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How Can I Help My Client Who Is Experiencing a Weight-Loss Plateau?
from the association
QUESTION OF THE MONTH
How Can I Help My Client Who Is Experiencing a Weight-Loss Plateau?
A
n observation made in a meta-analysis of 80 weightloss studies with a minimum follow-up of 12 months was that weight-loss plateaus occur at approximately 6 months of all interventions involving a reducedenergy diet and/or weight-management medication (1). A weight-loss plateau has been defined as occurring “when a person is in energy balance (calories eaten are equal to the calories burned) and therefore no weight loss occurs” (2). The reasons for a weight-loss plateau are as yet unclearly delineated, but as people lose weight, they lose muscle mass in addition to fat and water, which results in a lower metabolic rate. In addition, at their new lower body weight, they burn fewer calories doing the same physical activity. An important goal in nutrition therapy for overweight and obese individuals is to decrease caloric intake in order to achieve a negative energy balance to promote weight loss. An often cited weight-loss rule is that losing 1 lb requires a 3,500-kcal deficit. This rule was recently challenged in an article published in Lancet (3). The authors acknowledge the rule, while widely used, is generally understood to be overly simplistic and overestimates weight loss. According to the researchers, the static 3,500-kcal-per-pound rule was derived by estimation of the energy content of weight lost. The rule fails to take into account the body’s response to dynamic metabolic changes that occur as weight is lost and the effect of those changes on the rate of weight loss. They presented a new mathematical model and online simulator based on the model that simulates energy expenditure adaptations during weight loss. The researchers believe that plateaus occur much later than the observed 6 months and propose that what happens at 6 months is nonadherence to the prescribed diet, not a weight-loss plateau. The mathematical model, assuming perfect adherence to a constant energy reduction, predicts a plateau on a much longer time scale of several years. The online simulation tool based on the mathematical model is intended as a research tool and not as a weightloss guide for the public. The online tool enables researchers to predict how body weight will change and how long it will likely take to reach weight goals based on a starting weight and estimated physical activity. The bodyweight simulation tool will be updated to reflect continuing improvements in the model. The tool, at http:// bwsimulator.niddk.nih.gov/, simulates how factors such as diet and exercise can alter metabolism over time and
This article was written Eleese Cunningham, RD, of the American Dietetic Association’s Knowledge Center Team, Chicago, IL. ADA members can contact the Knowledge Center by sending an e-mail to [email protected]. doi: 10.1016/j.jada.2011.10.020
1966
Journal of the AMERICAN DIETETIC ASSOCIATION
thereby lead to changes in weight and body fat. Emerging research often challenges the status quo, and definitions of weight-loss plateaus will likely evolve as research continues. A negative energy balance is the most important factor affecting weight loss amount and rate. Current recommendations from the American Dietetic Association and the National Institutes of Health call for a reduction of 500 to 1,000 kcal/day to promote an initial weight loss of 1 to 2 lb/week (4,5). Weight-loss plateaus are a common and frustrating phenomenon experienced during the weight-loss process. The following suggestions may help your clients decide how to weather the weight-loss plateaus they are likely to encounter (4,6). ●
●
●
●
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Initial patient-centered interviews should start with realistic, sustainable weight-loss goals. Include the topic of weight-loss plateaus as a normal and expected part of the weight-loss process. Encourage continued accurate self-monitoring of diet, physical activity, and weight. Self-reports can be flawed, but research supports a significant positive relationship between self-monitoring diet, physical activity, or weight, and successful outcomes related to weight management. The goals of weight management go well beyond the numbers on a scale. Encourage your clients with a focus on how health can be improved with relatively minor weight loss. Is it time to move from weight loss to weight-loss maintenance and prevent weight regain? The partnership between registered dietitians and their clients should focus on developing strategies that will enhance opportunities for clients to control their own behaviors and prevent reversion to old habits. Whatever choice the client makes, challenge him or her to build on their strengths during a weight-loss plateau and move on to long-term success.
References 1. Franz MJ, VanWormer JJ, Crain AL, Boucher JL, Histon T, Caplan W, Bowman JD, Pronk NP. Weight-loss outcomes: A systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc. 2007;10:1755-1767. 2. Kushner RF, Kushner N, Jackson Blatner D. Counseling Overweight Adults: The Lifestyle Patterns Approach and Toolkit. Chicago, IL: American Dietetic Association; 2009. 3. Hall KD, Sacks G, Chandramohan D, Chow CC, Wang YC, Gortmaker SL, Swinburn BA. Quantification of the effect of energy imbalance on bodyweight. Lancet. 2011;378:826-837. 4. Adult weight management evidence-based nutrition practice guideline American Dietetic Association Evidence Analysis Library Web site. http:// www.adaevidencelibrary.com/topic.cfm?cat⫽2798. Accessed October 5, 2011. 5. The Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Rockland, MD: US Department of Health and Human Services; 1998; NIH Publication No. 98-4083. 6. Gillette Dormer C. Clinical challenge: Weight loss plateau. Weight Management Dietetic Practice Group Newsletter. Fall 2003;1:4-5.
© 2011 by the American Dietetic Association
QUESTION OF THE MONTH
How Can I Help My Client Who Is Experiencing a Weight-Loss Plateau?
A
n observation made in a meta-analysis of 80 weightloss studies with a minimum follow-up of 12 months was that weight-loss plateaus occur at approximately 6 months of all interventions involving a reducedenergy diet and/or weight-management medication (1). A weight-loss plateau has been defined as occurring “when a person is in energy balance (calories eaten are equal to the calories burned) and therefore no weight loss occurs” (2). The reasons for a weight-loss plateau are as yet unclearly delineated, but as people lose weight, they lose muscle mass in addition to fat and water, which results in a lower metabolic rate. In addition, at their new lower body weight, they burn fewer calories doing the same physical activity. An important goal in nutrition therapy for overweight and obese individuals is to decrease caloric intake in order to achieve a negative energy balance to promote weight loss. An often cited weight-loss rule is that losing 1 lb requires a 3,500-kcal deficit. This rule was recently challenged in an article published in Lancet (3). The authors acknowledge the rule, while widely used, is generally understood to be overly simplistic and overestimates weight loss. According to the researchers, the static 3,500-kcal-per-pound rule was derived by estimation of the energy content of weight lost. The rule fails to take into account the body’s response to dynamic metabolic changes that occur as weight is lost and the effect of those changes on the rate of weight loss. They presented a new mathematical model and online simulator based on the model that simulates energy expenditure adaptations during weight loss. The researchers believe that plateaus occur much later than the observed 6 months and propose that what happens at 6 months is nonadherence to the prescribed diet, not a weight-loss plateau. The mathematical model, assuming perfect adherence to a constant energy reduction, predicts a plateau on a much longer time scale of several years. The online simulation tool based on the mathematical model is intended as a research tool and not as a weightloss guide for the public. The online tool enables researchers to predict how body weight will change and how long it will likely take to reach weight goals based on a starting weight and estimated physical activity. The bodyweight simulation tool will be updated to reflect continuing improvements in the model. The tool, at http:// bwsimulator.niddk.nih.gov/, simulates how factors such as diet and exercise can alter metabolism over time and
This article was written Eleese Cunningham, RD, of the American Dietetic Association’s Knowledge Center Team, Chicago, IL. ADA members can contact the Knowledge Center by sending an e-mail to [email protected]. doi: 10.1016/j.jada.2011.10.020
1966
Journal of the AMERICAN DIETETIC ASSOCIATION
thereby lead to changes in weight and body fat. Emerging research often challenges the status quo, and definitions of weight-loss plateaus will likely evolve as research continues. A negative energy balance is the most important factor affecting weight loss amount and rate. Current recommendations from the American Dietetic Association and the National Institutes of Health call for a reduction of 500 to 1,000 kcal/day to promote an initial weight loss of 1 to 2 lb/week (4,5). Weight-loss plateaus are a common and frustrating phenomenon experienced during the weight-loss process. The following suggestions may help your clients decide how to weather the weight-loss plateaus they are likely to encounter (4,6). ●
●
●
●
●
Initial patient-centered interviews should start with realistic, sustainable weight-loss goals. Include the topic of weight-loss plateaus as a normal and expected part of the weight-loss process. Encourage continued accurate self-monitoring of diet, physical activity, and weight. Self-reports can be flawed, but research supports a significant positive relationship between self-monitoring diet, physical activity, or weight, and successful outcomes related to weight management. The goals of weight management go well beyond the numbers on a scale. Encourage your clients with a focus on how health can be improved with relatively minor weight loss. Is it time to move from weight loss to weight-loss maintenance and prevent weight regain? The partnership between registered dietitians and their clients should focus on developing strategies that will enhance opportunities for clients to control their own behaviors and prevent reversion to old habits. Whatever choice the client makes, challenge him or her to build on their strengths during a weight-loss plateau and move on to long-term success.
References 1. Franz MJ, VanWormer JJ, Crain AL, Boucher JL, Histon T, Caplan W, Bowman JD, Pronk NP. Weight-loss outcomes: A systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc. 2007;10:1755-1767. 2. Kushner RF, Kushner N, Jackson Blatner D. Counseling Overweight Adults: The Lifestyle Patterns Approach and Toolkit. Chicago, IL: American Dietetic Association; 2009. 3. Hall KD, Sacks G, Chandramohan D, Chow CC, Wang YC, Gortmaker SL, Swinburn BA. Quantification of the effect of energy imbalance on bodyweight. Lancet. 2011;378:826-837. 4. Adult weight management evidence-based nutrition practice guideline American Dietetic Association Evidence Analysis Library Web site. http:// www.adaevidencelibrary.com/topic.cfm?cat⫽2798. Accessed October 5, 2011. 5. The Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Rockland, MD: US Department of Health and Human Services; 1998; NIH Publication No. 98-4083. 6. Gillette Dormer C. Clinical challenge: Weight loss plateau. Weight Management Dietetic Practice Group Newsletter. Fall 2003;1:4-5.
© 2011 by the American Dietetic Association