Perspectives into the experience of successful, substantial long-term weight-loss maintenance: a systematic review

Figures & data

Figure 1. PRISMA flow diagram of studies identified

Table I. Study quality assessments

Author (Year) Country	Validity Questions						Overall Quality Rating
	1	2	3	4	5	6
Barnes et al. (2007) USA	Y	Y	Y	Y	Y	Y	Positive
Carrard and Kruseman (2016) Switzerland	Y	Y	Y	Y	Y	Y	Positive
Cleo et al. (2018) Australia	Y	N	Y	Y	Y	N	Neutral
Epiphaniou and Ogden (2010) UK	Y	Y	Y	Y	Y	N	Positive
Ingels and Zizzi (2018) USA	Y	N	Y	Y	Y	N	Neutral
Karfopoulou et al. (2013) Greece	Y	Y	Y	Y	Y	Y	Positive
Kruseman et al. (2017) Switzerland	Y	Y	Y	Y	Y	Y	Positive
Kwasnicka et al. (2019) Australia	Y	Y	Y	Y	Y	Y	Positive
McKee et al. (2013) UK	Y	Y	Y	Y	Y	Y	Positive
Metzgar et al. (2015) USA	Y	Y	Y	Y	Y	Y	Positive
Natvik et al. (2019) Norway	Y	Y	Y	Y	Y	Y	Positive
Natvik et al. (2018) Norway	Y	Y	Y	Y	Y	Y	Positive
Pedersen et al. (2018) Denmark	Y	Y	Y	Y	Y	Y	Positive
Reilly et al. (2015) Ireland	Y	Y	Y	Y	Y	Y	Positive
Sarlio-Lähteenkorva (2000) Finland	Y	Y	Y	Y	Y	Y	Positive
Y = Criteria met, N = Criteria not met
Validity Questions	Rating Method
1) Clear research question 2) Unbiased participant selection 3) Study procedure described 4) Clearly defined outcomes 5) Results support conclusions 6) Bias unlikely	Positive = Criteria 2,3,4, and 5 met Neutral = Criteria 2,3,4, or 5 not met Negative = Majority of criteria not met

Y = Criteria met, N = Criteria not met

Figure 2. Determinants of sustainable weight loss—a framework

Table II. Hierarchy of prevalence

Frequency Mentioned/Prevalence	Theme	Category
Consistently Mentioned	Structured Plans Regular weighing Calorie/portion tracking Meal Planning Pre-planning for events Clear relapse protocols Visual reminders	Self-Monitoring
	Weight support groups Peer feedback HCP feedback	External Monitoring
	Better self-image Stronger self-confidence Improving health Better social opportunities (relationships, work)	Intrinsic Motivators
	Clear activity goals Mapped out eating goals Continuously reassessed goals Highly personalized goals Prioritization of goals	Self-Defined, Personalized Goals
	Unforeseen life events (death, divorce) Emotional eating	Intrinsic Challenges
	Holidays Celebrations Work/personal stress Unsupportive peers	Extrinsic Challenges
	New Community New Identity Reinvention	Encouraging Experiences
	Fear of Regain Criticism	Discouraging Experiences
Often Mentioned	Home cooking	Self-Monitoring
	Online support	External Monitoring
	Social standing/acceptance Decreased stigmatization	Extrinsic Motivators
	On-going adjustment of goals	Self-Defined, Personalized Goals
	HCP defined goals Weight loss club goals	Externally Defined Goals
	Stress Lack of time Cultural norms Pregnancy, Illness, Injury Trigger foods Overreliance on support system	Intrinsic Challenges
	Obesogenic Food Environment	Extrinsic Challenges
	Opportunities Compliments	Encouraging Experiences
	Frustration	Discouraging Experiences
Sometimes Mentioned	Being a role model Sense of belonging Career opportunities	Extrinsic Motivators
	Sports events	Externally Defined Goals
	Lack of structure Social isolation	Intrinsic Challenges
	Relationship changes	Extrinsic Challenges
	Feeling liberated Sense of purpose	Encouraging Experiences
	Isolation Exclusion Loneliness Feeling deprived	Discouraging Experiences

Table III. Summary of data extracted from studies

Author (Year); Country	Title	Aim	Sample Size	Approach	Weight Loss Maintenance Criteria
Barnes et al. (2007) USA	Weight Loss Maintenance in African–American Women: Focus Group Results and Questionnaire Development	To understand the experience of weight loss maintenance in African-American women	37	Qualitative study consisting of 7 focus groups, 4 with successful WLMs, 3 with regainers.	Two groups: 1) Maintainers = Intentional weight loss ≥10% of BW sustained ≥1 year. 2) Regainers = Intentional weight loss ≥10% of BW but regained the lost weight.
Carrard and Kruseman (2016) Switzerland	Qualitative Analysis of the Role of Self-Weighing as a Strategy of Weight Control for Weight-Loss Maintainers in Comparison with a Normal, Stable Weight Group	To understand the role of self-weighing for weight control utilized by WLMs compared to weight stable group.	18	Qualitative study consisting of individual, face-to-face, semi-structured interviews with all participants.	Two groups: 1) Intentional weight loss of at ≥10% sustained ≥1 year 2) Healthy BMI range during adulthood stable within a 5 kg range
Cleo et al. (2018) Australia	Participant Experiences of Two Successful Habit-Based Weight-Loss Interventions in Australia: A Qualitative Study	To understand the experiences and perspectives of participants from a series of 2-year, habit-based weight-management programme.	15	Qualitative study consisting of individual, face-to-face, semi-structured interviews with all participants.	Weight change ranging from −10.4% BW to +4.0% BW over 1 year.
Epiphaniou and Ogden (2010) UK	Successful Weight Loss Maintenance and a Shift in Identity from Restriction to a New Liberated Self	To understand the experiences of weight loss for successful WLMs with a focus on self- perception from their heaviest to their current weight.	10	Qualitative study consisting of individual, face-to-face and phone semi-structured interviews with all participants.	Intentional weight loss ≥10% of BW sustained ≥1 year.
Ingels and Zizzi (2018) USA	A Qualitative Analysis of the Role of Emotions in Different Patterns of Long-Term Weight Loss	To understand and analyse the emotions entailed in different patterns of long-term weight loss	21	Qualitative study consisting of semi-structured interviews with weight management programme participants.	Three groups over 18 months: 1) large loss = intentional weight loss of ≥7% of BW 2) moderate loss = intentional weight loss of ≥3–6% of BW 3) regainer = no loss or weight gain
Karfopoulou et al. (2013) Greece	Behaviours Associated With Weight Loss Maintenance and Regaining in a Mediterranean Population Sample. A Qualitative Study	To understand lifestyle behaviours associated with weight loss and WLM in participants who had lost ≥10% of BW and either kept if off for ≥1 year or regained it.	44	Qualitative study consisting of 8 focus groups, 4 with WLMs and 4 with regainers, focusing on the experience and beliefs around weight loss and WLM.	Intentional weight loss ≥ 10% of BW sustained ≥1 year.
Kruseman et al. (2017) Switzerland	Long-Term Weight Maintenance Strategies Are Experienced as a Burden by Persons Who Have Lost Weight Compared to Persons with a lifetime Normal, Stable Weight	To understand strategies and perceptions of the experience of WLMs in participants who have lost ≥10% of BW and kept if off for ≥1 year compared with matched, lifelong normal weight controls.	32	Mixed methods, cross-sectional study consisting of surveys and semi-structured interviews. Interviews investigated strategies and experiences of WLM.	Intentional weight loss ≥10% of BW sustained ≥1 year.
Kwasnicka et al. (2019) Australia	‘It’s not a diet, it’s a lifestyle’: A Longitudinal, Data-Prompted Interview Study of Weight Loss Maintenance	To understand the factors underpinning WLM (individual and environmental).	12	Qualitative study consisting of semi-structured, data-prompted interviews with 12 participants that had lost ≥5% of body weight (BW) in the year prior.	Intentional weight loss of ≥5% of BW sustained ≥1 year.
McKee et al. (2013) UK	Weight Maintenance: Self-Regulatory Factors Underpinning Success and Failure	To understand the contributing factors involved in weight maintenance both success and failure	18	Qualitative study consisting of semi-structured interviews with successful and unsuccessful WLMs.	Two groups: 1) Maintainers = Intentional weight loss ≥10% of BW sustained ≥1 year 2) Regainers = Previously achieved intentional weight loss ≥10% of BW yet unable to maintain the new weight for a 1 year.
Metzgar et al. (2015) USA	Facilitators and Barriers to Weight Loss and Weight Loss Maintenance: A Qualitative Exploration	To understand facilitators and barriers to weight loss and WLM in individuals who participated in primary care weight loss study.	23	Qualitative study consisting of 7 focus groups using open-ended questions and probes with WLMs and regainers.	Intentional weight lost ≥13.6 kg sustained for ≥1 year.
Natvik et al. (2019) Norway	An Experientially Derived Model of Flexible and Intentional Actions for Weight Loss Maintenance After Severe Obesity	To understand the experiences of weight loss and WLM for ≥5 years following severe obesity.	10	Qualitative study consisting of individual, open, in-depth interviews focused on the experience of weight loss and WLM after severe obesity.	Intentional weight loss of ≥10% of BW sustained ≥5 years.
Natvik et al. (2018) Norway	Living a Successful Weight Loss After Severe Obesity	To understand the experiences of successful weight loss after severe obesity.	10	Qualitative study consisting of individual, in-depth, face to-face interviews with WLMs who have maintained a 10% weight loss for ≥5 years.	Intentional weight lost over 10% of BW sustained ≥5 years.
Pedersen et al. (2018) Denmark	The Complexity of Self-Regulating Food Intake in Weight Loss Maintenance. A Qualitative Study Among Short- and Long-Term Weight Loss Maintainers	To understand self-regulatory strategies and self-efficacy beliefs utilized by short- and long-term WLMs.	18	Qualitative study consisting of individual, semi-structured interviews with 9 short and 9 long-term WLMs focusing on self-regulatory strategies and self-efficacy beliefs.	Two groups with intentional weight loss ≥10% of BW with no more than 2 kg regain and a stable weight for at ≥2 months. 1) Short-term maintainers (2–12 months) 2) Long-term maintainers (≥12 months)
Reilly et al. (2015) Ireland	Lessons Learned about Primary Weight Maintenance and Secondary Weight Maintenance: Results From a Qualitative Study	To understand attitudes, behaviours, motivations and strategies of WLMs, lifelong weight maintainers and weight regainers.	17	Qualitative study consisting of 7 focus groups and 3 individual interviews with primary and secondary weight maintainers and weight regainers.	Three groups: 1) Participants who maintained their weight within a healthy BMI range over their lifetime 2) Participants who achieved intentional weight loss ≥6.35 kg sustained ≥1 year. 3) Participants who tried repeatedly but had not lost weight in the past year
Sarlio-Lähteenkorva (2000) Finland	‘The battle is not over after weight loss’: Stories of Successful Weight Loss Maintenance	To understand the experience of weight loss maintenance among the ‘reduced-obese’.	9	Qualitative study consisting of open interviews with nine women who lost 10–27 kg of weight and kept it off for ≥7 years.	Intentional weight loss of ≥10 kg sustained ≥7 years.

Table AI. Evidence underpinning key concepts

Synthesis concept	Themes and sub-themes	Supporting study data	Supporting studies
Continuous Monitoring	Self-Monitoring: Calorie/portion tracking Meal Planning Home cooking Structured Plans Regular weighing Visual reminders Pre-planning for events Clear relapse protocols	Self-Monitoring tools utilized by WLMs: Calorie tracking, meal planning, meal prepping for work, decreasing portion sizes, weighing food, increasing vegetables and fruits, reducing alcohol intake, not ordering take out, home cooking, drinking more water/coffee/tea/diet drinks, avoiding junk food, activity monitors, tracking apps, regular weighing, structured programmes, eating low carb/low fat/high protein, skipping meals, compensation, coping strategies for high risk situations, food diaries, reading labels, reformulating recipes, purchasing low-calorie foods, compensation with exercise, goal adjustment, before-and-after pictures, planned cheat meals, distractions from eating e.g., more time outside, healthier menu options, healthy snacks, visual meal plans in kitchen, relapse protocols, infrequent, planned food shopping to limit exposure, replacing large plates, mindful eating, meal replacements, clothes fit as cue, establish routines, remove temptations, savouring treats, creation of emotional regulation strategies, continuous reading, recommending healthier restaurants for social events, pre-assessing menus for outings, swapping starches for vegetables	Kwasnicka et al. (2019), Sarlio-Lähteenkorva (2000), Sarlio-Lähteenkorva (2000), Natvik et al. (2019), Karfopoulou et al. (2013), Pedersen et al. (2018), Metzgar et al. (2015), Reilly et al. (2015), Kruseman et al. (2017), Cleo et al. (2018), Carrard and Kruseman (2016), Epiphaniou and Ogden (2010),, Barnes et al. (2007), McKee et al. (2013), Natvik et al. (2018), Ingels and Zizzi (2018), Natvik et al. (2018)
	External Monitoring: Weight support groups HCP feedback Online support Peer feedback	External monitoring utilized by WLMs: Weight maintenance groups, weight loss clubs (e.g., Weight Watchers), nutrition education about portion control, healthy eating, recipes and energy balance, mandatory reporting to HCPs, external weigh-ins, compliance assessments, external adjustment of goals, tailored, continuous feedback, healthy living support groups, support from colleagues and managers at work, support from local physician, online, on-going support from HCPs, support from friends and family members, regular educational group meetings, structured support, external encouragement, psychological support, researcher support, programme/study feeling of accountability	Sarlio-Lähteenkorva (2000), Karfopoulou et al. (2013), Metzgar et al. (2015), Cleo et al. (2018), Natvik et al. (2019), Metzgar et al. (2015), Reilly et al. (2015), Cleo et al. (2018), McKee et al. (2013), Natvik et al. (2018)
Motivation	Intrinsic motivators: Improving health Better self-image Stronger self-confidence Reinvention Better social opportunities (relationships, work)	Intrinsic motivators of WLMs: health, fitness, self-image, self-confidence, clothing size/slimness/vanity, new identity, liberation, relationship opportunities, quality of life, being in control, self-empowerment, normalcy, energy, sense of purpose, self-responsibility, mental health, increased self-efficacy, new skills, reinvention, new life, compliments	Kwasnicka et al. (2019), Sarlio-Lähteenkorva (2000), Natvik et al. (2019), Karfopoulou et al. (2013), Pedersen et al. (2018), Reilly et al. (2015), Kruseman et al. (2017), Carrard and Kruseman (2016), Epiphaniou and Ogden (2010), McKee et al. (2013), Natvik et al. (2018), Metzgar et al. (2015)
	Extrinsic motivators: Social standing/acceptance Decreased stigmatization Sense of belonging Career opportunities Being a role model	Extrinsic motivators of WLMs: social acceptance, social standing, career opportunities, decreased stigmatization, being a role model, impressing WL group peers, new identity, social respect, solidarity and sense of belonging from weight loss group, changing careers to help others lose weight	Sarlio-Lähteenkorva (2000) Karfopoulou et al. (2013), Carrard and Kruseman (2016), Epiphaniou and Ogden (2010), Barnes et al. (2007), Barnes et al. (2007), Natvik et al. (2018)
Goal Setting	Self- defined, personalized goals: Clear activity goals Mapped out eating goals Highly personalized goals Continuously reassessed goals Prioritization of goals Ongoing adjustment of goals	Self-defined goal setting by WLMs: Activity goals (e.g., gym visits, walking, cycling), eating goals (e.g., calories per day/week, macronutrients, portions), reduced alcohol intake, reduced snacking, increased vegetable and fruit intake, reflecting and continuously reassessing goals, refining and renewing goals, setting realistic goals, having realistic expectations, personalized goals, no “one-size-fits-all”, tailored approach, setting non-temporary goals, weight loss goals, lifestyle change goals, mutually facilitative goals (e.g., exercise leading to weight loss), prioritizing goals adequately	Kwasnicka et al. (2019), Natvik et al. (2019), Reilly et al. (2015), Kruseman et al. (2017), McKee et al. (2013), Natvik et al. (2018)
	Externally defined goals: Sports events HCP defined goals Weight loss club goals	Externally defined goal setting for WLMs: Cycling races, marathons, triathlons, HCP defined goals, HCPs continuously adjusting goals, on-going evaluation and assessment of goals, provision of external, neutral perspective on progress, utilization of pre-defined goal framework, programme defined goals (e.g., Weight Watchers goals)	Natvik et al. (2019), Reilly et al. (2015), McKee et al. (2013)
Enduring Challenges	Intrinsic challenges: Stress Lack of time Emotional eating Pregnancy/Illness/Injury Social isolation Overreliance on support system Lack of structure Unforeseen life events (death, divorce) Trigger foods	Intrinsic challenges faced by WLMs: stress, boredom, tiredness, lack of time, unhealthy food choices, sedentary behaviours, feelings of isolation, fear or regain, exhaustion, feeling disconnected from ‘former‘ self, lack of self-belief, inability to manage emotions, using foods to manage emotions, lack of awareness of emotional impact on WLM, weight cycling, appetite changes, psychological changes, feeling of deprivation, eating for pleasure, frustration over weight loss, urges, unforeseen circumstances, low impulse control with certain foods, lack of cooking skills, distorted sense of hunger, lack of accountability, feeling guilty for “taking time for themselves”, lack of willpower, lack of exercise, feeling guilty, retuning to “real” life, lack of focus, illness, injury, lifelong battle/effort, binge eating bouts, secret eating, pregnancy related weight gain, feeling out of control, frustration, lack of structure, low self-esteem, not prioritizing exercise, hairstyle concerns related to physical activity, injuries, feelings of disgust (e.g., in photographs), feeling powerless, loneliness, perceived unfairness, feeling restricted, social isolation, comfort eating, dichotomous thinking (all or nothing), disinhibited eating, loss of restraint, unforeseen life events, exercise increasing appetite, balancing responsibilities, overreliance on support system (e.g., HCPs, slimming clubs), exhaustion, constant fear of relapse	Kwasnicka et al. (2019), Sarlio-Lähteenkorva (2000), Ingels and Zizzi (2018), Karfopoulou et al. (2013), Pedersen et al. (2018), Pedersen et al. (2018), Metzgar et al. (2015), Reilly et al. (2015), Kruseman et al. (2017), Epiphaniou and Ogden (2010),, Barnes et al. (2007), McKee et al. (2013), Natvik et al. (2018)
	Extrinsic challenges: Work/personal stress Holidays Celebrations Relationship changes Obesogenic food environment Unsupportive peers Cultural norms	Extrinsic challenges faced by WLMs: Stress at work (e.g., tough meetings), house-renovations, traffic jams, unhealthy food option availability, being outside of the normal environment e.g., travelling, visiting family, holidays, cultural pressure to eat, social occasions e.g., celebrations, not eating seen as having bad manners, accusations of narrow mindedness, becoming disconnected, switching jobs, becoming a parent, relationship changes, reliance on others for emotional regulation, seasonal changes, temptations (sweets/desserts, calorie dense foods) in home, going out with friends, external cues to eat, food shopping, cooking for the household, not in charge of food preparation in the household, continuously declining foods at parties, family members criticizing results, conflict with household because of new food preferences, 24/7 food availability, snide remarks regarding food choices at restaurants, social gatherings and family meal times, work gatherings, unintentional sabotage, lack of family time, open discrimination, balancing responsibilities, cultural norms, finding communities with same lifestyle/new values	Kwasnicka et al. (2019), Sarlio-Lähteenkorva (2000), Ingels and Zizzi (2018), Karfopoulou et al. (2013), Pedersen et al. (2018), Metzgar et al. (2015), Reilly et al. (2015), Epiphaniou and Ogden (2010), Barnes et al. (2007), Natvik et al. (2018)
Overall Experience	Encouraging experiences: Feeling liberated Sense of Purpose New Identity Reinvention Compliments New Community Opportunities	Encouraging experiences with WLMs: new identity, liberation, relationship opportunities, self-empowerment, sense of purpose, self-responsibility, increased self-efficacy, new skills, reinvention, new life, compliments, social acceptance, social standing, career opportunities, decreased stigmatization, being a role model, impressing WL group peers, new identity, social respect, solidarity and sense of belonging from weight loss group, changing careers to help others lose weight	Epiphaniou and Ogden (2010), Natvik et al. (2019), McKee et al. (2013), Natvik et al. (2018), Kwasnicka et al. (2019), Sarlio-Lähteenkorva (2000)
	Discouraging experiences: Fear of Regain Loneliness Criticism Frustration Exclusion Isolation Feeling deprived	Discouraging experiences with WLMs: boredom, feelings of isolation, fear or regain, exhaustion, feeling disconnected from ‘former‘ self, lack of self-belief, inability to manage emotions, weight cycling, psychological changes, feeling of deprivation, frustration over weight loss, urges, unforeseen circumstances, lack of accountability, feeling guilty for “taking time for themselves”, lifelong battle/effort, feeling out of control, feeling guilty, frustration, low self-esteem, feelings of disgust (e.g., in photographs), feeling powerless, loneliness, perceived unfairness, feeling restricted, social isolation, overreliance on support system (e.g., HCPs, slimming clubs), exhaustion, constant fear of relapse, cultural pressure to eat, not eating seen as having bad manners, accusations of narrow mindedness, becoming disconnected, reliance on others for emotional regulation, family members criticizing results, conflict with household because of new food preferences, snide remarks regarding food choices at restaurants, social gatherings and family meal times, open discrimination	Sarlio-Lähteenkorva (2000), Natvik et al. (2019), Reilly et al. (2015), Kruseman et al. (2017), Kwasnicka et al. (2019), Metzgar et al. (2015), Pedersen et al. (2018), Karfopoulou et al. (2013), Natvik et al. (2018)

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