The world is in the grip of an obesity epidemic. In my post, Is obesity a disease or risk factor for other conditions? I had discussed the magnitude of obesity and had also highlighted that today most of the major international and national health organisations, including the World Health Organization (WHO), World Obesity Federation, and American Medical Association recognise obesity as a disease. However, rather than considering obesity in a conventional way, one aspect that needs serious consideration is that normal weight doesn’t always equal healthy weight. In my post ‘What is obesity – is it merely about BMI?‘ obesity had been defined as “excessive body fat accumulation (not weighing too much), which is associated with clear risks to health.” In my post ‘Normal Weight Obesity – a myth or a reality? I had described individuals who have weight within normal limits according to the BMI but have a high body fat percentage and are predisposed to the same health risks as in obesity. Lifestyle modifications encompassing dieting, physical activity and behavioural modifications often lead to weight loss. However, over the long term, the vast majority of individuals regain the weight they have lost. Thus, long-term weight loss maintenance remains the main challenge of obesity treatment. Various studies have shown that this relapse has a strong physiological basis and is not simply the result of the voluntary resumption of old habits.
What is the successful maintenance of weight loss?
To assess the population of individuals who successfully maintain weight loss, it is pertinent to lay down objective criteria to define ‘successful maintenance of weight loss’. The most commonly followed definition of successful maintenance of weight loss was proposed by Wing and Hill; they define successful maintenance of weight loss as “intentionally losing at least 10 per cent of the initial body weight and keeping it off for at least one year.” Rossner proposed that sustained weight loss of about 5% to 10% of baseline body weight represents a definite degree of success. This goal for weight loss is in accordance with the recommendation of various health and nutrition organisations for reducing the risk of various disease conditions associated with obesity.
As discussed under ‘setting weight-loss targets’ in my post ‘Diet Plan for Weight Loss – it’s going to be a journey‘, this amount of weight loss significantly reduces the risk of various disease conditions associated with obesity and improves psychological functioning, in particular mood, body image and binge eating. Though the term “successful” would require that weight loss is maintained for much longer periods, hopefully lifelong, the criteria of one year have been set in the definition from the research target point of view.
Though only a few studies have assessed the effect of lifestyle modification on long-term weight maintenance, the available data indicate that ranging from 30% to 50% of the lost weight is regained by the end of first-year follow-up, with nearly all remaining lost weight regained thereafter in the vast majority of individuals. According to the National Health and Nutrition Examination Survey (NHANES) in the US, a mere one in six overweight and obese adults reported maintaining a weight loss of at least 10% for one year, at any point in their lives. According to data published in the International Journal of Obesity, based on the definition of successful maintenance of weight loss, approximately a quarter of overweight individuals report successfully maintaining weight loss.
Regulation of body weight
Before discussing the factors responsible for failure to maintain weight loss in the long-term, it would be pertinent to look at the process involved in the regulation of body weight. Bodyweight is regulated by a complex system involving parts of the brain, mainly hypothalamus, which act in concert with several neuropeptides (a group of compounds used by the cells in the brain to communicate with each other) and hormones to regulate food intake and energy expenditure; the balance of which determines our body weight. Together, this is known as homeostatic regulation (homeostasis ~ the tendency of a system to maintain internal stability by way of self-regulating processes) of body weight. The hedonic system is another system involved in the regulation of body weight, which guides food intake based upon palatability. The environment in which we live (primarily the food and physical activity environment) and our behaviour (primarily our diet and exercise behaviour), also have a major influence on the regulation of body weight. Salient features of these will be discussed here briefly.
In homeostatic regulation, hypothalamus (a small region of the brain, located at the base of the brain) plays a central role in integrating signals regarding food intake, energy balance and body weight, received via various hormones released from the gastrointestinal tract (the large muscular tube that extends from the mouth to the anus, where the movement of muscles, along with the release of hormones and enzymes, allows the digestion of food; also called the digestive tract), pancreas, and adipose tissue. The neuropeptides and hormones involved in the regulation of appetite can be grouped into two categories – orexigenic, which stimulate hunger and anorexigenic, which suppress hunger. Orexigenic hormones include ghrelin, produced and released mainly by the stomach, with small amounts also released by the small intestine, pancreas and brain and gastric inhibitory polypeptide, released from the upper sections of the small intestine. Anorexigenic hormones include glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and cholecystokinin (CCK) from the gastrointestinal tract; pancreatic polypeptide (PP), amylin, and insulin from the pancreas; and leptin from adipose tissue.
A feedback loop is formed between the brain and peripheral organs involved with food intake, digestion, utilisation and storage of excess energy, viz. gastrointestinal tract, pancreas, liver, muscles, and adipose tissue. Broadly speaking, leptin conveys information about long-term energy balance (i.e. energy stores in the form of adipose tissue) and acts on the hypothalamus to reduce food intake and increase energy expenditure. Most other hormones regulate short-term food intake (i.e. nutrient availability). Hypothalamus achieves energy homeostasis by processing and integrating these signals.
This metabolic regulation of body weight centres around the ‘body weight set point’. A popular, well-known theory, the ‘set point theory’, states that “every individual, whether lean or obese, has a well-regulated internal control mechanism that strives to maintain a pre-set level of body weight and/or body fat within a limited range.” This metabolic body weight set point has a genetic basis. Change in body weight, above or below the set point body weight, as a result of energy imbalance, elicits a compensatory increase or decrease in energy intake and energy expenditure, in an opposite direction, in order to restore the original body weight set point. As highlighted above, energy balance is regulated by the hypothalamus based on the hormonal feedbacks about energy stores and nutrient availability, received from the periphery.
Any change in the body weight, and thus the energy stores, is communicated to the hypothalamus through an array of hormones which regulate appetite. Hypothalamus, in turn, activates opposite sets of metabolic reactions in order to restore the setpoint body weight. For example, the hormone leptin, derived from adipose tissue, is produced in proportion to the adipocyte size and fat mass, and thus acts as an indicator of the body’s fatness. Increased level of leptin in the circulation, associated with a gain in body weight, activates the hypothalamus, which in turn, increases energy expenditure by increasing the resting metabolic rate and reduces energy intake by suppressing appetite, so as to promote weight loss. In contrast, decreased levels of leptin, associated with weight loss, results in slowing down of resting metabolic rate to conserve energy and increases intake of food, so as to promote weight gain. As discussed above, in addition to leptin, hypothalamus and other specific regions of the brain, receive numerous other feedback signals that in various ways reflect the body’s energy status.
Limitations of set-point theory
Even though there is now overwhelming experimental evidence to support the homeostatic regulation of body weight, a major drawback of this concept of a set point is that it fails to explain the current obesity epidemic. The basic question that arises is that if bodyweight is determined by a genetically programmed set-point, then why are more and more people becoming obese now than just a few decades ago, even though population genome pool has not changed over this period. Secondly, if the body has a system by virtue of which the body weight will always return to an individual’s set point range, no matter how much it deviates from the set-point, then why should consuming unhealthy or junk food matter?
Recently evidence has emerged that even though the body weight set point has a genetic basis, it is modifiable by environmental factors too, mainly the food intake. As stated above, set point theory suggests that body tends to maintain a pre-set level of body weight and/or body fat in a limited range and deviation of body weight from this set point elicits compensatory changes in energy intake and expenditure in opposite direction, in order to restore the energy equilibrium and the original body weight set point. However, there is evidence to suggest that if the positive energy balance is sufficiently large and sustained for long enough period, the persistent weight gain overcomes the physiological mechanisms which attempt to defend the set-point body weight, leading to an upward shift of the bodyweight set point and body will now defend this new set point. If the calorie intake is further increased and sustained for long periods of time, over time you develop a series of set-points that your body will attempt to defend.
This model is in accordance with the dynamic equilibrium of bodyweight model discussed in my post Diet plan for weight loss, referred to above. As in the case of weight loss, an initial increase in energy intake, even if sustained over a long period, will not lead to a large, linear weight gain. Instead, as the energy intake increases and body weight starts to increase, compensatory changes set in to increase energy expenditure. The increase in energy expenditure is the result of changes in three processes – increased REE, AEE and TEF. The REE is increased as a result of an increase in both fat and lean body mass; AEE is increased due to the increased cost of moving a heavier body weight and TEF is increased due to higher food intake and increased protein turn-over (due to gain of lean tissue) and its associated cost. As a result, the gap between energy intake and expenditure becomes lower and lower to reach a point of new equilibrium where without actually changing your energy expenditure yourself, your energy intake now matches your energy expenditure and this new equilibrium will now be defended. Obesity resulting from an elevation of the metabolic set point, which is characterised by an elevated body weight which is metabolically defended just as normal body weight is defended at its set point, is termed ‘metabolic obesity.’
Another factor which explains the gain in body weight beyond the set point body weight is the existence of a hedonic (of, relating to, or characterised by pleasure) system controlling food intake and body weight. This system is spread out/dispersed over regions of the brain termed as a corticolimbic system and involves multiple neuronal pathways connecting different regions of the brain, including the hypothalamus. The hedonic system, in principle, guides food intake based upon palatability (for example sight, smell, and taste) of food. This system is also modulated by factors such as emotion and stress. A primary characteristic of the hedonic system, concerning the onset and maintenance of obesity, is that these hedonic pathways can override the homeostatic regulatory systems for energy balance in response to rewarding food items, as eating stimulates brain centres involved in pleasure and reward.
Hedonic eating is governed by the reward system to satisfy the need for pleasure and is non-homeostatic with regard to energy balance. In individuals susceptible to developing disorders of the hedonic system, there is a strong desire to consume energy-rich foods, despite a state of satiety and abundant energy stores, potentially stimulating weight gain. Thus, despite the inherent logic and appeal of the dietary strategies for weight loss and maintenance, successful implementation of dietary modifications is difficult because of the physiology associated with the hedonic reward system. Hedonic processes intricately interact with homeostatic hypothalamic processes, which operate completely outside our awareness, as a result, hedonic processes are also less under conscious control. It is therefore unlikely that obese individuals can simply will themselves to weight loss. Obesity resulting from sustained hedonic over-eating despite satiation and replete energy stores is termed as ‘hedonic obesity’.
The obesogenic environment in which we live greatly influences energy balance, and by implication, body weight. Increased availability of sugary, high-fat, energy-dense foods, increased portion sizes, and intense marketing of these foods, create a food environment in which people are more likely to consume these foods. The high degree of stress associated with modern lifestyles stimulates compensatory food intake. This increase in food intake is coupled with reduced opportunities for physical activity. Ultimately, an obesogenic environment makes it more challenging for individuals to maintain a healthy weight.
An obesogenic environment in itself cannot lead to obesity. Ultimately, it is our behaviour, particularly concerning diet and exercise, which plays a fundamental role in the causation of obesity. Personal motivation for change is an important driving factor in modifying unhealthy habits and lifestyles.
Factors responsible for weight regain
Lifestyle modification, encompassing nutrition, physical activity and behavioural modification is the most commonly used strategy to help obese patients achieve and maintain weight loss. However, weight regain is the major limitation which mars the efficacy of this strategy. Weight regain commonly occurs in patients who have lost weight by adopting lifestyle modification strategies, regardless of what dietary or behavioural intervention strategies have been used for weight loss.
It has been speculated that the body cannot distinguish between ‘dieting’ and ‘starvation’, and as such, the body’s first response to weight loss is to prevent adverse effects of starvation. Within 24 hrs of energy restriction, the body triggers ‘starvation defence response’. As a result, following weight loss, compensatory changes in biological pathways involved in appetite regulation, energy utilisation, and storage promote weight regain. Broadly, these compensatory changes include decreases in energy expenditure, fat oxidation, and anorexigenic hormones (e.g. leptin) levels and increases in orexigenic hormones (e.g. ghrelin), appetite and cravings. These physiological adaptations would have been advantageous for a lean person in an environment where food was scarce; however, in an environment in which energy-dense food is abundant and lifestyles are largely sedentary, it results in a high rate of relapse after weight loss. Activation of these compensatory mechanisms also supports the existence of an elevated body weight set point in obese people, as discussed above. However, overfeeding results in fewer compensatory changes in energy expenditure than food restriction, and the degree of conservation is proportional to the degree of underfeeding. Therefore, we can conclude that human beings are better adapted to protect against weight loss compared to weight gain, demonstrating the efficiency of food utilization, particularly when food resources are scarce.
Although a large proportion of obese individuals regain weight following weight loss, a proportion of individuals is able to successfully maintain a long-term weight loss. Further, those that do regain lost weight, do so at different rates. This may be largely explained by individual differences in genetic make-up, food environment and psychological factors.
Compensatory changes favouring weight regain
Energy metabolism (Energy balance)
Bodyweight greatly influences energy expenditure; higher body weight is associated with a much higher Total daily energy expenditure (TDEE). Loss of body weight following lifestyle modification results in loss of both fat and lean mass. The reduction in body weight results in compensatory changes leading to a reduction in the TDEE. The reduction in energy output is the result of changes in the three processes – reduced Resting Energy Expenditure (REE), Activity Energy Expenditure (AEE), and Thermic Effect of Food (TEF). The REE is reduced secondary to loss of lean and fat mass, AEE is reduced due to decreased cost of moving a reduced body mass and TEF is reduced due to lower intake of food and reduction in protein turnover and its associated energy cost. This decrease in energy expenditure as a consequence of weight loss is known as “adaptive thermogenesis.”
A large number of studies have demonstrated that there is a disproportionately greater reduction in REE and TDEE during weight loss than can be explained by the loss in the fat and lean mass. This disproportionate reduction in energy expenditure, relative to body mass and composition, during weight loss maintenance, may be largely attributable to increases in metabolic efficiency of the body; an adaptation which takes place within 24 hrs of calorie restriction, before any loss of body mass. Persistence of this metabolic adaptation, in the absence of a proportionately reduced energy intake, will predispose individuals to weight regain. As a result of the metabolic adaptation, energy intake requirements during weight loss maintenance are lower than that of never obese individuals with the same BMI. However, physiological adaptations to weight loss also include perturbations in the levels of circulating appetite-related hormones and increase in hedonic eating.
An additional theory points to changes in body composition that may result from the cycles of weight loss and regain, which most obese people go through. There is some evidence to suggest that the fat-to-lean ratio of mass regained during weight regain is higher than that of the mass lost initially during a weight loss diet. Simply stated, when you regain weight after weight loss, the body regains less amount of lean mass and higher amount of fat than it lost during weight loss, i.e. a proportion of leans mass is replaced with fat during the weight regain after weight loss. Thus, with each successive “weight-cycle”, the proportion of body fat begins to increase, in comparison to lean mass. As fat is metabolically less active compared to lean mass, increase in the fat-to-lean ratio will lower the metabolic rate i.e. REE.
Levels of appetite hormones
Appetite-related hormones play a key role in the regulation of body weight. Expectedly, levels of many of these hormones are perturbed after weight loss. Following diet-induced weight loss, there is a significant and persistent reduction in the level of anorexigenic hormones like leptin, peptide YY (PYY), and cholecystokinin and increase in the level of orexigenic hormone, ghrelin. Thus, changes in appetite-related hormones following weight loss tend to favour weight regain by inducing a simultaneous decrease in satiety and increase in hunger. In fact, leptin levels are reduced within 24 hrs of energy restriction, which triggers a starvation defence response, despite the persistence of abundant fat stores. This results in a reduction in energy output and increases in energy intake.
More worryingly, findings from various studies have revealed that hormonal alterations in response to weight loss tend to persist long-term i.e. one year or longer. Thus, these findings suggest that compensatory changes in levels of appetite-related hormones, which promote weight regain following diet-induced weight loss are not a transient response to weight loss. As a result, long-term strategies may be needed to address hunger and thus prevent obesity relapse.
Role of Adipose cellularity in weight regain
The adipose tissue mass increases in two ways – hypertrophy (enlargement) of the existing adipocytes (fat cells) and increases in the number of adipocytes. To begin with, excess calorie intake may lead to increases in fat cell size. However, as body fat increases, fat cells eventually reach a biologic upper size limit. Once this occurs, in extreme weight gain, an increase in the number of fat cells determines the further gain in body weight. When the body loses weight, the size of the fat cells decreases; however, the number of fat cells remains the same. Thus, relative to individuals who have never been obese, weight-suppressed formerly obese individuals (particularly severely obese individuals) of the same BMI, will have a significantly greater number of fat cells, which cannot be reduced by behavioural therapy. In other words, it can be said that weight loss in severely obese persons does not really “cure” their obesity, at least in terms of the number of fat cells. Liposuction is the only known treatment which can reduce the number of fat cells, but it has its complications.
However, regarding the effect of the increased number of fat cells, on weight regain, it is not yet definitively known if the increased number of residual fat cells encourages weight to regain after weight loss, in obese persons.
Role of increased appetite in weight regain
Subjective appetite is the result of the integration of biochemical, mechanical, neurological, and psychological pathways that regulate food intake and it manifests as ‘desire to eat’. All the compensatory changes following weight loss tend to increase appetite and various studies have revealed that these increases in appetite are sustained long-term. Evidence also suggests that in addition to an increase in the desire for food, weight loss increases reward properties of food which results in a preference for higher-calorie foods.
Psychological factors affecting weight regain
Despite the biological pressures on individuals to overeat in order to restore their original weight (i.e. set-point body weight) and living in an obesogenic environment, a proportion of individuals manage to continue to practice weight control behaviour and therefore maintain long-term weight loss. The answer to this central question, namely, why some individuals persist in practising weight-control behaviours, while others abandon it, has been provided by some research studies which have pointed to large differences in the psychological characteristics of the obese population seeking treatment.
A complex of cognitive factors and personality traits has been shown to influence complex eating and exercise behaviours involved in weight loss and maintenance of long-term weight loss.
Cognitive factors associated with weight loss
The two most influential factors found to be associated with weight loss are ‘dietary restraint’ and reduction in ‘disinhibition’. Dietary restraint is defined as the intention to restrict food intake in order to control body weight and shape. Disinhibition, on the other hand, is defined as the tendency to overeat in the presence of palatable foods or other disinhibiting stimuli, such as emotional stress. A plausible reason for weight loss is a reduction in calorie intake as a result of increased dietary restraint and reduced disinhibition.
Cognitive factors associated with weight-loss maintenance
Satisfaction with the bodyweight achieved during treatment and confidence in their ability to lose additional weight without professional help is positively correlated with weight-loss maintenance.
Personality traits and weight loss maintenance
Personality traits are distinguishing qualities or characteristics that are the embodiment of an individual. They are your habitual patterns of behaviour, thoughts, and emotions that are relatively consistent and stable over the years and differ across individuals. By influencing behaviour they may play an important role in weight loss and weight loss maintenance. Among the various personality traits, ‘novelty-seeking’ is associated with obesity as well as with difficulty in losing weight. Novelty seeking is one of the defining characteristics of a ‘sensation-seeking’ personality in humans. It has been defined as “the seeking of novel sensations, and the willingness to take physical, social, legal and financial risks for the sake of such experiences.” High novelty-seeking scores indicate a strong appetite drive; as a result, binge eaters were found to score high on novelty seeking. Studies have shown that obese subjects who were successful in losing more than 10 per cent of their weight scored significantly lower on novelty-seeking than those who did not manage to lose that much weight; high scores in novelty-seeking are associated with less success in achieving behavioural therapy-induced weight loss.
Another aspect of personality ‘locus of control’, has also been shown to influence weight loss maintenance. Locus of control is the degree to which people believe that they have control over the outcome of events in their lives, as opposed to external forces beyond their control. Individuals with “internal locus of control” perceive they have control over the environment and feel they can control stimuli; in contrast, individuals with “external locus of control” perceive that their life is regulated by something outside their control. Individuals with an internal locus of control are more likely to lose weight and maintain weight loss without any external support, compared to individuals with an external locus of control. The concept of locus of control is intimately connected with self-efficacy (one’s belief in one’s ability to succeed in specific situations or accomplish a task).
Strategies to promote weight loss maintenance
Though short-term weight loss can be successfully achieved by restricting food intake through dieting, many individuals regain the lost weight. Maintenance of weight loss in the long-term is crucial for the management of obesity, and hence, for reducing the burden of obesity-related comorbidities. To maintain weight loss, individuals must adhere to obesity-reducing behaviours that counteract the compensatory physiological adaptations and other factors associated with weight regain. Reduction in food intake, dietary modifications and increased physical activity are logical behavioural interventions to counteract the process of weight regain. There is also a need for modifying the obesogenic environment in a way that it supports individual behavioural changes. Importance of environmental modifications is evident from the findings that suggest that rather than something being ‘wrong’ per se with the homeostatic control of food intake, it is not geared up sufficiently to cope with radical changes in the environment and thus overwhelmed to the point where activation of the hedonic pathways becomes a major driving force for overconsumption. Unfortunately, creating a built-up environment that favours healthy behaviour, has been, and is likely to remain difficult as it may not only entail creating new infrastructure but may require changing the city structure itself to make it, for example, cycle-friendly. Changing the food environment is also difficult because of the legal and financial issues involved.
As behaviour patterns play an important role in the causation of obesity, therefore behavioural therapy is often a key part of the management of obese individuals. Sustained behaviour change can lead to long-term maintenance of weight loss. However, as highlighted in the preceding sections, there are unyielding and potentially mounting biological pressures that tend to undermine weight loss efforts and promote weight regain. These biological pressures come into play almost immediately, even when an obese individual is attempting modest and healthy weight reduction. As a result, obese individuals face an extremely uphill battle in having to overcome powerful biological drives that appear insurmountable, via behavioural interventions alone. Cognitive behaviour therapy (CBT), largely neglected in traditional weight loss lifestyle modification programs, can play an important role in countering the biological pressures and thereby help in sustaining behavioural interventions concerning diet and exercise. Psychological traits such as higher levels of autonomous motivation (defined as engaging in a behaviour because it is perceived to be consistent with intrinsic goals or outcomes and emanates from the self), self-efficacy and barriers (beliefs that a person has about himself/herself regarding his/her ability, potential and self-worth), self-regulation skills (including self-monitoring), flexible eating restraint, and positive body image are positive mediators for weight maintenance. Because of the large differences in the psychological characteristics of obese individuals seeking treatment, it is desirable to have an individualised, tailored approach rather than a standardised approach.
Role of physical activity
Physical activity has a modest impact during the weight loss phase; however, it is an essential part of the weight loss maintenance phase. Incorporating pleasant leisure-time physical activities may increase adherence to exercise programs and thus help maintain long-term weight loss. This aspect has been dealt with extensively in my posts – Health Benefits of Exercise: a grossly underutilised therapy; Exercise Prescription for Optimum Health Benefits; Aerobic Exercise Prescription for Optimum Health Benefits; and Weight Training Program Design for Optimum Health.
Extended care beyond weight loss phase
Provision of extended care beyond the weight loss phase, during which various strategies are adopted to encourage and motivate individuals to persist with weight control behaviours, has been found to promote long-term weight loss maintenance. After the weight loss phase is over, regular periodic group sessions, delivered every fortnight have been shown to keep patients in active treatment and thus help patients maintain the weight loss. Forming self-help groups provide the requisite social support which helps individuals to maintain the weight loss behaviours. In cases where in-person, face-to-face interaction is not feasible, maintaining contact via telephone or the internet can also help to maintain weight loss in the long-term. Even though extended care approaches provide individuals with the support and motivation needed to continue to practice weight control behaviours, these may not be easily accepted by all individuals.
Anti-obesity medications and bariatric surgery
An important limitation of behavioural interventions is that it is difficult to overcome physiology with behaviour over the long-term. In severely obese cases, where behaviour therapy has failed to deliver the desired results, use of anti-obesity medications and/or bariatric surgery, also known as metabolic or, rather inappropriately, weight loss surgery, are useful interventions that help to reset an individual’s physiology. The control of body weight physiology enables the adoption of lifestyle modifications, including eating a low-calorie diet and undertaking increased physical activity. However, both drug therapy and bariatric surgery have their limitations. In selected cases, residential inpatient treatment might be successful in reinforcing strategies for behavioural change.
Characteristics of individuals who successfully maintain weight loss
Among the various studies that have studied the long-term weight loss maintenance, the National Weight Control Registry (NWCR) is the most important and longest study, which assessed the characteristics of individuals who successfully lost and maintained their weight loss, as well as the strategies they used to maintain their weight loss. The study was established in 1994 as a prospective investigation of long-term successful weight loss maintenance. In a large NWCR analysis, the members reported an average weight loss of 33 kg, which was maintained for more than 5 years. The main strategies adopted by members to keep a stable weight in the long-term were:
- High level of physical activity (about 1 hr per day)
- Eating a low-calorie, low-fat diet.
- Eating breakfast regularly
- Self-monitoring weight, and
- Maintaining a consistent eating pattern across weekdays and weekends.
An encouraging finding was that individuals who had managed to maintain their weight loss for two years or more, their chances of a longer-term success were higher.
Importance of early intervention and prevention
It is much easier to prevent obesity from developing than to treat it once it occurs. As discussed in my posts Complications of obesity: the mother of all diseases and Childhood obesity: a serious public health challenge, untreated obesity is responsible for a significant proportion of non-communicable diseases (NCDs) including heart disease, diabetes, liver disease and many types of cancers. Unfortunately), long-term management of weight in individuals with obesity remains a very difficult task and is associated with a high risk of failure and weight regain. This illustrates the critical importance of obesity prevention efforts for normal and overweight individuals – invest in prevention to reduce the need for treatment. Investing in the prevention, management and treatment of obesity is a cost-effective action for governments and health services. To underline the significance of early intervention and prevention, the World Obesity Federation selected the theme “Treat obesity now and avoid the consequences later,” for the ‘World Obesity Day 2017.