eat Real Food.
If you are not replacing food with a meal replacement, then eat real food. Minimize foods in bags, boxes and wrappers. If it has a bar code, be wary. The food industry has picked up on low carb and health fads and responded by turning our Cheetos into Peatos. They have turned potato chips into veggie crisps. The problem? They are still crunchy with salt and oil and processed. Why is the ingredients list so long? Is it really the same as eating peas? Put them next to each other and do an experiment. Eat 200 calories in real peas and then 200 calories in peatos and see if you feel the same. Eat food that looks just like it did before people did stuff to it. This is probably what you know as “shopping on the outside of the grocery store.” But, since we shop online now?!
Section 2: Habits
Rule 1: Limit Recreational Screen Time.
Screen time is directly related to weight gain. You may need to be on the screen for work, but a requisite step in weight maintenance is to look at recreational screen time. You can do this with screen time monitors on your phone, but there are multiple screens you are watching. Statistics on this number were alarming even before Covid. You can imagine what it is like after. Here is an eye opening article.
It is not just the time as well, it is the content. You are likely exposed either to high stress news items, social media posts that may create depressive thoughts through comparative reality (only seeing happy photos), or exposed to advertisements for food or alcohol or to images that reinforce negative body image which tends to lead to more binge eating. Turning off the screens is the first step in the next rule.
Rule 2: Nurture an active lifestyle.
An active lifestyle is one in which you are constantly lightly active just doing everyday things. It is one in which your hobbies contain physical activity. Physical activity is not exercise. Studies show that even if you exercise for an hour a day, if you are sedentary most of the rest of the day, your calories expenditure for the day is not increased. How do you nurture an active lifestyle? The first step is turning off screens. The second is finding a hobby that is active, such as birdwatching or gardening or geocaching. These are not your exercise, they are just what you do when you are not working or exercising.
Rule 3: Weigh Yourself at Least 4 times per week.
You can not manage what you do not measure. It is very easy to gain 5 pounds without realizing it, especially if you are not required to wear fitted clothing. Five pound weight gain can quickly create more cravings, trigger some knee pain or fatigue, or lead to some snoring, which can make it turn into 10 pounds. Think of when you are trying to save money. Did you look at your bank account and your spending? If you use a credit card and never look at the balance until the end of the month, chances are that it is going to be higher than if you used cash for everything you bought or looked at your balance daily. If you gain 3 pounds and you see it, you are likely to make slightly different choices that day to lose the 3 pounds. So, you may have to lose 3 pounds twenty times, but you will not have to lose 60 pounds every again.
Rule 4: Engineer your food environment.
Studies show that weight is incredible related to food environment, and we live in an incredible obesogenic food environment. The macro food environment is one filled with fast food drive through and super sized warehouse stores. You may not be able to control the macro environment, so work on your micro environment. This is your kitchen and pantry. Keep your kitchen and pantry stocked with foods on your plan. This should be easy since there are not many different foods on your plan. If you have other people in your household, keep food out of sight and not at eye level. Put it behind a cabinet door or in a refrigerator drawer. Think about foods that the others in your house like but you do not. Frequently, a person will say that someone in their house wants to keep ice cream or some sweets around to eat just a little every night, but they can not limit portions on those things. So, they choose flavors that they do not like, such as peanut m and ms instead of regular, or strawberry ice cream, and that works just fine. Does your work environment have trigger foods? You may need to eat lunch outside instead of the break room, or take a different route to the printer than by the person’s desk that has candy on it. This is not about willpower, which is a consumable resource and in short supply if you are tired, upset, or have decision fatigue.
Section 3: Do the Work
Rule 1: Exercise for an 45 minutes a day everyday.
Most people are surprised at the science that shows the volume of exercise it takes to lose weight or keep it off. The science shows that 150 minutes a week is for general cardiovascular risk reduction, 300 minutes a week is for preventing weight regain, and 450 minutes is for weight loss. Where will you find this time? You will take it from your screen time! Do the exercise like it is your job. The most commonly reported exercise in prevention of weight regain is brisk walking. It is low risk for injury, it does not take anything but a pair of sneakers, and the intensity is not so high that you can not do it everyday, or it triggers hunger, or makes you feel like you need to lie on the couch afterwards.
Section 4: Medical Components
This is the part that is left off of commercial maintenance programs. This includes things like medication regimens, medical conditions and medical foods. For example, if you are taking medications that cause weight gain, have medical conditions that lead to weight gain, or have medical conditions that interfere with any exercise or habits, then these need to be addressed. Metabolisms vary, and metabolic adaptation is real, so anti-obesity medications may be a part of a weight maintenance program. That is why they are not called “weight loss” medications any more. Just like someone’s blood pressure may go back up if their blood pressure medication is stopped, for some people, their weight goes up no matter what they do. As you can see, the medical component is just a part of a comprehensive maintenance program, but it can be a necessary requisite for the rest to be successful. This is why a longitudinal relationship with a physician trained in obesity medicine, even for people who have had bariatric surgery, can be the missing piece that can lead to frustrating weight cycling. Studies show that measures like continuing to replace one meal per day with a meal replacement (which is not the same as a protein drink) is linked with preventing weight regain.
This blog is just a brief summary of what a maintenance plan looks like. It is a framework. Making a plan specific for you will take more details. It is all in the details and making it specific to you. At Rainier Medical, I recommend visits monthly for the first 3 months, then quarterly for 2 years, then anytime weight increases by 10% of the total weight lost.
To read more, here is a great book as well.
Remember, during weight loss, you are laying the foundation for maintenance. The habits, rituals, and work are 80% of weight maintenance. Much of weight maintenance is what you take out, and you have done that!
Take Back Your Health,
Valerie Sutherland, MD