Many people with diabetes have difficulty maintaining their weight after weight loss, and weight regain is common. Jamy Ard, MD, professor of epidemiology and prevention at Wake Forest University School of Medicine and co-director of the Weight Management Center at Wake Forest Baptist Health, discusses what diabetes health care professionals can do to support their patients in managing their weight after weight loss.

Q: What does the process of managing weight look like for most people after weight loss?

A: Obesity is a chronic disease that requires ongoing management. People need continued support to deal with the constant obesity-promoting environment and changes in their day-to-day lives, such as getting older, changing activity patterns, managing illnesses, or dealing with other events. All of these can ultimately have an impact on their state of energy balance. Managing weight after achieving a new weight plateau means that you must take those things into account.

For a lot of people, the cornerstone of managing weight is monitoring their weight and understanding how their body is responding to challenges.

Q: What are some of the challenges people with prediabetes or type 2 diabetes face when trying to maintain their weight after weight loss?

A: For people with prediabetes or type 2 diabetes, the same overarching principles still apply. However, for people with type 2 diabetes, health care professionals must also consider managing blood glucose levels and any medications that help manage blood glucose. For example, sulfonylureas may increase someone’s risk of hypoglycemia, especially after weight loss. Because of this risk, health care professionals may have to discuss with their patients the safest way to significantly decrease or stop these types of medications altogether during active weight loss or after they’ve lost weight. Also, some medications used to treat diabetes—such as sulfonylureas and insulin—may also promote weight gain.

Q: How can diabetes health care professionals encourage their patients who may feel discouraged because of regained weight? How do you encourage your patients?

A: I think one of the key things for patients to understand is that weight regain is not an individual failing. A lot of people think, “Well, I was doing something that helped me lose weight, and I just needed to keep doing that for maintaining weight loss. I couldn’t do that, so that’s why I regained weight.”

Diabetes health care professionals can explain to their patients that the brain doesn’t realize that the weight loss was on purpose. The brain thinks something bad is happening to cause the weight loss, and the brain signals the body to not only avoid losing more weight but to also try to get back to the weight they were before. That’s why regaining weight is so common.

One example I often use is if someone loses their appetite because they have COVID-19 or some other short-term illness, they may lose weight without trying. The weight loss just happens because of the illness. After they recover and get back to doing what they normally do, their weight returns to what it was before they got sick. In this case, neither losing nor gaining weight was intentional; their body did it naturally.

Q: What strategies can diabetes health care professionals use to help their patients with prediabetes or type 2 diabetes maintain their weight or navigate a weight plateau after weight loss?

A: The strategies are generally like the strategies used for those without prediabetes or type 2 diabetes. It’s often a combination of strategies. Diabetes health care professionals should focus on helping their patients start or increase physical activity, include strength training as part of their physical activity routine, and consume a healthy dietary pattern. Explain that what they eat and drink can have a direct impact on managing blood glucose and insulin sensitivity.

Some people can maintain their weight with lifestyle alone, but the data suggest that only one out of five people can do so. Several factors play a role in someone’s ability to lose weight and maintain weight loss, such as the type of obesity they had, their social circumstances, their genetics, and so on. Many people will likely need some form of treatment—such as medication, surgery, or a combination of the two—to help them maintain weight loss long term.

Another strategy is to try and minimize the use of medications that may promote weight gain in people with type 2 diabetes. This is key in the maintenance phase because we don’t want to make it harder on someone by having them try to counteract a medication that promotes weight gain, like sulfonylureas or insulin. We want to use as little insulin as possible to manage blood glucose as well as body weight. That’s where alternative medications can be especially helpful. Choose medications that are either weight neutral or weight loss promoting and have a direct impact on energy balance.

Q: What can diabetes health care professionals do to help prepare their patients with type 2 diabetes and overweight or obesity who may be considering losing weight?

A: For most people, this won’t be their first time trying to lose weight. Diabetes health care professionals should talk with patients about their prior experiences. Use those experiences to help patients understand what happens in their body and the idea that managing weight is a long-term process.

I tell patients all the time that losing weight is the easy part; maintaining it is the hard part. People tend to think short-term when it comes to treating obesity. They may think, “I’m going to lose weight, and then I’m done. I’ve achieved my goal.” Help patients understand that achieving weight loss is not the end of the journey. Weight loss is one phase of treatment but maintaining that weight loss is the next phase.

Help patients understand that obesity is a disease, and they may have lapses in the disease as life circumstances change. For example, they may need to start taking medication that promotes weight gain, they may be going through menopause, or they may deal with losing a family member. All of these can impact their weight in ways that they may not expect.

Q: What are we learning, or hoping to learn, from research on maintaining weight after weight loss?

A: We still have a lot to learn about how to best help people over the long term who have been successful with weight loss. Treating obesity chronically has not been the norm in our healthcare system, and there’s still a lot of research to be done on which strategies are best. In doing that, we also must consider patient preferences, cost-effectiveness, combinations of therapies, and the needs of each phase of therapy. There is still a lot for us to understand, but at this point, we can see clearly that the vast majority of people will need some type of ongoing treatment in order to maintain weight loss long term.