You know how you just get tired. Maybe I got bored. It's just hard to stick with it.” That was the response he gave me to, “What happened”?
He is a 48-year-old man whom I had a medical student see as a demonstration of “my” success. He weighed 350 lb when we started 18 months ago with a hemoglobin A1c (A1C) of 12.7%. Over the next year, he had lost nearly 30 lb, was quickly transitioned off insulin after 6 weeks of therapy, and was only taking metformin and a low dose of glipizide for glycemic control some 6 months after his initial visit. Eventually, he lowered his weight to 310 lb and his A1C to 6.4%, and he said he felt good. I thought he looked good. He said he was walking more, watching his portion sizes, and had sworn off snacks. A buddy at work was also dieting, and he said he benefitted from being able to talk to somebody who was going through the same challenging experience. At one of our visits, he told me that I was a great doctor. I was the one who motivated him to take care of himself. His wife baked me a loaf of bread as an expression of their gratitude. I congratulated him on his success and told him what a great job he had done. At one visit, we were tripping over each other with our expressions of mutual admiration.
Yesterday, he weighed 354 lb, had basically stopped exercising (although it was not much to stop), had stopped monitoring his weight and glucose, and was eating... well, I'm not sure what he was eating. He was still taking his metformin but had stopped his glipizide. His A1C was 9.6%. When I tried to drill down beyond, “It's just hard to stick with it,” he seemed disinterested in talking. “Tell me more” only generated shrugs and silence. He looked at me differently during the visit.
His expression was a combination of self-guilt and a recognition that I was, alas, no different than the rest. This latest effort to regulate his weight and its comorbidities was like the rest. He wondered if maintaining weight loss was an elusive goal.
In this issue of Clinical Diabetes, Garcia Ulen and colleagues provide a comprehensive review of weight loss maintenance strategies(p. 100). The more than 100 references cited by Garcia Ulen and colleagues underscore that weight regain is still a common phenomenon, and strategies to limit the problem have had limited success. Nevertheless, the data clearly reflect the benefits of approaches that include consistent follow-up, frequent monitoring, ongoing physical activity, and possible pharmacotherapy. Perhaps equally important is the anticipation of lapses, if not relapse. Practitioners might give greater attention in grounding patient expectations and engaging in some degree of planning for lapses. There needs to be greater attention and emphasis to an inescapable, empirically validated phenomenon: people are prone to wander. Although the reasons for doing so are complex, a first step is to plan for such a reality.
Unfortunately, I overlooked this step when my patient and I were congratulating each other over his previous sucesses. Instead of seeking positive reinforcement through questions that intentionally provided cognitive rewards, I should have spent more time establishing a clear plan for follow-up and maintenance, and such a plan should have anticipated a tendency to wander off course. Perhaps I could have given a clear maintenance exercise strategy,as outlined in this issue by Sheri R. Colberg, PhD, FACSM(p. 123), or emphasized one of the many points highlighted by Garcia Ulen and colleagues in the aforementioned feature article. Had I done that, it's possible that he and I would not be reviewing the landmark study on the benefits of bariatric surgery, summarized in this issue by Associate Editor Michael Pignone, MD, MPH(p. 121).