Post on 01-Mar-2023
REVIEW
Lifestyle modification in the management of obesity:achievements and challenges
Riccardo Dalle Grave • Simona Calugi •
Marwan El Ghoch
Received: 10 April 2013 / Accepted: 17 July 2013 / Published online: 27 July 2013
� Springer International Publishing Switzerland 2013
Abstract Lifestyle modification therapy for overweight
and obese patients combines specific recommendations on
diet and exercise with behavioral and cognitive procedures
and strategies. In completers it produces a mean weight
loss of 8–10 % in about 30 weeks of treatment. However,
two main issues still to be resolved are how to improve
dissemination of this approach, and how to help patients
maintain the healthy behavioral changes and avoid weight
gain in the long term. In recent years, several strategies for
promoting and maintaining lifestyle modification have
been evaluated, and promising results have been achieved
by individualising the treatment, delivering the interven-
tion by phone and internet or in a community setting, and
combining lifestyle modification programs with residential
treatment and bariatric surgery. These new strategies raise
optimistic expectations for the effective management of
obesity through lifestyle modification.
Keywords Obesity � Lifestyle modification �Cognitive behavioral therapy � Exercise � Diet �Residential treatment � Bariatric surgery � Drugs
Introduction
Behavioral therapy for the management of obesity has been
designed to provide patients with a set of procedures and
strategies to improve their long-term adherence to the
changes in their eating and exercising habits [1]. The
treatment was originally based exclusively on learning
theory (i.e., behaviorism), which postulates that the
behaviors that cause obesity (overeating and under-exer-
cising) are largely learned, and could therefore be modified
or relearned. It suggests that positive changes in eating and
exercising can be achieved by modifying the environ-
mental cues (antecedents) and reinforcements of these
behaviors (consequences) [2, 3]. Behavioral therapy was
later integrated with cognitive strategies (e.g., problem
solving and cognitive restructuring) and specific recom-
mendations on diet and exercise, and this multifaceted
combination is commonly referred to as ‘‘lifestyle modifi-
cation’’ [4]. Recent developments include the use of
community settings, phone, and internet to facilitate the
delivery of the intervention, and combining lifestyle
modification with residential treatment and/or bariatric
surgery to improve the weight loss outcome.
The aim of this article is to provide a narrative review of
the principal components and achievable results of lifestyle
modification programs in the management of obesity.
Indications and contraindications of weight loss lifestyle
modification
Practice guidelines formulated by the US National Heart,
Lung and Blood Institute and the North American Asso-
ciation for the Study of Obesity, as well as more recent
guidelines [5], recommend that the association of diet,
physical activity, and behavioral therapy should be con-
sidered as the primary option for treating obese (i.e., body
mass index C30 kg/m2) and overweight (i.e., body mass
index of 25–29.9 kg/m2) patients with two or more weight-
related comorbidities [6]. However, weight loss lifestyle
modification is contraindicated in pregnant or lactating
women, those with serious psychiatric illness (e.g., major
R. Dalle Grave (&) � S. Calugi � M. El Ghoch
Department of Eating and Weight Disorders, Villa Garda
Hospital, Via Montebaldo, 89, 37016 Garda (VR), Italy
e-mail: rdalleg@tin.it
123
Eat Weight Disord (2013) 18:339–349
DOI 10.1007/s40519-013-0049-4
depression, bulimia nervosa), and patients who have a
variety of severe medical conditions in whom caloric
restriction might exacerbate the illness [7].
Lifestyle modification program delivery
Lifestyle modification can be delivered in various clinical
settings, including primary care [8], clinical research [9],
private dietetics practices [10], inpatient rehabilitation
units [11], and commercial clinics [12]. In clinical research
settings, the treatment has been delivered in individual
sessions (as in the Diabetes Prevention Program—DPP)
[9], in groups of *10–20 participants [1], and in a com-
bination of group and individual sessions (as in the Look
AHEAD—Action for Health in Diabetes—study) [13]. In
the real world, however, it has been suggested that in
clinical management of severe obesity and other medical
conditions associated with obesity (e.g., metabolic syn-
drome, diabetes, and non-alcoholic fatty liver disease), the
treatment is best delivered by a multidisciplinary lifestyle
modification team comprising medical doctors and other
health professionals such as dieticians [14]. Also suitable
for inclusion in the team are professionals with Masters’
degree training in exercise physiology, behavioral psy-
chology, and/or health education [15]. In these multidis-
ciplinary teams, the physicians, who are generally faced
with considerable time constraints, should make the
assessment, manage any medical complications, engage the
patient in the lifestyle modification treatment, and conduct
periodic medical evaluation. The treatment itself can then
be delivered by non-physician health professionals, also
known as ‘‘lifestyle modification counsellors’’, which has
the added bonus of reducing costs.
Lifestyle modification programs generally include an
intensive weight loss phase, consisting of 16–24 weekly
sessions, followed by a weight maintenance phase (see
Fig. 1) [16]. While there is general agreement about the
length of the weight loss phase [6], which tends to reach a
plateau after 6 months, no definitive data is yet available
about the optimal duration and intensity of the weight
maintenance phase.
Assessment and preparation of patients for weight loss
lifestyle modification
The assessment of patients with obesity should include the
measurement of body weight, height and waist circumfer-
ence, risk assessment for cardiovascular disease and dia-
betes, and assessment of eating behavior, physical fitness,
psychosocial functioning, and quality of life [6]. It is also
important to ascertain the patient’s motivation for lifestyle
modification, determining the reasons for weight loss, any
previous history of successful or unsuccessful weight loss
attempts, support from family, friends and co-workers, the
patient’s understanding of their condition and how it con-
tributes to obesity-related diseases, their attitude toward
physical activity, and the existence of any barriers to
change [6]. Informing patients about the aims, duration,
organization, procedures, and results of the treatment with
the aid of written materials (see Table 1) are a good
practice that should be always form an integral part of the
preparation phase [7]. Finally, since stigma influences the
decision of patients with obesity to start treatment, it is
vital that clinicians recognize obesity as a medical condi-
tion, and not the product of lack of willpower, and treat
them accordingly, providing them with the respect and
support they need [17].
Lifestyle modification program components
Standard lifestyle modification programs have three main
components: (1) dietary recommendations, (2) physical
activity recommendations, and (3) cognitive behavioral
therapy [18].
Available data indicate that two key components of the
lifestyle modification package, namely self-monitoring
[19, 20] and physical activity [21], are consistently
Fig. 1 General organization and principal procedures of a lifestyle modification program
340 Eat Weight Disord (2013) 18:339–349
123
associated with better weight control in the short and long
term, respectively, while the efficacy of other procedures
and strategies still remains to be confirmed. Little is also
known about the possible mechanism through which the
treatment achieves its effect, since no studies have yet
assessed the mediators [22] of lifestyle modification pro-
grams. In interim, however, the lifestyle modification
package is a good treatment option, because it is well
validated as a whole, and different components of the
intervention can be given precedence to suit the needs of
individual patients [23].
The following paragraphs report the principal cognitive
behavioral procedures used to address weight loss and
weight maintenance obstacles, as described in the most
recent manuals and articles on lifestyle modification [16,
18, 24, 25]. Table 2 shows the dietary and physical activity
recommendations of the Look AHEAD trial [26], the
largest study conducted to date to assess the long-term
efficacy of lifestyle modification.
Addressing weight loss obstacles
Standard lifestyle modification group programs have tra-
ditionally been delivered as a series of pre-packaged les-
sons in which the clinicians teach patients all the
procedures and strategies involved in the program. The
lessons continue in the pre-planned order, even if the
patient has not overcome their problems or has failed to
understand. The nature of these programs is significantly
different from modern cognitive behavioral therapy, usu-
ally applied for the treatment of other disorders, where the
treatment is highly personalized and the procedures and
strategies introduced depend on the specific processes
maintaining the patient’s problems [25]. The most recent
Table 1 Main points made when describing lifestyle modification to the patient
Lifestyle modification is recommended by national and international guidelines as a key strategy for managing excess weight and obesity.
Research data indicate that lifestyle intervention produces an average reduction of about 10 % of body weight in patients completing the
treatment [6]. This weight loss is associated with a significant reduction of cardiovascular risk factors (i.e., blood glucose, serum lipids, and
blood pressure), abdominal fat, prevalence of the metabolic syndrome [69], in addition to an improvement in quality of life, body image,
binge eating, and symptoms of depression and anxiety [10]
Lifestyle modification has three main components [16]:
Diet. The diet is designed to create a calorie deficit (i.e., expenditure [ intake) of 500–1,000 kcal/day during the weight loss phase to
produce a weight loss of � to 1 kg per week, and then to maintain the weight in a range of 3 kg [12]
Exercise. Walking is the preferred exercise, and the aims are to gradually achieve 10,000 steps per day, and to produce a calorie deficit of at
least 400 kcal/day, favoring weight loss, maintaining muscle mass, and preventing weight cycling [70]
Cognitive behavioral therapy. Cognitive behavioral therapy has been designed to provide a set of procedures and strategies for helping to
improve adherence to diet and exercise. Behavioral strategies include self-monitoring of eating, exercise and weight, goal setting, and
stimulus control (i.e., modifying your external environment to facilitate lifestyle modification), and alternative behaviors (i.e., managing
non-eating cues, like emotions, through alternative behaviors to eating) [16]. Cognitive strategies include problem solving and addressing
dysfunctional thoughts that hinder lifestyle modification [16]
The treatment is delivered by a lifestyle counselor and supervised by a physician. The treatment will be tailored to your specific lifestyle
problem and your needs, and may be administered in group and/or individual sessions. These will be held weekly for the first 6 months, and
then twice a month over the following 6 months
The treatment should be seen as an opportunity to make a fresh start and build a new life [27], no longer conditioned by the problems
associated with obesity and its complications. As in any lifestyle change, there will be difficulties, but the benefits you can achieve are
enormous and include: reducing the risk of diabetes and cardiovascular diseases, and improving cardiovascular fitness, self-esteem and
quality of life
Data on the treatment indicate that the magnitude of changes in weight achieved in the first 4 weeks is the most important predictor of the
treatment outcome [71]. We, therefore, encourage you to ‘‘start well’’ to obtain the best benefits. It is also important that there are as few
breaks in treatment as possible. This is because we want to establish what we call ‘‘momentum’’, in which we work from session to session
to crack your lifestyle problem. Breaks in treatment are very disruptive as momentum is lost. To avoid any treatment interruption, absent
therapists will be replaced by other therapists [27]
It is important that every appointment starts and ends on time. Your therapist will make sure they are ready to start, and we request that you do
the same. It is a good idea to arrive a little in advance—say 10–15 min. This will give you an opportunity to settle and think things over [27]
You and your therapist will be working together as a team to help you change your lifestyle. You will agree on specific tasks (or ‘‘next steps’’)
for you to undertake between each session [27]. These tasks are very important and will need to be given priority. It is what you do between
sessions (e.g., self-monitoring of eating, exercising, and weight) that will govern to a large extent how much you benefit from treatment.
Data from the research indicate, for example, that self-monitoring consistency is associated with greater weight loss [34]
Since you have had your lifestyle problems for quite a while, it is crucial that you make the most of this opportunity to change; otherwise, the
problem is likely to persist. Treatment will be hard work but it will be worth it. The more you put in, the more you will get out [27]
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developments in lifestyle modification, as in the DPP [9]
and the Look AHEAD [13] study, have improved the
success of the program in targeting the specific problems of
the individual patient through the introduction of the case
manager.
Constructing the personal formulation
The personal formulation is a procedure, developed by the
Villa Garda lifestyle modification program, which might
help to further individualise the treatment. This procedure,
widely used in cognitive behavioral therapy [27], but not in
standard lifestyle modification programs, is a visual rep-
resentation (a diagram) of the main cognitive behavioral
processes that hinder weight loss in that particular patient.
The formulation should be created step by step, without
haste, with the clinician taking the lead but actively
involving the patients [27]. A good first step in this process
is to begin analyzing with the patients which, if any, eating
(i.e., the sight of food, social eating situations) and/or non-
eating stimuli (i.e., events and changes of mood) influence
their eating behavior. The clinician should then assess
whether overeating is maintained by any positive emo-
tional and/or physical consequences of food intake, and/or
any problematic thoughts (see Fig. 2).
After the formulation has been drawn up, the clinician
should discuss its implications with the patient, empha-
sizing that the control of eating is not dependent on the
patient’s willpower, but can be addressed through specific
strategies designed to counteract the processes hampering
adhesion to the eating changes necessary to lose weight.
The clinician should stress that the formulation is provi-
sional and will be modified as needed during the course of
the treatment. In our clinical experience, the personal
formulation is well accepted by patients, although we as
yet have no data regarding its efficacy in improving weight
loss outcomes.
Self-monitoring of eating, exercise, and body weight
Self-monitoring of food intake, physical activity, and body
weight is the core procedure of lifestyle modification
treatment [25]. The more the self-monitoring the larger the
amount of weight lost [19]. Hence, patients should be
encouraged to write the time, amount, type, and calorie
content of foods and beverages they will consume on a
monitoring record in advance, and then to check and record
in real time (while they are eating) whether or not they are
sticking to their plan. Any changes should be noted in the
food diary, together with the revised calorie intake. Thus,
real-time monitoring promotes self-awareness and may
help patients to interrupt behaviors that seem automatic and
out of control [28].
Physical activity, calculated in minutes (of programmed
activity) and/or steps (of lifestyle activity) using a
pedometer, can be recorded in the same monitoring record
with the final goal of at least 10,000 steps per day [18]. A
meta-analysis of 26 RCTs and observational studies indi-
cate that the daily use of pedometers is associated with
significant increases in physical activity and reductions in
BMI and systolic blood pressure [29]. It has been suggested
that the combination of having step goals and immediate
feedback from a pedometer prompts behavioral change by
raising awareness of current walking behaviors [30].
Patients interested in having a more precise measurement
of their daily energy expenditure may use an accelerome-
ter, which measures not only their total energy expenditure
over a prescribed period, but also the energy expended
Table 2 Summary of the practical recommendations for diet and physical exercise provided by the Look AHEAD Study [26]
Dietary recommendations
Energy goal: 1,200–1,500 kcal/day per person \114 kg (250 pounds); 1,500–1,800 kcal/day for individuals C114 kg
The prescribed diet included\30 % of calories from fat, with\10 % from saturated fat. Specifically, participants are encouraged to follow
the Food Pyramid guidelines and to consume the equivalent of a National Cholesterol Education Program Step 1 diet
Participants count calories and fat grams with the aid of a booklet provided
Meal replacement products were provided at no cost to help participants adhere to their dietary goals. From weeks 3 to 19, participants were
instructed to replace two meals each day with a liquid shake and one snack with a bar. The other meal (typically dinner) consisted of
conventional foods with fruits and vegetables added to reach the calorie goal. From week 20 onwards, meal replacements were used for one
meal per day only
Physical exercise recommendations
Physical activity goal: C175 min/week of moderately intense activity, achieved by the 6th month, given findings that higher levels of
physical activity (C2,500 kcal/week) significantly improve the maintenance of lost weight
Participants are instructed to increase their daily steps by 250 a week, until they reach a goal C10,000 steps/day. Participants are encouraged
to increase their lifestyle activity by methods such as using stairs rather than elevators, walking rather than driving, and reducing their use of
labor saving devices (e.g., e-mailing colleagues at work)
The lifestyle intervention relies principally on at-home exercise, as studies have found it is easier to implement and is associated with more
minutes of weekly exercise and better maintenance of weight loss than on-site physical activity
342 Eat Weight Disord (2013) 18:339–349
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during a particular session of physical activity, the duration
and the levels (in metabolic equivalent of task) of the
session, and the time spent lying down and sleeping.
Patients are also encouraged to check their weight regularly
(e.g., once a week) because frequent weighing is associated
with better long-term weight maintenance [31]. They are
asked to record their weight on a graph and to discuss their
interpretation of any change in weight with the clinician
during the group or the individual sessions. It has been sug-
gested that patients should be discouraged from practicing
excessive self-monitoring (e.g., checking their weight several
times a day), as this behavior may increase preoccupation with
minimal variations of weight due to changes in body hydra-
tion, and may trigger dysfunctional behaviors (e.g., adoption
of extreme and rigid dietary rules) or cause the patient to
abandon the attempt to lose weight altogether [25]. That being
said, one study has found that daily weighing has no apparent
link with adverse psychological effects [32].
Goal setting
Patients in lifestyle modification programs are encouraged
to set specific achievable and quantifiable weekly goals (for
example, adding 1,000 steps a week or only eating at the
table). These should be realistic and moderately challeng-
ing [18] to provoke a sense of accomplishment, which is
reinforcing and enhances self-efficacy [15], a construct
associated with long-term weight loss [33].
Particular attention should be paid to patients’ weight loss
expectations, since higher weight loss expectations are asso-
ciated with attrition [34]. However, some data indicate that
encouraging participants to seek only modest initial weight
losses does not facilitate weight maintenance, and produces a
lower weight loss than standard behavioral treatments [35]. It,
therefore, seems more useful at the beginning of treatment to
focus patients on weekly weight loss goals (e.g., losing from �to 1 kg a week) and to detect and promptly address any
warning signs of weight loss dissatisfaction to minimize the
risk of attrition [34]. Unrealistic weight loss expectations may
be more easily changed later in the course of treatment, when
patients have reached some intermediate goals, and the rate of
weight loss is declining [16].
Specific strategies to change weight goals have recently
been described in modern cognitive behavioral treatments
of obesity [25]. A crucial aspect favoring the modification
of unrealistic weight goals is the development of a trusting
and collaborative clinician-to-patient relationship [34].
Stimulus control
These procedures are based on the principles of classical
and operant conditioning. Stimulus control is aimed at
Fig. 2 A sample patient’s personal cognitive behavioral formulation
of their main obstacles to weight loss (based on this formulation, the
treatment was designed to include cognitive behavioral procedures
and strategies to reduce food stimuli, cope with non-eating stimuli,
address stress and anxiety, and challenge problematic thoughts)
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modifying the patient’s environment (i.e., external eating
cues) to make it more conducive to their making choices
that support changes in eating and in exercising, breaking
the associations of non-food cues with eating, and estab-
lishing a reward system not based on food. Patients should
be encouraged to remove excessive eating triggers (e.g.,
keeping tempting food out of sight or, even better, not
buying it), and increase positive cues for exercising (e.g.,
laying out exercise clothes before going to bed). They are
also stimulated to increase positive cues for desirable
behavior (e.g., putting food records on the dining table to
facilitate its real-time compilation during eating). Patients
are also helped to identify internal eating cues (e.g., crav-
ing or emotional stimuli) and to counter them with alter-
native behaviors, which are more effective if incompatible
with eating (e.g., writing, knitting, housekeeping, exercis-
ing or taking a bath). Indeed, other behaviors such as lis-
tening to music or reading may not be as effective, as they
can be performed while eating [18].
Establishing a reward system may be used to reinforce
adherence to eating control and exercising (e.g., encour-
aging patients to set weekly behavioral goals and reward
themselves upon achievement, but not through food or
inactivity) [18]. Positive reinforcements may also be used
by clinicians who should congratulate patients for every
small success they achieve, and never criticize their fail-
ures [36].
Involving significant others
Several studies suggest that social support is a key ingre-
dient for behavioral change, and it is considered an
important aid for body weight maintenance [37]. A recent
meta-analysis concluded that the involvement of family
members can lead to an additional 3-kg weight loss with
respect to programs from which they are excluded [38].
Therefore, patients are encouraged to evaluate the pros and
cons of involving significant others, i.e., partners or
parental figures, in the treatment to create the optimum
environment for change. Needs vary from patient to
patient, but this involvement could include planning toge-
ther a written shopping list, eating the same foods, exer-
cising together, creating a relaxed environment, and
reinforcing the patient’s positive behaviors.
Problem solving
Patients should be helped to use problem-solving tech-
niques to address their obstacles to lifestyle modification.
The typical problem-solving approach includes five steps
[39]. Step 1 encourages patients to describe a problem they
have encountered and the chain of events (i.e., situations)
leading up to it. Step 2 helps patients to brainstorm the
potential solutions should they encounter such a problem
again. In step 3, patients list the pros and cons of each
potential solution, and in step 4 they should use this
information to choose the best option, which they will
agree to implement for a fixed amount of time. Finally,
during step 5, the patients assess the results achieved in
real-world application of their chosen solution, and, if this
fails, the process should be repeated. The importance of
incorporating this approach in the management of obesity
has been highlighted by a study in which the participants
who completed behavioral therapy coupled with problem
solving showed significantly greater long-term body weight
loss than participants who completed standard behavioral
therapy alone [40].
Cognitive restructuring
Through this technique, patients learn the degree to which
their thoughts influence both their mood and behavior, and
that a more rational and functional way of thinking can help
to improve adherence to lifestyle programs [18]. Cognitive
restructuring is used to modify cognitive biases about body
weight regulation (all-or-nothing thinking) and to correct
unrealistic weight loss and exercise expectations. Specifi-
cally, when patients identify a dysfunctional thought, they
should write it under a heading ‘‘Dysfunctional thoughts’’ in
their monitoring record and then turn the sheet over and
address it by writing out the cognitive restructuring steps
learned. Although cognitive restructuring is included in
standard lifestyle modification programs, no data are yet
available on its efficacy in promoting weight loss.
Addressing weight maintenance obstacles
Some additional cognitive behavioral procedures and
strategies to help patients to achieve long-term weight loss
maintenance, described in the following paragraphs, appear
to be indicated.
Providing continuous care model
Some studies showed that group sessions delivered twice a
month for 1 year after the weight loss phase, retaining
patients in active treatment, facilitated weight loss main-
tenance [1, 41]. It has been suggested that a continuous
care model of treatment may provide patients the support
and motivation needed to continue to practice weight
control behaviors [42]. However, continuous care up to
3 years outside the research setting produced long-term
weight loss only in one subgroup of obese patients, and was
associated with a rate of attrition of 84.3 % [33]. Future
research should identify the patients for which continuous
care would be more suitable, and those more likely to
344 Eat Weight Disord (2013) 18:339–349
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benefit from a shorter duration of treatment. Preliminary
data indicate that older patients whose primary motivation
for weight loss is improving health are more compliant in
continuous care, while patients satisfied with the results
achieved with treatment, and those confident self-managing
additional weight loss may avoid weight gain without
continuous professional assistance [33].
Unfortunately, the continuous care model for obesity, a
condition with a high prevalence in the population, requires
economic resources that are difficult to provide as part of a
national healthcare system. Nevertheless, a less expensive
but promising strategy could be the use of self-help group.
The efficacy of this from of treatment has been shown by
the Trevose Behavior Modification Program, a self-help
group offering continuous care for obese patients, which
has found that members completing 5 years of treatment
(21.6 %) lost 17.3 % of their initial body weight [43].
Building the long-term weight control mindset
Cognitive processes are involved in the maintenance of
complex behaviors such as adopting a long-term low-cal-
orie, low-fat diet and practicing high duration and fre-
quency of physical activity (two key behaviors for
maintaining the weight loss). It is, therefore, surprising that
cognitive strategies for dealing with this issue are not
exploited more often in standard body weight control
programs, and may be one of the reasons for their limited
long-term effectiveness [44]. Preliminary study found that
adding cognitive procedures to lifestyle modification is
associated with better weight loss maintenance [45]. That
being said, a recent randomized control trial failed to
observe a positive effect on long-term weight loss main-
tenance of a cognitive behavioral intervention specifically
designed to address the cognitive processes associated with
weight regain [46].
Discontinuing self-monitoring
It is unrealistic to expect patients to continue to monitor
eating and exercise for the rest of their lives. To prevent the
risk of relapse associated with the discontinuation of self-
monitoring, it is therefore advisable to evaluate with
patients the pros and cons of stopping writing in their food
diary towards the end of the treatment, when they are still
under the care of the therapist [25]. In this way, patients
can gauge their ability to control their eating and perform
adequate levels of physical activity with a safety net still in
place, as they will need to practice this skill for a long
period of time if they wish to keep their weight under
control.
Maintaining a low-fat, low-calorie diet and high level
of physical activity
Data from the National Weight Control Registry show that
successful weight loss maintainers report eating a low-fat
diet of about 1,400 kcal/day and exercise enough to burn
400 kcal/day [47]. A randomized control trial confirmed
that recommending higher physical activity (2,500 kcal/
week) than that normally suggested in standard behavioral
treatments (1,000 kcal/week) promotes better long-term
weight loss [48]. The high level of physical activity nec-
essary to maintain weight is probably due to the decrease in
total energy expenditure of about 300–500 kcal/day,
greater than that predicted by changes in body mass com-
position observed in patients who had lost 10 % of initial
weight [49]. This means that, even if they are likely to
underestimate the reported value of food intake, patients
should be encouraged to follow the same dietary and
physical activity recommendations, with minimal neces-
sary variations, as they did in the weight loss phase.
Establishing weight maintenance range and long-term
weight self-monitoring
Studies showed that increases in frequency of self-weigh-
ing are associated with weight gain prevention [50], and
changes in frequency of self-weighing are related to weight
regain [51]. For this reason, patients are encouraged to
weigh themselves at least once a week, and to maintain
their weight within a range of 2–3 kg of their target, the
‘‘maintenance binary’’, to allow for natural weight fluctu-
ation. Patients should also be taught to distinguish between
real increases in body weight from its natural fluctuations
[25]. To this end, patients should be instructed to interpret
any weight variation every 4 weeks [25].
Establishing a contingency plan
Patients should be prepared to take immediate, specific
action as soon as their weight goes beyond the maintenance
binary. Weight increase is generally due to changes in food
intake and/or energy expenditure, and patients are
encouraged to examine the underlying causes of these
changes [25]. Once identified, these underlying causes
should be addressed using the problem-solving procedure.
Patients should also be taught to restart daily food and
exercise monitoring and to follow the weight loss diet and
exercise recommendations until they are back to their tar-
get weight [25]. Once they have returned to the weight
maintenance binary, they should use the weight mainte-
nance strategies to ensure they stay that way.
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Constructing a weight maintenance plan
The last procedure in the treatment is to help patients
construct a written weight maintenance plan. The patients
should be informed about the importance of this plan,
emphasizing that it is both a useful reminder of what has
been learned about weight maintenance and a guide to what
to do in the future. The plan should be built collaboratively
with the patients and should include two sections: one for
the weight maintenance, including the procedures and
strategies used to maintain the weight and avoid relapse,
and the other addressing an eventual weight gain over the
established threshold [25].
Outcome of weight loss lifestyle modification programs
Randomized controlled trials of structured group weight
loss interventions have typically shown that 80 % of
patients who begin treatment complete it [52], and that
weight losses average 8–10 % of initial weight in 30 weeks
of treatment [52, 53]. This amount of weight loss satisfies
the criterion for success (i.e., a 5–10 % reduction of initial
weight) proposed by the World Health Organization [54].
A recent meta-analysis assessing the effect of lifestyle
modification programs (duration range from 13 to 52 ses-
sions) concluded that at 1 year, 28 % of participants had a
weight loss C10 % of baseline weight, 26 % of 5–9.9 %,
and 38 % of B4.9 % [55]. This weight reduction is asso-
ciated with a marked reduction in the incidence of type-2
diabetes [56], and statistically and clinically substantial
improvements in weight-related medical comorbidities
(e.g., sleep apnea, diabetes, hypertension, hyperlipidemia)
and psychosocial outcomes (e.g., mood, quality of life, and
body image) [7, 57–59].
The main problem afflicting the standard lifestyle
modification programs is maintaining the weight lost, as
patients typically regain about 30–35 % in the year fol-
lowing treatment. Weight regain appears to slow after the
first year, but by 5 years, 50 % or more of patients are
likely to have returned to their baseline weight [60].
Nevertheless, the latest generation of lifestyle modification
trials, which include the most innovative and powerful
weight loss lifestyle modification procedures, have shown
better long-term weight loss outcome. An example is the
Look AHEAD study, a 13.5-year randomized trial that
included 5,100 overweight participants with type 2 diabetes
randomly assigned to an intensive lifestyle intervention
(ILI) or a diabetes support and education (DSE) group. At
year 10, participants assigned to the ILI maintained a mean
weight loss of 6 %, in comparison with 3 % in the diabetes
support and education (DSE) group (P \ 0.001), demon-
strating that long-term weight loss can be achieved with
continued behavioral treatment [61]. Unfortunately, even
though the intervention group maintained significantly
greater improvements than DSE at 4-year follow-up in
terms of HbA1c, fitness, high-density lipoprotein choles-
terol and systolic blood pressure [62], at 10-year follow-up
the ILI did not reduce cardiovascular events such as heart
attack and stroke, the primary aim, and for this reason in
September 2012, the US NIH dropped the intervention arm.
(http://www.nih.gov/news/health/oct2012/niddk-19.htm).
However, as the editorials accompanying the data suggest,
clinicians can now use the results of the Look AHEAD
study to inform their patients with diabetes that a lifestyle
modification program does reduce weight, the need for and
cost of medications and the rate of sleep apnoea, as well as
improving well-being, and (in some cases) lead to a dia-
betes remission, even though it is not conclusively proven
to reduce cardiovascular events [63].
Lifestyle modification combined with an initial phase of
residential rehabilitative treatment also shows promise in
individuals with morbid obesity and severe comorbidities
and/or disability who do not respond to standard outpatient
treatment [14]. Indeed, a recent randomized controlled
study showed that a treatment including 3 weeks of resi-
dential lifestyle modification program followed by 12
individual sessions of 45 min each over 40 weeks with a
trained dietitian produced a mean weight loss of about
15 %, accompanied by a significant improvement in car-
diovascular risk factors and psychological profiles [11].
The percentage weight loss obtained in this study was
higher than the mean 8–10 % obtained in conventional
lifestyle modification programs [52, 53], presumably due to
two main factors: (1) the lack of exposure to additional
food stimuli during the inpatient stage may have facilitated
initial adherence to the diet, and (2) de-conditioning of
patients’ food- and non-food-related eating stimuli during
the 3 weeks of inpatient treatment may have promoted
long-term adherence after discharge. These data, if con-
firmed by studies with longer follow-up, appear to suggest
that residential treatment may increase the effect of life-
style modification on weight loss, and may be indicated, as
an alternative or precursor to bariatric surgery, for patients
with morbid obesity and associated comorbidities and/or
disability.
Recent studies also indicate that lifestyle modification
may improve the outcome of bariatric surgery. For
instance, in a trial of 144 Hispanic Americans randomized,
6 months following gastric bypass surgery, to compre-
hensive nutrition and lifestyle educational intervention or
comparison groups [64] showed that at 12 months fol-
lowing surgery, both groups had lost significant weight, but
the former participants experienced greater excess weight
loss, and were significantly more involved in physical
activity than those in the comparison group. Another study
346 Eat Weight Disord (2013) 18:339–349
123
randomized 60 consecutive morbidly obese patients, who
had undergone gastric bypass surgery, into a low-exercise
group or a multiple-exercise group. The multiple-exercise
group had a significantly more rapid reduction of body
mass index, excess weight loss, and fat mass compared
with the low-exercise group [65]. As a whole, these find-
ings indicate that bariatric surgery may be more effective if
integrated into a broader strategy of obesity management
including education and lifestyle modification.
Positive and negative outcomes have been achieved
when lifestyle modification programs have been delivered
in non-specialist settings of care, in the attempt to reach a
larger proportion of the overweight and obese individuals
who would benefit from them. For example, in a primary
care setting the intervention produced little weight loss and
poor weight maintenance outcome [66, 67]. This lack of
results has been attributed to lack of physician time,
repayment, and training [66]. In contrast, promising results
have been reported when the lifestyle modification pro-
grams have been delivered in the community. For example,
an adaptation of the DPP delivered in a workplace setting
through a 16-session group treatment produced a weight
loss of about 6.0 % of the initial weight after 6 months.
This compares favorably with a loss of 2.0 % in a group
that only received nutritional counseling [68]. What is
more, in the DPP group, a significant difference was
maintained after 12 months. In another study, an adapted
version of the DPP program was delivered by trained staff
of the local Cooperative Extension Service office to general
population communities [69]. The intervention produced
an average weight loss of 10.0 kg after 6 months. After this
initial phase, participants were randomized into three arms
(telephone counseling, face-to-face counseling, or news-
letters twice monthly) for another year. The telephone and
face-to-face groups regained less weight (1.2 kg in both)
than the newsletter group (3.7 kg). These data, if repli-
cated, suggest that lifestyle modification programs can be
delivered with success in the community.
Promising results have been also found delivering life-
style modification programs via phone and internet. The
available data indicate that internet programs induce a
mean weight loss of about two-thirds of that achieved
through traditional on-site delivery [70]. In addition,
studies comparing internet-delivered programs with those
delivered on-site or by phone found that person-to-person
interventions are more effective in maintaining weight loss.
However, the lower efficacy of the internet route is
somewhat mitigated by its easier accessibility, affordabil-
ity, and convenience [42].
Finally, the efficacy of lifestyle modification programs
has recently been assessed in a psychiatric rehabilitation
setting with adults with serious mental illness [71]. At
18 months, the mean between-group difference in weight
(change in intervention group minus change in control
group) was -3.2 kg. The authors concluded that the data
support implementation of targeted behavioral weight loss
interventions in obese adults with serious mental illness, a
population where obesity is an important problem due to
physical inactivity and unhealthy diet, as well as psycho-
tropic medications leading to weight gain.
Summary
Lifestyle modification plays a central role in the manage-
ment of obesity. Programs based on lifestyle modification
have been improved over recent years, and, although little
is known about their precise mode of action (i.e., what the
mediators of the treatment are), we now have data showing
their efficacy in producing a modest long-term weight loss,
associated with a marked reduction in the incidence of
diabetes, as well as improvements in weight-related med-
ical comorbidities and psychosocial outcomes. The prom-
ising results obtained through individualising the treatment,
using innovative cognitive behavioral procedures, deliver-
ing more frequent consultations using modern electronic
means of communication, and combining lifestyle modifi-
cation with residential treatment and bariatric surgery, are
grounds for optimism about the possibility of effective
management of obesity and related comorbidities.
Conflict of interest All authors declare no conflict of interest.
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