Suppose you recommend that your patient eat 550 fewer calories each day. He would lose approximately 15 lbs and stop. To maintain that weight loss, he would have to continue eating 550 calories less each day. He will not continue to lose weight indefinitely. If that patient needed to lose more weight, then he would have to either decrease his caloric intake further or significantly increase his energy expenditure.

Herein lies the reason why most diets don’t work in the long term. An individual can’t starve himself by eating a 500-calorie diet, lose 50 lbs, and then return to his normal diet before the weight loss, or even to a healthy diet, and expect to keep the weight off. As he loses weight it becomes harder to lose more weight — unless he does something to disrupt the relationship between total energy expenditure and fat-free mass.

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This is one of the reasons that, as physicians, we should always include exercise as part of a patient’s weight-loss program. However, if you have ever jogged on a treadmill, you would have noticed that it is significantly easier to cut 500 calories out of your diet than to burn it via exercise.

For these reasons, diet and exercise alone are not getting patients to their goals — and obesity remains a major risk factor for cardiovascular disease and death.

A recent study noted that high BMI accounts for 4 million deaths globally, with two-thirds of the deaths related to cardiovascular disease.2 To make matters worse, a recent study found that frequent weight gains after successful weight loss may be increasing patients’ risk for adverse cardiovascular events. 

In a post-hoc analysis of the Treating to New Targets Trial (TNT), Dr Bangalor et al explored the risks associated with fluctuating weight in patients with established coronary artery disease. A total of 9509 participants with known coronary artery disease were evaluated, and hazard ratios for various cardiovascular events (including stroke, myocardial infarction, and death) were calculated for different quartiles of weight variation. 

After controlling for known coronary arterial disease (CAD) risk factors, the authors found that compared to the lowest quartile of weight variation, the highest quartile (ie, those with the greatest fluctuations in weight) had the highest risk of having a myocardial infarction, stroke, or even dying — independent of traditional risk factors.3

It seems that as physicians, we have found ourselves in an unfortunate “catch-22.” We all recognize the health benefits of exercise and weight loss in reducing cardiovascular risk. We are also starting to understand that sustained weight loss is a complex problem that cannot be solved by the over-simplified equation that “energy in equals energy out.” Now we have data suggesting that patients with established coronary disease who have wide fluctuations in weight have a significantly higher risk for adverse cardiovascular outcomes than those who didn’t lose weight and gain it back.

Having struggled with weight issues for most of my life, I can relate to many of my patients’ difficulties losing weight. As a result, rather than recommending weight loss as the solve-all solution to their cardiovascular health, I’ve started promoting healthy diets rich in fruits and vegetables, low in carbohydrates, salt, and saturated fats, with daily exercise. 

I encourage my patients to follow the diet and exercise as a lifestyle change and not as a means to losing weight. Eating healthy and exercising is the goal — not weight loss. It remains to be seen how successful this strategy is. But thus far, my patients seem to find this strategy more encouraging and supportive than just telling them to lose weight.


  1. Gardner D G, Shoback D M, and Greenspan F S. Greenspan’s Basic & Clinical Endocrinology. New York: McGraw-Hill Medical, 2011.
  2. “Health Effects of Overweight and Obesity in 195 Countries over 25 Years.” The New England Journal of Medicine. 2017. doi: 10.1056/NEJMoa1614362
  3. Bangalore S et al. “Body-Weight Fluctuations and Outcomes in Coronary Disease.” The New England Journal of Medicine. 2017;376: 1332-1340. doi: 10.1056/NEJMoa1606148