Weight Loss Maintenance Remains Challenging—Even With Personalized Support

In this issue of JAMA Network Open, Ross and colleagues 1 report the results of a randomized clinical trial evaluating whether a 20-month, telephone-based, adaptive weight maintenance program, triggered by an algorithmic assessment of risk for weight regain (based on self-monitoring frequency, hunger, and self-rated importance of staying on track), improved long-term outcomes compared with a static, scheduled monthly support model also delivered for 20 months via telephone. 1Among 255 adults who achieved 5% or more weight loss in a 16-week initial lifestyle-based weight management intervention (based on the Diabetes Prevention Program), 2 the authors found no significant difference in weight maintenance between the adaptive and static groups.At 24 months, both groups maintained a mean weight loss of approximately 8% from baseline, and nearly 60% of participants in both groups sustained at least a 5% loss 1 -a clinically meaningful threshold associated with reduced risk of type 2 diabetes, cardiovascular disease, and other obesity-related conditions. 3ight loss is difficult to achieve and difficult to sustain.Even when initial lifestyle interventions are intensive and evidence-based, typically between 20% to 64% of participants lose clinically meaningful amounts of weight (5%)-similar to the 56.8% seen after the initial 16-week intervention in this study. 1Moreover, weight is often regained within 1 to 2 years, even when weight maintenance strategies are in place. 4These patterns reflect not a failure of willpower but a chronic, biologically defended condition.Once patients lose weight, metabolic adaptations kick in to promote weight regain-levels of hunger-promoting hormones (eg, ghrelin) increase, satiety hormones (eg, peptide YY and leptin) decrease, and resting energy expenditure drops beyond what is expected from weight loss alone. 5ight maintenance interventions can slow or reduce weight regain, potentially countering the biological and behavioral challenges to weight maintenance. 4,6Extended care models-in which participants receive regular weight management contacts after initial weight loss-are the current reference standard for maintenance and are often delivered on a static schedule. 1However, results are variable.A meta-analysis 6 of 11 weight maintenance studies concluded that the average effect of extended care on weight loss maintenance would be the equivalent of maintaining an additional 3.2 kg over 17.6 months.Another systematic review 4 of 8 intensive behavioral interventions showed that 4 of 8 interventions had continued weight loss while the other 4 had weight gain with no statistical difference in effect size between intervention and control groups on meta-analysis.Thus, improving delivery and outcomes of scalable, cost-effective weight maintenance models remains a critical need.The adaptive intervention tested in this study 1 aimed to improve weight maintenance efficiency.Participants received weekly self-monitoring prompts to assess hunger, motivation, and behavioral adherence to self-monitoring.A tailored algorithm then triggered intervention calls only when a participant appeared at high risk for weight gain.In theory, this approach is potentially more personalized and responsive, but it did not improve weight maintenance compared with monthly static counseling.The adaptive model had several implementation challenges that may have led to this result.Patients randomized to the adaptive group received more attempted calls on average than those in the static model (mean [SD], 56.2 [20.4] vs 17.8 [4.6] calls in the static model), and although they had longer total contact time, the proportion of completed calls was significantly lower than in the static group (mean [SD], 55.7% [21.4%] vs 96.1% [9.9%] calls in the static model).This may be due, in part, to the algorithm's design: calls were triggered not only by risk but also by missing self-report data, which could have led to unexpected or undesired outreach.In contrast, participants in the static group had the predictability of scheduled contact, which may have helped sustain