The “news” that a sampling of contestants on “The Biggest Loser” reality show had regained much of the weight they lost set off shock waves in the media. “Isn’t this a depressing finding?” several interviewers asked me. If you look only at the headlines, yes, it can be depressing. Dig deeper, though, and this finding points the way to smarter and more effective ways to lose weight and keep it off.

The research paper in the journal Obesity by Erin Fothergill and her colleagues that got everyone talking about regaining weight made several key points.

Metabolism slows. Losing weight slows the body’s metabolism. That means calories are burned more slowly, both at rest and during exercise. This is likely a survival mechanism. Experts believed that metabolism would eventually speed up on its own after weight loss stopped or when weight gain started. Not so, according to the new research. Among the 14 “Biggest Loser” contestants, a slowed metabolism persisted for six years or more despite significant weight gain.


Hormones change. Leptin, one of several hormones that controls satiety, tells the brain and other parts of the body when you’ve eaten enough. Weight loss lowers the leptin level, making you feel constantly hungry. In the “Biggest Loser” group, leptin levels had dropped twentyfold at the end of the 30-week competition, and were still down by one-third six years later.

Everyone is different. Among the contestants, some gained back almost all of the weight they had lost; others gained back a fair amount of it. One contestant, however, continued to lose weight.

The weight gain sagas of “Biggest Loser” contestants aren’t new. Time magazine wrote about it in 2007. The first female winner, Ali Vincent, recently revealed on Facebook that she was joining Weight Watchers where she “weighed in close to the weight I started at on The Biggest Loser.” Some contestants, though, have been able to keep off the weight they lost.

The setpoint

Losing weight is about far more than how many calories you take in and how many you burn. It’s essentially about changing the communication between your brain and your digestive system.

Each of us has a setpoint — the weight that the brain and metabolism see as “right” for us. It is determined by genes, the environment we are exposed to in the nine months before being born, and family and social influences early in life. Extreme dieting and exercise can yield rapid weight loss. But, as the Fothergill paper showed, the brain and metabolism tend to nudge weight back to the setpoint. The combination of low leptin and a slowed metabolism drive this weight gain.

The setpoint concept reveals a fundamental tenet of obesity: It is a chronic condition, much like high blood pressure and diabetes. It isn’t something that can be fixed once, but requires lifelong attention.

Fighting weight regain

Here’s the good news: It is possible to lose weight, even a lot of weight, and keep it off. Be warned: There’s no cookie-cutter approach, and it takes a lifetime of vigilance. Here are the basic elements that my colleagues and I at the Massachusetts General Hospital Weight Center work on with our patients.

Food. Pay attention to diet quality, not just calories. Nutritious foods such as fruits, vegetables, whole grains, beans, and other healthful protein sources are best for weight loss.

Exercise. For the average person, normal amounts of exercise — an hour or so a day, not the hours and hours put in on “The Biggest Loser” — do little for weight loss. Instead, exercise is excellent for maintaining weight and preventing weight gain.

Sleep. Poor sleep can promote weight gain. In some people, correcting sleep apnea or other sleep disorders can open the gate to weight loss.

Medication review. Some antipsychotic medications, antidepressants, sleep medications, insulin, prednisone, and other prescription medications may cause people to gain weight. It is often possible to switch to related medications that don’t cause weight gain.

Weight-loss medications. Several FDA-approved drugs effectively control weight. But they are not used widely, either because physicians are skeptical of them or patients feel like they are “cheating” by taking a medication. It is really no different than taking a medication over the long term to control high blood pressure. Medication can be a tool to help achieve a healthy weight.

Weight-loss surgery. We used to believe that weight-loss surgery (bariatric surgery) worked by shrinking the size of the stomach so it accepted less food. While a reduced stomach size may play a minor role in weight loss, procedures such as the vertical sleeve gastrectomy or Roux-en-Y gastric bypass affect the back-and-forth hormonal signaling between the brain and the stomach. This can change the weight setpoint. Many of my patients who have undergone one of these procedures say they don’t feel as hungry as they used to feel.

If you’ve struggled with your weight or, like many of the Biggest Losers, have regained what you’ve lost, don’t give up. Find a health care provider who understands what you have been going through, supports your efforts, and works with you over the long haul.

Fatima Cody Stanford, MD, is an obesity specialist at Massachusetts General Hospital’s Weight Center and an instructor in medicine and pediatrics at Harvard Medical School. She has received payments from Novo Nordisk.

This article was edited to update the author’s disclosures.

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  • I always feel frustrated when I hear people saying that obese people cannot walk around the block, or that they sit and eat junk food all day. I am obese and I eat vegetables every day, I eat almost exclusively whole grain products when I eat carb heavy foods, I watch my protein and fibre intake. I also walk my dogs between 3-5km nearly every day, and lift heavy weights 2 days a week, and I had a job for two years where I stood up all day long (and gained weight, not lost it). I wear a fitbit and get 10 000 steps on the majority of days. If I do not monitor my calories closely, I gain weight non-stop. I lost significant amounts of weight in the past and feel this might be part of an explanation as to why I have to eat less than other people to maintain my weight. (I lost 112lbs in 2005, regained 87lbs, lost 67lbs in 2008-2010 -kept it off for two years before regaining again) I’m not saying there is something physically wrong with me (I do have hypothyroidism but it is controlled), just that I love food. Good food. Healthy food. But a bite here and there adds up fast, and if I’m not careful I’m over 2000 calories if I’m not purposely trying to hit a target goal. I am so frustrated that people think from looking at me that I am lazy, don’t exercise and eat junk food non-stop. It simply is not the truth. I can’t “give up pop and lose 10lbs” because I do not drink pop! I can’t “fidget more” and lose weight, because I already fidget non-stop! This sort of news just explains what I already knew inside, that if I want to lose weight and keep it off I will have to closely monitor and control my calorie intake to 1200-1500 calories a day, while exercising, for the rest of my life. The rest of my life sounds like an awfully long time to never have cake when people are celebrating, or other such events, but it is what has to be done if I want to be successful.

    I started this all because of the comment that most obese people are sedentary. I very much disagree with this as most obese people I know, you would say “Oh you aren’t obese, you are just a bit overweight” and most of the people, even the larger ones like me, are actually just as active, if not more so, as many “normal” weight individuals.

  • I don’t understand where it states that moderate exercise doesn’t help weight loss. Of course it does, particularly for the sedentary…which most obese people are. And it’s supposed to help metabolism too.

    • It shows tremendous weight bias to assume that persons with obesity are all inactive. This is certainly not true.


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