B e h a v i o r a l Tre a t m e n t o f

t he Pa tien t wi t h Ob esi ty
a, b
Naji Alamuddin, MD, BCh, MTR *, Thomas A. Wadden, PhD

KEYWORDS

Obesity
Weight loss
Behavioral treatment
Lifestyle modification
Health

KEY POINTS

Weight loss of 5% to 10% of initial body weight is produced by a comprehensive 16 to
26 week behavioral intervention, consisting of diet, exercise, and behavior therapy.

Behavioral treatment can be combined with diets of varying macronutrient composition,
all of which are successful if they induce an appropriate energy deficit.

Physical activity alone is of limited benefit for inducing weight loss but is important for
improving health and quality of life and for facilitating long-term weight management.

Weight regain is common following behavioral treatment but can be prevented by
providing patients twice monthly or monthly weight loss maintenance sessions.

The Diabetes Prevention Program and the Look AHEAD study provide examples of
comprehensive behavioral interventions that produced long-term improvements in
weight-related comorbid conditions.

INTRODUCTION

Expert panels sponsored by the World Health Organization, the National Institutes of
Health, and several professional societies have recommended that obese individuals
lose approximately 10% of initial body weight to improve their health and quality of
life.1–3 This goal can be achieved using a comprehensive behavioral program that in-
cludes 3 principal components: diet, physical activity, and behavior therapy. This
article describes behavioral treatment of obesity (also referred to as behavioral weight
control or lifestyle modification), its short-term and long-term results of treatment, and
new developments in the field.

Disclosure Statement: T.A. Wadden serves on advisory boards for Nutrisystem and Weight
Watchers International, each of which provides behavioral weight loss programs. N. Alamud-
din has no disclosures.
a
Division of Endocrinology, Diabetes, and Metabolism; and Center for Weight and Eating Dis-
orders, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite
3025, Philadelphia, PA 19104, USA; b Department of Psychiatry, Center for Weight and Eating
Disorders, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite
3029, Philadelphia, PA 19104, USA
* Corresponding author.
E-mail address: Naji.alamuddin@uphs.upenn.edu

Endocrinol Metab Clin N Am 45 (2016) 565–580

http://dx.doi.org/10.1016/j.ecl.2016.04.008 endo.theclinics.com
0889-8529/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
566 Alamuddin & Wadden

OVERVIEW OF BEHAVIORAL TREATMENT

The Diabetes Prevention Program (DPP) provides an excellent example of a compre-

hensive behavioral intervention.4 It randomly assigned more than 3200 overweight or
obese subjects with impaired glucose tolerance to placebo, metformin, or an intensive
lifestyle intervention (ILI); the latter was designed to induce and maintain a 7 kg reduc-
tion in initial weight. The study’s primary outcome was the reduction in the incidence of
type 2 diabetes. Lifestyle participants attended 16 individual counseling sessions (with
a registered dietitian) during the first 24 weeks and then had 1 contact at least every
other month for the remainder of the 4-year study. Subjects were instructed to
consume a low-fat, reduced-calorie diet (ie, 1200–2000 kcal/d, based on body
weight), made up of conventional foods that they selected. The physical activity
goal was 150 min/wk (principally of brisk walking). The study was stopped after a
mean of 2.8 years, at which time lifestyle participants had achieved a mean loss of
5.6 kg, compared with significantly smaller losses of 2.1 kg for metformin and
0.1 kg for placebo. The lifestyle intervention, compared with the placebo and metfor-
min groups, reduced the risk of developing type 2 diabetes by 58% and 31%, respec-
tively, leading to the study’s early termination to provide lifestyle modification to the
other 2 groups. A 10-year follow-up assessment found that, compared with placebo,
the lifestyle intervention maintained a 34% reduction in the risk of developing type 2
diabetes, even though the latter subjects had regained most of their lost weight.5
Comparable favorable findings were observed in trials conducted in Finland and
China.6,7
The following section provides a fuller description of the components of behavioral
treatment as provided in the DPP and clinical practice. Detailed accounts are provided
by treatment manuals such as the Lifestyle, Exercise, Attitudes, Relationships, Nutri-
tion (LEARN) Program for Weight Control or the protocols developed for the DPP and
Action for Health in Diabetes (Look AHEAD) trials.4,8,9

PRINCIPAL COMPONENTS OF BEHAVIORAL TREATMENT

Diet
Behavioral weight control typically prescribes a calorie target to induce an energy
deficit of 500 to 1000 kcal/d.8 The target is usually 1200 to 1500 kcal/d for women
and 1500 to 1800 kcal/d for men.10 Alternatively, numerous studies have prescribed
calorie goals based on body weight, with 1200 to 1499 kcal/d for individuals less
than 250 lb and 1500 to 1800 kcal/d for those greater than this weight.11 A couple
of weeks of calibration may be required for participants to identify the calorie level
that produces the desired loss of 0.5 to 1 kg/wk.
Although the DPP prescribed a traditional low-fat, low-calorie diet, a variety of
different interventions can be incorporated in behavioral treatment, including low-
carbohydrate, low-glycemic, and Mediterranean-type diets. All diets will produce
weight loss, regardless of their macronutrient composition, if a consistent caloric
deficit is achieved. This was demonstrated by the 2-year Preventing Obesity Using
Novel Dietary Strategies (POUNDS) Lost study, in which participants in 4 diets groups
were all prescribed a 750 kcal/d deficit but were instructed to consume different per-
centages of protein (15% or 25%), fat (20% or 40%), and carbohydrate (ranging from
35% to 65% of daily calories).12 Short-term and long-term weight losses did not differ
significantly at any time among the 4 dietary interventions, all of which were combined
with a comprehensive program of lifestyle modification. Foster and colleagues13 simi-
larly found no significant differences in short-term or long-term weight loss in subjects
assigned to low-carbohydrate versus low-fat diets, each combined with intensive
 Behavioral Treatment of the Patient with Obesity 567

lifestyle modification. Although the macronutrient composition of the reducing diet

does not seem to affect weight loss, it may contribute to improvements in cardiome-
tabolic risk factors. A low-glycemic index diet, for example, produced greater im-
provements in hemoglobin A1c (HbA1c) in overweight subjects with type 2 diabetes
than did a traditional low-fat diet that induced comparable weight loss.14 Table 1 sum-
marizes the results of selected randomized trials that examined the effects of macro-
nutrient composition on changes in weight and health outcomes.12–21
Self-Monitoring
Recording the type and amount of foods and beverages consumed, along with their
calorie content, is a critical component of behavioral treatment. Self-monitoring helps
patients identify patterns in their eating (including times and places associated with
consumption), select targets for reducing calorie intake, and track progress in meeting
calorie goals. Self-monitoring records can be expanded to include the patient’s
thoughts and feelings associated with inappropriate eating. More frequent self-
monitoring is associated with greater weight loss.22,23
Patients traditionally have used paper records and a calorie book to track their food
intake but these have been largely replaced by on-line trackers and applications
(apps), such as My Fitness Pal or Lose It. Self-monitoring of physical activity is similarly
encouraged, using a paper log or a device such as a pedometer or accelerometer (as
provided by a Fitbit or a smartphone). Patients also are instructed to weigh themselves
regularly, usually once or twice per week during active weight loss and as often as
daily during weight loss maintenance. Cellular-connected “smart” scales, which mea-
sure weight digitally and send participants a graph of their progress, may help to
induce weight loss when used as a primary intervention.24
Stimulus Control
Stimulus control teaches patients to manage external cues, such as the sight or smell
of food, as well as times, places, and events associated with eating.8,11 By reducing
exposure to problem foods, patients are less likely to overeat. For example, patients
are advised to avoid venues (eg, fast-food restaurants or all-you-can-eat buffets) that
increase the risk of excess eating. At home, they are instructed to store foods out of
sight, to serve modest portion sizes, to keep the table free of serving dishes, and to
clean plates immediately after eating. They similarly are taught to limit eating to 1 or
2 rooms in the home and to avoid snacking while engaging in other behaviors (eg,
watching television).
Goal Setting
Behavioral treatment helps patients make objective, measurable changes in eating,
activity, and related behaviors.8,11 They are guided in setting specific targets for cal-
orie intake, minutes of physical activity, and frequency of self-monitoring. Goal setting
clearly identifies the behavior to be changed and stipulates when, where, and how it
will be performed. Patients regularly review with their interventionist progress made
in meeting goals, as recorded in their food and activity logs.
Problem-Solving
Behavioral weight control usually includes additional components, such as problem
solving skills that help patients analyze challenges they have in adhering to their
diet and activity prescriptions.8,11,23 They are taught to identify several possible solu-
tions to the problem, to pick the most promising, and then implement it. Patients also
learn cognitive restructuring skills, such as identifying cognitive distortions (eg, “I’ll
 568
Alamuddin & Wadden
Table 1
Weight losses from randomized trials that compared diets with varying macronutrient compositions

Number of
Lifestyle
Sessions
Study Number Provided Dietary Intervention Weight Change mo Comment or Other Results
Dansinger 160 (51% F) 4 Atkins 2.1 kga 12 All participants had hypertension, dyslipidemia, and/or
et al,15 2005 58% completed Zone 3.2 kga fasting hyperglycemia
Weight Watchers 3.0 kga Weight loss was associated with level of adherence
Ornish 3.3 kga Each diet decreased LDL to HDL ratio
No significant effects on BP or blood glucose at 12 months
Das et al,16 34 (% F unknown) 52 Low-glycemic load 7.8%a 12 No differences were observed between groups in change in
2007* 85% completed CVD risk factors
High-glycemic load 8.0%a
Fabricatore 79 (80% F) 30 Low-glycemic load 4.5%a 9 All participants had type 2 diabetes
et al,14 2011 63% completed Low-fat 6.4%a Larger reductions in HbA1c in the low-glycemic load groupy
Foster et al,17 63 (68% F) 3 Low-carbohydrate (high 4.4%a 12 HDL cholesterol increased more and triglycerides
2003 59% completed protein, high fat) decreased more in the low-carbohydrate groupy
Conventional (high- 2.5%a Greater reductions in LDL and total cholesterol in the low-
carbohydrate, low-fat) fat group at 3 moy
Diastolic BP decreased in both groups
Foster et al,13 307 (68% F) 38 Low-carbohydrate 6.3 kga 24 Greater increase in HDL cholesterol in the low-
2010 63% completed Low-fat 7.4 kga carbohydrate groupy
Greater decrease in triglycerides at 3 and 6 mo in the low-
carbohydrate groupy
Greater decrease in LDL at 3 and 6 mo in the low-fat groupy
Gardner 311 (100% F) 8 Atkins (low-carbohydrate) 4.7 kga 12 Greater increase in HDL cholesterol larger in Atkins than
et al,18 2007 80% completed Zone (even distribution) 1.6 kgb Ornish group and greater decrease in triglyceride levels
LEARN (calorie-restricted) 2.2 kgab in Atkins than Zone group
Ornish (low-fat) 2.6 kgab No differences in insulin or blood glucose between groups
Systolic BP decreased more in Atkins than in all other
groupsy Diastolic BP decreased more in Atkins group
than in Ornish groupy All participants had diabetes
 Sacks et al,12 811 (64% F) 66 Low-fat, average protein 2.9 kga 24 LDL cholesterol decreased significantly more in lowest fat
2009 80% completed (highest carbohydrate) to highest carbohydrate than in highest fat groups to
Low-fat, high-protein 3.8 kga lowest carbohydrate groupsy
High-fat, average-protein 3.1 kga HDL cholesterol increased more with lowest carbohydrate
High-fat, high-protein 3.5 kga than with the highest carbohydrate diety
(lowest carbohydrate) All diets decreased triglyceride levels similarly
All diets, except the highest carbohydrate, decreased
fasting insulin (greater decrease in the high protein vs
average protein diets)
Shai et al,19 322 (14% F) 24 Low-fat 2.9 kga 24 No significant change in LDL cholesterol in any group
2008 85% completed Mediterranean 4.4 kgb HDL cholesterol increased in all groups, significantly more
Low-carbohydrate 4.7 kgb in the low-carbohydrate than low-fat group
Triglyceride levels decreased more in the low-carbohydrate
than in the low-fat groupy
In diabetic participants, only the Mediterranean diet group

Behavioral Treatment of the Patient with Obesity

had a decrease in fasting glucose
Insulin decreased in all groups, for both diabetic and
nondiabetic participants
All groups had a significant decrease in BP
Stern et al,20 132 (17% F) 15 Low-carbohydrate 5.1 kga 12 Triglyceride levels decreased more in the low-carbohydrate
2004 66% completed Conventional (low-fat) 3.1 kga group than in the low-fat groupy
HDL cholesterol decreased less in the low-carbohydrate
group than in the low-fat groupy
Greater improvements in HbA1C in type 2 diabetics in the
low-carbohydrate groupy
Yancy et al,21 120 (76% F) 9 Low-fat diet 6.5%a 6 All participants were hyperlipidemic
2004 66% completed Low-carbohydrate, 12.0%b Low-carbohydrate group showed greater decreases in
ketogenic diet with triglycerides and greater increases in HDLy
nutritional supplements

All studies were analyzed by use of an intention-to-treat population, with the exception as indicated by an asterisk (*).
Different letters (in superscript) indicate statistically significant differences in weight loss between groups.
Abbreviations: BP, blood pressure; CVD, cardiovascular disease; F, female; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MR, meal replacements;
VLDL, very low density lipoprotein.
* A completer’s population was examined.
y
Results reported as “greater,” “larger,” “increased more,” and so forth represent statistically significant differences between treatment conditions.

569
570 Alamuddin & Wadden

never be able to lose weight because I ate that dessert”) and replacing them with
rational responses (eg, “The 150 calories in ice cream is not going to hinder my weight
loss, particularly if I walk after dinner”). Relapse prevention training teaches patients to
anticipate and respond to lapses (eg, slips in their diet or exercise adherence) and
high-risk situations (eg, the winter eating holidays). Details of problem solving and
relapse prevention have been provided by Perri and colleagues25

Physical Activity
Patients in behavioral weight control programs are instructed to gradually increase
their physical activity to approximately 150 to 180 min/wk over the first 6 months.10,11
Activity usually consists of brisk walking or other forms of moderate-intensity aerobic
exercise. Short-term studies (<6 months) have shown that physical activity alone in-
duces minimal reductions in body weight compared with losses produced by dieting
(ie, caloric restriction). Wing and colleagues,26 for example, found that physical activity
alone, diet alone, and diet plus physical activity interventions produced mean losses of
2.1, 9.1, and 10.3 kg, respectively, in 6 months of weekly intervention. Many obese in-
dividuals are not able to engage, at least initially, in the high levels of physical activity
required to reduce body weight by 1 lb per week (by exercise alone). Patients must
walk approximately 35 miles per week to achieve this loss. Alternatively, they can
lose 1 lb/wk by just reducing their food intake by 500 kcal/d (the equivalent of elimi-
nating 2 20 oz sugared sodas per day). Thus, patients must be cautioned not to expect
significant weight loss from exercising alone or to try to use physical activity as a
means of offsetting dietary indiscretions.
High levels of physical activity are required to facilitate the maintenance of lost
weight (see later discussion). Patients, however, should be encouraged to exercise
in the near term to improve their cardiovascular health. Several investigations have
found that high levels of cardiorespiratory fitness significantly attenuate the risk of car-
diovascular disease (CVD) mortality in overweight and obese individuals. A 10-study
meta-analysis that assessed the combined effects of cardiorespiratory fitness and
obesity on mortality found that, compared with normal weight and fit individuals, unfit
individuals had twice the mortality rate, regardless of body mass index (BMI).27 Obese
but fit individuals had similar rates of survival as individuals of average weight (ie, BMI
<25 kg/m2). Similarly, Lee and colleagues28 found in a longitudinal study of 25,000
men that obese but fit individuals had lower rates of CVD death than lean but unfit
men. Even in the absence of weight loss, regular aerobic activity reduces blood pres-
sure (BP), lipid concentrations, and visceral fat, while ameliorating glucose intolerance
and insulin resistance in nondiabetic individuals, and improving glycemic control in
persons with type 2 diabetes.29

STRUCTURE AND FREQUENCY OF BEHAVIORAL WEIGHT CONTROL

Behavioral treatment typically is delivered by a registered dietitian, psychologist, or

other health professional, in an individual or group format.11,30 Visits are usually held
weekly for 16 to 24 weeks, followed by every-other-week or monthly meetings. Ses-
sions begin with patients being weighed in private, which provides an important op-
portunity for accountability and prompts participants to examine the relationship
between their changes in weight and behavior.30 After the weigh-in, they report on
their progress in meeting their calorie and physical activity goals and use problem
solving skills to address difficulties encountered. The remainder of the meeting fo-
cuses on discussing a new weight management skill, as described in the structured
curriculum. The session concludes with goals and assignments for the coming week.
 Behavioral Treatment of the Patient with Obesity 571

Group sessions usually include 10 to 20 members and run 60 to 90 minutes, with

individual meetings lasting about half that time.11,30 Group treatment, in addition to be-
ing less costly than individual care, has the advantage of providing social support,
empathy, and a healthy dose of competition for patients.30 A randomized controlled
trial found that a group-delivered intervention produced approximately 2 kg greater
weight loss than individual treatment.31

SHORT-TERM AND LONG-TERM WEIGHT LOSSES

Short-Term Efficacy
Structured lifestyle modification programs (see previous discussion) produce an
average loss of 7 to 10 kg in the first 6 months, equal to a reduction of 7% to 10%
of initial weight.3,11 Weight losses are largest when at least 14 intervention sessions
are provided during this time; lower intensity treatment is not as effective.3 Approxi-
mately 50% to 70% of patients achieve a 5% or greater reduction in initial weight, a
criterion for clinically meaningful weight loss.3 Individuals with the best attendance
and greatest consistency in keeping self-monitoring records achieve the largest
weight losses.22,23
The previously described study by Foster and colleagues13 provides an excellent
example of a state-of-the-art lifestyle intervention for the first year. Subjects in both
the low-fat and low-carbohydrate diet groups were provided 20 weekly group ses-
sions, 10 every-other-week sessions (through week 40), and then every-other-
month sessions through 2 years. As shown in Fig. 1, participants in both groups
lost approximately 11.8 kg at 6 months and maintained a loss of approximately this
size at 12 months (10.8 kg for both groups).

Long-Term Efficacy
Gradual weight regain is common following behavioral treatment, as illustrated by
Foster and colleagues13 study at month 24. In the absence of further treatment, par-
ticipants typically regain 3 to 4 kg in the first year following intervention, with 1 to 2 kg
per year thereafter. Five years after treatment, about half of the participants have
returned to their baseline weight.11,30 Decreased adherence to diet and exercise

Fig. 1. Change in body weight for participants in low-fat and low-carbohydrate diet groups
after 24 months, based on random-effects linear model. (From Foster GD, Wyatt HR, Hill JO,
et al. Weight and metabolic outcomes after 2 years on a low-carbohydrate versus low-fat
diet: a randomized trial. Ann Intern Med 2010;153:147–57; with permission.)
572 Alamuddin & Wadden

prescriptions and a return to previous habits contribute to weight regain,30 as do un-

favorable changes in appetite hormones (eg, ghrelin, leptin) and energy expenditure
(both resting and nonresting).32 Caloric restriction and weight loss induce decreases
in leptin (a hormone that facilitates satiety), and increases in ghrelin (a hormone that
stimulates hunger). Thus, decreased leptin and increased ghrelin promote overfeeding
and weight regain. Sumithran and colleagues32 demonstrated that these changes are
not transient but continue even when patients stop losing weight and start to regain it,
suggesting that these compensatory biological responses regrettably defend the body
against weight reduction.

IMPROVING THE MAINTENANCE OF LOST WEIGHT

Weight Loss Maintenance Sessions
The most effective method for preventing weight regain is to provide patients
continued behavioral support on an every-other-week or monthly basis following
the initial weight loss program. Perri and colleagues33 found that participants who
attended group sessions every other week for 1 year after weight reduction main-
tained 13 kg of their 13.2 kg end-of-treatment weight loss. Those who received no
further care regained 5.1 kg during the year. Wing and colleagues23 similarly demon-
strated that monthly weight loss maintenance sessions attenuated weight regain over
18 months. The most successful patients monitored their weight weekly or more
frequently and responded quickly to small increases in weight. Table 2 summarizes
what the authors believe are the key components of lifestyle modification for both
inducing and maintaining a weight loss of 7% to 10% of initial body weight.11
Weight loss maintenance sessions provide patients important support and account-
ability.30 In addition, participants are instructed in the cardinal behaviors practiced by
individuals in the National Weight Control Registry, all of whom have lost at least 13.6 kg
(30 lb) and kept the weight off for 1 year or more.34 Registry members engage in high
levels of physical activity (eg, 225–300 min/wk), eat a low-fat, low-calorie diet (1200–
1300 kcal/d for women), and weigh themselves frequently (once a week or more).

High Levels of Physical Activity

Numerous studies have demonstrated the critical role of increased physical activity in
facilitating the maintenance of lost weight. Jeffery and colleagues,35 for example,
randomly assigned subjects to expend either 1000 kcal/wk or 2500 kcal/wk (princi-
pally through walking). Both groups also received a comprehensive program of life-
style modification. There were no significant differences in weight loss between the
2 groups at month 6 (8.1 and 9.0 kg, respectively), consistent with the previous discus-
sion of the limited effects of exercise on short-term weight loss. However, at month 18,
subjects in the high activity group maintained a loss of 6.7 kg, compared with a signif-
icantly smaller 4.1 kg for the low-activity group. In a secondary analysis of a random-
ized controlled trial, Jakicic and colleagues36 similarly demonstrated that women who
exercised more than 200 min/wk maintained greater weight loss than those who exer-
cised 150 to 199 min/wk, or less than 150 min/wk. The American College of Sports
Medicine recommends physical activity of 60 minutes/d (ie, brisk walking or its equiv-
alent) to facilitate the maintenance of lost weight.37
Physical activity may improve long-term weight loss by multiple mechanisms,
including exercise’s positive effects on mood, body composition, and resting meta-
bolic rate.38 Compelling findings indicate that high levels of physical activity are
needed to compensate for increased energy efficiency following weight loss. Rose-
nbaum and colleagues39 had obese individuals lose 10% of initial weight and found
 Behavioral Treatment of the Patient with Obesity 573

Table 2
Key components of comprehensive behavioral weight loss interventions to achieve and
maintain a 7% to 10% weight loss

Component Weight Loss Weight Loss Maintenance

Frequency and Weekly contact, in person, or by Every-other-week contact for
duration of telephone, for 20–26 wk. 52 wk (or longer)
treatment contact (Internet or e-mail contact yields Monthly contact may be adequate
smaller weight loss) Group or individual contact
Group or individual contact
Dietary prescription Low-calorie diet (1200–1499 kcal Consumption of a hypocaloric diet
for those <250 lb; 1500– to maintain reduced body
1800 kcal for those 250 lb) weight
Typical macronutrient Typical macronutrient
composition: 30% fat (7% composition: similar to that for
saturated fat); 15%–25% weight loss
protein; remainder from
carbohydrate (diet composition
may vary based on individual
needs or preferences)
Physical activity 180 min/wk of moderately 200–300 min/wk of moderately
prescription vigorous aerobic activity (eg, vigorous aerobic activity (eg,
brisk walking); strength training brisk walking); strength training
also desirable also desirable
Behavior therapy Daily monitoring of food intake Occasional to daily monitoring of
prescription and physical activity by use of food intake and physical activity
paper or electronic diaries by use of similar diaries
Weekly monitoring of weight Twice weekly to daily monitoring
Structured curriculum of behavior of weight.
change (eg, DPP) Curriculum of behavior change,
Regular feedback from an including relapse prevention
interventionist and individualized problem
solving
Periodic feedback from an
interventionist

From Wadden TA, Webb VL, Moran CH, et al. Lifestyle modification for obesity: new developments
in diet, physical activity, and behavior therapy. Circulation 2012;125:1157–70; with permission.

that maintenance of a reduced body weight was associated with a decrease in total
energy expenditure (TEE) that was approximately 300 to 500 kcal/d greater than
that predicted by changes in body weight and composition. The decrease in TEE
was due predominately to reduced energy expended during physical activity (ie, non-
resting energy expenditure), reflecting increased work efficiency of skeletal muscle.
Thus, paradoxically, successful weight losers may have to approximately double their
amount of physical activity to compensate for their increased (undesired) energy
efficiency.
Practitioners should emphasize that for weight control this activity can be performed
at a moderate intensity and in short bouts, as brief as 10 minutes. When included as
part of a comprehensive weight loss program, multiple short bouts of activity
(throughout the day) are as effective as 1 long bout (>40 min) in achieving weight con-
trol.40,41 Additional studies have shown that lifestyle activity, which involves increasing
energy expenditure throughout the course of the day, without concern for the intensity
or duration of the activity, is as effective for weight control as more traditional
574 Alamuddin & Wadden

programmed activity (eg, jogging, swimming, or biking).42,43 Pedometers and a new

generation of activity trackers (eg, Fitbit, Jawbone, smartphones) provide some of
the most convenient methods of monitoring lifestyle activity.44 The ultimate goal is
to walk approximately 10,000 steps daily, the equivalent of 4 to 5 miles, as practiced
by members of the National Weight Control Registry.

HEALTH BENEFITS OF LIFESTYLE MODIFICATION FOR OBESITY

An extensive literature has demonstrated that losses of 5% or more of initial body

weight are associated with both short-term and long-term improvements in cardiome-
tabolic health, cardiorespiratory fitness, physical function, quality of life, mood, and
sleep apnea (only a partial list of the benefits).1–3 The Look AHEAD trial has provided
the most extensive assessment of the health consequences of a lifestyle intervention,
including its effects on cardiovascular morbidity and mortality over a 10-year period.9
More than 5100 overweight or obese individuals with type 2 diabetes mellitus were
randomly assigned to a diabetes support and education (DSE) group or an ILI group.
The DSE participants received medical care from their own health professional who
were encouraged to provide state-of-the-art care to manage comorbid conditions.
Participants in ILI also received medical care from their own providers. In addition,
they were provided a high-intensity lifestyle intervention, described previously, which
was designed to help subjects achieve (and maintain) at least at 7% reduction in initial
weight and 175 min/wk of physical activity.45
At the end of year 1, ILI participants lost a mean of 8.6% of initial weight, compared
with a significantly smaller 0.7% in the DSE group.46 The ILI group was superior to DSE
in improvements in BP, blood glucose, HbA1c, fitness, quality of life, physical function,
sleep apnea, and other outcomes. A secondary analysis of selected outcomes, shown
in Fig. 2, revealed the strong linear relationship between weight loss and improve-
ments in selected cardiometabolic outcomes.47 Losses as little as 2% to 4.9% of initial
weight were sufficient to improve systolic BP and triglyceride levels, while reductions
of 5% to 9.9% also improved HbA1c, diastolic BP, and high-density lipoprotein (HDL)
cholesterol. These findings are useful in underscoring to patients the benefits of losing
as few as 5 to 10 lb (2.3–4.6 kg). The results also clearly demonstrated that larger
weight losses generally were associated with greater improvements in cardiometa-
bolic risk factors. Thus, patients should be encouraged to achieve a loss of 10% or
more of initial weight when feasible.
Look AHEAD’s primary outcome was a composite of cardiovascular morbidity and
mortality (ie, fatal and nonfatal stroke and myocardial infarction, plus hospitalization
for angina). The study was terminated after a mean follow-up of 9.6 years when statis-
tical analyses revealed no significant differences between the ILI and DSE groups on
the primary outcome, and investigators determined that extending the period of
follow-up was unlikely to reveal any.9 This was an unexpected result that led some
commentators to suggest that weight loss was not beneficial. To the contrary, the
ILI, compared with DSE, was associated with greater reductions in HbA1C; decreased
use of medications to treat diabetes, hypertension, and hyperlipidemia; lower medical
costs; and reduced risk of developing very-high risk chronic kidney disease.9,48,49 It
was also associated with reduced hospitalization and other medical costs. Investiga-
tors currently are examining whether the ILI resulted in reduced all-cause mortality.

NEW DEVELOPMENTS IN THE DELIVERY OF LIFESTYLE MODIFICATION

New methods of delivering lifestyle modification are emerging with the rapid growth in
digital means of communication (eg, Internet, e-mail, text messaging, Facebook,
 Behavioral Treatment of the Patient with Obesity 575

Change in BP by Weight Loss Category Change in HbA1c% by Weight Loss Category

0 0

–2
–0.2
Change in BP (mm Hg)

Change in HbA1c (%)

–4

–0.4
–6

–8 –0.6
P<.0001
–10
SBP: P<.0001 SBP
DBP: P<.0001 DBP –0.8
–12

–14 Gained >2% Gained ≤2% ∼ Lost ≥2% ∼ Lost ≥5% ∼ Lost ≥10% ∼ Lost ≥15%
–1
Gained >2% Gained ≤2% ∼ Lost ≥2% ∼ Lost ≥5% ∼ Lost ≥10% ∼ Lost ≥15%
Lost <2% Lost <5% Lost <10% Lost <15% Lost <2% Lost <5% Lost <10% Lost <15%

Change in Triglycerides by Weight Loss Category Change in HDL and LDL by Weight Loss Category
20 8
HDL:P<.0001 HDL
LDL:P = .3614 LDL
Change in Triglycerides (mg/dl)

0
Change in HDL and LDL (mg/dl)

–20
0

–40

–4
–60
P<.0001
–8
–80

–100 –12
Gained >2% Gained ≤2% ∼ Lost ≥2% ∼ Lost ≥5% ∼ Lost ≥10% ∼ Lost ≥15% Gained >2% Gained ≤2% ∼ Lost ≥2% ∼ Lost ≥5% ∼ Lost ≥10% ∼ Lost ≥15%
Lost <2% Lost <5 Lost <10% Lost <15% Lost <2% Lost <5% Lost <10% Lost <15%

Fig. 2. Change in risk factors by weight loss categories for the Look AHEAD cohort. Data in
all figures are presented as least square means and 95% confidence intervals adjusted for
clinical sites, age, sex, race or ethnicity, baseline weight, baseline measurement of the
outcome variable, and treatment group assignment. HDL, high-density lipoprotein; LDL,
low-density lipoprotein. (Adapted from Wing RR, Lang W, Wadden TA, et al. Benefits of
modest weight loss in improving cardiovascular risk factors in overweight and obese individ-
uals with type 2 diabetes. Diabetes Care 2011;34:1481.)

Twitter), with their potentially greater convenience and reduced cost. This section
briefly examines efforts to deliver lifestyle modification by telephone and the Internet.

Telephone-Delivered Programs
Participants treated by Donnelly and colleagues50 received a 12-week weight loss
program (ie, a 1200–1500 kcal/d diet of meal replacements and conventional foods)
followed by a 14-week weight maintenance program. Half of the participants received
all instruction via group conference calls and the other half attended on-site groups.
Median weight losses at 12 weeks were 10.6 kg and 12.7 kg, respectively
(P<.05) and at 26 weeks were 12.8 kg and 12.5 kg, respectively (not significantly
different).
Perri and colleagues51 demonstrated the effectiveness of telephone-based coun-
seling for maintaining lost weight. Obese women who had lost an average of 10 kg dur-
ing a 6-month run-in period were randomly assigned to receive a twice-monthly
weight loss maintenance program that was delivered by telephone or on site. Women
in a third group received newsletters only. Participants in the 2 weight loss
576 Alamuddin & Wadden

maintenance interventions regained only 1.2 kg in the year of treatment compared with
a significantly greater gain of 3.7 kg for those in the newsletter group. Appel and
colleagues52 also reported excellent maintenance of weight loss at 2 years with a prin-
cipally telephone-delivered intervention. These findings suggest that lifestyle modifi-
cation could be effectively delivered by call centers, as currently used for smoking
cessation, diabetes management, and other conditions. Cost-effectiveness analyses
are needed to compare further the benefits of on-site versus telephone-delivered
interventions.

Digitally-Delivered Programs
In a first-generation study, Tate and colleagues53 randomly assigned participants to 1
of 2 6-month programs delivered by Internet. The educational (control) intervention
provided a directory of Internet resources for weight management (but no specific in-
struction in changing eating and activity habits). The behavior therapy intervention
included this directory but also 24 weekly lessons conducted by e-mail in which par-
ticipants submitted their food and activity records on-line and received feedback from
an interventionist. Participants in the behavior therapy group lost significantly more
weight than those in the educational group (4.1 vs 1.6 kg). In a 1-year follow-up study,
Tate and colleagues54 randomly assigned individuals at risk of type 2 diabetes to a
low-intensity Internet intervention or to the same program with the addition of weekly
behavioral counseling, delivered by e-mail. Participants in the latter group lost signif-
icantly more weight at 1 year (2.0 vs 4.4 kg). These 2 studies underscore the impor-
tance of patients keeping records of their food intake, physical activity, and other
behavioral assignments. Educational instruction (ie, information) alone is not sufficient
to induce clinically meaningful weight loss. This point was underscored by a recent
study by Svetkey and colleagues55 of young adults who used a smartphone-
delivered program without the support of an interventionist. Similarly, despite their
popularity, little is known about the effectiveness of smartphone apps for weight man-
agement. A randomized controlled trial that compared differences in weight loss in
overweight patients who received either a MyFitnessPal app, along with usual primary
care, or usual primary care only, revealed essentially no weight loss over 6 months.56
Most participants used the app for the first month; however, logins decreased signif-
icantly after that with few participants using the app at 6 months.
The first head-to-head comparison of an Internet versus on-site delivered interven-
tion was conducted by Harvey-Berino and colleagues.57 They provided obese adults
in the 2 groups the same 24-session intervention (delivered by different modalities).
Participants in the Internet program lost 5.5 kg in 6 months, compared with a signifi-
cantly greater 8.0 kg for those who received on-site treatment. Collectively, these
studies suggest that the most successful Internet programs, in which therapists pro-
vide weekly e-mail feedback to participants, will induce weight losses of approxi-
mately two-thirds the size of those achieved by traditional on-site behavioral
programs.11 The reduced efficacy of Internet programs, however, is offset by the
potentially greater accessibility and affordability of this approach, compared with
traditional face-to-face behavioral treatment.

SUMMARY

Obese individuals can lose 7% to 10% of initial weight with a comprehensive behav-
ioral weight control program consisting of caloric restriction, physical activity, and
behavioral therapy. This weight loss produces clinically important improvements in
CVD risk factors and quality of life. The main challenges facing researchers,
 Behavioral Treatment of the Patient with Obesity 577

practitioners, and patients are improving the maintenance of lost weight and making
behavior weight control more available to the millions of individuals who would benefit
from it.

ACKNOWLEDGMENTS

The authors thank Zayna M. Bakizada for her editorial assistance.

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