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How To Keep Weight Off After a Low Calorie Diet

sharma-obesity-mealreplacementsLow calorie diets (LCD: usually restricting intake to less than 1,000 calories per day with a formula diet) are highly effective in promoting weight loss and generally safe, when medically supervised.

However, as with all diets, the problem is not so much as how to lose weight – the real problem is keeping it off.

Now a paper by Kari Johansson and colleagues from the Karolinska Institute, Stockholm, Sweden, published in the American Journal of Clinical Nutrition, provides a systematic review and meta-analysis of randomised controlled trials on weight-loss maintenance post-LCDs.

The authors identified 20  studies with a total of 27 intervention arms in 3017 participants with the following treatment categories:

  • anti-obesity drugs (3 arms; n = 658),
  • meal replacements (4 arms; n = 322),
  • high-protein diets (6 arms; n = 865),
  • dietary supplements (6 arms; n = 261),
  • other diets (3 arms; n = 564),
  • exercise (5 arms; n = 347).

The low-calorie diet periods in these studies ranged with 3 and 16 weeks with an average weight loss of about 12 Kg.

Compared with controls, anti-obesity drugs and continued use of meal replacements improved weight-loss maintenance by about 3.5 kg.

Switching to a high-protein diet was only 1.5 kg better than control whereas, exercise (0.8 kg) and dietary supplements (0.0 kg) did not significantly improve weight-loss maintenance compared with control.

Thus, as one may have expected, adding anti-obesity drugs or continuing on (less restrictive) meal replacements were the most effective means of sustaining weight loss, whereas high-protein diets, exercise and dietary supplements were far less effective.

The message for both patients and clinicians here is clear: if you are going to go on a low-calorie diet – your best chances of actually keeping that weight of is if you go on anti-obesity medication or continue with the intermittent use of meal replacements.

All other strategies will likely result in rapid weight regain.

I’d certainly like to hear from my readers as to their experience with low-calorie diets and their success in keeping their weight off (or not).

Edmonton, AB

ResearchBlogging.orgJohansson K, Neovius M, & Hemmingsson E (2013). Effects of anti-obesity drugs, diet, and exercise on weight-loss maintenance after a very-low-calorie diet or low-calorie diet: a systematic review and meta-analysis of randomized controlled trials. The American journal of clinical nutrition PMID: 24172297




  1. How disheartening– I can’t say I love the idea of being on a permanent diet or eating fake food on an ongoing basis. As for the drugs, I’m not that far gone though I am glad they are there for those who need them. I’ll stick to moderation even though that means I am unlikely to fit into those size 10s again.

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  2. The honest reporting of the true results of maintaining weight-loss are very appreciated. Thank you, Dr. Sharma, for reassuring those of us who have re-gained. I am now primarily trying to not gain any more weight and exercise for cardio benefits and general fitness, not for weight loss. (I am overweight, not obese.) I call this re-gain phenomenon the “Unfair Cupcake Syndrome: losing weight requires not eating five cupcakes, only to have it all come back the moment you eat one cupcake.” Or some such ratio!

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  3. I’ve read this article with high interest and appreciate that the study was done! I’m very curious what ‘anti obesity’ drugs are out there and which ones would be recommended. Is this something that is very individual? Also, do these drugs help trick the body into storing less fat? I’m assuming they have some pretty drastic side effects?
    I’ve never been successful in keeping weight off after a low calorie diet. Diets have helped me gain even more as I went back to eating in a similar way. Obviously I know that this is the main problem. It was as if my body, mind and soul craved more food afterward; something I had very little control over.
    Thank you for being there and making this site available!! Cheers, Nicole

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    • Please refer to previous posts on obesity medications. These are currently only available in the US.

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  4. I lost about 25kg over about a year and have been stable for several years. Left to my own devices I would have gained as I suffer food cravings. I carefully monitor my intake, measure my weight at least weekly and respond to trends, and am physically active with an hour of aerobics and over an hour of fast walking a day.

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  5. I restricted calories in order to lose, but I don’t know whether my diet counted as LCD. I ate 1600 mostly healthy calories and exercised (high intensity) an hour a day. That resulted in a 68-pound loss in 2002-2003. I am now maintaining a 57-pound loss with one hour of daily (morning) exercise and a diet average of 1800 calories per day. I had to switch from running to weighted aerobics on a padded surface, which is slightly less intense, because of orthopedic issues. My diet is more heavily weighted to proteins and fats, since they abate insulin-triggered hunger, but I don’t count grams or anything. It’s informal. I also limit grains/starches to less that 200 calories per day. I think the purpose of the exercise (and the reason I do it in the morning) is to nudge my grehlin slightly down and create a cascade reaction among other hunger-related hormones in my system. This doesn’t eliminate “eat impulses” entirely, but it makes them manageable, less distracting. I can accomplish the work of my day. Morning exercise also helps with sleep regulation. I have less insomnia, which is also related to ghrelin and weight issues. Hope this is helpful.

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  6. I am curious how WLS fits into this. It obiously creates a situation where a person is on a very low calorie diet. But, we all know that many people eventually regain. Should WLS patients consider anti-obesity drugs or meal replacements for life on top of the surger? Does meal replacements include protein shakes?

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    • WLS post an LCD is certainly an option and we use that strategy occasionally in our clinic. So far there is not much evidence that obesity meds are of value in WLS patients. Meal replacements are just that – they should contain at least one third of daily nutrient requirements. This is not simpky an energy or granola bar or protein shake.

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  7. I can’t say I am surprised at the lack of an effect with exercise. . .however given the health benefit of physical activity, I wonder how clinicians and others can help weight loss patients include significant amounts of physical activity in their lives without said activity affecting weight regain.

    Not being an MD, I am not familiar with the anti-obesity medications—if the side effects interfere with being active, then it is problematic. If not, then I suppose there is no reason why patients can’t introduce physical activity after weight loss and starting medication.

    Also, there has to be a cross over of sorts at some point. Although these data indicate that medication and meal replacements have a bigger impact on weight loss maintenance, physical activity does show some benefit—just less than the medication arms. But again given the health benefits of physical activity, and the negative aspects of long-term medication, where do you draw the line and take away the meds and steer people to physical activity?

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    • Exercise and physical activity should be part of any weight management regime – as you say, there are all kinds of health benefits that go beyond weight loss. The medications that are available do not interfere with physical activity – so that is a benefit.

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  8. We’ve all got to stay on top of it! Losing weight for me was just the start of the battle and finding the discipline to avoid some foods and also exercising regularly was even harder. This is an under-researched subject and the paper you highlight is valuable. I hear you say that continuing anti-obesity medication is useful, but what about simple appetite suppressors?

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  9. Hi everyone
    Thank you Arya for posting about our study and to everyone who has shared. Here are some of my own personal reflections now that the study is published.

    #1: There will always be weight regain unless we can get to the underlying causes of weight gain. These causes are likely to be unique to each individual, which is why treatment needs to be tailored.

    #2: Causes of weight gain usually go much deeper than a poor diet or lack of exercise, for me this means psychological and emotional issues, mostly through adverse life experiences.

    #3: The very consistent pattern of weight regain clearly indicates a body weight set-point, and any deviation (ie weight loss) will only trigger the underlying weight loss defenses, including increased hunger, reduced energy expenditure and behavior relapse.

    #4: We need to remember the positive effects of eating a healthy diet and physical activity, even though the effects on body weight may be smaller that we would have liked. Carrying a few extra pounds is certainly not a disaster, especially if overall lifestyle is sound.


    Erik Hemmingsson
    Stockholm, Sweden

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  10. Hello Dr. Sharma,

    Thank you for your work in the field of obesity. I had been overweight since the age of 6 to the age of 45, (I’m now 47) with lots of attempts, large weight losses (60 pounds, with 70 regained). via Weight Watchers. In mid 2011, I started a commercial weight loss packaged VLCD with a loss of 2 pounds per week, I lost 70 pounds. I found this approach very effective for me, but I did not want to maintain my weight on packaged foods.

    I transitioned over from the packaged diet to a Paleo food template (95% of the time). I find this food template (once optimized for my own body- I’m post autoimmune thyroid disease) to be very sustainable in keeping the weight off, keeping emotional/binge eating urges to a new time low (I’ve been in long term remission since the VLCD).

    Not only is my health great, but I also went completely through menopause the first year of weight maintenance. I have about a +/- 3 pound variance around 115 pounds, I’m 5’1″ so that puts me right in the middle of my BMI range. I walk for 10,000 steps a day, strength train 1-2 times a week, sprint once a week.

    I’m now 21 months+ into weight maintenance. Sleeping well, rarely ever sick and feeling like I’m 27 instead of 47. Very few menopause symptoms. If I eat junky food, my hot flashes and scale have a noteable uptick. I’m rarely have cravings or am hungry- just normal hunger.

    I blog (non-commercial) at and I update my progress with graphs monthly, maintenance photos and blood work/biomarkers when I have labs done. I share my n=1 experiences. Feel free to ask questions. I’m a single parent with a teen aged daughter, 2 hour daily commute, mainly desk job, and I work in health care in a licensed position in a laboratory.

    Thank you again for your important work in the field of obesity, weight loss, and weight maintenance. Karen P, CLS, MT (ASCP)

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  11. I’d like to applaud loudly the comments of Erik Hemmingsson about the need for personalized psycho-emotional therapeutic treatment and supports during and after an LCD. I’ve gone through two 12-week cycles of OptiFast 900 with a medically-supervised group program in Nova Scotia and experienced an exciting level of weight loss during each cycle, but I’ve also found, along with pretty much all of my co-participants, that I needed significantly more psychological treatment than was on offer. This was entirely due to the reasons outlined by Erik: obese subjects with disordered eating habits almost always suffer from various, predictable emotional precursors to their overeating and they need a personalized treatment regiment to address those issues both during the meal replacement phase and after they transition back to solid food.

    This need is easily overlooked, but it is a significant need. Every subject needs to conduct some form of self-reflective work to determine what their own personal reasons are for their disordered eating habits, and they all need to learn non-food-related tactics for dealing with the negative emotions and daily stressors that they experience. There’s a fantastic, nearly euphoric feeling that accompanies meal replacement; for the first time in decades, each subject gets to experience the unalloyed joy that accompanies dealing with their regular stressors without eating a SINGLE BITE of food! We all felt like superheroes during that phase of the program.

    But that joy dissolves quickly once solid food is reintroduced, and unless the subject has spent some serious time during meal replacement cultivating new behaviours, attitudes and beliefs about their need to eat for emotional comfort and stress relief, it’s nearly impossible for them to transition back to solid food without returning to their former habits and gaining most or all of their weight back.

    To repurpose James Carville’s catchphrase from Bill Clinton’s election campaign: It’s the psychology, stupid…

    Big love to you, Dr. Sharma. I’m an avid reader of your blog and a HUGE fan of your work. Many thanks for your continued dedication to this field. 🙂

    Dustin LindenSmith
    Nova Scotia, Canada

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  12. Erik and Dustin make good points. I found both the resources, support -both physical and emotional in real life to be very lacking for the maintnence phase. I’ve now spent twice the time in maintenance than in loss. I’ve probably done 5x the work that I put into weight maintnence as compared to weight loss.

    Food prep, food buying, relaxation, facing old binge/emotional urges and patterns, dealing with family ,friends and co-workers let alone hormonal aging changes. All are dynamic processes that I deal with over the weeks and months.

    So much focus on weight loss, a lot fewer resources and much needed customization and emotional tool in weight maintnence. If you get 10 long term maintainers in a room there will be as many common practices overlap as much as there are differences.

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  13. I am 66 years old, six foot five, actual weight 200. I lost 160 lbs in 18 months.

    I am on maintenance for 4 months. My weight varies between 198 and 208, excluding temporary water and bowel retention, my weight most likely varies between 200 and 203.

    Weight maintenance is a huge problem as you can see with the 3 lbs fluctuation.

    Like anyone else, I lost and regained weight all my life, as well as going through Weight Watchers, Atkins, weight loss pills, etc….

    I exercise 4 hours per week.

    Weight maintenance calculators indicate I should eat approx 2,000 to 2,200 calories per day to maintain my weight. However I eat an average of 1,600 calories per day to maintain my weight.

    I lost the weight by following the food guide. I made this a project, a hobby of recuperating my health with informations learned via internet.

    I made a computer program on Microsoft Excel and I use it five minutes every day to monitor the calories and nutriments I absorb.

    For the past 5 months I follow 95% of the Ornish strictest diet in an effort to clean out my arteries.

    I also motivate my new lifestyle with several notions such as the fact obesity was very rare in 1950. I therefore eat similarly to what people ate in the 50’s. People rarely used restaurants for entertainment, therefore I cut down 95% of my resto eatings. I have listed several dozens of such notions.

    Since day one of this project I know that maintenance is more difficult than loosing the weight, however today I claim that maintenance is much more difficult than I thought. But, it is feasible

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  14. Hi ,
    thanks for your good articles. I have been on low-carb hight-protein diet for about 10 months and it worked great for me , I lost about 50lbs in 10-11 months, during the diet I was semi-active with about two cardio sessions-(running/swimming/tennis/gym) per week
    after that year my life style changed a little but I have managed to keep most of the weight off mainly by observing the food intake. During last two years I gained back about 10lbs in average but I can still wear the same dresses ( same size)
    my point is , from my experience changing the food habits (permanently) and being concerned and cautious about the food intake should work well to keep the lost weight off
    ( those 8lbs that I got back were because of sedentary life style within the past year )

    Good Luck 🙂

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  15. I had a friend (seriously, not myself), who lost overy 75 pounds drinking a large raspberry mocha every morning and a BurgerKing hamburger for dinner. He did not gain his weight back. I think he was very motivated for a life change and felt so good when the weight came off, that he really watched everything he ate aftwards. Mainly salads with protein, then grandually moved to a balanced diet with more variety. The only thing that didn’t work for him is when he added desserts in the evening. I think all of our bodies work differently. Obviously the lcd he chose wasn’t the most nutritious, but he is alive and well and healthy today.

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