Intensive Lifestyle Intervention for Obesity: Principles, Practices, and Results
2017; Elsevier BV; Volume: 152; Issue: 7 Linguagem: Inglês
10.1053/j.gastro.2017.01.045
ISSN1528-0012
AutoresVictoria L. Webb, Thomas A. Wadden,
Tópico(s)Eating Disorders and Behaviors
ResumoUsing the Guidelines for the Management of Overweight and Obesity in Adults as a framework, this article reviews intensive lifestyle interventions for weight loss. The Guidelines recommend a minimum of 6 months of high-intensity, comprehensive lifestyle intervention, consisting of a reduced-calorie diet, increased physical activity, and behavior therapy. Persons with obesity typically lose approximately 8 kg (approximately 8% of initial weight) with this approach, accompanied by improvements in health and quality of life. To prevent weight regain, the Guidelines recommend a 1-year weight loss maintenance program that includes at least monthly counseling with a trained interventionist. Lifestyle interventions usually are delivered in-person; however, treatment increasingly is being disseminated through community- and commercial-based programs, as well as delivered by telephone, Internet, and smartphone platforms. These latter modalities expand treatment reach but usually produce smaller weight losses than in-person interventions. The review concludes with an examination of challenges in weight management. Using the Guidelines for the Management of Overweight and Obesity in Adults as a framework, this article reviews intensive lifestyle interventions for weight loss. The Guidelines recommend a minimum of 6 months of high-intensity, comprehensive lifestyle intervention, consisting of a reduced-calorie diet, increased physical activity, and behavior therapy. Persons with obesity typically lose approximately 8 kg (approximately 8% of initial weight) with this approach, accompanied by improvements in health and quality of life. To prevent weight regain, the Guidelines recommend a 1-year weight loss maintenance program that includes at least monthly counseling with a trained interventionist. Lifestyle interventions usually are delivered in-person; however, treatment increasingly is being disseminated through community- and commercial-based programs, as well as delivered by telephone, Internet, and smartphone platforms. These latter modalities expand treatment reach but usually produce smaller weight losses than in-person interventions. The review concludes with an examination of challenges in weight management. Thomas A. WaddenView Large Image Figure ViewerDownload Hi-res image Download (PPT) The United States Preventive Services Task Force recommends that all adults be screened for obesity and that those with a body mass index (BMI) ≥30 kg/m2 be offered “intensive, multicomponent behavioral interventions.”1Moyer V.A. on behalf of the U.S. Preventive Services Task ForceScreening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement.Ann Intern Med. 2012; 157: 373-378Crossref PubMed Scopus (403) Google Scholar Recent Guidelines for the Management of Overweight and Obesity in Adults, published by the American Heart Association/American College of Cardiology/Obesity Society (referred to as Obesity Guidelines herein), provide more detailed guidance on the provision of intensive lifestyle intervention for weight loss.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar By using these Guidelines as a framework, this article reviews the current evidence-based recommendations for intensive lifestyle treatment (also referred to as intensive behavior therapy or behavioral treatment), as well as the principal components, structure, and efficacy of this approach. This article also reviews the dissemination of lifestyle intervention, including in community and commercial settings, as well as remotely delivered interventions (eg, telephone, Internet, smartphone). The increasing role of technology in behavioral treatment is considered, as are current challenges in weight management. The Obesity Guidelines recommend that individuals who are overweight (BMI 25.0–29.9 kg/m2) or obese (BMI ≥ 30 kg/m2), and would benefit from weight loss, be advised to participate in a comprehensive lifestyle intervention for at least 6 months.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar As described later, comprehensive programs provide instruction in diet, physical activity, and behavior therapy (all 3 components), delivered by a trained interventionist. Interventionists typically are health professionals, such as registered dietitians, exercise specialists, psychologists, or health counselors, or, more rarely, lay persons who have received training in delivering treatment.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar During the first 6 months, individuals should receive at least 14 on-site individual or group treatment sessions, a frequency defined by the Obesity Guidelines as high intensity.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar Frequent contact is critical for inducing clinically meaningful weight loss (ie, ≥5% of initial body weight). This was shown by Perri et al3Perri M.G. Limacher M.C. von Castel-Roberts K. et al.Comparative effectiveness of three doses of weight-loss counseling: two-year findings from the rural LITE trial.Obesity. 2014; 22: 2293-2300Crossref PubMed Scopus (35) Google Scholar who randomly assigned participants to a control intervention (8 sessions of nutrition education) or to low (8 sessions), moderate (16 sessions), or high (24 sessions) doses of group behavioral treatment for 6 months. The moderate- and high-dose groups lost 9.3% and 10.9% of their initial weight, respectively, at month 6, and both of these groups had greater weight losses than the low-dose (-7.2%) and control (-4.1%) conditions. These findings confirm the benefits of providing patients with 14 or more sessions, as recommended by the Obesity Guidelines, but question whether there is substantial weight-loss benefit in providing more than 16 sessions in 6 months. The Obesity Guidelines recommend the provision of on-site (ie, face-to-face) individual or group counseling sessions.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar Individual counseling could be expected to produce greater weight loss than group treatment because of the greater opportunity to provide tailored instruction in individual meetings. Several studies, however, have suggested that group treatment is at least as effective, if not more, than individual counseling.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar, 4Renjilian D.A. Perri M.G. Nezu A.M. et al.Individual versus group therapy for obesity: effects of matching participants to their treatment preferences.J Consult Clin Psychol. 2001; 69: 717-721Crossref PubMed Scopus (245) Google Scholar Renjilian et al,4Renjilian D.A. Perri M.G. Nezu A.M. et al.Individual versus group therapy for obesity: effects of matching participants to their treatment preferences.J Consult Clin Psychol. 2001; 69: 717-721Crossref PubMed Scopus (245) Google Scholar for example, found that participants who received group treatment, regardless of whether they preferred individual or group sessions, lost significantly more weight at 6 months than those who received individual counseling. Group treatment is less expensive to provide than individual care and likely offers greater social support and motivation.5Wadden T.A. Webb V.L. Moran C.H. et al.Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy.Circulation. 2012; 125: 1157-1170Crossref PubMed Scopus (380) Google Scholar The 3 principal components of a comprehensive lifestyle intervention (ie, diet, physical activity, and behavior therapy) are discussed briefly later. More extensive descriptions can be obtained by reviewing the Obesity Guidelines2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar or the treatment protocols for the Diabetes Prevention Program (DPP)6Diabetes Prevention Program (DPP) Research GroupThe Diabetes Prevention Program (DPP): description of lifestyle intervention.Diabetes Care. 2002; 25: 2165-2171Crossref PubMed Scopus (1476) Google Scholar or the Action for Health in Diabetes (Look AHEAD) trial.7Wadden T.A. West D.S. et al.Look AHEAD Research GroupThe Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it.Obesity. 2006; 14: 737-752Crossref PubMed Scopus (604) Google Scholar Comprehensive interventions are designed to induce a weight loss of approximately 0.5–1 kg per week for the first 12 weeks, with more gradual weight loss thereafter, until weight loss typically plateaus at 6–9 months.5Wadden T.A. Webb V.L. Moran C.H. et al.Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy.Circulation. 2012; 125: 1157-1170Crossref PubMed Scopus (380) Google Scholar The Obesity Guidelines recommend that patients consume a diet designed to induce a deficit of 500–750 kcal/day and a loss of 0.5–1.0 kg/wk.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar Accordingly, women often are prescribed a 1200–1500 kcal/day diet and men a 1500–1800 kcal/day diet,2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar with higher calorie levels prescribed for individuals with higher BMIs or activity levels. (The calorie target can be adjusted accordingly if patients do not achieve the expected rate of loss.) The Guidelines also acknowledge the benefit of evidence-based approaches that restrict the consumption of a specific macronutrient to induce an energy deficit.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar The macronutrient composition of the diet with which individuals induce an energy deficit has been a focus of much debate and research. The DPP and Look AHEAD interventions prescribed a traditional low-fat, low-calorie diet.6Diabetes Prevention Program (DPP) Research GroupThe Diabetes Prevention Program (DPP): description of lifestyle intervention.Diabetes Care. 2002; 25: 2165-2171Crossref PubMed Scopus (1476) Google Scholar, 7Wadden T.A. West D.S. et al.Look AHEAD Research GroupThe Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it.Obesity. 2006; 14: 737-752Crossref PubMed Scopus (604) Google Scholar A variety of other dietary approaches also have been investigated, including low-carbohydrate/high-protein diets, Mediterranean-style diets, and low-glycemic-load diets.8Alamuddin N. Wadden T.A. Behavioral treatment of the patient with obesity.Endocrinol Metab Clin North Am. 2016; 3: 565-580Abstract Full Text Full Text PDF Scopus (23) Google Scholar Some randomized controlled trials have shown that the prescription of low-carbohydrate, high-protein diets induced the largest short-term weight losses,9Foster G.D. Wyatt H.R. Hill J.O. et al.A randomized trial of a low-carbohydrate diet for obesity.N Engl J Med. 2003; 348: 2082-2090Crossref PubMed Scopus (1405) Google Scholar, 10Yancy Jr., W.S. Olsen M.K. Guyton J.R. et al.A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial.Ann Intern Med. 2004; 140: 769-777Crossref PubMed Scopus (722) Google Scholar but few studies have found significant long-term differences in weight loss related to the prescribed macronutrient composition of the diet.11Foster G.D. Wyatt H.R. Hill J.O. 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: 147-157Crossref PubMed Scopus (408) Google Scholar, 12Dansinger M.L. Gleason J.A. Griffith J.L. et al.Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial.JAMA. 2005; 293: 43-53Crossref PubMed Scopus (1310) Google Scholar, 13Sacks F.M. Bray G.A. Carey V.J. et al.Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates.N Engl J Med. 2009; 360: 859-873Crossref PubMed Scopus (1381) Google Scholar For example, Foster et al11Foster G.D. Wyatt H.R. Hill J.O. 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: 147-157Crossref PubMed Scopus (408) Google Scholar compared low-fat and low-carbohydrate diets, both combined with a high-intensity lifestyle intervention. Weight losses in the 2 groups did not differ significantly at 6, 12, or 24 months (Figure 1). In summary, a variety of dietary approaches can produce weight loss, provided that a sufficient calorie deficit is induced. A patient’s ability to adhere to the selected reducing diet is the key to the successful induction of weight loss.12Dansinger M.L. Gleason J.A. Griffith J.L. et al.Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial.JAMA. 2005; 293: 43-53Crossref PubMed Scopus (1310) Google Scholar The use of portion-controlled diets, including shakes, meal bars, and prepackaged entrees, also has been shown to facilitate patients’ meeting their calorie targets and weight loss goals.14Tsai A.G. Wadden T.A. The evolution of very-low-calorie diets: an update and meta-analysis.Obesity. 2006; 14: 1283-1293Crossref PubMed Scopus (240) Google Scholar A meta-analysis showed that the prescription of a portion-controlled diet, as compared with an isocaloric diet comprising conventional self-selected foods, significantly increased weight loss by approximately 3 kg at both 3 and 12 months.15Heymsfield S.B. Van Mierlo C.A.J. Van der Knaap H.C.M. et al.Weight management using a meal replacement strategy: meta and pooling analysis from six studies.Int J Obes. 2003; 27: 537-549Crossref PubMed Scopus (439) Google Scholar Although calorie restriction appears to drive weight loss, the macronutrient composition of diets may affect cardiometabolic risk factors.11Foster G.D. Wyatt H.R. Hill J.O. 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: 147-157Crossref PubMed Scopus (408) Google Scholar, 13Sacks F.M. Bray G.A. Carey V.J. et al.Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates.N Engl J Med. 2009; 360: 859-873Crossref PubMed Scopus (1381) Google Scholar, 16Fabricatore A.N. Wadden T.A. Ebbeling C.B. et al.Targeting dietary fat or glycemic load in the treatment of obesity and type 2 diabetes: a randomized controlled trial.Diabetes Res Clin Pract. 2011; 92: 37-45Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar For example, Fabricatore et al16Fabricatore A.N. Wadden T.A. Ebbeling C.B. et al.Targeting dietary fat or glycemic load in the treatment of obesity and type 2 diabetes: a randomized controlled trial.Diabetes Res Clin Pract. 2011; 92: 37-45Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar found that a low-glycemic-index diet produced larger reductions in hemoglobin A1c (HbA1c) than did a low-fat diet, although the 2 diets did not produce significantly different weight loss amounts. Thus, an individual’s cardiometabolic risk factors, dietary preferences, and ability to adhere to a regimen should be considered when choosing a dietary approach.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar Lifestyle interventions typically prescribe 150–180 minutes per week of aerobic activity, such as brisk walking or other types of moderate-intensity aerobic exercise.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar Regular aerobic activity is associated with a host of health benefits including improvements in lipid levels, blood pressure, and visceral fat.17Gaesser G.A. Angadi S.S. Sawyer B.J. Exercise and diet, independent of weight loss, improve cardiometabolic risk profile in overweight and obese individuals.Phys Sportsmed. 2011; 39: 87-97Crossref PubMed Scopus (92) Google Scholar Physical activity also is associated with improved fitness, which may attenuate the risk of mortality associated with obesity.18Barry V.W. Baruth M. Beets M.W. et al.Fitness vs. fatness on all-cause mortality: a meta-analysis.Prog Cardiovasc Dis. 2014; 56: 382-390Abstract Full Text Full Text PDF PubMed Scopus (440) Google Scholar Physical activity alone, however, contributes minimally to weight loss in the short term. Individuals who engage in high levels of physical activity in the absence of dietary restriction lose small amounts of weight.19Slentz C.A. Duscha B.D. Johnson J.L. et al.Effects of the amount of exercise on body weight, body composition, and measures of central obesity: STRRIDE–a randomized controlled study.Arch Intern Med. 2004; 164: 31-39Crossref PubMed Scopus (483) Google Scholar Moreover, Wing et al20Wing R.R. Venditti E. Jakicic J.M. et al.Lifestyle intervention in overweight individuals with a family history of diabetes.Diabetes Care. 1998; 21: 350-359Crossref PubMed Scopus (338) Google Scholar found that the addition of an exercise program to calorie restriction alone only marginally enhanced weight loss at 6 months (-10.3 kg for diet plus exercise vs -9.1 kg for diet only). As such, in the near term, obese individuals should engage in physical activity primarily for its cardiovascular benefits, rather than its effects on weight. The Obesity Guidelines recommend that patients be instructed in behavior therapy, which provides a set of strategies and techniques to modify diet and physical activity patterns.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar The cornerstone of behavior change is self-monitoring of food and calorie intake, along with recording physical activity and weight.5Wadden T.A. Webb V.L. Moran C.H. et al.Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy.Circulation. 2012; 125: 1157-1170Crossref PubMed Scopus (380) Google Scholar, 6Diabetes Prevention Program (DPP) Research GroupThe Diabetes Prevention Program (DPP): description of lifestyle intervention.Diabetes Care. 2002; 25: 2165-2171Crossref PubMed Scopus (1476) Google Scholar, 7Wadden T.A. West D.S. et al.Look AHEAD Research GroupThe Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it.Obesity. 2006; 14: 737-752Crossref PubMed Scopus (604) Google Scholar Paper records traditionally have been used to track these variables but, as described later, technological advances provide new ways for patients to self-monitor. Monitoring helps individuals identify behavioral patterns, target areas for change, and track progress toward goals. Those who engage in frequent self-monitoring of eating and weight achieve the largest weight losses.21Wadden T.A. Berkowitz R.I. Womble L.G. et al.Randomized trial of lifestyle modification and pharmacotherapy for obesity.N Engl J Med. 2005; 353: 2111-2120Crossref PubMed Scopus (637) Google Scholar, 22Wing R.R. Tate D.F. Gorin A.A. et al.A self-regulation program for maintenance of weight loss.N Engl J Med. 2006; 355: 1563-1571Crossref PubMed Scopus (623) Google Scholar, 23Steinberg D.M. Bennett G.G. Askew S. et al.Weighing every day matters: daily weighing improves weight loss and adoption of weight control behaviors.J Acad Nutr Diet. 2015; 115: 511-518Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Individuals also are instructed to set specific, attainable goals for behavior change, which clearly identify the behavior to be modified and how it will be achieved.5Wadden T.A. Webb V.L. Moran C.H. et al.Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy.Circulation. 2012; 125: 1157-1170Crossref PubMed Scopus (380) Google Scholar Frequent review of patients’ progress toward these goals provides accountability and reinforcement.6Diabetes Prevention Program (DPP) Research GroupThe Diabetes Prevention Program (DPP): description of lifestyle intervention.Diabetes Care. 2002; 25: 2165-2171Crossref PubMed Scopus (1476) Google Scholar, 7Wadden T.A. West D.S. et al.Look AHEAD Research GroupThe Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it.Obesity. 2006; 14: 737-752Crossref PubMed Scopus (604) Google Scholar Problem solving helps to facilitate progress toward goals by encouraging patients to analyze challenges and develop effective solutions.6Diabetes Prevention Program (DPP) Research GroupThe Diabetes Prevention Program (DPP): description of lifestyle intervention.Diabetes Care. 2002; 25: 2165-2171Crossref PubMed Scopus (1476) Google Scholar, 7Wadden T.A. West D.S. et al.Look AHEAD Research GroupThe Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it.Obesity. 2006; 14: 737-752Crossref PubMed Scopus (604) Google Scholar Patients also are encouraged to engage in stimulus control by altering eating- and activity-related cues in their environment.6Diabetes Prevention Program (DPP) Research GroupThe Diabetes Prevention Program (DPP): description of lifestyle intervention.Diabetes Care. 2002; 25: 2165-2171Crossref PubMed Scopus (1476) Google Scholar, 7Wadden T.A. West D.S. et al.Look AHEAD Research GroupThe Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it.Obesity. 2006; 14: 737-752Crossref PubMed Scopus (604) Google Scholar For instance, they might minimize the risk of overeating by limiting the types of foods in their home. Behavioral treatment also may include motivational interviewing to support patients’ commitment to change24DiLillo V. West D.S. Motivational interviewing for weight loss.Psychiatr Clin North Am. 2011; 34: 861-869Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar and cognitive techniques to address maladaptive thinking.7Wadden T.A. West D.S. et al.Look AHEAD Research GroupThe Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it.Obesity. 2006; 14: 737-752Crossref PubMed Scopus (604) Google Scholar Recent studies have suggested that an acceptance-based approach, which emphasizes self-regulation, mindfulness, distress tolerance, and commitment to ones’ values, may increase weight loss by as much as 3 kg compared with traditional lifestyle intervention.25Forman E.M. Butryn M.L. Manasse S.M. et al.Acceptance-based versus standard behavioral treatment for obesity: results from the mind your health randomized controlled trial.Obesity. 2016; 24: 2050-2056Crossref PubMed Scopus (96) Google Scholar The systematic review conducted for the Obesity Guidelines found that comprehensive, high-intensity lifestyle interventions produced mean weight losses of up to 8 kg at 6 months, with similar weight losses at 1 year.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar These losses were significantly greater than those observed in individuals who received usual care. The DPP, for example, provided 16 individual, on-site counseling sessions with a registered dietitian in the first 6 months, with at least every-other-month sessions through month 12.6Diabetes Prevention Program (DPP) Research GroupThe Diabetes Prevention Program (DPP): description of lifestyle intervention.Diabetes Care. 2002; 25: 2165-2171Crossref PubMed Scopus (1476) Google Scholar Participants in the lifestyle intervention lost 7.1 kg (equal to 7% of their initial weight) at month 6 and maintained this loss at 12 months.26Knowler W.C. Barrett-Connor E. Fowler S.E. et al.Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.N Engl J Med. 2002; 346: 393-403Crossref PubMed Scopus (14578) Google Scholar, 27West D.S. Prewitt T.E. Bursac Z. et al.Weight loss of black, white, and Hispanic men and women in the Diabetes Prevention Program.Obesity. 2008; 16: 1413-1420Crossref PubMed Scopus (228) Google Scholar At 12 months, 62% of participants lost 5% or more of their initial weight, an amount considered to be clinically meaningful.2Jensen M.D. Ryan D.H. Apovian C.M. et al.AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Abstract Full Text Full Text PDF PubMed Scopus (1408) Google Scholar, 28National Institutes of HealthClinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The Evidence Report.Obes Res. 1998; 6: 51S-209SCrossref PubMed Google Scholar By contrast, participants who received metformin (an oral diabetes medication) lost an average of only 2.3 kg and 2.8 kg at 6 and 12 months, respectively, as compared with essentially no loss for participants assigned to placebo. All of these participants had impaired glucose tolerance at baseline. The Look AHEAD study enrolled participants who were overweight/obese and had type 2 diabetes.7Wadden T.A. West D.S. et al.Look AHEAD Research GroupThe Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it.Obesity. 2006; 14: 737-752Crossref PubMed Scopus (604) Google Scholar In the first year, participants in the intensive lifestyle intervention (ILI) had 3 weekly group treatment sessions per month, complemented by 1 individual visit per month. From months 7 to 12, participants had 1 individual and 2 group sessions per month.7Wadden T.A. West D.S. et al.Look AHEAD Research GroupThe Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it.Obesity. 2006; 14: 737-752Crossref PubMed Scopus (604) Google Scholar Participants in a control group, referred to as diabetes support and education (DSE), receiv
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