Eat Weight Disord (2013) 18:339–349 DOI 10.1007/s40519-013-0049-4 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 Ó 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 intervention 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 theory (i.e., behaviorism), which postulates that the behaviors that cause obesity (overeating and under-exercising) 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 environmental 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 recommendations on diet and exercise, and this multifaceted combination is commonly referred to as ‘‘lifestyle modification’’ [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 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 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 Practice guidelines formulated by the US National Heart, Lung and Blood Institute and the North American Association 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 considered 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 weightrelated comorbidities [6]. However, weight loss lifestyle modification is contraindicated in pregnant or lactating women, those with serious psychiatric illness (e.g., major 123 340 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 combination 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 syndrome, 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 psychology, and/or health education [15]. In these multidisciplinary 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 Eat Weight Disord (2013) 18:339–349 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 circumference, risk assessment for cardiovascular disease and diabetes, 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 contributes 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 condition, 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 123 Eat Weight Disord (2013) 18:339–349 341 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] 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 programs. 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 traditionally been delivered as a series of pre-packaged lessons 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, usually 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 123 342 Eat Weight Disord (2013) 18:339–349 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 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. formulation is well accepted by patients, although we as yet have no data regarding its efficacy in improving weight loss outcomes. Constructing the personal formulation 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 indicate 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 accelerometer, which measures not only their total energy expenditure over a prescribed period, but also the energy expended 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 representation (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 noneating stimuli (i.e., events and changes of mood) influence their eating behavior. The clinician should then assess whether overeating is maintained by any positive emotional 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, emphasizing 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 provisional and will be modified as needed during the course of the treatment. In our clinical experience, the personal 123 Self-monitoring of eating, exercise, and body weight Eat Weight Disord (2013) 18:339–349 343 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) 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 suggested 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 hydration, 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]. 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 associated 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]. 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 challenging [18] to provoke a sense of accomplishment, which is Stimulus control These procedures are based on the principles of classical and operant conditioning. Stimulus control is aimed at 123 344 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 establishing 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., craving or emotional stimuli) and to counter them with alternative behaviors, which are more effective if incompatible with eating (e.g., writing, knitting, housekeeping, exercising or taking a bath). Indeed, other behaviors such as listening 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., encouraging 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 failures [36]. Involving significant others Several studies suggest that social support is a key ingredient 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 together a written shopping list, eating the same foods, exercising together, creating a relaxed environment, and reinforcing the patient’s positive behaviors. Problem solving Patients should be helped to use problem-solving techniques 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 123 Eat Weight Disord (2013) 18:339–349 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. Specifically, 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 maintenance [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 Eat Weight Disord (2013) 18:339–349 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-calorie, low-fat diet and practicing high duration and frequency 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 maintenance of a cognitive behavioral intervention specifically designed to address the cognitive processes associated with weight regain [46]. 345 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 necessary 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 composition 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 necessary 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-weighing 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 fluctuation. 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 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 selfmonitoring, 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. 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 target weight [25]. Once they have returned to the weight maintenance binary, they should use the weight maintenance strategies to ensure they stay that way. 123 346 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 sessions) 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 associated 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 following 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), demonstrating that long-term weight loss can be achieved with 123 Eat Weight Disord (2013) 18:339–349 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 cholesterol 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 diabetes 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 residential 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 cardiovascular 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 confirmed by studies with longer follow-up, appear to suggest that residential treatment may increase the effect of lifestyle 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 comprehensive nutrition and lifestyle educational intervention or comparison groups [64] showed that at 12 months following 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 Eat Weight Disord (2013) 18:339–349 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 findings 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 programs 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 newsletters 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 replicated, suggest that lifestyle modification programs can be delivered with success in the community. Promising results have been also found delivering lifestyle 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, affordability, 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 347 (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 psychotropic medications leading to weight gain. Summary Lifestyle modification plays a central role in the management of obesity. 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