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

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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

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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

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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.

References

1. Wadden TA, Butryn ML, Byrne KJ (2004) Efficacy of lifestyle

modification for long-term weight control. Obes Res 12(Sup-

pl):151S–162S

2. Ferster CB, Nurberger JI, Levitt EE (1962) The control of eating.

J Math 1:87–109

3. Stuart RR (1967) Behavioral control of overeating. Behav Res

Ther 5:357–365

4. Wadden TA, McGuckin BG, Rothman RA, Sargent SL (2003)

Lifestyle modification in the management of obesity. J Gastroin-

test Surg 7:452–463

5. Sbraccia P, Vettor R (2012) SIO, Societa Italiana dell’Obesita e

ADI, Associazione Dietetica Italiana. Standard italiani per la cura

dell’obesita 2012–2013. Societa Italiana dell’Obesita, Roma

6. National Heart, Lung, and Blood Institute (NHLBI) and the North

American Association for the Study of Obesity (NAASO) (2000)

The practical guide: identification, evaluation, and treatment of

overweight and obesity in adults. National Institutes of Health,

Bethesda

7. National Institutes of Health (1998) Clinical guidelines on the

identification, evaluation, and treatment of overweight and

obesity in adults—the evidence report. Obes Res 6(Suppl 2):51S–

209S

8. Wadden TA, Berkowitz RI, Womble LG, Sarwer DB, Phelan S,

Cato RK, Hesson LA, Osei SY, Kaplan R, Stunkard AJ (2005)

Randomized trial of lifestyle modification and pharmacotherapy

for obesity. N Engl J Med 353:2111–2120

Eat Weight Disord (2013) 18:339–349 347

123

9. Diabetes Prevention Program (DPP) Research Group (2002) The

Diabetes Prevention Program (DPP): description of lifestyle

intervention. Diabetes Care 25:2165–2171

10. Willaing I, Ladelund S, Jorgenson T, Simonsen T, Nielsen LM

(2004) Nutritional counselling in primary care: a randomized

comparison of an intervention by general practitioner or dietician.

Eur J Cardiovasc Prev Rehabil 11:513–520

11. Dalle Grave R, Calugi S, Gavasso I, El Ghoch M, Marchesini G

(2013) A randomized trial of energy-restricted high-protein ver-

sus high-carbohydrate, low-fat diet in morbid obesity. Obesity.

doi:10.1002/oby.20320

12. Heshka S, Anderson JW, Atkinson RL, Greenway FL, Hill JO,

Phinney SD, Kolotkin RL, Miller-Kovach K, Pi-Sunyer FX

(2003) Weight loss with self-help compared with a structured

commercial program: a randomized trial. JAMA 289:1792–1798

13. Ryan DH, Espeland MA, Foster GD, Haffner SM, Hubbard VS,

Johnson KC, Kahn SE, Knowler WC, Yanovski SZ (2003) Look

AHEAD (Action for Health in Diabetes): design and methods for

a clinical trial of weight loss for the prevention of cardiovascular

disease in type 2 diabetes. Control Clin Trials 24:610–628

14. Donini LM, Cuzzolaro M, Spera G, Badiali M, Basso N, Bollea

MR, Bosello O, Brunani A, Busetto L, Cairella G, Cannella C,

Capodaglio P, Carbonelli MG, Castellaneta E, Castra R, Clini E,

Contaldo F, Dalla Ragione L, Dalle Grave R, D’Andrea F, Del

Balzo V, De Cristofaro P, Di Flaviano E, Fassino S, Ferro AM,

Forestieri P, Franzoni E, Gentile MG, Giustini A, Jacoangeli F,

Lubrano C, Lucchin L, Manara F, Marangi G, Marcelli M,

Marchesini G, Marri G, Marrocco W, Melchionda N, Mezzani B,

Migliaccio P, Muratori F, Nizzoli U, Ostuzzi R, Panzolato G,

Pasanisi F, Persichetti P, Petroni ML, Pontieri V, Prosperi E,

Renna C, Rovera G, Santini F, Saraceni V, Savina C, Scuderi N,

Silecchia G, Strollo F, Todisco P, Tubili C, Ugolini G, Zamboni

M (2010) Obesity and eating disorders. Indications for the dif-

ferent levels of care. An Italian Expert Consensus Document. Eat

Weight Disord 15 (1–2 Suppl):1–31

15. Bellentani S, Dalle Grave R, Suppini A, Marchesini G (2008)

Behavior therapy for nonalcoholic fatty liver disease: the need for

a multidisciplinary approach. Hepatology 47:746–754

16. Dalle Grave R, Calugi S, Centis E, Marzocchi R, El Ghoch M,

Marchesini G (2010) Lifestyle modification in the management of

the metabolic syndrome: achievements and challenges. Diabetes

Metab Syndr Obes 3:373–385

17. Kushner RF (2003) Roadmaps for clinician practice: case studies

in disease prevention and health promotion—assessment and

management of adult obesity: a primer for physicians. American

Medical Association, Chicago

18. Fabricatore AN (2007) Behavior therapy and cognitive-behavioral

therapy of obesity: is there a difference? J Am Diet Assoc 107:92–99

19. Baker RC, Kirschenbaum DS (1993) Self-monitoring may be

necessary for successful weight control. Behav Ther 24:377–394

20. O’Neil PM (2001) Assessing dietary intake in the management of

obesity. Obes Res 9(Suppl):S361–S366

21. Jakicic JM (2003) Exercise in the treatment of obesity. Endo-

crinol Metab Clin North Am 32:967–980

22. Kraemer HC, Wilson GT, Fairburn CG, Agras WS (2002)

Mediators and moderators of treatment effects in randomized

clinical trials. Arch Gen Psychiatry 59:877–883

23. Foster GD, Makris AP, Bailer BA (2005) Behavioral treatment of

obesity. Am J Clin Nutr 82(1 Suppl):230S–235S

24. Brownell KD (2000) The LEARN manual for weight manage-

ment. American Health Publishing Co, Dallas

25. Cooper Z, Fairburn CG, Hawker DM (2003) Cognitive-behav-

ioral treatment of obesity: a clinician’s guide. Guilford Press,

New York

26. Wadden TA, West DS, Delahanty L, Jakicic J, Rejeski J, Wil-

liamson D, Berkowitz RI, Kelley DE, Tomchee C, Hill JO,

Kumanyika S (2006) The Look AHEAD study: a description of

the lifestyle intervention and the evidence supporting it. Obesity

14:737–752

27. Fairburn CG, Cooper Z, Shafran R, Bohn K, Hawker DM,

Murphy R, Straebler S (2008) Enhanced cognitive behavior

therapy for eating disorders: The core protocol. In: Fairburn CG

(ed) Cognitive behavior therapy and eating disorders. Guilford

Press, New York, pp 45–193

28. Fairburn CG (2008) Cognitive behavior therapy and eating dis-

orders. Guilford Press, New York

29. Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin

N, Lewis R, Stave CD, Olkin I, Sirard JR (2007) Using pedom-

eters to increase physical activity and improve health: a sys-

tematic review. JAMA 298:2296–2304

30. Rooney B, Smalley K, Larson J, Havens S (2003) Is knowing

enough? Increasing physical activity by wearing a pedometer.

WMJ 102:31–36

31. O’Neil PM, Brown JD (2005) Weighing the evidence: benefits of

regular weight monitoring for weight control. J Nutr Educ Behav

37:319–322

32. Wing RR, Tate DF, Gorin AA, Raynor HA, Fava JL, Machan J

(2007) STOP regain: are there negative effects of daily weighing?

J Consult Clin Psychol 75:652–656

33. Dalle Grave R, Melchionda N, Calugi S, Centis E, Tufano A,

Fatati G, Fusco MA, Marchesini G (2005) Continuous care in the

treatment of obesity: an observational multicentre study. J Intern

Med 258:265–273

34. Dalle Grave R, Calugi S, Molinari E, Petroni ML, Bondi M,

Compare A, Marchesini G, the QSG (2005) Weight loss expec-

tations in obese patients and treatment attrition: an observational

multicenter study. Obes Res 13:1961–1969

35. Foster GD, Phelan S, Wadden TA, Gill D, Ermold J, Didie E

(2004) Promoting more modest weight losses: a pilot study. Obes

Res 12:1271–1277

36. Wadden TA, Crerand CE, Brock J (2005) Behavioral treatment of

obesity. Psychiatr Clin North Am 28:151–170, ix

37. Wing RR, Jeffery RW (1999) Benefits of recruiting participants

with friends and increasing social support for weight loss and

maintenance. J Consult Clin Psychol 67:132–138

38. Avenell A, Broom J, Brown TJ, Poobalan A, Aucott L, Stearns

SC, Smith WC, Jung RT, Campbell MK, Grant AM (2004)

Systematic review of the long-term effects and economic con-

sequences of treatments for obesity and implications for health

improvement. Health Technol Assess 8:iii–iv, 1–182

39. D’Zurilla TJ, Goldfried MR (1971) Problem solving and behavior

modification. J Abnorm Psychol 78:107–126

40. Perri MG, Nezu AM, McKelvey WF, Shermer RL, Renjilian DA,

Viegener BJ (2001) Relapse prevention training and problem-

solving therapy in the long-term management of obesity. J Con-

sult Clin Psychol 69:722–726

41. Perri MG, Nezu AM, Patti ET, McCann KL (1989) Effect of

length of treatment on weight loss. J Consult Clin Psychol

57:450–452

42. Wadden TA, Webb VL, Moran CH, Bailer BA (2012) Lifestyle

modification for obesity: new developments in diet, physical

activity, and behavior therapy. Circulation 125:1157–1170

43. Latner JD, Stunkard AJ, Wilson GT, Jackson ML, Zelitch DS,

Labouvie E (2000) Effective long-term treatment of obesity: a

continuing care model. Int J Obes Relat Metab Disord

24:893–898

44. Cooper Z, Fairburn CG (2001) A new cognitive behavioural

approach to the treatment of obesity. Behav Res Ther 39:499–511

45. Stahre L, Tarnell B, Hakanson CE, Hallstrom T (2007) A ran-

domized controlled trial of two weight-reducing short-term group

treatment programs for obesity with an 18-month follow-up. Int J

Behav Med 14:48–55

348 Eat Weight Disord (2013) 18:339–349

123

46. Cooper Z, Doll HA, Hawker DM, Byrne S, Bonner G, Eeley E,

O’Connor ME, Fairburn CG (2010) Testing a new cognitive

behavioural treatment for obesity: a randomized controlled trial

with three-year follow-up. Behav Res Ther 48:706–713

47. Wing RR, Phelan S (2005) Long-term weight loss maintenance.

Am J Clin Nutr 82(1 Suppl):222S–225S

48. Jeffery RW, Wing RR, Sherwood NE, Tate DF (2003) Physical

activity and weight loss: does prescribing higher physical activity

goals improve outcome? Am J Clin Nutr 78:684–689

49. Rosenbaum M, Hirsch J, Gallagher DA, Leibel RL (2008) Long-

term persistence of adaptive thermogenesis in subjects who have

maintained a reduced body weight. Am J Clin Nutr 88:906–912

50. Linde JA, Jeffery RW, French SA, Pronk NP, Boyle RG (2005)

Self-weighing in weight gain prevention and weight loss trials.

Ann Behav Med 30:210–216

51. Butryn ML, Phelan S, Hill JO, Wing RR (2007) Consistent self-

monitoring of weight: a key component of successful weight loss

maintenance. Obesity 15:3091–3096

52. Wadden TA, Butryn ML (2003) Behavioral treatment of obesity.

Endocrinol Metab Clin North Am 32:981–1003, x

53. Expert Panel on the Identification, Evaluation, and Treatment of

Overweight in Adults (1998) Clinical guidelines on the identifi-

cation, evaluation, and treatment of overweight and obesity in

adults: executive summary. Am J Clin Nutr 68:899–917

54. World Health Organization (2000) Obesity: preventing and

managing the global epidemic. Report of a WHO consultation.

World Health Organ Tech Rep Ser 894:i–xii, 1–253

55. Christian JG, Tsai AG, Bessesen DH (2010) Interpreting weight

losses from lifestyle modification trials: using categorical data.

Int J Obes 34:207–209

56. Diabetes Prevention Program Research Group (2002) Reduction

in the incidence of type 2 diabetes with lifestyle intervention or

metformin. N Engl J Med 346:393–403

57. Wing RR, Epstein LH, Marcus MD, Kupfer DJ (1984) Mood

changes in behavioral weight loss programs. J Psychosom Res

28(3):189–196

58. Fontaine KR, Barofsky I, Bartlett SJ, Franckowiak SC, Andersen

RE (2004) Weight loss and health-related quality of life: results at

1-year follow-up. Eat Behav 5(1):85–88

59. Dalle Grave R, Cuzzolaro M, Calugi S, Tomasi F, Temperilli F,

Marchesini G (2007) The effect of obesity management on body

image in patients seeking treatment at medical centers. Obesity

15:2320–2327

60. Perri MG, Corsica JA (2002) Improving maintenance of weight

lost in behavioral treatment of obesity. In: Wadden T, Stunkard A

(eds) Handbook of obesity treatment. Guilford Press, New York,

pp 357–379

61. Look AHEAD Research Group (2013) Cardiovascular effects of

intensive lifestyle intervention in type 2 diabetes. N Engl J Med

369:145–154

62. Wing RR (2010) Long-term effects of a lifestyle intervention on

weight and cardiovascular risk factors in individuals with type 2

diabetes mellitus: four-year results of the Look AHEAD trial.

Arch Intern Med 170:1566–1575

63. Gerstein HC (2013) Do lifestyle changes reduce serious outcomes

in diabetes? N Engl J Med 369:189–190

64. Nijamkin MP, Campa A, Sosa J, Baum M, Himburg S, Johnson P

(2012) Comprehensive nutrition and lifestyle education improves

weight loss and physical activity in Hispanic Americans fol-

lowing gastric bypass surgery: a randomized controlled trial.

J Acad Nutr Diet 112:382–390

65. Shang E, Hasenberg T (2010) Aerobic endurance training

improves weight loss, body composition, and co-morbidities in

patients after laparoscopic Roux-en-Y gastric bypass. Surg Obes

Relat Dis 6(3):260–266

66. Tsai AG, Wadden TA (2009) Treatment of obesity in primary

care practice in the United States: a systematic review. J Gen

Intern Med 24:1073–1079

67. Ashley JM, St Jeor ST, Schrage JP, Perumean-Chaney SE,

Gilbertson MC, McCall NL, Bovee V (2001) Weight control in

the physician’s office. Arch Intern Med 161:1599–1604

68. Perri MG, Limacher MC, Durning PE, Janicke DM, Lutes LD,

Bobroff LB, Dale MS, Daniels MJ, Radcliff TA, Martin AD (2008)

Extended-care programs for weight management in rural commu-

nities: the treatment of obesity in underserved rural settings

(TOURS) randomized trial. Arch Intern Med 168:2347–2354

69. Radcliff TA, Bobroff LB, Lutes LD, Durning PE, Daniels MJ,

Limacher MC, Janicke DM, Martin AD, Perri MG (2012)

Comparing costs of telephone vs face-to-face extended-care

programs for the management of obesity in rural settings. J Acad

Nutr Diet 112:1363–1373

70. Harvey-Berino J, West D, Krukowski R, Prewitt E, VanBiervliet

A, Ashikaga T, Skelly J (2010) Internet delivered behavioral

obesity treatment. Prev Med 51:123–128

71. Daumit GL, Dickerson FB, Wang NY, Dalcin A, Jerome GJ,

Anderson CA, Young DR, Frick KD, Yu A, Gennusa JV 3rd,

Oefinger M, Crum RM, Charleston J, Casagrande SS, Guallar E,

Goldberg RW, Campbell LM, Appel LJ (2013) A behavioral

weight loss intervention in persons with serious mental illness.

N Engl J Med 368:1594–1602

Eat Weight Disord (2013) 18:339–349 349

123