ABSTRACT

Obesity is extremely prevalent, affecting 42.5% of people in the United States alone. Advisory panels recommend a 5-10% reduction in initial weight for adults with obesity, or for those who are overweight, with a weight-related comorbidity. This loss can significantly reduce the risk of developing type 2 diabetes and improve other cardiovascular disease (CVD) risk factors, as seen in the Diabetes Prevention Program and Look AHEAD trials. Greater reductions in weight produce even greater improvements in CVD risk factors. Weight loss can be achieved with a comprehensive lifestyle program that consists of dietary change, increased physical activity, and behavior therapy, provided in individual or group sessions. Behavioral treatment can be combined with diets of varying macronutrient composition as long as they induce a caloric deficit. Physical activity should be gradually increased over a period of 6 months, and although it is not effective as a stand-alone intervention for inducing a clinically meaningful mean weight loss, it is very important for facilitating weight maintenance and improving health outcomes. Principles of behavioral treatment include self-monitoring, stimulus control, and goal setting. Weight regain is common after an initial treatment period of 6-12 months, but frequent follow-up with an interventionist, which includes at least monthly counseling, can mitigate it. Treatments delivered by telephone, internet, or smartphone can be more easily disseminated to larger populations and can produce clinically meaningful mean weight losses if they include content similar to that of in-person lifestyle interventions and provide personalized feedback. For complete coverage of all related areas of Endocrinology, please visit our on-line FREE web-text, WWW.ENDOTEXT.ORG.

INTRODUCTION

Obesity, defined by a body mass index (BMI) ≥ 30 kg/m², is the most common nutritional disease in the United States, affecting 42.5% of adults (1) and 19% of children and adolescents (2). An additional 31% of American adults have a BMI in the overweight range of 25.0-29.9 kg/m². Obesity is associated with an increased risk of developing cardiovascular disease (3), hypertension, dyslipidemia, and type 2 diabetes mellitus (4), along with other clinical conditions including nonalcoholic fatty liver disease, gastroesophageal reflux, obstructive sleep apnea, and osteoarthritis (5-7). A weight loss of 5-10% of initial body weight improves these complications and has been recommended by expert panels sponsored by the World Health Organization (8), the National Institutes of Health (9), and several professional societies. Losses of this magnitude can be achieved with a high-intensity lifestyle intervention (also known as lifestyle modification or behavioral weight loss treatment), as described in the Guidelines for the Management of Overweight and Obesity in Adults (i.e., Obesity Guidelines) (10) developed by The American College of Cardiology, American Heart Association, and the Obesity Society.

Comprehensive lifestyle interventions include three key components: diet, physical activity, and behavior therapy. This chapter describes each intervention component and reviews the short-term and long-term effectiveness of this approach. Lifestyle interventions have traditionally been delivered in 30-90 minute, in-person, group or individual sessions by a trained interventionist (usually a registered dietitian, psychologist, exercise physiologist, or other health-care professional). Although this is by far the best-researched treatment modality, the past two decades have seen an exponential growth in digital and other remote treatment approaches, which are reviewed in the final section.

EFFICACY OF HIGH-INTENSITY, IN-PERSON LIFESTYLE INTERVENTION PROGRAMS

Interventions categorized as “high-intensity” by the Obesity Guidelines provide a minimum of 14 treatment sessions during the first 6 months (10). Maintenance sessions may be delivered at a reduced frequency thereafter. In trials conducted in academic medical centers, participants treated by a 1200-1500 kcal/day diet, combined with regular exercise and a comprehensive program of group or individual behavior modification, lose an average of 5-8% of initial weight in 6 months (9-11), and approximately 60-65% of patients lose ≥5% of their initial weight. The lifestyle programs provided in the Diabetes Prevention Program and the Look AHEAD study provide excellent examples of high-intensity interventions.

Look AHEAD (Action for Health in Diabetes) Study

The Look AHEAD study enrolled more than 5,100 individuals with overweight/obesity and type 2 diabetes mellitus, and participants were randomly assigned to a diabetes support and education (DSE) group or an intensive lifestyle intervention (ILI) group, with the aim of examining the long-term effects of a 7% weight loss on cardiovascular morbidity and mortality (14). Participants randomized to the DSE group received three group education sessions each year in the first 4 years, whereas participants in the ILI group received treatment similar to that in the DPP with some modification. During the first 6 months, ILI participants had 3 weekly group treatment sessions and one individual visit per month and replaced two meals per day with a liquid supplement (i.e., shake). They were instructed to consume 1200-1800 kcal/day (with calories adjusted based on initial weight). During months 7 to 12, ILI participants had two group sessions and one individual visit each month, and used meal replacements for one meal per day. For the next 3 years, participants were offered one individual on-site visit and one phone (or e-mail) contact per month.

After 1 year, ILI participants lost 8.6% of baseline weight, compared with 0.6% for the DSE group, and at year 4, mean weight losses were 4.7% versus 1.1%, respectively. These latter losses were maintained at 8 years, at which time patients in the ILI group lost 4.7% of initial weight, compared with 2.1% for DSE participants. The study was ended at a mean of 9.6 years of post-randomization follow-up because there were no differences in cardiovascular morbidity and mortality between groups. However, patients in ILI, compared to DSE, had significantly greater reductions in HbA_1C, lost more weight, had larger improvements in cardiovascular disease risk factors (i.e., reductions in systolic and diastolic blood pressure and levels of triglycerides), and used fewer diabetes, hypertension, and lipid-lowering medications. Analyses showed that the greater the weight loss, the greater the improvements in those risk factors (Figure 1) (15).

Figure 1.

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% CIs adjusted for clinical sites, age, sex, race/ethnicity, baseline weight, baseline measurement of the outcome variable, and treatment group assignment. Figure is reprinted with permission from reference (15).

Compared to DSE, additional benefits in the ILI group included greater reduction of depression symptoms and remission or reduced severity of obstructive sleep apnea. The Look AHEAD and DPP studies both demonstrate that weight loss and long-term benefits to health can be achieved through participation in a lifestyle modification program. However, a follow-up assessment of ILI and DSE participants 16 years post-randomization continued to reveal no significant differences in CVD morbidity and mortality between the two groups (16).

LIFESTYLE INTERVENTION COMPONENTS

Dietary Recommendations

The primary goal of the dietary prescription in a behavioral weight loss program is to induce a 500-750 kcal/day deficit (10,11). For women, this involves consuming about 1200-1500 kcal/day, while for men the goal is about 1500-1800 kcal/day. Calorie targets also can be based on body weight, with 1200-1500 kcal/day recommended for people who weigh less than 250 lbs. at baseline and 1500-1800 kcal/day for those ≥250 lbs. (10,11). The ideal composition of dietary macronutrients for producing weight loss has been studied extensively, with options including low-glycemic index diets, Mediterranean-type diets, low-fat diets, and reduced-carbohydrate diets (17). A low glycemic index is based on eating a diet containing foods with a lower glycemic load, that are less likely to cause large increases in postprandial blood glucose levels (19,20). A Mediterranean diet focuses on consuming higher amounts of plant-based foods, including fruits, legumes, vegetables, monounsaturated fats such as olive oil, and fish; and reduced consumption of foods high in saturated fats, like red meat and butter (21). Low-fat diets provide 10% to 20% of calories from fat and recommend plant-based foods including whole-grains, fruits, and vegetables (22). A low carbohydrate diet approach, like an Atkins or “ketogenic” diet, is characterized by consuming as few as 20 g/day of carbohydrates, and focusing on foods that are higher in protein and fat (23).

The outcomes of comparative studies of these different types of diets have consistently concluded that adequate weight loss depends less on the macronutrient content of the diet and more on the caloric deficit (17). The POUNDS LOST trial supported this conclusion in a large, 2-year study that randomized patients to one of four diets with different macronutrient compositions, varying in proportions of fat, protein, and carbohydrate content (fat/protein/carbohydrate content: 20/15/65%; 20/25/55%; 40/15/45%; and 40/25/35%, respectively) (24). The study showed no difference in the amount of weight lost among the diet groups, all of which were designed to produce an energy deficit of approximately 750 kcal per day. Several other studies have also found that different dietary approaches produce weight losses that are comparable, provided there is a sufficient reduction in calories (25,26) (Figure 2). The use of portion-controlled diets have been shown to facilitate greater weight losses than diets of conventional foods, but this is primarily due to improved adherence to calorie goals and not to their macronutrient profile (27).

Figure 2.

Change in body weight for participants in low-fat and low-carbohydrate diet groups after 24 months, based on random-effects linear model. Figure is reprinted with permission from reference (25).

Because it appears that caloric restriction contributes to weight loss more than the macronutrient composition of the diet, diets should be chosen based on patients’ personal preferences and by the presence of comorbid conditions. For example, Fabricatore et al. (28) demonstrated that a low-glycemic index diet produced greater improvements in HbA_1c in patients with overweight and type 2 diabetes than did a traditional low-fat diet, even though the two diets produced comparable weight losses. Low-fat diets appear to be associated with greater reductions in low-density lipoprotein cholesterol (24,25,29), compared to low-carbohydrate diets. The latter diets, by contrast, are associated with greater reductions in triglycerides (26,29-33), increases in high-density lipoprotein cholesterol (25,26,29-33), and improvements in HbA_1C in patients with type 2 diabetes (33). Table 1 summarizes the results of selected randomized trials that examined the effects of macronutrient composition on changes in weight and health outcomes.

Table 1.

Weight Loss Results from Randomized Trials that Compared diets with Varying Macronutrient Compositions

View in own window

Study	N	No. Lifestyle Sessions Provided	Dietary Intervention	Weight Change	Month	Comment/ Other Results
Dansinger et al(26)	160 (51% F) 58% completed	4	Atkins (low-carb) Zone (even distribution) Weight Watchers (points based) Ornish (low-fat)	-2.1 kg a -3.2 kg a -3.0 kg a -3.3 kg a	12	All participants had hypertension, dyslipidemia, and/or fasting hyperglycemia. Weight loss was associated with level of adherence. Each diet decreased LDL/HDL ratio. N No significant changes in blood pressure or blood glucose at 12 months in either group.
Das et al(34)*	34 (% F unknown) 85% completed	52	Low-glycemic load High-glycemic load	-7.8% a -8.0% a	12	Triglycerides, total, HDL, and LDL cholesterol decreased in both groups.
Fabricatore et al(28)	79 (80% F) 63% completed	30	Low-glycemic load Low-fat	-4.5% a -6.4% a	9	All participants had type 2 diabetes. Larger reductions in HbA1c in the low-glycemic load group.
Foster et al(29)	63 (68% F) 59% completed	3	Low-carbohydrate (high protein, high fat) Conventional (high-carbohydrate, low-fat)	-4.4% a -2.5% a	12	HDL cholesterol increased more and triglycerides decreased more in the low-carbohydrate group. Greater reductions in LDL and total cholesterol in the low-fat group at 3 months.
Foster et al (25)	307 (68% F) 63% completed	38	Low-carbohydrate Low-fat	-6.3 kg a -7.4 kg a	24	HDL cholesterol increased more and triglycerides were lower only in the low-carbohydrate group. Greater decrease in LDL at 3 and 6 months in the low-fat group.
Gardner et al(30)	311 (100% F) 80% completed	8	Atkins (low-carbohydrate) Zone (even distribution) LEARN (calorie-restricted) Ornish (low-fat)	-4.7 kg a -1.6 kg b -2.2 kg ab -2.6 kg ab	12	HDL cholesterol increased more in Atkins than Ornish group. Triglyceride levels decreased more in Atkins than Zone group. No differences in insulin or blood glucose between groups. Systolic blood pressure decreased more in Atkins than in all other groups. Diastolic blood pressure decreased more in Atkins group than in Ornish group.
Sacks et al(24)	811 (64% F) 7 9.5% completed	66	Low-fat, average protein (highest carbohydrate) Low-fat, high-protein High-fat, average-protein High-fat, high-protein (lowest carbohydrate)	-3.0 kg a -3.8 kg a -3.2 kg a -3.4 kg a	24	LDL cholesterol decreased more in lowest fat than in highest fat group. HDL cholesterol increased more with lowest carbohydrate than with the highest carbohydrate diet. 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(32)	322 (14% F) 8 4.6% completed	24	Low-fat Mediterranean (moderate fat, restricted calorie with fat predominantly from olive oil and nuts) Low-carbohydrate	-2.9 kg a -4.4 kg b -4.7 kg b	24	No significant change in LDL cholesterol in any group. HDL cholesterol increased in all groups, significantly more in the low-carbohydrate than low-fat group. Triglyceride levels decreased more in the low-carbohydrate than in the low-fat group. In diabetic participants, only the Mediterranean diet group had a decrease in fasting glucose. Insulin decreased in all groups, for both diabetic and non-diabetic participants. All groups had a significant decrease in blood pressure. Adiponectin levels increased, and leptin levels decreased, in all groups.
Stern et al(33)	132 (17% F) 66% completed	15	Low-carbohydrate Conventional (low-fat)	-5.1 kg a -3.1 kg a	12	Triglyceride levels decreased more in the low-carbohydrate group than in the low-fat group. HDL cholesterol decreased less in the low-carbohydrate group than in the low-fat group. Changes in total and LDL cholesterol were not significantly different between groups.
Yancy et al(35)	120 (76% F) 66% completed	9	Low-fat diet Low-carbohydrate, ketogenic diet with nutritional supplements	-6.7% a -12.9% b	6	All participants were hyperlipidemic. Triglycerides decreased more and HDL cholesterol increased more in low-carbohydrate group.

Table is reprinted with permission from reference (18).

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.

F indicates female; LDL, low-density lipoprotein; HDL, high-density lipoprotein; VLDL, very low-density lipoprotein; HbA_1c, hemoglobin A_1c; MR, meal replacements; CVD, cardiovascular disease.

*

A completer’s population was examined. †Results reported as “greater,” “larger,” “increased more,” etc. represent statistically significant differences between treatment conditions.

STRUCTURE OF IN-PERSON BEHAVIORAL TREATMENT: SHORT- AND LONG-TERM

The lifestyle interventions provided in studies like the DPP and Look AHEAD followed a structured curriculum that gradually introduced different behavior change skills. Detailed treatment descriptions can be obtained from the intervention manuals for these two studies (50, 51) or an adaptation of the DPP protocol provided by Wadden, Tsai, and Tronieri for in-person delivery in primary care settings (60). Behavioral weight loss interventions are most commonly delivered in group sessions, which have been found to be as effective as individual counseling for weight loss in several studies (61,62). It may be that any weight loss benefit of receiving personalized support with individual counseling is roughly equivalent to the benefits of a greater degree of social support, empathic understanding, and healthy competition among group members. However, group treatment is more cost effective than individual counseling.

Frequency and duration of contact during the weight loss period are additional predictors of weight loss success (10,61). This benefit is apparent in trials comparing high-intensity lifestyle intervention programs to programs that provided identical dietary and physical activity recommendations with a lower session frequency, as well as in systematic reviews and meta-analyses of the efficacy of lifestyle interventions. For example, in a study by Perri and colleagues (63) that compared three different visit schedules to a control condition, the group that received 8 treatment sessions in the first 6 months had a weight loss of 3.5 kg at month 24 that did not differ significantly from the 2.9 kg loss of the control group, whereas patients who received 16 sessions had a loss of 6.7 kg that was superior to both groups. Of note, the group that received 24 sessions in the first 6 month did not differ in weight loss from the 16-session group at any time, suggesting that there may not be a benefit of further increasing visit intensity (while increasing costs). In 2012, the United States Preventative Services Task Force recommended that weight loss programs include at least 12-26 intervention sessions per year for optimal weight loss (64). This recommendation was based on their systematic review, which reported weight losses of 4 to 7 kg for programs with that level of intensity compared to 1.5 to 4 kg in programs offering fewer than 12 sessions (61). These findings were consistent with the Obesity Guideline’s conclusion that programs that provided at least 14 sessions in the first 6 months produce a weight loss of 5 to 8 kg, those that provide 6-13 sessions (1-2 sessions per month) produce a 2 to 4 kg loss, and those that provide less than monthly sessions induce minimal weight loss (10).

For weight loss maintenance, frequent, long-term contact with an interventionist is the most successful method for preventing weight regain. Weight loss maintenance sessions are important for providing individuals with the support and motivation needed to continue with the behavior changes they have made, such as engaging in physical activity, eating a low-calorie diet, and self-monitoring. Wing et al (65) demonstrated that monthly in-person sessions were more effective in preventing weight regain over 18 months of intervention than was an education-control group or an internet-based intervention. Participants in the three groups regained an average of 2.5, 4.9, and 4.7 kg, respectively, after an initial weight loss of 19 kg.

REMOTELY-DELIVERED LIFESTYLE MODIFICATION INTERVENTIONS

In-person interventions can be costly because they require adequate facilities for hosting the intervention, staff for checking in patients, and the time of trained providers to deliver the intervention. Travel time also can represent a cost and inconvenience for patients, and many individuals, particularly those in rural and economically disadvantaged urban areas, do not have adequate access to evidence-based care. Over the past two decades, a growing body of research has investigated the use of telephone, computer, and smartphone-based methods for delivering lifestyle interventions to patients. Larger numbers of individuals can be reached with these methods at a cost that is significantly less than that of in-person interventions, particularly if little to no provider input is required. The COVID-19 pandemic further highlighted the need to identify effective ways of delivering lifestyle interventions remotely, as in-person treatment programs were either suspended or quickly migrated to phone calls or videoconferencing platforms due to stay-at-home orders and social distancing policies.

CONCLUSION

There is clear evidence that intensive lifestyle interventions are effective in helping patients with obesity to lose 5-10% of initial body weight, a loss that is associated with improvements in CVD risk factors and other obesity-related comorbidities. Lifestyle approaches emphasize prescriptions for dietary intake, increased physical activity, and behavioral skills such as self-monitoring. Traditionally, these interventions have been delivered in-person by a trained interventionist, which limits their potential dissemination. It is also possible to achieve a clinically meaningful weight loss with digitally-delivered programs that include little to no contact from an interventionist, provided the intervention provides comprehensive session content, tailored feedback, and features that promote user engagement.

One of the most challenging aspects of behavioral weight control is keeping off lost weight. Several strategies can facilitate this goal, including maintaining patient-provider contact beyond the initial weight loss intervention, either in-person or remotely, and prescribing high levels of physical activity after weight is lost in the first 6 months. In addition, the more that patients practice the skills used by participants in the National Weight Control Registry, the more likely they will be to maintain their weight loss.

REFERENCES

1.

Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief, no 360. Hyattsville, MD: National Center for Health Statistics. 2020. [PubMed: 32487284]

2.

Fryar CD, Carroll MD, Afful J. Prevalence of overweight, obesity, and severe obesity among children and adolescents aged 2–19 years: United States, 1963–1965 through 2017–2018. NCHS Health E-Stats. 2020.

3.

Manson JE, Colditz GA, Stampfer MJ, Willett WC, Rosner B, Monson RR, Speizer FE, Hennekens CH. A prospective study of obesity and risk of coronary heart disease in women. The New England Journal of Medicine. 1990;322:882–889. [PubMed: 2314422]

4.

Colditz GA, Willett WC, Stampfer MJ, Manson JE, Hennekens CH, Arky RA, Speizer FE. Weight as a risk factor for clinical diabetes in women. American Journal of Epidemiology. 1990;132:501–513. [PubMed: 2389754]

5.

Carman WJ, Sowers M, Hawthorne VM, Weissfeld LA. Obesity as a risk factor for osteoarthritis of the hand and wrist: a prospective study. American Journal of Eepidemiology. 1994;139:119–129. [PubMed: 8296779]

6.

Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523–1529. [PubMed: 10546691]

7.

Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. Jama. 2003;289:76–79. [PubMed: 12503980]

8.

Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organization Technical Report Series. 2000;894:i–xii, 1-253. [PubMed: 11234459]

9.

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health. Obesity Research. 1998;6 Suppl 2:51s–209s. [PubMed: 9813653]

10.

Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, Hu FB, Hubbard VS, Jakicic JM, Kushner RF, Loria CM, Millen BE, Nonas CA, Pi-Sunyer FX, Stevens J, Stevens VJ, Wadden TA, Wolfe BM, Yanovski SZ, Jordan HS, Kendall KA, Lux LJ, Mentor-Marcel R, Morgan LC, Trisolini MG, Wnek J, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, DeMets D, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Smith SC Jr, Tomaselli GF. 2013 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. Circulation. 2014;129:S102–138. [PMC free article: PMC5819889] [PubMed: 24222017]

11.

Wadden TA, Tronieri JS, Butryn ML. Lifestyle modification approaches for the treatment of obesity in adults. American Psychologist. 2020;75(2):235. [PMC free article: PMC7027681] [PubMed: 32052997]

12.

Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England Journal of Medicine. 2002;346:393–403. [PMC free article: PMC1370926] [PubMed: 11832527]

13.

Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Brenneman AT, Brown-Friday JO, Goldberg R, Venditti E, Nathan DM. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet (London, England). 2009;374:1677–1686. [PMC free article: PMC3135022] [PubMed: 19878986]

14.

Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM, Coday M, Crow RS, Curtis JM, Egan CM, Espeland MA, Evans M, Foreyt JP, Ghazarian S, Gregg EW, Harrison B, Hazuda HP, Hill JO, Horton ES, Hubbard VS, Jakicic JM, Jeffery RW, Johnson KC, Kahn SE, Kitabchi AE, Knowler WC, Lewis CE, Maschak-Carey BJ, Montez MG, Murillo A, Nathan DM, Patricio J, Peters A, Pi-Sunyer X, Pownall H, Reboussin D, Regensteiner JG, Rickman AD, Ryan DH, Safford M, Wadden TA, Wagenknecht LE, West DS, Williamson DF, Yanovski SZ. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. The New England Journal of Medicine. 2013;369:145–154. [PMC free article: PMC3791615] [PubMed: 23796131]

15.

Wing RR, Lang W, Wadden TA, Safford M, Knowler WC, Bertoni AG, Hill JO, Brancati FL, Peters A, Wagenknecht L. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care. 2011;34:1481–1486. [PMC free article: PMC3120182] [PubMed: 21593294]

16.

Look AHEAD Research Group. Effects of Intensive Lifestyle Intervention on All-Cause Mortality in Older Adults With Type 2 Diabetes and Overweight/Obesity: Results From the Look AHEAD Study. Diabetes Care. 2022;45(5):1252–9. [PMC free article: PMC9174966] [PubMed: 35312758]

17.

Chao AM, Quigley KM, Wadden TA. Dietary interventions for obesity: clinical and mechanistic findings. The Journal of Clinical Investigation. 2021;131(1) [PMC free article: PMC7773341] [PubMed: 33393504]

18.

Wadden TA, Webb VL, Moran CH, Bailer BA. Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy. Circulation. 2012;125:1157–1170. [PMC free article: PMC3313649] [PubMed: 22392863]

19.

Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. The Cochrane Database of Systematic Reviews. 2009:Cd006296. [PMC free article: PMC6486008] [PubMed: 19160276]

20.

Jenkins DJ, Wolever TM, Taylor RH, Barker H, Fielden H, Baldwin JM, Bowling AC, Newman HC, Jenkins AL, Goff DV. Glycemic index of foods: A physiological basis for carbohydrate exchange. The American Journal of Clinical Nutrition. 1981;34:362–366. [PubMed: 6259925]

21.

Willett W, Skerrett PJ, Giovannucci EL, Callahan M. Eat, drink, and be healthy the Harvard Medical School guide to healthy eating. New York: Simon & Schuster Source.

22.

Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR, Deckelbaum RJ, Erdman JW Jr, Kris-Etherton P, Goldberg IJ, Kotchen TA, Lichtenstein AH, Mitch WE, Mullis R, Robinson K, Wylie-Rosett J, St Jeor S, Suttie J, Tribble DL, Bazzarre TL. AHA Dietary Guidelines: revision 2000: A statement for healthcare professionals from the Nutrition Committee of the American Heart Association. Circulation. 2000;102:2284–2299. [PubMed: 11056107]

23.

Atkins RC. Dr. Atkins' new diet revolution. 1st Avon pbk. ed. New York: Avon Books.

24.

Sacks FM, Bray GA, Carey VJ, Smith SR, Ryan DH, Anton SD, McManus K, Champagne CM, Bishop LM, Laranjo N, Leboff MS, Rood JC, de Jonge L, Greenway FL, Loria CM, Obarzanek E, Williamson DA. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. The New England Journal of Medicine. 2009;360:859–873. [PMC free article: PMC2763382] [PubMed: 19246357]

25.

Foster GD, Wyatt HR, Hill JO, Makris AP, Rosenbaum DL, Brill C, Stein RI, Mohammed BS, Miller B, Rader DJ, Zemel B, Wadden TA, Tenhave T, Newcomb CW, Klein S. Weight and metabolic outcomes after 2 years on a low-carbohydrate versus low-fat diet: a randomized trial. Annals of Internal Medicine. 2010;153:147–157. [PMC free article: PMC2949959] [PubMed: 20679559]

26.

Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA. 2005;293:43–53. [PubMed: 15632335]

27.

Tsai AG, Wadden TA. The evolution of very-low-calorie diets: an update and meta-analysis. Obesity (Silver Spring, Md). 2006;14:1283–1293. [PubMed: 16988070]

28.

Fabricatore AN, Wadden TA, Ebbeling CB, Thomas JG, Stallings VA, Schwartz S, Ludwig DS. Targeting dietary fat or glycemic load in the treatment of obesity and type 2 diabetes: a randomized controlled trial. Diabetes Research and Clinical Practice. 2011;92:37–45. [PMC free article: PMC3079199] [PubMed: 21208675]

29.

Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill C, Mohammed BS, Szapary PO, Rader DJ, Edman JS, Klein S. A randomized trial of a low-carbohydrate diet for obesity. The New England Journal of Medicine. 2003;348:2082–2090. [PubMed: 12761365]

30.

Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS, Balise RR, Kraemer HC, King AC. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007;297:969–977. [PubMed: 17341711]

31.

Samaha FF, Iqbal N, Seshadri P, Chicano KL, Daily DA, McGrory J, Williams T, Williams M, Gracely EJ, Stern L. A low-carbohydrate as compared with a low-fat diet in severe obesity. The New England Journal of Medicine. 2003;348:2074–2081. [PubMed: 12761364]

32.

Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, Golan R, Fraser D, Bolotin A, Vardi H, Tangi-Rozental O, Zuk-Ramot R, Sarusi B, Brickner D, Schwartz Z, Sheiner E, Marko R, Katorza E, Thiery J, Fiedler GM, Bluher M, Stumvoll M, Stampfer MJ. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. The New England Journal of Medicine. 2008;359:229–241. [PubMed: 18635428]

33.

Stern L, Iqbal N, Seshadri P, Chicano KL, Daily DA, McGrory J, Williams M, Gracely EJ, Samaha FF. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Annals of Internal Medicine. 2004;140:778–785. [PubMed: 15148064]

34.

Das SK, Gilhooly CH, Golden JK, Pittas AG, Fuss PJ, Cheatham RA, Tyler S, Tsay M, McCrory MA, Lichtenstein AH, Dallal GE, Dutta C, Bhapkar MV, Delany JP, Saltzman E, Roberts SB. Long-term effects of 2 energy-restricted diets differing in glycemic load on dietary adherence, body composition, and metabolism in CALERIE: a 1-y randomized controlled trial. The American Journal of Clinical Nutrition. 2007;85:1023–1030. [PubMed: 17413101]

35.

Yancy WS Jr, Olsen MK, Guyton JR, Bakst RP, Westman EC. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Annals of Internal Medicine. 2004;140:769–777. [PubMed: 15148063]

36.

Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Medicine and Science in Sports and Exercise. 2009;41:459–471. [PubMed: 19127177]

37.

Hagan RD, Upton SJ, Wong L, Whittam J. The effects of aerobic conditioning and/or caloric restriction in overweight men and women. Medicine and Science in Sports and Exercise. 1986;18:87–94. [PubMed: 3457234]

38.

Wing RR, Venditti E, Jakicic JM, Polley BA, Lang W. Lifestyle intervention in overweight individuals with a family history of diabetes. Diabetes Care. 1998;21:350–359. [PubMed: 9540015]

39.

Fogelholm M, Kukkonen-Harjula K. Does physical activity prevent weight gain--a systematic review. Obesity reviews : an official journal of the International Association for the Study of Obesity. 2000;1:95–111. [PubMed: 12119991]

40.

Jakicic JM, Marcus BH, Gallagher KI, Napolitano M, Lang W. Effect of exercise duration and intensity on weight loss in overweight, sedentary women: a randomized trial. JAMA. 2003;290:1323–1330. [PubMed: 12966123]

41.

Thomas JG, Bond DS, Phelan S, Hill JO, Wing RR. Weight-loss maintenance for 10 years in the National Weight Control Registry. American Journal of Preventive Medicine. 2014;46:17–23. [PubMed: 24355667]

42.

Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. The American Journal of Clinical Nutrition. 1997;66:239–246. [PubMed: 9250100]

43.

Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Annals of Internal Medicine. 2002;136:493–503. [PubMed: 11926784]

44.

Kraus WE, Houmard JA, Duscha BD, Knetzger KJ, Wharton MB, McCartney JS, Bales CW, Henes S, Samsa GP, Otvos JD, Kulkarni KR, Slentz CA. Effects of the amount and intensity of exercise on plasma lipoproteins. The New England Journal of Medicine. 2002;347:1483–1492. [PubMed: 12421890]

45.

Ross R, Dagnone D, Jones PJ, Smith H, Paddags A, Hudson R, Janssen I. Reduction in obesity and related comorbid conditions after diet-induced weight loss or exercise-induced weight loss in men. A randomized, controlled trial. Annals of Internal Medicine. 2000;133:92–103. [PubMed: 10896648]

46.

Hayes C, Kriska A. Role of physical activity in diabetes management and prevention. Journal of the American Dietetic Association. 2008;108:S19–23. [PubMed: 18358249]

47.

Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:1433–1438. [PubMed: 16732040]

48.

Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. Fitness vs. fatness on all-cause mortality: a meta-analysis. Progress in Cardiovascular Diseases. 2014;56:382–390. [PubMed: 24438729]

49.

Lee CD, Blair SN, Jackson AS. Cardiorespiratory fitness, body composition, and all-cause and cardiovascular disease mortality in men. The American Journal of Clinical Nutrition. 1999;69:373–380. [PubMed: 10075319]

50.

American Diabetes Association. The Diabetes Prevention Program. Design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes care. 1999;22(4):623–34. [PMC free article: PMC1351026] [PubMed: 10189543]

51.

Look AHEAD Research Group. The Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it. Obesity. 2006;14(5):737–52. [PMC free article: PMC2613279] [PubMed: 16855180]

52.

Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature. Journal of the American Dietetic Association. 2011;111(1):92–102. [PMC free article: PMC3268700] [PubMed: 21185970]

53.

Patel ML, Wakayama LN, Bennett GG. Self‐monitoring via digital health in weight loss interventions: a systematic review among adults with overweight or obesity. Obesity. 2021;29(3):478–99. [PubMed: 33624440]

54.

Hutchesson MJ, Rollo ME, Callister R, Collins CE. Self-monitoring of dietary intake by young women: online food records completed on computer or smartphone are as accurate as paper-based food records but more acceptable. Journal of the Academy of Nutrition and Dietetics. 2015;115(1):87–94. [PubMed: 25262244]

55.

Spring B, Pellegrini CA, Pfammatter A, Duncan JM, Pictor A, McFadden HG, Siddique J, Hedeker D. Effects of an abbreviated obesity intervention supported by mobile technology: the ENGAGED randomized clinical trial. Obesity. 2017;25(7):1191–8. [PMC free article: PMC5487285] [PubMed: 28494136]

56.

Jakicic JM, Davis KK, Rogers RJ, King WC, Marcus MD, Helsel D, Rickman AD, Wahed AS, Belle SH. Effect of wearable technology combined with a lifestyle intervention on long-term weight loss: the IDEA randomized clinical trial. JAMA. 2016;316(11):1161–71. [PMC free article: PMC5480209] [PubMed: 27654602]

57.

Turner‐McGrievy GM, Wilcox S, Boutté A, Hutto BE, Singletary C, Muth ER, Hoover AW. The Dietary Intervention to Enhance Tracking with Mobile Devices (DIET Mobile) study: a 6‐month randomized weight loss trial. Obesity. 2017;25(8):1336–42. [PMC free article: PMC5529231] [PubMed: 28600833]

58.

Lichtman SW, Pisarska K, Berman ER, Pestone M, Dowling H, Offenbacher E, Weisel H, Heshka S, Matthews DE, Heymsfield SB. Discrepancy between self-reported and actual caloric intake and exercise in obese subjects. The New England Journal of Medicine. 1992;327:1893–1898. [PubMed: 1454084]

59.

Tronieri JS, Wadden TA. In-person behavioral approaches for weight management. G. Bray, C. Bouchard, P. Katzmarzyk, L. Redman, and P. Schauer, eds. In: Handbook of Obesity - Volume II: Clinical Applications, 5^th ed. CRC Press; in press.

60.

Wadden TA, Tsai AG, Tronieri JS. A protocol to deliver intensive behavioral therapy (IBT) for obesity in primary care settings: the MODEL‐IBT program. Obesity. 2019;27(10):1562–6. [PMC free article: PMC6786257] [PubMed: 31544345]

61.

Leblanc ES, O'Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2011;155:434–447. [PubMed: 21969342]

62.

Perri MG, Shankar MN, Daniels MJ, Durning PE, Ross KM, Limacher MC, Janicke DM, Martin AD, Dhara K, Bobroff LB, Radcliff TA. Effect of telehealth extended care for maintenance of weight loss in rural US communities: a randomized clinical trial. JAMA Network Open. 2020;3(6):e206764. [PMC free article: PMC7296388] [PubMed: 32539150]

63.

Perri MG, Limacher MC, von Castel‐Roberts K, Daniels MJ, Durning PE, Janicke DM, Bobroff LB, Radcliff TA, Milsom VA, Kim C, Martin AD. Comparative effectiveness of three doses of weight‐loss counseling: Two‐year findings from the rural LITE trial. Obesity. 2014;22(11):2293–300. [PMC free article: PMC4225635] [PubMed: 25376396]

64.

Moyer VA. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine. 2012;157:373–378. [PubMed: 22733087]

65.

Wing RR, Tate DF, Gorin AA, Raynor HA, Fava JL. A self-regulation program for maintenance of weight loss. The New England Journal of Medicine. 2006;355:1563–1571. [PubMed: 17035649]

66.

Heymsfield SB, Wadden TA. Mechanisms, Pathophysiology, and Management of Obesity. The New England Journal of Medicine. 2017;376:254–266. [PubMed: 28099824]

67.

Donnelly JE, Smith BK, Dunn L, Mayo MM, Jacobsen DJ, Stewart EE, Gibson C, Sullivan DK. Comparison of a phone vs clinic approach to achieve 10% weight loss. International Journal of Obesity. 2007;31:1270–1276. [PubMed: 17325684]

68.

Appel LJ, Clark JM, Yeh HC, Wang NY, Coughlin JW, Daumit G, Miller ER 3rd, Dalcin A, Jerome GJ, Geller S, Noronha G, Pozefsky T, Charleston J, Reynolds JB, Durkin N, Rubin RR, Louis TA, Brancati FL. Comparative effectiveness of weight-loss interventions in clinical practice. The New England Journal of Medicine. 2011;365:1959–1968. [PMC free article: PMC4074540] [PubMed: 22085317]

69.

Perri MG, Limacher MC, Durning PE, Janicke DM, Lutes LD, Bobroff LB, Dale MS, Daniels MJ, Radcliff TA, Martin AD. Extended-care programs for weight management in rural communities: the treatment of obesity in underserved rural settings (TOURS) randomized trial. Archives of Internal Medicine. 2008;168:2347–2354. [PMC free article: PMC3772658] [PubMed: 19029500]

70.

Cliffe M, Di Battista E, Bishop S. Can you see me? Participant experience of accessing a weight management programme via group videoconference to overcome barriers to engagement. Health Expectations. 2021 Feb;24(1):66–76. [PMC free article: PMC7879542] [PubMed: 33089630]

71.

Azar KM, Aurora M, Wang EJ, Muzaffar A, Pressman A, Palaniappan LP. Virtual small groups for weight management: an innovative delivery mechanism for evidence-based lifestyle interventions among obese men. Translational Behavioral Medicine. 2015 Mar 1;5(1):37–44. [PMC free article: PMC4332901] [PubMed: 25729451]

72.

Johnson KE, Alencar MK, Coakley KE, Swift DL, Cole NH, Mermier CM, Kravitz L, Amorim FT, Gibson AL. Telemedicine-based health coaching is effective for inducing weight loss and improving metabolic markers. Telemedicine and E-Health. 2019;25(2):85–92. [PMC free article: PMC6384514] [PubMed: 29847222]

73.

Alencar MK, Johnson K, Mullur R, Gray V, Gutierrez E, Korosteleva O. The efficacy of a telemedicine-based weight loss program with video conference health coaching support. Journal of Telemedicine and Telecare. 2019;25(3):151–7. [PubMed: 29199544]

74.

Tate DF, Wing RR, Winett RA. Using Internet technology to deliver a behavioral weight loss program. JAMA. 2001;285:1172–1177. [PubMed: 11231746]

75.

Steinberg DM, Levine EL, Askew S, Foley P, Bennett GG. Daily text messaging for weight control among racial and ethnic minority women: randomized controlled pilot study. Journal of Medical Internet Research. 2013;15(11):e2844. [PMC free article: PMC3841371] [PubMed: 24246427]

76.

Harvey-Berino J, West D, Krukowski R, Prewitt E, VanBiervliet A, Ashikaga T, Skelly J. Internet delivered behavioral obesity treatment. Preventive Medicine. 2010;51:123–128. [PMC free article: PMC3101104] [PubMed: 20478333]

77.

Podina IR, Fodor LA. Critical review and meta-analysis of multicomponent behavioral e-health interventions for weight loss. Health Psychology. 2018;37(6):501. [PubMed: 29733617]

78.

Schippers M, Adam PC, Smolenski DJ, Wong HT, De Wit JB. A meta‐analysis of overall effects of weight loss interventions delivered via mobile phones and effect size differences according to delivery mode, personal contact, and intervention intensity and duration. Obesity Reviews. 2017;18(4):450–9. [PubMed: 28187246]

79.

Steinberg DM, Tate DF, Bennett GG, Ennett S, Samuel‐Hodge C, Ward DS. The efficacy of a daily self‐weighing weight loss intervention using smart scales and e‐mail. Obesity. 2013;21(9):1789–97. [PMC free article: PMC3788086] [PubMed: 23512320]

80.

Tate DF, Jackvony EH, Wing RR. A randomized trial comparing human e-mail counseling, computer-automated tailored counseling, and no counseling in an Internet weight loss program. Archives of Internal Medicine. 2006;166(15):1620–5. [PubMed: 16908795]

81.

Martin CK, Miller AC, Thomas DM, Champagne CM, Han H, Church T. Efficacy of Smart LossSM, a smartphone‐based weight loss intervention: Results from a randomized controlled trial. Obesity. 2015;23(5):935–42. [PMC free article: PMC4414058] [PubMed: 25919921]

82.

Forman EM, Goldstein SP, Crochiere RJ, Butryn ML, Juarascio AS, Zhang F, Foster GD. Randomized controlled trial of OnTrack, a just-in-time adaptive intervention designed to enhance weight loss. Translational Behavioral Medicine. 2019;9(6):989–1001. [PubMed: 31602471]

83.

Thomas JG, Leahey TM, Wing RR. An automated internet behavioral weight-loss program by physician referral: a randomized controlled trial. Diabetes Care. 2015;38(1):9–15. [PMC free article: PMC4274778] [PubMed: 25404659]

84.

Hales S, Turner-McGrievy GM, Wilcox S, Fahim A, Davis RE, Huhns M, Valafar H. Social networks for improving healthy weight loss behaviors for overweight and obese adults: a randomized clinical trial of the social pounds off digitally (Social POD) mobile app. International Journal of Medical Informatics. 2016;94:81–90. [PubMed: 27573315]

85.

Vaz CL, Carnes N, Pousti B, Zhao H, Williams KJ. A randomized controlled trial of an innovative, user‐friendly, interactive smartphone app‐based lifestyle intervention for weight loss. Obesity Science & Practice. 2021;7(5):555–68. [PMC free article: PMC8488442] [PubMed: 34631134]

86.

Pagoto S, Schneider K, Jojic M, DeBiasse M, Mann D. Evidence-based strategies in weight-loss mobile apps. American Journal of Preventive Medicine. 2013;45(5):576–82. [PubMed: 24139770]

87.

Laing BY, Mangione CM, Tseng CH, Leng M, Vaisberg E, Mahida M, Bholat M, Glazier E, Morisky DE, Bell DS. Effectiveness of a smartphone application for weight loss compared with usual care in overweight primary care patients: a randomized, controlled trial. Annals of internal medicine. 2014;161:S5–12. [PMC free article: PMC4422872] [PubMed: 25402403]

88.

Thomas JG, Raynor HA, Bond DS, Luke AK, Cardoso CC, Wojtanowski AC, Vander Veur S, Tate D, Wing RR, Foster GD. Weight loss and frequency of body‐weight self‐monitoring in an online commercial weight management program with and without a cellular‐connected ‘smart’scale: a randomized pilot study. Obesity Science & Practice. 2017;3(4):365–72. [PMC free article: PMC5729493] [PubMed: 29259794]