I recently visited my optometrist for an annual exam. He has a pleasant bedside manner and happens to be among the 40% of the U.S. adult population who are obese. As I stepped into his office, I noticed he looked different but couldn't quite pinpoint how – maybe it was his facial hair or his energetic greeting. Whatever it was, it was an improvement. As we chatted during the exam, he proceeded to share that he had lost 50 lbs on the keto diet over the last several months and was tickled pink that he didn't feel hungry. His friends made him keto cheesecake for Christmas, and he joined an online community. "It's just GREAT," he gushed. His enthusiasm was infectious, and there was no way I was going to dampen his spirit with the grim statistics on long-term weight loss.
Less than 20% can keep at least 10% of their body weight off for more than a year. 
The stats get even worse as more time goes by. Studies demonstrate that diets, regardless of the type, produce similar amounts of weight loss and are challenging to stick to.  I believe it’s at least in part because humans are creatures of habit, and habits are hard to change. Therefore, if my optometrist and the millions of others who start a diet cannot adopt it as a new lifestyle, they will likely regain the weight once they go back to their old habits. You can probably think of at least a few people who have lost weight only to gain it back and then some. The struggle is REAL!
As we embark on the start of a new year and a new decade, you've probably noticed the extra bodies in the gym which parallels the steep increase in people starting new diets, "detoxes," "cleanses," and so on. Inevitably, weight loss stalls at some point, leading to the dreaded plateau and business as usual in the gym by mid-February. As Fitness Professionals, there's nothing more satisfying than clients transforming, whether physical, mental, spiritual, or all the above, and it can be equally demoralizing when clients get stuck or experience a weight rebound. Weight loss plateaus are an inherent part of our job description, and knowing how to overcome them is a critical and valuable skillset. In this article, we'll review the common causes of plateaus and strategies to break them.
First, let's tackle the basics of weight loss. The human body follows the Laws of Thermodynamics, also referred to as energy balance. Energy is expressed in calories – the calories we burn through exercise, other movements, digestion, and metabolism (table below) and the calories contained in food and beverages. Weight loss occurs when there's a calorie deficit – that is, the calories you take in are fewer than the calories you expend. The body then mobilizes its calorie stores from adipose tissue, glycogen stores, and lean body mass to fuel all metabolic processes to keep you alive. By definition, a plateau occurs when calorie expenditure equals intake over time. In other words, the calories you consume equal the calories you burn, and the deficit no longer exists, thereby negating the body's need to pull calories from its stores.
Components of Calorie Expenditure
|BMR (basal metabolic rate)||60-70%|
|NEAT (non-exercise activity thermogenesis)||15-50%|
|TEF (thermic effect of food)||8-15%|
Common Causes of a Plateau
What causes a calorie deficit to diminish as one loses weight? For one, as body mass declines, there's less metabolically active tissue. One's BMR makes up the bulk of total calories expended daily and is based on body size. Essentially – the more mass you have, the more you burn and vice versa. Therefore, BMR declines with weight loss and to an even higher degree when muscle tissue is lost, thereby reducing daily calorie expenditure. A common misperception is that you drastically reduce BMR during weight loss, and people enter "starvation mode" in which the lack of calories causes their metabolism to plummet, thus resulting in a plateau. In reality, reductions in BMR beyond the loss of mass are slight for most (3-5% compared to weight-matched controls) and the body does make some adaptions to conserve energy, but these do not prevent weight loss from occurring when a calorie deficit persists. [2,3]
The Minnesota Starvation Study by Ancel Keys demonstrated the effects of actual starvation in 36 men who volunteered to lose 25% of their body weight so that scientists could study the impact of famine and ways to treat it.  Calories were restricted by ~1,600 per day and adjusted to continually maintain a calorie deficit to force weight loss over six months. They all lost weight despite reductions in BMR because a deficit was maintained through daily activity and by lowering calorie intake when needed. The claim that is not eating enough (i.e., starvation mode) causes one to retain body fat is not only unfounded but goes against human physiology.
When weight loss stalls, it's because the deficit no longer exists, not because of starvation, a messed-up metabolism, or "not eating enough."
Daily calorie expenditure also decreases during weight loss because fewer calories are required to move around. Imagine carrying around a 20-pound backpack for years and then taking it off for good – every movement is a little easier and costs less energy, including exercise. As one gets accustomed to regular exercise, the energy cost of exercise is lower due to increased metabolic efficiency.  As a result, you expend fewer calories for any given workout as fitness level increases.
you lose weight, your BMR decreases proportionately, and as you get more fit,
the number of calories you burn for the same workout drops. For weight loss to
continue, you must lower intake and/or increase expenditure. UGH. But hold on,
it's not all bad news.
An often-overlooked factor on the calorie expenditure side is NEAT – an acronym for non-exercise activity thermogenesis, the calories burned through any movement aside from planned workouts. Think activities of daily living such as chores and grocery shopping, as well as spontaneous movements such as fidgeting or pacing. Some NEAT is not under our conscious control, such as fidgeting or maintaining an upright posture, so we'll address the NEAT that is consciously modifiable.
Dr. James Levine’s work has demonstrated that NEAT levels can vary up to 2,000 calories per day among adults of similar size.  In other words, one person can burn approximately 2,000 more calories than another through their daily routine, not including exercise. That's HUGE. The type of work one does have the most significant impact on our conscious NEAT. The table below shows the effect of one's job on calories burned through NEAT. 
|Physical Activity Level of Job||NEAT Calories Expended Per Day|
|Seated with Some Movement||700-1,000|
Activities during leisure time also fall under NEAT. Watching TV or going to the movies requires less energy output than strolling along the beach, walking around a museum, or doing outdoor activities. What activities do your clients do when they're not working?
Calories Burned Per Hour Above Resting 
|Walking at 1 mph||70|
|Walking at 2 mph||150|
Weight loss has a profound impact on NEAT levels that often go unnoticed, and trainers often end up recommending clients perform more cardio when a plateau occurs. Although trainers may not mind this approach, clients tend not to be as enthusiastic. Research has demonstrated that individuals who lose 10% of their initial body weight experienced a 20-25% reduction in their daily calorie expenditure.  As noted, 10-15% of this is due to a lower BMR from the loss of mass, but lower NEAT levels account for at least half of the remaining reduction. 
People unknowingly move around a lot less when they’re in a calorie deficit.
This is good news because BMR is essentially unchangeable, and TEF is a small component of daily calorie expenditure. Yet, NEAT can be consciously and significantly increased to help clients expend more calories throughout the day WITHOUT having to add cardio. YAY!
Calorie Intake & Appetite
From a big-picture perspective, we humans are hard-wired to survive and propagate the species, so it makes sense that a lack of food (calorie deficit) would signal our brain to conserve energy and increase the drive to eat to stop us from wasting away to death. Indeed, hormonal changes occur during weight loss, such as decreases in leptin and insulin along with increases in ghrelin, which send signals that increase the drive to eat.  Hunger and appetite can be somewhat influenced by macronutrient composition. Still, hormonal changes are simply part of the process.
A common cause of weight loss plateaus, which we can help our clients with, is underreporting calories.  People think they eat less than they do, whether it's from under-guesstimating portion sizes, lack of calorie knowledge, and/or something I refer to as "calorie amnesia" – eating without being aware. Examples include grazing on the treats in the office, eating kids' leftovers, or mindlessly munching and downing adult beverages while binge-watching on Netflix.
In one study of obese individuals who claimed they couldn’t lose weight despite eating less than 1,200 calories a day, participants under-reported daily calorie intake by up to 2,000 calories while over-estimating their physical activity levels.  Furthermore, their resting metabolic rate and total energy expenditure were measured and found to be within normal ranges. Another study compared seven days of recording intake among trained nutrition professionals (dietitians) with untrained individuals and observed underreporting calories in both groups. On average, the untrained group underreported how much they ate by 429 calories while the dietitians underreported by 223 calories.  This goes to show that even trained professionals underestimate calorie intake. Weekend eating can be problematic, as well. People often have less structure on the weekends, eat out more, and tend to gravitate towards higher calorie options, which can contribute to underestimating calorie intake, thus slowing weight loss.
In summary – the most significant contributing factor to a plateau on the calorie expenditure side is NEAT. On the calorie intake side, hunger, adherence, and underestimating calories are all issues that can result in a plateau. That brings us to potential solutions.
Strategies to Break a Plateau
First and foremost, it's essential to
implement best practices to slow or help offset the body's attempt to adapt to
a calorie deficit. These include the following:
- Set an appropriate rate of weight loss of approximately 0.5 to 1.0% of the total weight weekly. More aggressive fat loss can occur in those with higher starting fat mass. However, drastic losses may signal the body to make more significant adaptations, plus slower weight loss may mitigate the loss of lean body mass, particularly in lean individuals. 
- Before recommending any diet or weight loss strategy, consider adherence to the protocol. Ask your client if they can see themselves eating this way for the long-term if permanent weight loss is the goal.  The closer the eating style is to their current one, the more likely they can stick to it.
- Increase daily protein intake to at least 0.7 – 1.0 g per pound of body weight. Higher amounts (2.3-3.1 g/kg of LBM per day) can benefit lean, trained individuals in a calorie deficit.  Protein not only helps preserve lean body mass but also has a higher thermic effect of food than carbs and fat and helps boost manage hunger levels by boosting satiety.
- Meet daily fiber requirements by including fiber-rich foods such as veggies, fruit, whole grains, and legumes. This can help lower calories while adding food volume to help manage hunger levels and boost micronutrient intake. 
- Don’t eliminate all dietary fat – your body requires fat for various reasons, including the production of hormones and absorption of vitamins.
- Resistance train regularly to protect and build muscle tissue.
- Get adequate sleep for overall health and appetite regulation. General recommendations include 7.5 hours a night.
- Manage stress to prevent emotional eating. Meditation, deep breathing, yoga, fun hobbies, and recreation, practicing gratitude, and nurturing relationships are effective.
Knowing that NEAT levels drop significantly with weight loss, monitor initial NEAT levels using daily steps, and make sure steps do not decrease. Steps may need to increase with weight loss to offset the drop in BMR. There is a link between higher step counts and more significant weight loss.  When I read Dr. Levine’s research on NEAT, I make shifted a treadmill desk by placing a boogie board on my treadmill so I could switch from being sedentary for 8+ hours a day to walking at 2.0 mph for a few hours a day while I worked on my computer and had conference calls. I burned an extra 350+ calories a day during my workday without having to do more cardio. Talk about a game-changer! It must've been karma because I ended up winning the TrekDesk (see image), which Dr. Levine helped invent, and I've been using it for the past ten years, which has helped me increase my daily calorie expenditure and make maintaining a healthy weight much more manageable.
Tips to Increase NEAT
|Set a daily step target||Have walking meetings|
|Set alarms to get up hourly and walk down the hall or up and down stairs||Walk slowly on a treadmill while watching TV, internet shopping or while working if feasible|
|Schedule short walks throughout the day||Pace while talking on the phone|
| Walk after meals
Walk during kids’ practices
|Make house chores inefficient – bringing several small loads of laundry up the stairs|
|Choose active leisure activities||Park your car further away at work|
Nutritional + Self-Monitoring Strategies
- To overcome under-reporting and calorie amnesia, have clients track food and beverage intake closely for at least a short period to increase their nutrition knowledge and calorie content of food. More frequent tracking for a more extended period is more effective than less frequent and shorter durations. 
- Increase the effectiveness of tracking food by using measuring cups and a food scale to help cure portion distortion.
- Use protein-rich meal replacements to reduce calorie intake, increase daily protein intake, and for convenience. Meal replacements have been shown to increase weight loss and maintenance compared to other forms of dieting. 
- Periodically increase calorie intake to maintenance levels for at least 2-3 days and up to 2 weeks of maintenance calories to improve adherence and possibly mitigate metabolic adaptations [16, 17]
- Self-weigh regularly at least three times a week if this doesn't cause emotional or psychological distress. More frequent weigh-ins are associated with more significant weight loss. 
Weight loss plateaus are not caused by a broken metabolism, starvation mode, or not eating enough. A plateau is an inevitable occurrence during weight loss because the body perceives a calorie deficit as a threat to survival. It responds by trying to close the gap by decreasing BMR and, to a higher degree, NEAT, while increasing the drive to eat. Science gives us various methods and best practices to overcome plateaus, yet the effectiveness of any given strategy depends on factors such as feasibility, consistency, and, most importantly, reestablishing a calorie deficit. As you apply this information and strategies and stay away from unproven methods, be sure to consider your client's readiness, lifestyle, preferences, and personality so that they adopt the skills and habits that are needed to not only break the plateau but to achieve lifelong satisfaction of a healthy body weight and active lifestyle.
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