The Role of Accountability in Weight Loss

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One of the most effective weight-loss programs ever was free. Why was it so powerful?

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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Among the more radical weight loss methods that have been employed: “therapeutic starvation.” How can you get people to stop eating? Wire their jaws shut. Yes, that used to be a thing. Terrible. I can’t even imagine the psychological toll.

Surgical fixes like jaw wiring aside, what is the most effective long-term obesity program ever published in the medical literature? The Trevose Behavior Modification Program. Named after a town in Pennsylvania, the program ran all-volunteer self-help support groups beginning in 1970, offering lifetime treatment at no cost. Wait, the most demonstrably successful weight loss program in history was free? Why haven’t more people heard about it? Probably because of that: it was free. Multimillion dollar corporations like Weight Watchers spend hundreds of millions of dollars on advertising each year.

How do the two programs compare? After two years in Weight Watchers, the average weight loss is about six pounds (2.7 kg). After two years in the Trevose program, the average weight loss was 39 pounds (17.7 kg), and after five years, Trevose participants were still down 35 pounds (16 kg). Now, that’s only for about the 20% who stayed in the program that long. What about Weight Watchers participants? After five years sticking with the most rigorous 52-week Weight Watchers program, participants did maintain a lower weight—but only about five and a half pounds (2.5 kg). And drop outs, when reported, averaged around 20%. What appears to be the secret to the Trevose Program’s success? Extreme accountability.

The Trevose program has been likened to “weight-loss boot camp,” but the rigor is in the rules, not the methods. The program utilizes the standard array of traditional techniques: calorie cutting, exercise, weekly weigh-ins, and group support. What sets it apart is the strictness of its enforcement. If members fail to attend meetings or meet their weight-loss goals, they are immediately kicked out, and they can never return. The program accepts almost anyone with one critical exception: no past participants are allowed. There are no second chances, no do-overs, no excuses. When people sign up, they understand that this is a once-in-a-lifetime opportunity. Unfortunately, the program closed in 2021, due to the challenges of hosting in-person groups during the COVID-19 pandemic.

Trevose’s tough-love approach may not be for everyone, but key principles for success, such as social support, may be universal. A randomized trial found that group therapy tends to produce greater results than going it on our own, even among those who initially expressed a preference for individual treatment. Similarly, health coaches can also help people stay engaged and accountable. Self-monitoring is another important takeaway––considered the “cornerstone” of behavioral change for weight loss. Without awareness of our progress, it may be heard to reach our goals.

There are now high-tech wearable activity trackers to monitor our exercise to facilitate weight loss, but the best device for monitoring calorie intake may be the humble bathroom scale. In the past, though, frequent self-weighing for weight control was actively discouraged. Clinicians were concerned dieters might be discouraged by the slow rate of weight loss, or worse, suffer negative psychological effects, potentially putting one at risk for depression or body image issues.

Self-weighing may indeed have a negative impact for adolescents and adults without excess weight, but daily or weekly self-weighing among adults who are overweight or obese appears to actually improve psychological health and wellbeing. Among those who need to lose weight, self-weighing is broadly positive––associated with less depression, disordered eating, and body dissatisfaction––but this may be confounded by the fact that regular self-weighing improves weight loss.

Findings from more than a dozen such prospective studies have consistently found regular self-weighing to be associated with successful weight loss and maintenance, but they are all stricken with the same nagging question. It’s unknown whether those who weigh themselves daily are more motivated to lose weight and, therefore, more likely to weigh themselves more frequently––OR whether frequent weighing sparks behavior change that leads to weight loss. Or maybe there’s a third factor at play. You can’t prove cause-and-effect until you put it to the test.

Randomized, controlled trials have shown that those assigned to daily weighing accompanied by weekly email messaging tailored to their progress lost more weight: about 6% more. They were better able to resist weight gain, and maintained more weight loss. The control groups received nothing, though; so, it’s hard to separate the effects of the weighing from the regular contact. Just telling individuals with obesity to weigh themselves each day without any further instruction or feedback is ineffective as a sole strategy. Self-monitoring has been shown to be an effective behavioral technique for helping people eat more healthfully, exercise more, and drink less alcohol. But unlike those cases, self-weighing is monitoring an outcome, rather than specific behaviors. If people don’t know what do about the fact that they’re gaining weight, it may not help. Self-weighing is just a feedback tool to allow for personal accountability, offering positive or negative reinforcement for whatever strategies you’ve chosen to try out.

The evidence supporting frequent self-weighing as a part of weight management interventions is now considered so strong that it’s been incorporated into the official weight management guidelines put out by the Obesity Society, along with the American Heart Association and the American College of Cardiology, and as part of their most recent guidelines for the prevention of heart disease among people who are overweight or have obesity.

So, how often should we weigh ourselves? There is insufficient evidence to support a specific frequency of weighing, whether weekly or daily. One study found that twice daily—upon waking and again right before bed—appeared superior to once a day (about six pounds (2.7 kg) versus two pounds (0.9 kg) of weight loss over twelve weeks). So, that’s the frequency recommended by Dr. Greger in his book on evidence-based weight loss, How Not to Diet.

Please consider volunteering to help out on the site.

Motion graphics by Avo Media

Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Among the more radical weight loss methods that have been employed: “therapeutic starvation.” How can you get people to stop eating? Wire their jaws shut. Yes, that used to be a thing. Terrible. I can’t even imagine the psychological toll.

Surgical fixes like jaw wiring aside, what is the most effective long-term obesity program ever published in the medical literature? The Trevose Behavior Modification Program. Named after a town in Pennsylvania, the program ran all-volunteer self-help support groups beginning in 1970, offering lifetime treatment at no cost. Wait, the most demonstrably successful weight loss program in history was free? Why haven’t more people heard about it? Probably because of that: it was free. Multimillion dollar corporations like Weight Watchers spend hundreds of millions of dollars on advertising each year.

How do the two programs compare? After two years in Weight Watchers, the average weight loss is about six pounds (2.7 kg). After two years in the Trevose program, the average weight loss was 39 pounds (17.7 kg), and after five years, Trevose participants were still down 35 pounds (16 kg). Now, that’s only for about the 20% who stayed in the program that long. What about Weight Watchers participants? After five years sticking with the most rigorous 52-week Weight Watchers program, participants did maintain a lower weight—but only about five and a half pounds (2.5 kg). And drop outs, when reported, averaged around 20%. What appears to be the secret to the Trevose Program’s success? Extreme accountability.

The Trevose program has been likened to “weight-loss boot camp,” but the rigor is in the rules, not the methods. The program utilizes the standard array of traditional techniques: calorie cutting, exercise, weekly weigh-ins, and group support. What sets it apart is the strictness of its enforcement. If members fail to attend meetings or meet their weight-loss goals, they are immediately kicked out, and they can never return. The program accepts almost anyone with one critical exception: no past participants are allowed. There are no second chances, no do-overs, no excuses. When people sign up, they understand that this is a once-in-a-lifetime opportunity. Unfortunately, the program closed in 2021, due to the challenges of hosting in-person groups during the COVID-19 pandemic.

Trevose’s tough-love approach may not be for everyone, but key principles for success, such as social support, may be universal. A randomized trial found that group therapy tends to produce greater results than going it on our own, even among those who initially expressed a preference for individual treatment. Similarly, health coaches can also help people stay engaged and accountable. Self-monitoring is another important takeaway––considered the “cornerstone” of behavioral change for weight loss. Without awareness of our progress, it may be heard to reach our goals.

There are now high-tech wearable activity trackers to monitor our exercise to facilitate weight loss, but the best device for monitoring calorie intake may be the humble bathroom scale. In the past, though, frequent self-weighing for weight control was actively discouraged. Clinicians were concerned dieters might be discouraged by the slow rate of weight loss, or worse, suffer negative psychological effects, potentially putting one at risk for depression or body image issues.

Self-weighing may indeed have a negative impact for adolescents and adults without excess weight, but daily or weekly self-weighing among adults who are overweight or obese appears to actually improve psychological health and wellbeing. Among those who need to lose weight, self-weighing is broadly positive––associated with less depression, disordered eating, and body dissatisfaction––but this may be confounded by the fact that regular self-weighing improves weight loss.

Findings from more than a dozen such prospective studies have consistently found regular self-weighing to be associated with successful weight loss and maintenance, but they are all stricken with the same nagging question. It’s unknown whether those who weigh themselves daily are more motivated to lose weight and, therefore, more likely to weigh themselves more frequently––OR whether frequent weighing sparks behavior change that leads to weight loss. Or maybe there’s a third factor at play. You can’t prove cause-and-effect until you put it to the test.

Randomized, controlled trials have shown that those assigned to daily weighing accompanied by weekly email messaging tailored to their progress lost more weight: about 6% more. They were better able to resist weight gain, and maintained more weight loss. The control groups received nothing, though; so, it’s hard to separate the effects of the weighing from the regular contact. Just telling individuals with obesity to weigh themselves each day without any further instruction or feedback is ineffective as a sole strategy. Self-monitoring has been shown to be an effective behavioral technique for helping people eat more healthfully, exercise more, and drink less alcohol. But unlike those cases, self-weighing is monitoring an outcome, rather than specific behaviors. If people don’t know what do about the fact that they’re gaining weight, it may not help. Self-weighing is just a feedback tool to allow for personal accountability, offering positive or negative reinforcement for whatever strategies you’ve chosen to try out.

The evidence supporting frequent self-weighing as a part of weight management interventions is now considered so strong that it’s been incorporated into the official weight management guidelines put out by the Obesity Society, along with the American Heart Association and the American College of Cardiology, and as part of their most recent guidelines for the prevention of heart disease among people who are overweight or have obesity.

So, how often should we weigh ourselves? There is insufficient evidence to support a specific frequency of weighing, whether weekly or daily. One study found that twice daily—upon waking and again right before bed—appeared superior to once a day (about six pounds (2.7 kg) versus two pounds (0.9 kg) of weight loss over twelve weeks). So, that’s the frequency recommended by Dr. Greger in his book on evidence-based weight loss, How Not to Diet.

Please consider volunteering to help out on the site.

Motion graphics by Avo Media

Doctor's Note

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