Continuing Education Activity

Obesity is a leading public health concern worldwide, correlating with a growing risk of cardiometabolic disease, certain cancers, osteoarthritis, and all-cause mortality. The condition's prevalence has risen sharply in both high- and low-income countries, with global rates more than doubling since 1975. The World Health Organization sets the diagnostic cutoff for obesity at a threshold body mass index of 30 kg/m², and recent U.S. data indicate that more than 42% of adults meet this threshold.

Although obesity is multifactorial, an imbalance between energy intake and expenditure remains a fundamental driver. Diet composition, physical inactivity, psychological stress, and socioeconomic and biological factors, including genetics, the gut microbiome, and neuroendocrine regulation, further shape individual risk.

Initial weight loss is often achieved through dietary restriction, but sustaining this loss is considerably more difficult. Physiological adaptations, such as reduced resting metabolic rate and increased appetite, promote weight regain. Behavioral and environmental factors compound this challenge. Evidence consistently demonstrates that physical activity plays a critical role in weight loss maintenance by offsetting metabolic adaptation, supporting satiety regulation, and reinforcing long-term behavioral adherence.

This course for healthcare professionals is designed to enhance learners’ ability to evaluate, implement, and optimize physical activity strategies that support long-term weight loss maintenance. Participants will broaden their grasp of the physiological and behavioral adaptations that undermine weight loss maintenance, the role of physical activity in counteracting these mechanisms, and the evidence-based strategies that integrate exercise with dietary, behavioral, and pharmacologic interventions. Improved proficiency fosters interprofessional collaboration to enhance patient-centered weight management.

Objectives:

• Identify the risk factors predisposing patients to obesity and weight regain following initial weight loss.
• Implement evidence-based, personalized strategies for managing obesity and supporting long-term weight management.
• Improve patient understanding of behavioral and physiological factors to support effective weight loss and long-term maintenance.
• Collaborate with the interprofessional team to educate, treat, and monitor patients with obesity, supporting sustainable weight loss, reducing comorbidities, and improving health outcomes.

Introduction

Obesity constitutes a major public health concern around the globe, with serious medical, economic, and social consequences. The condition is associated with elevated risks of cardiovascular disease, type 2 diabetes, certain cancers, osteoarthritis, and all-cause mortality (see Image. Relative Mortality Risk by Body Mass Index).[1][2] The World Health Organization identifies obesity as having a body mass index of or more than 30 kg/m², with recent data showing increasing prevalence. In the U.S., adult obesity increased from 30.5% during the years 1999 to 2000 to 42.4% in 2017 to 2018.

The global burden of obesity has escalated markedly. A pooled analysis of 1,698 population-based studies encompassing 19.2 million adults found that worldwide obesity prevalence more than doubled between 1975 and 2014.[3] High-income countries experienced particularly steep increases, although low- and middle-income countries are also increasingly affected.

While obesity is multifactorial, a primary driver is an imbalance between energy intake and expenditure. Weight management involves more than calories in versus calories out. Dietary quality also plays a critical role. Plant-based diets, in particular, may support weight loss by enhancing satiety and regulating hormones.[4] Additional contributors include physical inactivity, consumption of ultra-processed foods, sleep deprivation, psychological stress, and socioeconomic factors. Genetics, microbiome composition, and neuroendocrine feedback loops further modulate individual susceptibility to weight gain. Therefore, strategies for obesity prevention and treatment must be multifaceted and personalized, with emphasis on long-term behavioral and environmental interventions.

Function

Physiology of Weight Loss and Weight Loss Maintenance

Sustained weight loss is a biologically complex process, driven by coordinated physiological adaptations that promote energy conservation and increase appetite, making long-term maintenance particularly challenging. These changes include metabolic adjustment and energy balance, hormonal regulation of appetite, hypothalamic–neuroendocrine responses, dynamics of energy expenditure, and behavioral and psychological factors.

Metabolic adaptation and energy balance

Weight loss triggers physiological adaptations that resist further loss and promote regain. Resting metabolic rate (RMR) decreases more than expected for the new body composition—a phenomenon known as metabolic adaptation. This effect persists during weight maintenance and results from reduced thyroid hormone levels, changes in mitochondrial efficiency, and decreased energy expenditure during physical activity. Notably, in the "The Biggest Loser" cohort, metabolic adaptation persisted at -499 kcal/day even 6 years after weight loss.[5]

Hormonal regulation of appetite

After weight loss, circulating levels of leptin, glucagon-like peptide 1 (GLP-1), peptide YY, and cholecystokinin decrease, while ghrelin levels increase, leading to heightened hunger and reduced satiety. These hormonal shifts produce an approximate increase in appetite of 100 kcal/day for each kilogram lost, outweighing the concurrent decrease in energy expenditure.[6]

Hypothalamic and neuroendocrine responses

Neuroendocrine mechanisms shift after weight loss. Activation of the hypothalamic-pituitary-adrenal axis elevates cortisol levels, promoting fat storage and increased appetite. Thyroid-stimulating hormone (TSH) and triiodothyronine levels decline, lowering RMR. Additionally, reduced sympathetic nervous system activity diminishes thermogenesis.[7][8]

Energy expenditure dynamics

The body further adjusts by reducing nonexercise activity thermogenesis and enhancing mitochondrial efficiency, lowering the energy cost per movement. In humans undergoing calorie restriction, resting energy expenditure decreases by approximately 100 kcal/day, with mitochondrial effects confirmed in skeletal muscle.[9]

Behavioral and Psychological Factors

Behavioral and psychological factors strongly influence weight loss and maintenance. Appetite dysregulation represents a key challenge. Diets that promote greater satiety have been associated with approximately 3.6 kg more weight loss, highlighting hunger control as an essential strategy.[10] Emotional eating also contributes to weight management difficulties. A meta-analysis of 11 studies (n = 7,207) found that individuals with obesity scored significantly higher on measures of emotional eating compared to healthy-weight peers.[11]

Self-monitoring presents additional challenges. The effectiveness of frequent self-weighing remains somewhat controversial. A systematic review of 20 studies reported that frequent self-weighing can negatively affect mood, self-esteem, and body image in women and younger adults. Conversely, a meta-analysis found that weight loss programs incorporating participant accountability through self-weighing achieved greater success than control groups.[12] Integrating psychological support alongside monitoring further improved outcomes.[13]

Table 1 summarizes the key physiological adaptations that counteract weight loss and promote weight regain. The table also outlines the mechanisms and effects of these adaptations on long-term weight maintenance.

Table

Table 1. Summary of Physiological Adaptations That Promote Weight Regain Following Weight Loss.

Issues of Concern

Energy expenditure associated with physical activity decreases as people lose weight and improve cardiovascular fitness. Consequently, both caloric intake and activity levels must be continually adjusted to prevent weight regain.[16]

However, many individuals struggle to adhere to intensive diet and physical activity programs, particularly when expectations are unrealistic or routines are unsustainable. This difficulty frequently leads to frustration and eventual discontinuation of efforts. Managing patient expectations and emphasizing realistic, motivational, and personalized goals is essential to support long-term adherence. For patients with comorbidities or physical limitations, incorporating alternative forms of physical activity, such as nonweight-bearing aerobic exercises or resistance training, is critical, underscoring the importance of considering patient preferences and capabilities in counseling.[17]

Additionally, psychological factors play a critical role in weight loss maintenance, as mood and eating disorders can significantly impair the ability to sustain weight reduction. Referring patients to behavioral health specialists is essential for long-term success. Although self-monitoring of weight, diet, and physical activity can be beneficial, recent studies indicate that frequent self-weighing may have negative psychological effects for some individuals. These findings underscore the importance of balancing the benefits and drawbacks of self-monitoring and involving behavioral health professionals when necessary.[18][19]

Clinical Significance

Successful long-term weight loss maintenance requires sustained changes in physical activity, diet, behavior, and psychological resilience. Strategies must specifically target biological adaptations that otherwise promote weight regain.

High-Volume Physical Activity

Engaging in high volumes of moderate-to-vigorous physical activity is a strong predictor of long-term success. Observational studies and clinical trials consistently demonstrate that individuals maintaining at least 250 minutes of physical activity per week are significantly more likely to sustain weight loss. This level of activity counteracts the persistent decline in RMR and helps preserve lean body mass. Resistance training may also support weight maintenance. However, a systematic review found that aerobic training produced greater weight loss than resistance training in programs lasting at least 10 weeks, highlighting the particular value of aerobic exercise as an adjunct to diet and other measures.[20]

Nutrition Strategies for Weight Maintenance

Diets high in protein and low in energy density enhance satiety, increase thermogenesis, and support lean mass retention. Protein typically promotes greater satiety than carbohydrates or fat, increases diet-induced thermogenesis, and helps preserve lean muscle mass during weight loss.[21]

Increasing the intake of vegetables, whole grains, and legumes helps reduce caloric intake without increasing hunger. Strategically incorporating low-energy-density foods promotes satiety and supports long-term weight control, as demonstrated in both randomized and observational studies.[22]

Appetite Hormone Regulation and Pharmacotherapy

Persistent hormonal adaptations following weight loss include decreased leptin and increased ghrelin levels, which heighten hunger and reduce satiety.[23] These hormonal changes can undermine efforts to maintain a reduced weight. GLP-1 receptor agonists have shown promise in mitigating these effects. A 2024 randomized trial demonstrated that combining GLP-1 receptor agonists with structured exercise resulted in approximately 6 kg greater weight loss, which was maintained after medication cessation, compared with GLP-1 therapy alone.

Behavioral Self-Regulation

Ongoing self-monitoring, including regular weighing, food logging, and tracking physical activity, is strongly associated with improved weight maintenance outcomes. Data from the National Weight Control Registry and a 2011 systematic review indicate that consistent self-monitoring enhances awareness and facilitates early detection of potential weight regain.[24][25]

Structured Support and Coaching

Professional and peer support enhance motivation and problem-solving skills. A 12-month randomized controlled trial (RCT) demonstrated that individuals with suboptimal early weight loss who received extended telephone coaching achieved significantly greater weight loss at 12 months compared with controls.[26] Programs incorporating behavioral goal-setting, ongoing feedback, and regular contact generally produce more sustainable outcomes.

Addressing Psychological Barriers

Emotional eating, stress, and psychological comorbidities often impede long-term weight loss maintenance. Emotional eating is notably more prevalent among individuals with overweight or obesity and is associated with poorer dietary quality. Identifying and addressing these barriers through counseling, cognitive-behavioral therapy, or mindfulness-based interventions represents a critical component of comprehensive weight maintenance strategies.

Table 2 summarizes evidence-based interventions that support long-term weight loss maintenance. The table highlights the mechanism of each strategy, relevant citations, and the quality of evidence, providing clinicians with guidance on effective approaches to sustain weight reduction and promote patient adherence. The grade or strength of evidence is indicated, considering study design and consistency of results.

Table

Table 2. Summary of Weight Loss Maintenance Strategies.

Enhancing Healthcare Team Outcomes

A coordinated, interprofessional approach is essential for supporting long-term weight loss maintenance in patients with obesity, particularly those with comorbidities. Collaboration among physicians, registered dietitians, behavioral specialists, and exercise professionals enhances adherence and improves outcomes.

For instance, a real-world, team-based obesity treatment program, including a physician, dietitian, nurse, and exercise physiologist, achieved significantly greater weight loss maintenance over 24 months compared with usual care.[30] Expert involvement from behavioral health professionals is particularly valuable for addressing emotional eating, binge eating, and body-image concerns. A systematic review and meta-analysis of motivational interviewing in adults with overweight or obesity reported a standardized mean weight loss of -0.51 kg/m², corresponding to approximately 1.5 kg reduction compared with control groups.[31]

Referral to a bariatric surgery team may be appropriate when lifestyle interventions fail to achieve meaningful weight loss, rather than for weight loss maintenance alone. The Enhanced Recovery After Surgery (ERAS^®) Society's 2022 guidelines for bariatric surgery recommend comprehensive, evidence-based preoperative and postoperative protocols to optimize surgical outcomes.[32]

Exercise professionals, including lifestyle coaches, trainers, and physical therapists, develop individualized activity plans that accommodate mobility limitations and minimize injury risk, enhancing adherence in patients with functional impairments. The American College of Sports Medicine recommends 250 to 300 min/wk of moderate-intensity aerobic exercise to support long-term weight loss maintenance.[33]

Nursing, Allied Health, and Interprofessional Team Interventions

Physical activity effectively promotes weight loss maintenance in patients with obesity or overweight.[20] Maintaining patient adherence and commitment to physical activity programs alongside calorie-restriction interventions benefits from consistent guidance from an interprofessional healthcare team. Such support helps prevent unrealistic patient expectations and the resulting frustration and discontinuation of efforts. A coordinated, interprofessional approach provides patients with sustained support to maintain weight loss.[34]

Nursing, Allied Health, and Interprofessional Team Monitoring

Nurses and allied health professionals, including dietitians, physical therapists, and psychologists, provide personalized care, education, and ongoing patient support. The involvement of these professionals in comprehensive assessment, regular monitoring, and behavioral counseling has been shown to improve adherence and outcomes in weight management programs significantly. Interprofessional collaboration, where nurses, allied health professionals, and medical providers work together, enhances the effectiveness of interventions by combining expertise across disciplines. This approach fosters more individualized and sustainable treatment plans. Clinical evidence demonstrates that team-based care improves both weight loss and maintenance while addressing the psychological and behavioral complexities of obesity.[35]

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Disclosure: Anees Alyafei declares no relevant financial relationships with ineligible companies.

Disclosure: James Balfour declares no relevant financial relationships with ineligible companies.

Disclosure: Daniel Keyes declares no relevant financial relationships with ineligible companies.