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Am Fam Physician. 2020;102(9):567-570

Author disclosure: No relevant financial affiliations.

Case Scenario

A 50-year-old patient, M.W., successfully reached their goal weight by losing 15 lb (6.8 kg) over six months on a Mediterranean diet. After maintaining the weight loss for more than a year, my patient is now 30 lb (13.6 kg) over their ideal body weight of 140 lb (63.5 kg). My patient has developed cardiometabolic syndrome and receives intensive lifestyle counseling. M.W. feels ashamed by the “failure” and has been avoiding seeing a physician.

Commentary

Internalized weight bias, or self-criticism of one's weight, can cause significant distress in patients trying to lose weight1 and may be particularly pronounced in patients who have regained some or most of their original weight loss.2 An appropriate clinical response to a patient's weight regain includes validation of the patient's effort, acknowledgment of the biological set point that regulates weight as tightly as sodium or water balance,3 and a step-wise approach to weight loss that incorporates lifestyle changes, environmental factors, pharmacotherapy, and, if necessary, bariatric surgery.

To assist a patient who has experienced weight regain, the physician should acknowledge, congratulate, and build on the patient's previous commitment and success in losing weight.4 The patient should be reminded that weight regain may not be a failure of willpower but rather part of the body's innate biology to maintain weight for survival.3 Following weight loss, this drive causes an increase in appetite and produces adaptive thermogenesis, or a lower metabolic rate, compared with others who have a similar body composition; however, there are various ways to ensure long-term weight-loss success.5

To begin, the definition of successful weight loss should be clarified to the patient. For those at risk of diabetes mellitus, a 5% weight loss has shown a significant decrease in progression to diabetes, whereas a 5% to 10% weight loss is needed to see significant reductions in A1C for people who have confirmed diabetes. For most patients, a 5% weight loss results in a modest improvement in cholesterol and triglyceride levels and blood pressure.6 A 3% to 5% minimum weight loss seems necessary to improve steatosis in patients with nonalcoholic fatty liver disease, whereas a 7% to 10% weight loss is needed to improve fibrosis.7

Optimization of lifestyle with diet and activity plus behavioral support remain critical interventions in weight management after weight regain. These changes may be perceived as less difficult by focusing on the positive impact of a healthy diet rather than on dietary deprivation or extreme physical or psychosocial measures. A simple set of goals, consistent with the literature that describes how lifestyle behaviors support longevity, can be established using the 5-2-1-0 approach8 (Table 18,9 ).

55 servings of fruits and vegetables per day
5% weight loss if body mass index ≥ 30 kg per m2; consider body mass index ≥ 27 kg per m2 in Asian or Asian American patients9
22 hours or less of nonwork screen time per day
2 drinks or less of alcohol per day for men
11 hour of activity per day
1 drink or less of alcohol per day for women
00 sweetened drinks
No smoking

If these strategies are ineffective, pharmacotherapy can be an appropriate next step (Table 21022 ). To be approved by the U.S. Food and Drug Administration (FDA) for weight loss, a medication must show at least a 5% weight loss vs. a placebo.22 Other than orlistat (Xenical), a pancreatic lipase inhibitor that works in the gastrointestinal tract to inhibit triglyceride absorption, all other anti-obesity–specific medications work through neurohormonal changes that decrease appetite.22 Currently, no medications approved by the FDA increase thermogenesis or energy expenditure. The lack of pharmacologic interventions that can affect the pathways responsible for changing the body's set point explains why medications are only modestly effective in helping maintain weight loss and combating weight regain. On average, anti-obesity medications result in a 5% to 10% weight loss, and patients should have achieved at least a 5% weight loss after three months on the maximally tolerated dose to continue taking an anti-obesity medication. Phentermine is the only weight-loss medication not approved by the FDA for long-term use. A randomized trial demonstrated that a combination of a behavioral weight-loss program and medication is superior to either strategy alone.23

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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

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