Gastroenterology

Gastroenterology

Volume 132, Issue 6, May 2007, Pages 2226-2238
Gastroenterology

Lifestyle Modification for the Management of Obesity

https://doi.org/10.1053/j.gastro.2007.03.051Get rights and content

Several expert panels have recommended that obese individuals attempt to lose 10% of their initial body weight through a combination of diet, physical activity, and behavior therapy (frequently referred to as lifestyle modification). This article reviews the short-and long-term results of lifestyle modification and methods to improve them. Randomized controlled trials were examined that compared different diet and activity interventions for inducing and maintaining weight loss. Studies that compared different methods of providing lifestyle modification, including on-site vs. Internet-based delivery, also were examined. A comprehensive lifestyle modification program was found to induce a loss of approximately 10% of initial weight in 16 to 26 weeks of group or individual treatment, delivered on-site. Comprehensive Internet-based programs induced a loss of approximately half this size. Patients’ consumption of portion-controlled diets, including liquid meal replacements, was associated with significantly greater short-term weight loss than was the consumption of isocaloric diets comprised of conventional foods. Factors associated with long-term weight control included continued patient–practitioner contact (whether on-site or by e-mail), high levels of physical activity, and the long-term use of pharmacotherapy combined with lifestyle modification. In summary, lifestyle modification induces clinically significant weight loss that is associated with the prevention or amelioration of cardiovascular risk factors.

Section snippets

Diabetes Prevention Program

The Diabetes Prevention Program provides an excellent example of the components of behavioral treatment and of the benefits of this approach.5 This study examined more than 3200 overweight individuals with impaired glucose tolerance who were randomly assigned to 1 of 3 treatment conditions: (1) placebo, (2) metformin (ie, 850 mg twice a day), or (3) a lifestyle intervention designed to induce a loss of 7% of initial weight and to increase physical activity. The lifestyle intervention provided

Structure of Behavioral Treatment

In academic medical centers, lifestyle modification is typically provided on a weekly basis for an initial period of 16 to 26 weeks, similar to the Diabetes Prevention Program.11, 12 This time-limited approach provides a clear starting and finishing line that helps participants pace their efforts. Treatment is usually provided to groups of 10 to 20 individuals (during 60- to 90-minute sessions) by registered dietitians, behavioral psychologists, exercise specialists, or related health

Short-Term Results of Treatment

Table 2 summarizes the results of a sample of randomized controlled trials published between 1974 to 2002. The studies selected were all published in Addictive Behaviors, Behaviour Research and Therapy, Behavior Therapy, and Journal of Consulting and Clinical Psychology. Studies were included if the intervention was representative of standard behavioral treatment and did not prescribe a diet of <900 kcal per day. The table is adapted from an earlier publication11 and updated.17, 18, 19, 20, 21,

Dietary Options for Weight Loss

Participants in behavioral programs are usually encouraged to consume a high-carbohydrate, low-fat diet (ie, fewer than 30% of calories from fat) that emphasizes consumption of fruits, vegetables, and whole grains.6, 14 This diet is consistent with recommendations of the U.S. Department of Agriculture.26 Lifestyle modification, however, can be combined with a variety of other dietary approaches, several of which have been designed to produce greater initial weight losses, which are so desired

Physical Activity for Cardiovascular Health and Weight Management

Physical activity plays a critical role in improving cardiovascular health, particularly in persons with obesity and its related health complications.71 Regular bouts of aerobic activity may reduce lipid levels, blood pressure, and the risk of osteoporosis71 and, in patients with type 2 diabetes, improve insulin sensitivity, abdominal adiposity, and glycemic control.72 The extent to which physical fitness reduces obesity-related mortality is less clear. Lee et al73, 74 examined more than 21,000

Long-Term Weight Management

Weight regain is a problem following virtually all dietary and behavioral interventions.91 As shown in Table 2, patients treated by behavior therapy for 20 to 30 weeks typically regain about 30% to 35% of their lost weight in the year following treatment. Weight regain slows after the first year but by 5 years 50% or more of patients are likely to have returned to their baseline weight.92

Summary and Conclusions

This review has shown that a comprehensive program of lifestyle modification is effective in inducing and maintaining losses of approximately 10% of initial weight. Losses of this size are associated with the prevention and amelioration of obesity-related health complications including type 2 diabetes and hypertension. Research is now needed to identify methods of making lifestyle modification available to the millions of people who would benefit from it. Moreover, far greater efforts and

References (125)

  • A.P. Makris et al.

    Dietary approaches to the treatment of obesity

    Psychiatr Clin North Am

    (2005)
  • S.K. Raatz et al.

    Reduced glycemic index and glycemic load diets do not increase the effects of energy restriction on weight loss and insulin sensitivity in obese men and women

    J Nutr

    (2005)
  • B. Sloth et al.

    No difference in body weight decrease between a low-glycemic-index and a high-glycemic-index diet but reduced LDL cholesterol after 10-wk ad libitum intake of the low-glycemic-index diet

    Am J Clin Nutr

    (2004)
  • C.D. Lee et al.

    Cardiorespiratory fitness, body composition, and cardiovascular disease mortality in men

    Am J Clin Nutr

    (1999)
  • R.W. Jeffery et al.

    Physical activity and weight loss: does prescribing higher physical activity goals improve outcome?

    Am J Clin Nutr

    (2003)
  • J.M. Rippe et al.

    The role of physical activity in the prevention and management of obesity

    J Am Diet Assoc

    (1998)
  • L.H. Epstein et al.

    A comparison of lifestyle exercise, aerobic exercise, and calisthenics on weight loss in obese children

    Behav Ther

    (1985)
  • Obesity: preventing and managing the global epidemic

    (1998)
  • Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults

    Obes Res

    (1998)
  • The practical guide: identification, evaluation, and treatment of overweight and obesity in adults

    (2000)
  • T.A. Wadden et al.

    Efficacy of lifestyle modification for long-term weight control

    Obes Res

    (2004)
  • Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin

    N Engl J Med

    (2002)
  • The Diabetes Prevention Program: description of lifestyle intervention

    Diabetes Care

    (2002)
  • T.J. Orchard et al.

    The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial

    Ann Intern Med

    (2005)
  • J. Tuomilehto et al.

    Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance

    N Engl J Med

    (2001)
  • V.J. Stevens et al.

    Long-term weight loss and changes in blood pressure: results of the trials of hypertension prevention, phase II

    Ann Intern Med

    (2001)
  • R.R. Wing

    Behavioral weight control

  • D.A. Renjilian et al.

    Individual vs. group therapy for obesity: effects of matching participants to their treatment preference

    J Consult Clin Psychol

    (2001)
  • K.D. Brownell

    The LEARN program for weight management

    (2000)
  • T.A. Wadden et al.

    Randomized trial of lifestyle modification and pharmacotherapy for obesity

    N Engl J Med

    (2005)
  • R.I. Berkowitz et al.

    Behavior therapy and sibutramine for the treatment of adolescent obesity: a randomized controlled trial

    JAMA

    (2003)
  • M.G. Perri et al.

    Effects of group- versus home-based exercise training in healthy older men and women

    J Consult Clin Psychol

    (1997)
  • A.W. Meyers et al.

    An evaluation of a television-delivered behavioral weight loss program: are the ratings acceptable

    J Consult Clin Psychol

    (1996)
  • T.A. Wadden et al.

    Exercise in the treatment of obesity: effects of four interventions on body composition, resting energy expenditure, appetite and mood

    J Consult Clin Psychol

    (1997)
  • T. Sbrocco et al.

    Behavioral choice treatment promotes continuing weight loss: preliminary results of a cognitive-behavioral decision-based treatment for obesity

    J Consult Clin Psychol

    (1999)
  • R.R. Wing et al.

    Benefits of recruiting participants with friends and increasing social support for weight loss and maintenance

    J Consult Clin Psychol

    (1999)
  • M.G. Perri et al.

    Relapse prevention training and problem-solving therapy in the long-term management of obesity

    J Consult Clin Psychol

    (2001)
  • E.M. Ramirez et al.

    A comparison of weight control and weight control plus body image therapy for obese men and women

    J Consult Clin Psychol

    (2001)
  • Dietary Guidelines for Americans

    (2005)
  • G.D. Foster et al.

    Obese patients’ perceptions of treatment outcomes and the factors that influence them

    Arch Intern Med

    (2001)
  • T.A. Wadden et al.

    Great expectations: “I’m losing 25% of my weight no matter what you say.”

    J Consult Clin Psychol

    (2003)
  • T.A. Wadden et al.

    Responsible and irresponsible use of very-low-calorie diets in the treatment of obesity

    JAMA

    (1990)
  • Very low calorie diets

    JAMA

    (1993)
  • A.G. Tsai et al.

    The evolution of very-low-calorie diets: an update and meta-analysis

    Obesity

    (2006)
  • K.R. Ryttig et al.

    Long-term effects of a very low calorie diet (Nutrilett) in obesity treatment: a prospective, randomized, comparison between VLCD and a hypocaloric diet + behavior modification and their combination

    Int J Obes

    (1997)
  • T.A. Wadden et al.

    One-year behavioral treatment of obesity: comparison of moderate and severe caloric restriction and the effects of weight maintenance therapy

    J Consult Clin Psychol

    (1994)
  • J.S. Torgerson et al.

    VLCD plus dietary and behavioural support versus support alone in the treatment of severe obesity: a randomised two-year clinical trial

    Int J Obes

    (1997)
  • A.G. Tsai et al.

    Systematic review: an evaluation of major commercial weight loss programs in the United States

    Ann Intern Med

    (2005)
  • S.W. Lichtman et al.

    Discrepancy between self-reported and actual caloric intake and exercise in obese subjects

    N Engl J Med

    (1992)
  • M. Flechtner-Mors et al.

    Metabolic and weight loss effects of long-term intervention in obese patients: four-year results

    Obes Res

    (2000)
  • Cited by (0)

    Preparation of this article was supported, in part, by grant DK065018 from the National Institute of Diabetes, Digestive, and Kidney Disease.

    View full text