Journal of Psychosomatic Research 53 (2002) 1029 – 1036
Psychological aspects of weight maintenance and relapse in obesity
Susan M. Byrne*,1
Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
Abstract
Studies have shown that, among formerly obese individuals,
the continued practice of the behavioural strategies adopted
during weight loss is associated with the successful main-
tenance of a new lower weight. Much less attention has been
focused on the psychological factors that motivate the continued
use or abandonment of these critical weight maintenance
behaviours. This paper reviews studies that have attempted to
identify psychological characteristics that may be associated
with weight maintenance and relapse in obesity. This is
Keywords: Obesity; Psychological factors; Weight maintenance; Weight regain
Introduction
There is substantial evidence to suggest that the two most
widely available treatments for obesity (behavioural treat-
ment and pharmacological treatment) can produce modest
weight loss in the region of 5 –10% of initial body weight
[1].2 This amount of weight loss is associated with signific-
ant physical and psychosocial benefits for obese people so
long as it is maintained [2 –7]. The problem is that the
weight lost as a result of these treatments is almost always
regained over time [8– 12].
The issue of how best to prevent, or at least minimise, the
weight regain that follows treatment for obesity has become
a priority area for obesity research [13 –17]. Attempts to
improve the maintenance of a new lower weight, by
incorporating specific maintenance strategies into standard
behaviour therapy (BT) programmes, have, at best, delayed
weight regain [17 –22]. However, these strategies have been
largely atheoretical and pragmatic in nature, and have not
* Tel.: +44-1865-226479; fax: +44-1865-226244.
E-mail address: sbyrne@psy.uwa.edu.au (S.M. Byrne).
1
Present address: University of Western Australia, Department of
Psychology, Nedlands, W. A. 6009. Tel.: +61-8938-03579; fax: +61-
8938-02655.
2
Surgical interventions result in much greater weight loss but are
only available, at present, for a small proportion of morbidly obese
individuals [32].
0022-3999/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved.
PII: S 0 0 2 2 - 3 9 9 9 ( 0 2 ) 0 0 4 8 7 - 7
important because a better understanding of these factors may
lead to the development of improved psychological treatments
for obesity. The results of the studies suggest that a number
psychological factors, such as having unrealistic weight goals,
poor coping or problem-solving skills and low self-efficacy,
may have an important effect on the behaviours involved
in weight maintenance and relapse in obesity, and further
research in this area is warranted. D 2002 Elsevier Science Inc.
All rights reserved.
been based on a systematic analysis of the range of
processes that are involved in weight maintenance and
weight regain (as opposed to weight loss) in obesity.
Relapse in obesity appears to be attributable to individ-
uals’ failure to adhere to the weight-control behaviours that
they adopted in order to lose weight, such as the continued
consumption of a low-fat diet, the use of regular physical
activity and the regular monitoring of weight [8,9,17,
18,23 – 31]. However, little information has been obtained
regarding the psychological mechanisms that drive these
behaviours. It is not clear how or why some formerly
obese individuals (about 15 – 20% of successful weight
losers) are able to persevere with these forms of behaviour
when the majority fail to do so. This paper will review
research that has attempted to identify the psychological
factors that may be associated with weight maintenance
and weight regain in obesity. A better understanding of
these factors may help to inform the development of new
psychological treatments for obesity that are designed to
address them.
Research investigating psychological factors associated
with weight maintenance and relapse
There have been two main approaches to obtaining
information about the psychological variables that might
1030 S.M. Byrne / Journal of Psychosomatic Research 53 (2002) 1029–1036
be involved in weight maintenance. One approach has been
prospective — subjects who have been recruited to take part
in treatment trials are followed over time in order to identify
variables associated with the maintenance of a new lower
weight. A second approach has been retrospective — indi-
viduals who have lost weight in the past and who have been
able to demonstrate successful long-term weight mainten-
ance are recruited and interviewed in order to determine
how they have achieved this success.
These studies have been limited in several ways. The
prospective studies have been conducted primarily in uni-
versity-based settings, which may not represent typical
methods for weight loss, and patients who volunteer for
clinical trials may not be representative of all individuals
seeking to lose weight. The retrospective studies have
usually drawn samples from the general population who
are likely to be more representative of obese people who
have lost weight. However, their results have relied on self-
reported retrospective data often collected many years after
the initial weight loss had occurred. Many of the studies
from both categories are limited by small sample sizes.
In addition, there is considerable variation in the way in
which successful weight maintenance and weight regain
have been defined. In some studies, maintainers have been
defined as subjects who have maintained, for at least 1 year,
a weight loss of 5 –10% of their maximum body weight
[33], while in others, subjects have only been classified as
maintainers if they have achieved and maintained a healthy
weight (BMI = 20 –25 kg/m2) for more than 2 years [34,35].
Similarly, in some studies, only subjects who have returned
to their pretreatment weight have been classified as
regainers [34,36], whereas in other studies a regain of 5 lb
(2.2 kg) from posttreatment weight has warranted this
classification [33,37].
Finally, the majority of studies are limited by a cause
and effect confound. Even when the overall design has
been prospective, the analyses involving psychological
factors have usually been correlational in nature because
the variables of interest have only been assessed at follow-
up (rather than at pretreatment and/or posttreatment as
well). Therefore, it cannot be determined whether the
characteristic is a cause, consequence or correlate of
weight maintenance.
Despite these limitations, some data have begun to
emerge about various psychological factors that may play
a role in weight maintenance.
Prospective studies
While a relatively large number of studies have followed-
up patients who have participated in treatment trials for
obesity, only a small proportion of these have assessed
psychological factors to determine their association with
weight maintenance. Four factors have been identified as
potentially important.
Self-efficacy
Jeffery et al. [25] followed a sample of 89 middle-aged
men for 2 years after they had completed a 15-week group
BT programme. The mean weight loss during the treatment
period was 13.5 kg (13.4% of initial body weight), but by
the end of follow-up (in which 91% of the original sample
participated) subjects had regained an average of 63% of
the weight lost. As part of the assessment protocol,
questionnaires (developed by the authors) to measure
perceived psychological well-being, self-efficacy and self-
satisfaction were administered to the men at pretreatment,
posttreatment and at 1-year follow-up. Pre- and posttreat-
ment level of self-efficacy (defined as the confidence
subjects felt in their ability to refrain from eating in the
context of different emotional states or situations involving
food) was the only factor that was found to be positively
related to weight maintenance at both 1- and 2-year
follow-up.
The results of another prospective study are also sug-
gestive of a link between self-efficacy and successful weight
maintenance. Gormally et al. [23] interviewed 33 of 40
female subjects 7 months after they had completed a
4-month BT programme and lost an average of 5.5 kg. Of
the subjects interviewed, 7 (23%) were classified as suc-
cessful maintainers ( < 30% weight regain) and 13 (37%) as
regainers ( > 50% regain). The remaining 13 subjects had
shown little weight change throughout the study. At the
follow-up interview, maintainers reported significantly
greater confidence than the regainers (on a five-point
Likert-type scale) in being able to control both eating urges
and their weight. However, since these data are correla-
tional, the results are clearly subject to the cause and effect
confound that was mentioned previously.
Adverse life events and coping skills
Three prospective studies have reported an association
between experiencing stressful life events and weight regain
[23,24,36]. Dubbert and Wilson [36], for instance, followed
up (via mail and telephone) 58 of an original 62 subjects 30
months after they had completed a 19-week BT programme.
At follow-up, 43% of the subjects who had regained all of
the weight lost (n = 14), but only 15% of those who had
maintained at least part of the weight lost (n = 44) reported
the occurrence of major illnesses, bereavements and other
environmental stressors after the end of treatment.
Other studies have shown that it is not the absence of
stress, but rather the ability to cope with stress, that appears
to be associated with successful weight maintenance
[23,24,38,39]. Gormally and Rardin [24] analysed data from
the interviews of 38 (of an initial 112) female subjects
7 months after attending 16 group BT sessions. Sixteen of
these subjects (42%) were classified as maintainers and 22
(58%) as regainers (had regained >50% of the weight lost).
Both groups reported a similar proportion of unpredictable
 S.M. Byrne / Journal of Psychosomatic Research 53 (2002) 1029–1036
major life changes following treatment (such as a pro-
motion, illness, bereavement, etc.), but only 20% of the
maintainers, compared to 81% of the regainers, reported a
relapse in diet and exercise during the life change. In
addition, none of the maintainers, but almost all (82%) of
the regainers, reported eating in response to emotions
elicited by day-to-day life stressors. Nearly all of the
maintainers (80%) reported using effective problem solving
to cope with stress, either by generating new solutions or
applying concepts learned in treatment. In contrast, none of
the regainers reported such behaviour.
Drapkin et al. [38] found that the ability to generate
coping responses to a number of hypothetical high risk
scenarios predicted future outcome among 79 of an
original group of 93 obese subjects who had participated
in a year-long BT programme. Before starting treatment,
subjects were asked to listen to four scenarios describing
high-risk situations, such as a family mealtime celebra-
tion, an argument, watching television or a stressful
situation at work. The number of coping responses
generated in each situation was assessed. The results
showed that subjects who generated coping responses to
more of the situations showed better maintenance of a
new lower weight at 12-month posttreatment. The ability
to generate any coping response, rather than the number
or type of coping responses generated, appeared to be the
important factor.
Weight goals
The results of one prospective study [40] have suggested
that individuals’ weight goals may play a role in determin-
ing whether they will succeed or fail at maintaining a new
lower weight. In this study, nine men and 38 women, who
had been 15% or more overweight but had reached their
self-determined goal weight in the preceding year, were
recruited using newspaper advertisements.3 Questionnaires
developed by the authors were mailed to subjects every
4 months for 1 year. At the end of the year, over half (58%)
of the subjects were classified as maintainers (had regained
< 20% of the weight lost). The only questionnaire items to
discriminate significantly between maintainers and regainers
related to weight goals, with maintainers being more likely
to have achieved their goal weight by the end of their weight
loss effort.
Dietary restraint and subjective hunger
Two prospective studies have examined whether pretreat-
ment scores on measures of dietary restraint, disinhibition
and hunger, such as Three Factor Eating Questionnaire
3
This study differed from the others in this category, because it
involved subjects who had lost weight on their own, rather than those who
had taken part in a treatment trial.
1031
(TFEQ [41]) or the Restraint Scale [42], predicted long-
term weight maintenance [43,44]. Westerterp-Plantenga
et al. [43] followed-up 27 obese women who had undergone
two 8-week bouts of a very-low-calorie-diet (VLCD). Two
years after the start of the first VLCD, the most successful
subjects (seven women who had regained less than 50%
of the weight lost) showed a significant increase in dietary
restraint and this increase was found to be significantly
negatively correlated with weight regain. This finding,
however, is not particularly informative. It probably
reflects the fact that maintainers were able to persist in
the conscious restraint of food intake more successfully
than were regainers. In a subsequent study using data
from two VLCD treatment groups, Pasman et al. [44]
found that a high pretreatment score on the hunger scale
of the TFEQ (which measures the subjective feeling of
hunger) significantly predicted weight regain at 14-month
follow-up.
Retrospective studies
The majority of retrospective studies in this field have
been quasi-qualitative in nature, using open-ended questions
or semistructured interviews to identify common features
among individuals recruited from the community who
report that they have successfully maintained a new lower
weight. These studies have taken several different forms.
Studies of successful weight maintainers
Colvin and Olson [37] interviewed a sample of 13 males
and 41 females who had lost at least 20% of their initial
body weight and maintained their new lower weight
(to within a range of 2.2 kg) for 2 years. The amount of
weight lost ranged from 9 to 123 kg. Three psychological
characteristics were observed to be common among the
participants. First, all of the subjects reported that they had
achieved their weight goals and they expressed high levels
of satisfaction with their present weight. Second, subjects
reported that losing weight had increased their concern with
and the attention they paid to, their weight, shape and
appearance. Third, the female subjects, in particular,
reported that since losing weight they had become more
confident, self-assured and autonomous, and more capable
of taking control of, and responsibility for, their lives.
Studies of maintainers versus regainers
Rather than focusing exclusively on maintainers, a sub-
set of retrospective studies have examined differences
between formerly obese individuals who have managed to
maintain a new lower weight and those who have lost
weight but subsequently regained it [35,45]. Ferguson et al.
[45], for example, compared the characteristics of 41
women and 41 men who had lost at least 15% of their
1032 S.M. Byrne / Journal of Psychosomatic Research 53 (2002) 1029–1036
body weight and maintained their new lower weight (to
within 2.2 kg) for 1 year, with those of a group of
‘‘unsuccessful dieters’’ (32 women and 28 men whose lack
of success was not defined). All of the subjects took part in
a face-to-face interview. The maintainers were more likely
than their unsuccessful counterparts to report coping easily
with cravings for food and they attributed their suc-
cess to characteristics such as determination, commitment
and patience.
Tinker and Tucker [35] interviewed a small sample
(n = 21) of previously obese men and women who had lost
weight to within the healthy range and maintained their new
lower weight for an average of 4.5 years. A group of 20
currently obese adults who had lost, but regained, weight
were also interviewed. Compared to regainers, maintainers
reported experiencing fewer negative events during, and
especially after, weight loss. This led the authors to suggest
that maintenance may depend on stable circumstances after
active behaviour change. However, this finding may well be
a consequence, rather than a cause, of successful weight
maintenance. Regainers may be more likely to recall nega-
tive events after weight loss by way of explaining their
weight regain, or because of the negative impact of their
failure to maintain weight.
Studies comparing maintainers, regainers and stable
healthy weight individuals
One limitation of studies, which have compared success-
ful maintainers to regainers, is that the maintainers generally
weigh less than the regainers, so any psychological differ-
ences may be due to differences in current body weight. One
study [34] has compared maintainers to both regainers and
to stable healthy-weight subjects. In this study, 700 female
volunteers recruited from a large health maintenance organ-
ization were asked to categorize themselves as maintainers,
regainers or healthy weight. Fifty volunteers were then
randomly selected from each of these categories for further
screening and a final sample of 108 women were selected
for interview — 30 formerly obese women who had main-
tained a healthy weight for at least 2 years, 44 obese women
who had previously lost at least 20% of their weight but had
regained all of it and 34 healthy weight subjects with no
history of obesity who had always remained within 3.6 kg of
their current weight.
The main features distinguishing maintainers from
regainers related to problem solving skills. Over 70% of
the regainers attributed their weight regain to eating in
response to stressful life events or to negative emotional
states. Few regainers (10%) reported using problem-solving
or direct ways of coping with problems compared with
maintainers (95%) and normal weight subjects (60%). For
example, rather than dealing with problems directly, most
regainers reported using ‘‘escape-avoidance’’ ways of cop-
ing such as eating, sleeping more or wishing the problem
would go away.
Studies based on the American National Weight Control
Registry (NWCR)
The most detailed information so far about successful
weight maintainers has been provided by a series of studies
based on the NWCR. The NWCR is an ongoing registry that
was set up in 1997 by Wing and colleagues, in order to
identify individuals who are successfully maintaining a new
lower weight [46]. To enrol in the NWCR, participants must
have lost at least 13.6 kg (30 lb) and must have maintained
this weight loss for at least 1 year. Currently, there are over
3000 individuals in this registry [47].
Participants are initially recruited through local and
national television, radio, magazine and newspaper adver-
tisements and then screened to verify that they fit the
inclusion criteria. Registry members are sent a packet of
questionnaires, which include questions about demographic
and weight characteristics, weight-loss and weight mainten-
ance strategies, and the effect of weight loss and mainten-
ance on aspects of their lives. Additional self-report
questionnaires include the 20-item Centre for Epidemiologic
Studies Depression scale (CES-D [48]), the TFEQ and
questions taken from the self-report version of the Eating
Disorders Examination [49].
In 1999, McGuire et al. [33] reported on the 1-year
follow-up of 714 NWCR members (91% of the original
sample). They investigated whether any of the character-
istics measured at entry into the registry predicted weight
regain versus continued weight maintenance over the
subsequent year, and whether change in psychological
characteristics would occur in weight regainers compared
with maintainers.
Of the individuals assessed at 1-year follow-up (subjects
were asked to report their present weight and to complete
again the self-report measures that were administered on
entry into the NWCR), 36% were classified as having
gained weight over the year (i.e., gained more than 5 lb
[2.2 kg]); 57% were classified as having maintained weight
(within 2.2 kg); and 6% were classified as having lost
weight (i.e., more than 2.2 kg). It should be pointed out
here that a weight gain of 2.2 kg is a very narrow definition
of regain, so the categorization described above may be
problematic, especially given the study’s reliance on self-
report data and the fact that weight fluctuation of this
magnitude is common.4
The regainers were found to differ significantly from the
maintainers on several of the initial assessment variables,
and a stepwise logistic regression model revealed four
factors that independently predicted which individuals
would gain weight over the year versus those who would
4
Moreover, despite an average weight gain of 7 kg, 81% of the
regainers still met the entry criterion for the NWCR and 96% were still
maintaining a 10% weight loss. None had returned to their maximum
lifetime weight.
 S.M. Byrne / Journal of Psychosomatic Research 53 (2002) 1029–1036
maintain weight. First, those subjects who had a higher
maximum weight and a greater initial weight loss were
more likely to have relapsed. Second, subjects who had
maintained their new lower weight for a shorter period of
time were more likely to have regained weight at 1-year
follow-up. Third, subjects who, at the initial assessment,
reported that they were still trying to lose weight were at
higher risk of weight regain than those who reported that
they were aiming to maintain weight. And fourth, subjects
who reported higher dietary disinhibition levels at the
initial assessment were at greater risk of gaining weight
at 1-year follow-up.
Over the follow-up period, maintainers showed no
changes on any of the psychological measures taken at
baseline, whereas the regainers, not surprisingly, reported a
marked decrease in dietary restraint. In addition, regainers
not only reported higher levels of dietary disinhibition,
binge eating and depressive symptoms than maintainers at
the initial assessment, but also worsening on these param-
eters over time. These findings suggest the possibility that
the regainers had already started to regain weight when
they entered the registry, and then merely continued to
regain weight over the following year. The reliability of
the data relating to binge eating in this study is uncertain
since it was assessed by self-report questionnaire only
(rather than by interview).
A subsequent study based on the NWCR [50] looked at
the relationship between duration of weight maintenance
and the effort, attention and pleasure associated with weight
maintenance. Registry members (758 women and 173 men)
who had completed 1-year follow-up assessments were
asked to indicate, using Likert-type scales, firstly, how much
effort they devoted to weight maintenance; secondly, how
much attention they felt was required to maintain their new
lower weight; and, thirdly, how much pleasure they felt that
they derived from successful weight maintenance.
Linear regression analysis indicated that as the duration
of weight maintenance increased, a shift in the balance
between effort and pleasure seemed to occur. Subjects
who had maintained a new lower weight for longer periods
of time reported that significantly less effort and less
attention was needed to be applied to maintain their weight.
In contrast, the pleasure derived from weight maintenance
was not affected by duration. So the duration of weight
maintenance was associated with greater pleasure relative to
the effort required to maintain weight. The decrease in the
burden of maintaining the weight lost, coupled with no
change in the associated pleasure, may facilitate continued
maintenance of a new lower weight.
Some caution should be used in generalising the find-
ings from this group of studies based on the NWCR for
two main reasons. Firstly, registry members may not be
representative of all successful weight maintainers (97% of
the participants were white and 54% had a college degree).
Secondly, although the attrition rate from the registry over
time (10%) was low, there may still have been a response
1033
bias, because the subjects who chose not to answer
questionnaires after 1 year may have been more likely to
have regained weight.
Conclusions
The role of psychological processes in weight maintenance
and relapse
It has been suggested that weight regain following
successful weight loss can be attributed almost entirely to
biological processes [51 – 54], and that behaviour modifica-
tion is simply inadequate to counteract physiological fac-
tors, such as a relatively low metabolic rate [55,56],
adaptive thermogenesis [57,58], decreased fat oxidation
[59,60], increased insulin sensitivity [61] or leptin resistance
[62], which may prime formerly obese people to regain the
weight they have lost.
Further information regarding the contribution of bio-
logical factors to success or failure in long-term weight
maintenance should become available as research in this
area progresses. However, so far, studies have found little
evidence that any of the factors listed above are consistently
predictive of subsequent weight regain in formerly obese
individuals [63,64]. Therefore, the role of other processes,
including psychological processes that might account for the
phenomenon of weight regain, should not be overlooked.
The findings from the studies reviewed here have been
inconsistent and not always informative. Nevertheless, some
evidence has emerged to suggest that the following psycho-
logical factors may offer some potential explanations for
why many formerly obese individuals fail to persist with
critical weight control behaviours following successful
weight loss.
Weight goals
Several studies have suggested that those who achieve
their predetermined goal weight, as compared with those
who do not, may be more successful at long-term weight
maintenance [33,37,40]. Cooper and Fairburn [13,14] have
suggested that the failure to achieve a desired weight may
lead individuals to believe that any further attempts to
control their weight will not be worthwhile, resulting in
the abandonment of weight maintenance behaviours.
Coping strategies and problem-solving skills
Studies from both categories have found that weight
maintainers tend to cope more successfully with adverse
life events than do regainers [23,24,34,38]. It appears that
maintainers may be able to use problem-solving skills to
cope with stressful situations in a way that does not interfere
with their adherence to a weight maintenance regime. One
study has also observed that regainers are more likely to
report over-eating in response to negative emotional states
than are maintainers [34]. This may reflect a tendency for
1034 S.M. Byrne / Journal of Psychosomatic Research 53 (2002) 1029–1036
regainers to use food or eating to moderate negative mood
states, rather than apply more appropriate coping strategies.
Self-efficacy
Two studies have found that successful weight main-
tainers report greater confidence than regainers in their
ability to control their weight and their food intake
[23,25]. It is possible that the belief that they can control
their weight increases the likelihood that individuals will
continue to engage in effective weight control behaviours
following weight loss. There is also some evidence that, for
maintainers, this increase in confidence can permeate other
aspects of their lives [35,37].
Vigilance with regard to weight control
Formerly obese people probably have to impose con-
tinual control on energy intake and energy expenditure in
order to maintain a new lower weight, especially in the
context of an environment that increasingly favours weight
gain because of the ready availability of highly palatable,
high-fat foods and of a sedentary lifestyle [54]. Maintainers
appear to have recognised (and responded to) the need for
continued vigilance in this regard [37,43,45].
Effort versus benefits
In one study [50], maintainers reported that the benefits
afforded by weight maintenance fully justified the effort
involved in adhering to a weight maintenance regime. It is
possible that the balance between the effort involved and the
benefits received from weight maintenance plays a role in
either facilitating or hindering adherence to weight main-
tenance behaviours.
Binge eating, dietary restraint, disinhibition and hunger
A small number of studies have found that scores on
various measures of binge eating, dietary restraint, disinhi-
bition and subjective feelings of hunger are related to weight
regain [33,43,44]. However, it is possible that some of these
results simply reflect subjects’ actual weight trajectories
over time. For instance, the finding that an increase in
dietary restraint is associated with weight maintenance
(and a decrease with weight regain) is not at all surprising.
High pretreatment levels of binge eating, disinhibition and
subjective hunger have been found to predict weight regain
at follow-up [33,44]. However, the data relating to binge
eating in particular are unreliable, since they have been
based solely on self-report questionnaire measures.
Directions for future research
Most pressing among the questions that remain
unanswered in obesity research is: why do most people
who lose weight regain it? Relatively little research has been
carried out on the psychological mechanisms that may be
associated with successful maintenance of a new lower
weight, as opposed to relapse, in obesity. The results of
the studies reviewed in this paper have provided some
limited information about the psychological factors that
may be important in this regard, however, the ways in
which these factors work to influence weight maintenance
is unknown. Further research, which focuses specifically on
the psychological processes (particularly the cognitive pro-
cesses) involved in weight maintenance and relapse, is
clearly needed if we are to improve psychological interven-
tions for obesity.
A first step in this direction would be to generate some
initial hypotheses regarding the whole range of psycho-
logical factors that might account for why, after losing
weight, many individuals do not persist with the forms of
behaviour that are crucial for weight maintenance. These
hypotheses would then need to be tested in a series of
prospective studies following-up formerly obese subjects for
a period of time after they have lost weight. Such a
systematic analysis of the factors that influence successful
weight maintenance, as opposed to weight regain, in obesity
will lay the foundation for more focused psychological
treatments, which may result in substantial improvements
in treatment response.
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