Saturday, April 6, 2013


FANS is an acronym for Fitness, Attitude, Nutrition, and Self-Monitoring. It started out as my personal effort to emulate the STOP Regain study conducted by the National Weight Control Registry. From Maintenance of Long Term Weight Loss (2009), I knew the program was called STOP regain, and my imagination came up with what STOP could be an acronym for, that would cover the predictors of successful weight maintenance. It turnes out it stood for “Study TO Prevent Regain.” I wanted another catchy acronym and came up with FANS.

Maintenance FANS is a practical guide to the findings of the NWCR survey of 1 year maintainers and its STOP Regain study on teaching those behaviors to new maintainers. It is designed to be used either as a personal workbook or as a discussion guide for a support group. The 13 chapters cover the Getting Ready post and then three cycles through key predictors of sucessful maintenance represented by FANS:

Fitness The NWCR study found most successful maintainers exercised consistently and at fairly high levels. This not only burns calories, but keeps the metabolism conditioned.

Attitude Key predictors of success included fewer depressive symptoms and less disinhibited eating. There is significant overlap between mood disorders and obesity.

Nutrition Eating breakfast and practicing cognitive restraint in eating habits are an important difference between maintaining and regaining. The NWCR has found that people using many different nutritional strategies can be successful maintainers. The patterns that have emerged address ways to eat more than what to eat.

Self-Monitoring Weighing yourself seems like it would be a simple matter, but demotivation from weigh-ins is a major area of concern in many lifestyle change programs. Rather than discouraging frequent weighing, we strive to understand the significance of weight and other tracking data.

Disclaimer: I am not a doctor, you should see a doctor before undertaking an exercise or calorie restriction regimen, information is provided for educational purposes and does not constitute medical advice.

Maintenance of Long-term Weight Loss 2009 9-02/2009-02-53.pdf
The STOP Regain Study aspx?articleid=181605
Long-term Weight Loss Maintenance /1/222S.long

Table of contents

Maintenance FANS: Fitness, Attitude, Nutrition, Self-Monitoring
A practical guide to the findings of National Weight Control Registry findings on long-term weight maintainers
0 Getting ready: your success story and maintenance plan
F I gradual buildup of physical activity (If you're not already active)
A I depressive symptomology and support
N I breakfast and regular meals
S I frequent weigh ins (not what you've probably been told)
F II target fitness levels (1 hour a day or 200 min/wk)
A II disinhibited eating (negative emotional eating, eating to distract)
N II situations that encourage overeating (These vary but I have a few ideas)
S II cognitive restraint (How do you decide what to eat?)
F III lean bodymass and metabolism (when you lose weight, you lose calorie burning capacity)
A III Emotional self regulation (Handling setbacks, self care)
N III dietary consistency (weekends and holidays?)
S III data vs intelligence (applying the numbers)
Link to chart layout:

Getting ready: Your success story and plan

Getting Ready Your Story Your answers to these questions may be long or short. I’d encourage you to shoot for about a paragraph about each question. The purpose of the resulting document is to celebrate your success and to give you something to think about if you find yourself in relapse. A success story was part of the intervention kit used in the STOP Regain study. Why were you overweight? Some of us have been chronically overweight for as long as we can remember. Some experience a trauma or illness, or life event and find ourselves overweight. Many medications can cause excess weight as a symptom. Very often we start to carry excess weight as we age (technically, as our muscle mass decreases).

When did you decide to do something about it? For many of us there is an “ah ha” moment when we realized enough was enough, or we had a paradigm shift that we could make a change where previously we had not. The NWCR identified such moments as a predictor of success in long term weight management.

How did you lose the weight? What was your initial plan or strategy? Did it change as time went by? What would you tell someone just starting out? Is there maybe something you would have done differently?

What is different about your life now? Recognizing that weight loss does not in itself fix everything, what are some specific things you couldn’t do before that you can do now? What feelings and attitudes are different? Are there behaviors that are different?

Pictures! Find a picture of you before you lost weight. You may not have had one taken (I got very wiley about avoiding cameras when I was at my high weight). I wound up capturing images from video footage. Have a nice picture of yourself at goal.

Your Maintenance Plan

Think of the FANS acronym:

Fitness What is your balance of cardio and strength? Where will you work out? How will you fit it into your day?

Attitude Key predictors of success included fewer depressive symptoms. What is your support system like? What kinds of challenges to do think are likely, and how will you respond?

Nutrition What do you eat, when and how much? Do you have a plan from your weight loss, or a maintenance plan from some other source? Do you monitor or track quantities, or do you avoid particular types of food? Do you get enough water, and how?

Self­-Monitoring Do you have a system for tracking weight, food and fitness?

Fitness I Gradually build up fitness

Fitness I

One of the strongest predictors of maintenance success is physical activity. Weight lost through diet alone will generally decrease lean body mass, resulting in a lower total daily energy expenditure (TDEE or calories burned). People who reach goal weight without exercise will be unlikely to maintain because they do not have the lean bodymass to keep up their metabolism at a reasonable calorie level.

However, it is not wise to jump full throttle into an intense exercise regimen (besides the disclaimer that you should always see your doctor to get cleared for increased physical activity.) Too much activity too soon will raise your TDEE too fast, resulting in increased hunger and the likelihood of overeating. Over exercising can also cause transitory water weight gain. In the STOP Regain study new maintainers were instructed to build up their level of physical activity gradually.

Action step: evaluate your current level of physical activity and find ways to increase it gradually each week -- five additional minutes of moderate to intense activity or ten minutes of walking per day. Increase this each week unless you already do 35-60 minutes a week.

Attitude I Depression and Support

One of the less obvious predictors from the NWCR surveys is depressive symptoms. So depression awareness is something that would be important to discuss in a maintenance support group. I am not a doctor or therapist, but if you experience symptoms of depression please get in touch with local resources.

What is Depression? (from NIH)
"Everyone occasionally feels blue or sad. But these feelings are usually short-lived and pass within a couple of days. When you have depression, it interferes with daily life and causes pain for both you and those who care about you. Depression is a common but serious illness.

Many people with a depressive illness never seek treatment. But the majority, even those with the most severe depression, can get better with treatment. Medications, psychotherapies, and other methods can effectively treat people with depression."

Link to signs and symptoms

One of the key strategies that the STOP Regain study looked at was how different levels of support affected maintenance, including depressive symptomology and de motivation. The control group received a newsletter, and then there was an interactive website group and a face to face group. The newsletter group regained the most weigh on average and had the most participants regain. The Internet group regained nearly as much weight on average as the newsletter group, but the number of participants who regained was close to the face to face group (which met with a professional counselor). So Internet support had mixed results, at least in 2006.

Developments with Web 2.0 could hold more promise for maintenance support. There are communities of maintainers on sparkpeople, reddit, and Other resources (like this one) are being developed. The action step for this week is to investigate options for support in you maintenance.

Nutrition I Breakfast and meal pacing

Nutrition I Breakfast and Pacing

The importance of eating breakfast for maintenance comes from the NWCR survey reported in Maintenance and Long-Term Weight Loss. It is a common rule of thumb in other diet and lifestyle change programs. The Sparkpeople survey of 100+ pound losers found that this group ate a breakfast of at least 400 calories as a key nutrition behavior (along with 8 cups of water and 5 fruits or vegetables a day)(Downie, Chris The Spark pg 213). When I implemented this breakfast suggestion, I found a decrease in my mid afternoon cravings.

The NWCR members ate several small meals spaced throughout the day (4.87 meals on average) as a strategy to decrease overeating. Though care must be taken to avoid a total increase in calories consumed. In my experience, six meals a day was too many because I never really stopped thinking about food in between these mini meals.

One of the challenges to getting daily breakfast is time, especially if you work and have children to get to school. Prepared breakfast items are often very carb-heavy which may not provide sustained energy. Consider supplementing them with milk, an egg, or nuts, keeping appropriate portion sizes in mind. These protein and fat sources also pair well with fruit, though I always need some kind of complex carb with fruit.

If you are already a breakfast eater, what are some of your favorites, and what are their nutritional advantages? If you struggle to eat breakfast, look for ideas that you can implement. Start simple and work up gradually to the ideal of a balanced and substantial breakfast.

Self-Monitoring I: Frequent weighing

Self-Monitoring I

If you’ve been on a diet/lifestyle change in the last 20 years, chances are you’ve been advised to avoid weighing yourself too often. I’m not sure if this advice is something that will prove one of the things that separates weight loss from maintenance. The impetus for such advice seems to be concern that too frequent weighing might be demotivational.

However, studies over the last 10 years are finding that frequent weighing is correlated with successful weight loss and weight maintenance, and the particular issue of weighing in and mood was explored by researchers at the University of Minnesota:

"Results from this study suggest that, after adjusting for BMI, there is no significant association between depressed mood and self-monitoring of body weight in a community-based sample of adult women.” (Linde et al. 2007)

The National Weight Control Registry identified frequent self-weighing as a predictor of successful weight maintenance in its 1 year maintainers, and included it their STOP Regain program for new maintainers, or people who had recently reached a weight loss goal. They found:
“Since self-weighing is a key component of the self-regulation model, we compared the proportion of participants in each group who reported weighing themselves at least daily… In addition, in the face-to-face and Internet groups, a smaller proportion of participants who weighed themselves daily regained 2.3 kg or more, as compared with those who weighed themselves less.” (Wing et al. 2006)

But does weighing in cause successful maintenance or does it follow it? The discussion of the STOP Regain study looked into this, and there is more to self-monitoring that simply weighing oneself and writing it down, which is why this is but the first lesson on self-monitoring. Knowing what to do with the weight data is key (and you’re free to skip ahead to data vs. information if you wish.)

If you’re not persuaded yet and are interested in further discussion of what the numbers on the scale mean, you might check out my blog “Talking back to the scale” which provides some tools for applying critical thinking to weigh in data.

The key is whether a higher reading on the scale makes you throw up your hands, or if you use that as a reason to try harder at your healthy habits. Seeing the scale as a tool and not an end unto itself can turn it into a powerful ally.

“Results support the idea that daily weighing is valuable to individuals trying to lose weight or prevent weight gain. Daily self-weighing should be emphasized in clinical and public health messages about weight control." (Linde et al. 2005)

References: Linde et al. 2005, Self weighing in weight gain prevention and weight loss trials) Wing et al. 2006, A Self-Regulation Program for Maintenance of Weight Loss Linde et al. 2007, Relation of body mass index to depression and weighing frequency in overweight women

Fitness II Target levels (aerobic)

How much do you need to work out? It's an interesting question. The short answer from Thomas and Wing (2009) is 1 hour a day of walking, or 200 minutes a week. Looking a little deeper, the 1 hour of walking is based off a finding that in the National Weight Control Registry, the average woman burns 2545 calories a week through exercise and the average man burns 3293. (Wing & Phelan 2005).

It's true that over 3/4 of the NWCR maintainers walk as their primary form of exercise, but most use more than one form of exercise, and cycling and weights were used by over 20% of respondents. I think rather than set the perhaps daunting goal of dedicating an hour a day to walking, it's better to encourage people to consider a variety of exercises that meet the calorie goal, and multiple modes of exercise are in keeping with the survey findings.

Hopefully you are using a fitness tracker. They are available on Sparkpeople, fitbit, myfitnesspal, and a number of other websites generally on a free basis with ads. Motion sensing video game consoles and smartphone apps are other means to track fitness.

The 200 minutes figure comes from Jakicic (2003), and looking closer at that study I saw that the 200 minutes were only required to be in bouts of 10 minutes at a time. There is ongoing debate about this, with some people saying aerobic exercise needs to happen in 20 minute bouts, but the total amount of work being done was what most predictive of successful weight management in this study. 200 minutes, which was the maximum exercise "dose" prescribed in this study, was also associated with greater cardiovascular fitness. Would ever more fitness prove even better? For me, I think 45 minutes a day is the longest I'd be interested in working out, though participation in dance, sports, and leisure activities are certainly possibilities, but there's only so much time I can put into working out at this stage in my life.

Another key predictor the NWCR has identified in their maintainers is that they watch much less TV than the average American, and Thomas and Wing (2009) theorize that this gives them more time for exercise, monitoring food intake and other weight related strategies. The average amount of TV watched by an NWCR maintainer was 6 to 10 hours vs. the national average of 28 hours. I'm already in the lower range, though I also will march in place while watching TV, especially during commercial breaks. It does not burn as many calories as actual walking (according to my tracking device), but it beats sitting down.

Finally, it is important to remember that the vast majority of calories we burn are not from working out, but from our metabolism. For myself (at 160 and 67.5 inches) I might burn 450 calories in a day exercising, but I burn over 1700 calories in the same day just keeping my temperature at 98.6 and breathing, eating, and my various less intense activities. The thing is, if I weren't exercising, this larger proportion of calorie burn would start to diminish. There is a post exercise boost to the metabolism that can extend for many hours after exercise.(Knab et al. 2011) Exercise is also necessary to preserve and build lean body mass, which is the topic for the third Fitness installment.

Action Step: Find out how many calories you burn (based on your weight) walking briskly for one hour. This can be done on one of the nutrition trackers mentioned above. If you are interested in other forms of exercise, you can also look into how much time it would take to burn that number of calories in the other exercise. Weight training is a different story, which will be covered in the next installment.

Thomas and Wing, 2009. Maintenance of Long-Term Weight Loss
Wing and Phelan, 2005. Long-Term Weight Loss Maintenance Jakicic et al. 2003. Effect of exercise duration and intensity on weight loss in overweight, sedentary women: a randomized trial. Knab et al. 2011. A 45-Minute Vigorous Exercise Bout Increases Metabolic Rate for 14 Hours

Attitude II Disinhibited Eating

Thus far we have focused on the attributes of successful maintainers, but it is also important to look at factors of people who have not succeeded at managing their weight. One of the behaviors to look out for is known as Disinhibited Eating, or difficulty controlling overeating (Thomas and Wing, 2009) or "A measure of periodic loss of control over eating." (Wing and Phelan 2005)

These findings came from a tool called the Three Factor Eating Questionnaire. Looking into the Questionnaire and how it can measure someone's disinhibited eating, I came across a couple of interesting studies. Keskitalo et al. 2008 was a twin study that found that uncontrolled eating and emotional eating were distinct behaviors, though it is not uncommon in my experience for them to be comorbid. They found that while BMI was not itself genetic between identical twins, it was correlated with the eating behaviors which showed a strong genetic link. Perhaps more interesting, they found that uncontrolled eating was associated with a liking of salty, fatty foods and emotional eating was associated with a liking of sweet, fatty foods.

De Lauzon et al. 2004 explored a modified eating questionnaire, and I was finally able to get a glimpse of what was on the questionnaire. I can certainly understand the concern of the public getting too familiar with these tools, so I'll just post a link to the abstract. My impression of the difference between uncontrolled eating and emotional eating was that emotional eating involved eating to sooth agitated moods. Uncontrolled eating involved the inability to stop eating and desire to eat (called hunger in the questionnaire) despite being full, just having eaten, or for no reason besides the allure of a food or situation. This study concluded that in clinical practice so much focus goes into what people eat, when the eating behaviors are what really could use modification.

Looking at uncontrolled eating, I think one issue it describes is confounding hunger, appetite, craving and a third type I'll call externally motivated eating. This includes eating because other people are eating and eating because an item is scarce or coveted. The other large issue is the inability to stop eating.

Unfortunately, animal studies indicate that fatty diets defeat the insulin moderated hunger controls in the brain. (cite) Many diets these days focus on the elimination of carbs because they stimulate insulin release, but there are other diets that lead to insulin resistance including high fat and high calorie. Thomas and Wing (2009) notes that diets of maintainers contain more fat now than they used to, which they speculate is due to low carb diets.

Getting back to emotional eating, a possible strategy for this would be finding alternate ways to sooth negative moods besides eating. We will look further at emotional regulation in the next Attitude segment.

Action steps: If you are an overeater, do you think you are more of an uncontrolled eater or an emotional eater, or both? Do you recognize the difference between physical hunger, appetite, craving, externally motivated hunger, and eating for comfort?

De Lauzon et al. 2004, The Three-Factor Eating Questionnaire R-18 is Able to Distinguish among Different Eating Patterns in a General Population (Abstract)

Keskitalo et al. 2008, The Three-Factor Eating Questionnaire, body mass index, and responses to sweet and salty fatty foods: a twin study of genetic and environmental associations

Nutrition II Avoiding trigger situations

Avoiding situations that encourage overeating
Eating out:
Buffets, family style, pizza
Fast food (value combos, upsizing)
Eating out in general is decreased among NWCR maintainers
At home:
Tasting during food prep
Trigger foods
Eating directly out of the package
Conditions that stimulate overeating are individual. Choose a few from this list, or come up with some we may have overlooked.

Self Monitoring II: Cognitive Restraint

In the segment on Disinhibition, we learned about a Three Factor Eating Questionnaire. Two of the factors were Uncontrolled Eating and Emotional Eating, while the third is Cognitive Restraint. Successful NWCR maintainers scored high on measures of Cognitive restraint. This means that before they ate something, they evaluated it using one or more parameters, such as portion size, types of food and eating less than they might be inclined to with the object of weight management in mind. In this area, it is important to note that the average maintainer response was elevated, but not extreme. "Registry members scored high on this measure (mean of 7.1), with levels similar to those seen in patients who have recently completed a treatment program for obesity, although not as high as eating-disordered patients. These findings suggest that successful weight loss maintainers continue to act like recently successful weight losers for many years after their weight loss." (Wing and Phelan, 2005) Of course it's difficult to quantify how much concern over food is too much. Since reaching goal, it's likely you've run into situations where someone might have remarked you're too worried about food. If you have such a concern, has an anonymous and simple online screening tool. Thomas and Wing (2009) reported that NWCR maintainers eat an average of 1385 cal/day with the observation that over half of those surveyed were still trying to lose weight. Wing and Phelan (2005) elaborates that the tool used for this estimate is often 20-30% low: "Thus, registry members are probably eating closer to 1800 kcal/d. However, even with this adjustment, it is apparent that registry members maintain their weight loss by continuing to eat a low-calorie, low-fat diet."

Fitness III: Lean mass and metabolism

"Myths, Presumptions and Facts about Obesity" appeared a January 2013 issue of the New England Journal of medicine. Among the presumptions, which means ideas that are widely circulated but have not been confirmed or denied by academic research, is that "weigth cycling is associated with increased mortality". Weight cycling, aka yo yo dieting, refers to repeated weight loss and regain. When we lose weight, we are trying to lose fat but as I learned in analyzing my own numbers, we also lose quite a bit of lean mass. If my own figures are accurate(based on caliper measurement of bodyfat %) 20-30% of my weight loss was lean mass while I was exercising daily. I shudder to think what happened when I was just dieting. It's probable that of 46 pounds I lost in 2012, as much as 15 were lean mass. Let's hope some of that was skin. There are a couple of ways the amount of calories you burn in a day can be calculated. The Harris Benedict equation takes your height and age into account along with your age. It assumes your metabolism and lean mass decrease as you age. Whereas the Katch McArdle equation goes simply off lean body mass (which is 100% minus bodyfat%) What all this means is that part of the reason exercise is so important to weight maintenance is because you have probably lost a lot of your lean mass as you attained your goal weight. Getting back to the presumption about yo yo dieting, there is a sense that weight loss somehow damages the metabolism. This was addressed in an NWCR study that found the decreased caloric needs of maintainers were consistent with known the known factors of calorie equations such as age and lean mass. (Wyatt et al. 1999) While only 20% of NWCR maintainers lifted weights, it was the third most prevalent exercise used (Thomas and Wing 2009). My experience was that when I began eating a maintenance diet, my strength training became much more effective, whereas while I was losing weight progress in my strength program was miniscule. So the action step for this segment is to think about the role of building lean mass in your fitness program. Do you do strength training either weights or other kinds of resistance training? Have you tried increasing intensity since reaching goal, and what have you found? Resources: Wyatt et al. 1999, Reduced Energy Expenditure in reduced-obese subjects in the National Weight Control Registry A blog post by a bariatric doctor that discusses the points of Myths, presumptions and facts about obesity (the full article is not available to the public).

Attitude III Emotional Regulation

post under construction You may have heard the addage "happiness is a choice" and if you've had a mood disorder or known someone in the grip of one, it becomes clear that in many situations choosing happiness is easier said than done. "these findings suggest that negative affect and tendencies to uncontrolled eating may be associated with problems in the long term maintenance of weight loss. Behavioral weight control programs teach participants to identify and try to change negative thoughts and to plan ahead to prevent lapses from becoming relapses. Those individuals who practice these skills may be better able to deal effectively with periods of overeating or slips from the program" (Wing et al. 2008) Wing et al. 2008 Maintaining large weight losses McGuire et al. 1999 What predicts weight regain in a group of successful weight losers

Nutrition III Dietary Consistency

Post under construction Weekends and holidays Dietary consistency In addition to how a person eats day to day, the consistency of eating habits throughout the week and across special occasions is also predictive of success. Wing and Phelan (2005) outlines that 59% of the Registry participants ate the same on weekends as during the week. 45% ate the same on vacations and holidays as during the rest of the year. Maintainers who practice these behaviors were 1.5 times more likely to maintain their weight beyond the second year (by the +/- 5 lbs. definition).

Self monitoring III Data vs. information

Post under construction You can try and do everything it says, low calorie, low fat, daily weighing, x numbers of exercise but the essence of all these things is understanding that successful maintenance is a series of choices.