An Obesity Doctor’s Action Plan for Sustainable Weight Loss

A professional guide to losing weight (and keeping it off).
Note to new readers: This blog post is the finale of the series, “Everything You Need to Know About Losing Weight,” sharing essential knowledge for sustainable weight loss. This article will be a high-yield action plan to achieve long-term weight loss; however, a recommendation’s “why” will often be omitted as this blog post builds on previous information. I will be providing links to prior articles for additional reading (or you can start at the introduction and sequentially move through the content). Enjoy!

A Medical Disclaimer
As a physician specializing in obesity medicine, I must be cautious to ensure the content below is perceived and handled appropriately. Unfortunately, although I am a medical doctor, I am not your doctor, so my opinion is not medical advice. I recommend talking with your doctor before starting any weight loss plan. The intent of the following information is for general health and wellness education. Now, let’s get started!

The Complexity of Long-Term Weight Loss
Long-term weight loss is much more complex than meets the eye, as much is happening under the surface. Losing weight is the easy part; the challenge is keeping it off.

Human physiology is hardwired for survive and your body will vigorously defend its excess energy storage (body fat), protecting against perceived starvation. Unfortunately, it does not differentiate between intentional and unintentional weight loss. The result? Self-preservation causes eventual weight regain.

Do you struggle with unhealthy weight? If so, you have been fighting your physiology for years without knowing it! The odds are that you have never addressed the root cause. Instead, you have repeatedly taken traditional weight loss approaches (such as dieting), which have done nothing more than awaken an unseen enemy who sabotages all of your best efforts. So inevitably, you end up right where you started.

Adding insult to injury, friends, family, and every other person on social media fail to comprehend your struggle. Just eat less, eat healthier, and exercise more. It’s simple!

Well, yes, but no. The advice is correct to help you lose weight but does nothing to address the root cause of weight regain — your physiology.

So, if you feel stuck in an unending cycle of dieting, losing the same 10 or 20 pounds over and over again, keep reading and give yourself some grace. You are not alone. It’s a new day and time for a fresh start!

What’s Your Motivation?
Before reviewing “how,” knowing your personal “why” for weight loss is critical. Why is weight loss important to you? And this “why” really needs to be something from within.

An internal (or intrinsic) motivation is necessary to carry you through your weight loss journey, as sustainable weight loss requires permanent change. Otherwise, when you think you have reached your goal, your body’s survival mechanisms kick in, and weight regain ensues.

Always remember that weight loss is a journey, not a destination.

Diets Will Fail
A short-term, destination-based perspective is one reason why diets inevitably fail. The idea that you only have to maintain a lifestyle change for a defined timeframe is a common misconception. The result is an unsustainable diet (or exercise routine) requiring tremendous self-control to stick to your plan. If (or when) your willpower falters, human physiology is waiting to sabotage your hard-earned results.

So, how about a different approach? How would it feel to never go on a diet again?

Then, instead of dieting, it’s time to form new sustainable habits, resulting in lasting change.

The 4 Rules of Sustainability
A sustainability mindset will help you maintain eating and lifestyle changes long-term. Here are four overarching rules to apply to any weight loss plan.

The Rule of Reversibility: The human body has an incredible ability to adapt to environmental stressors. However, the same adaptation will regress when a stressor disappears. So, permanence is critical when making dietary and lifestyle changes for weight loss.
The Rule of Permanence: Ask yourself, “can I maintain this diet or lifestyle change indefinitely?” If the answer is “no,” you must consider why. Perhaps it simply is not a good fit for you, or maybe, you are merely trying to do too much too soon (needing a more gradual approach).
The Rule of Perseverance: The path to long-term weight loss is a marathon, not a sprint. Perseverance is the key. One important note is that the journey should not be burdensome or mentally taxing. If it is, you will burn out before reaching your goal. Making small, incremental, and sustainable changes will get you to the finish line.
The Rule of Thumb: What is your ideal goal? I am not referring to a number on the scale, but rather, what lifestyle and physique do you desire? Then, gradually work toward establishing new permanent habits that will move you in that direction.
Are You Ready, Willing, And Able?
Before putting your action plan together, the final consideration is to meet yourself where you are in life. What you want to do may not correlate with what you are ready or able to do. I am not suggesting you defer lifestyle changes but rather consider what is doable in your life now.

Are you ready to lose weight now? If the answer is “no,” then a goal for weight stability is reasonable and will keep you from the typical year-over-year weight gain seen in much of western culture. In the grand scheme of things, not gaining weight is a win!

What are you willing to change to reach your goal? Unfortunately, people often confuse a weight loss tool (i.e., eating healthier) with an answer to one’s struggle with weight. For example, although I recommend a healthy diet for many reasons, it is unnecessary (although helpful) for weight loss. So, if eating salad is unimaginable, then don’t start there! You can (and should) incorporate healthier choices with time, but it isn’t the best tool if you are unwilling to do it.

Finally, what are you able to do? Weight loss tools can impact either calorie intake or expenditure, and your approach should fit your capabilities. For example, if you suffer from arthritic pain, a vigorous exercise program may be something you are willing to do but unable to maintain.

So, if you are reading this article, you are clearly ready to make changes to pursue your goal. Remember to keep in mind what you are “willing” and “able” to do as you formulate a weight loss action plan.

A Common Denominator for Weight Loss
One commonality between all diets and weight loss programs is a calorie deficit. Remember that a deficit comprises calorie expenditure exceeding intake; any blend of burning more and consuming less can help you reach your goal.

Energy Expenditure
First, let’s review energy expenditure as it is relatively clear-cut.

Your basal metabolic rate (BMR, baseline metabolism), the thermic effect of food (TEF, energy used during digestion), non-exercise activity thermogenesis (NEAT, energy burned during the day), and exercise activity thermogenesis (EAT, energy utilized for exercise) comprise your total daily energy expenditure (TDEE).

Your BMR is relatively stable, and you can manipulate TEF (proteins have the most significant thermic effect and fats the least). Still, your primary means of burning more calories is through your daily activities (NEAT and EAT).

Non-Exercise Activity Thermogenesis
It is important to note that non-exercise activity is the greatest modifiable source of energy expenditure. This concept may come as a surprise, as standard practice is to focus on burning calories through exercise. However, it makes a ton of sense if you think about it.

NEAT is essentially the energy expenditure of your (non-exercise) daily routine. If you sleep 8 hours at night and exercise an hour each day, NEAT accounts for the other 15 hours! So, find ways to move more every day. Every little bit counts! Reflecting on the Rule of Thumb, consider your desired lifestyle, and gradually modify your daily routine to reach your goal.

Exercise
The importance and health benefits of exercise are without question, but when it comes to losing weight, exercise is not as helpful as you think!

“Research shows that weight loss does occur with exercise alone. However, diet-based weight loss interventions (diet alone or diet plus exercise) are far superior.”

Whereas exercise is not your best tool for weight loss, it is essential to maintain your hard-earned results. So, as you are implementing lifestyle changes for weight loss, consider the health benefits of exercise and ensure that you can sustain your routine long-term.

Exercise for Health
The U.S. Department of Health and Human Services adult physical activity guidelines are a great starting point for any exercise routine.

You will gain health benefits with as little as 60 minutes of weekly moderate-intensity aerobic exercise. Believe it or not, simply walking your dog classifies as moderately intense!
Once you achieve this 60-minute weekly target, the next goal is 150 minutes per week of moderate-intensity aerobic exercise (or 75 minutes of vigorous aerobic exercise).
Also, the guidelines recommend muscle strengthening exercises of your major muscle groups at least twice weekly.

Weight Loss Precautions
As a general rule, just get moving. And the more, the merrier! But, take two precautions when considering exercise as a tool for weight loss.

Exercise can enhance but should not replace dietary interventions. Also, be conscious of the impact of your exercise routine on your appetite (which can sometimes be counterproductive).
Be cautious that your exercise routine is not having an unforeseen negative impact on NEAT. You may hurt your net caloric deficit if you sit more throughout the day due to a strenuous workout.

Energy Intake
Now we will turn our attention to the flip side of the coin as we consider reducing energy intake to create a negative calorie balance for weight loss. The waters get much murkier as we begin to discuss your diet, as the internet is full of various recommendations! However, keeping the Rules for Sustainability in mind will be an excellent content filter for you. But let me simplify things a bit further. 😁

Calorie Tracking
It is beneficial to understand your baseline metabolic rate and estimated caloric expenditure from daily activity (see this article for more information). This knowledge will allow you to compare your calorie intake to expenditure using a calorie tracking app (i.e., MyFitnessPal).

However, there are limitations to consider when calorie counting.

Your estimated daily energy expenditure is an estimate and may not accurately represent your unique situation. Also, your metabolism will slow as you lose weight, further impairing the accuracy of your energy expenditure calculation.
Food labels are permitted to have a 20% margin of error regarding nutritional content. This margin of error is massive when trying to lose weight (and can easily result in a lack of progress despite calorie counting).
Reflecting on the Rule of Sustainability, how long will calorie counting last? Using calorie tracking to sporadically spot-check your eating habits is an excellent application of this weight-loss tool (without losing your sanity).
Let’s argue you love to track your food and calories. What happens to your relationship with food as you micromanage everything you eat? The concern is that your relationship can become unhealthy. So, please be self-aware. It’s time to find another approach if your eating becomes rigid or stressful (when you lose control of what you eat) or begins to dictate your life.

Diets and Weight Loss Programs

Any internet search about “weight loss” will provide innumerable results touting incredible outcomes associated with countless diets and weight loss programs. Scams aside, there is little doubt that many of these recipes for success will result in weight loss. So, pick your best fit and get started, right? Well, not so fast.

Remember that weight loss is not the primary issue at hand. Instead, the physiology of weight regain is the unseen villain undoing all your hard work.

So, if you choose to proceed with a formalized diet or weight loss program, please keep the Rule of Sustainability in mind. If you can continue the eating strategy long-term, you may have found an approach that works for you! If not, I strongly recommend saving time and money by considering something different. Even better, stop “dieting” altogether!

Simple Ways to Reduce Caloric Intake
Start With You
You are unique. A sustainable weight-loss plan will reflect your preferences and needs. Remember, there is no one-size-fits-all diet. You are the expert when it comes to you.

Establish a Baseline
Track your baseline eating habits for a few days. Snapping a quick picture before eating or drinking (excluding water) is a great approach (avoiding memory lapses). Resist the urge to start changing your diet, which is bound to happen when you start paying attention (but note where you want to modify). The goal is to establish your “normal” eating habits. This baseline will be a reference point on your weight loss journey (so please, don’t breeze past this step!). Note: If they significantly vary, you may need to track a bit longer to document weekend and weekday eating.

Modify from Baseline
The next step is to make initial changes to your “normal” eating habits. Any reduction in caloric intake from baseline will have one of three favorable outcomes.

You will gain less weight if the reduction partially offsets a significant calorie surplus.

Your weight will stabilize if the reduction sufficiently offsets a baseline calorie surplus.

You will lose weight if the outcome is a net calorie deficit.

So, although weight loss is the desired outcome, any change from your “normal” eating will have a positive effect! It is crucial to recognize that long-term behavior modification is your target, whereas weight loss is a byproduct of these new habits.

Reduce Portion Sizes
Frequently while establishing baseline eating habits, portion size tends to stand out as an area needing change. And quite frankly, in American culture, portion sizes (and calorie density) significantly contribute to weight gain. So, this tends to be the first area to address.

Reducing portions from your “normal” will immediately reduce your caloric intake from baseline. And with time and persistence, eating less will undoubtedly contribute to making a lasting change!

Please note that you will adapt to eating less, eventually becoming satisfied with smaller portions. This adaptation is essential for long-term weight maintenance as your basal metabolic rate will decline with weight loss. So, avoid a common pitfall of “filling up” on large portions of healthier, lower-calorie foods. This practice maintains baseline portion sizes and food quantity, which is counterproductive in the long run.

Make Healthier Choices
Although “filling up” on healthier foods is not ideal, making healthier choices can make a tangible difference in your caloric intake.

Generally, nutritious foods are nutrient-dense and have lower calories than other options. In addition, the closer a food is to its natural state, the better.

Regrettably, the highly palatable and flavorful foods you crave tend to be the calorie-dense foods to cut back on, and eating habits often become ingrained in childhood. Therefore, transitioning to better food choices will likely require perseverance (making incremental tweaks over time) as you incorporate new foods into your diet. So, always seek opportunities to integrate healthier, sustainable substitutions.

You will notice that I am not getting into an “eat this, not that” mentality but rather recommending you make gradual dietary tweaks that are sustainable for you. The key is that you are not making one adjustment and considering the job done! Instead, continually seek opportunities to improve your diet sustainably. With time it will have a powerful effect on reducing your caloric intake.

Avoid Excessive Overeating
Another considerable opportunity to facilitate a calorie deficit is avoiding excessive overeating. On a side note, I am not referencing medical eating disorders (please talk to your doctor if your relationship with food or eating concerns yourself or your loved ones). Instead, I am referring to binge-eating episodes that accompany the holidays or when you falter on a diet.

These episodes typically involve a “get it while you can mentality,” either trying everything at a big holiday meal or gorging yourself on “bad” food when you lose control of your diet. So, a change in mindset is essential!

No More Forbidden Foods
Another benefit of a personal and sustainable approach to weight loss is a change in perspective, eliminating the concept of forbidden food (except for medically necessary dietary restrictions). An unfortunate byproduct of a dieting mentality is that food becomes categorized as “good” or “bad.” Absence makes the heart grow fonder, and a diet slip-up quickly becomes a “get it while you can” mentality.

In contrast, if you permit yourself to eat the foods you love (incorporating the previously mentioned recommendations), “get it while you can” will become “I’ll save some for tomorrow.” The net result is a reduced caloric intake (considering the replacement of more food on subsequent days with your “forbidden” leftovers).

The Importance of Sleep
Another vital consideration when trying to lose weight is the importance of sleep. Inadequate sleep will directly influence your hunger-regulating hormones increasing cravings and appetite. Although sleep may be a premium with your busy schedule, make it a priority to attain 7–9 hours of sleep each night. Otherwise, the same physiology promoting weight regain will be problematic throughout your weight loss journey.

Be Mindful of Your Eating
The awareness of what you eat and why you eat it is a skill that takes practice. However, it may be the single most important recommendation from this article. Why? Because your eating cues provide a glimpse into the hypothalamus, the area of the brain regulating weight regain. Even stress and addiction pathways interface in this brain region, correlating with stress eating and more significant eating disorders.

Once you learn the cues of your body resisting weight loss, you will better grasp when to push a calorie deficit or when to back off.

But first, there are a few hunger signals correlating with the physiology of appetite control to be mindful of.

Satiation: This is the sense of being satisfied after a meal. Please note that this is not a sense of fullness (although it may be initially challenging to differentiate). Think of satiation as passing on a second helping of dessert because you feel satisfied but could eat more. Fullness is passing on a second helping because you would be uncomfortable if you ate more. So, as you adjust to smaller portion sizes, the sense of satiation may surprise you as it becomes distinguishable from fullness. It is your signal to stop eating.

Satiety: Satiety is different than satiation as it is the sense of satisfaction (absence of a drive to eat) between meals.

Hunger: This is a physiological drive to eat.

Cravings: This is a desire to eat specific foods.

Practice Mindful Eating
Being mindful of what you eat is having a curiosity about your motivations for eating, how the food affects your current state of being, and the after-effects of what you consume. Keeping it simple, you are a detective asking questions about all interactions with food.

Here are a few good questions, but I suspect you will intuitively know what to ask yourself in most scenarios.

Before eating:

Why am I eating or wanting to eat (hunger, cravings, stress, etc.)?
What is going on in life that may correlate with my desire to eat (stress, more exercise, missed meals, etc.)?
While eating:

Am I satiated (satisfied)?
Am I full?
After eating:

What was my cue for eating?
Did I over-eat? If so, was I even paying attention, or did I have a persistent urge to eat?
How can I improve things next time (better food choices, not eating in front of the t.v., meal splitting when dining out, etc.)?
Cues of the Hypothalamus
After becoming mindful of your eating habits, you can begin to identify the physiology of weight regain at work. Set point theory is the best explanation for this defense mechanism.

Your body keeps your weight steady and will resist increases or decreases from this set point (although it is more permissive of an increase in weight). So when you say you “normally weigh around [insert weight here], give or take a few pounds,” that is your set point.

Think about what happens to your appetite after an extended holiday with excessive overeating. Your desire to eat is down, and you probably don’t even want to think about food. And more than likely, you are ready, willing, and able to get back on track and address your weight concerns. This shift is your hypothalamus at work counterbalancing your weight gain to achieve homeostasis.

Now, let’s consider the effects of the hypothalamus during weight loss. Hunger and food cravings ensue, counterbalancing the bodyweight decline. And the harder you push, exerting willpower over a perceived loss of self-control, the stronger the resistance. In a conflict with your physiology, you lose every time. Practicing mindfulness while losing weight is crucial to avoid fighting an unwinnable battle.

So, be alert for waning satiation and satiety, or more definitively, an escalation of hunger and cravings as your weight drops. These are signals that your hypothalamus is no longer naive to your plans and is attempting to sabotage your hard-earned weight loss.

If you are circling the pantry like a shark, debating whether to hit the chocolate just begging you to eat it, the culprit is your hypothalamus!

Plateaus
One last area to comment on regarding your body’s set point is an inevitable weight loss plateau. Although exceedingly frustrating when you want to see continued progress, plateaus are an unavoidable pitstop on your weight loss journey.

The cues to hypothalamic resistance characterize these periods of weight stability, and you have two options. Either try to overcome the physiological resistance with sheer willpower (we know the likely outcome) or patiently persevere with your newly established habits, and wait for your body to adapt to a lower weight set point. My recommendation is the latter. 😁

With patience and time (think weeks to months), you will notice your weight holding steady despite eating more than it took to lose weight (but still less than your baseline eating habits). Your body has a new set point, and you have finally achieved sustainable weight loss! And before you know it, you will be ready, willing, and able to reach the next milestone on your weight loss journey as you move one step closer to your ideal goal.

Your Action Plan for Sustainable Weight Loss

Know your internal (or intrinsic) motivation.
Use the four Rules of Sustainability as your guide: Reversibility, Permanence, Perseverance, and the Rule of Thumb.
Meet yourself where you are in life. Are you ready, willing, and able?
Find ways to be active and move more every day.
Exercise for your health, eventually targeting 150+ minutes per week of aerobic exercise and muscle strengthening at least twice weekly.
Establish your baseline eating habits and incrementally modify your diet based on your personal needs and preferences.
Reduce your portion sizes.
Gradually adopt healthier food choices.
Eliminate the concept of forbidden food, avoiding excessive overeating.
Sleep 7–9 hours each night.
Always be mindful of what you eat and why you eat it, responding to hypothalamic cues of weight loss resistance.
And one last thing. Give yourself some grace! You will sometimes take detours and even get lost on your weight loss journey. Consider your “screw-ups” to be learning opportunities. Remember, you still come out ahead if getting off-track is better than your baseline. You’ve got this! 👍
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