Efficacy of Lifestyle Modification for
Long-Term Weight Control
Thomas A. Wadden,* Meghan L. Butryn,† and Kirstin J. Byrne*
WADDEN, THOMAS A., MEGHAN L. BUTRYN, AND
KIRSTIN J. BYRNE. Efficacy of lifestyle modification for
long-term weight control. Obes Res. 2004;12:151S–162S.
A comprehensive program of lifestyle modification induces
loss of ?10% of initial weight in 16 to 26 weeks, as
revealed by a review of recent randomized controlled trials,
including the Diabetes Prevention Program. Long-term
weight control is facilitated by continued patient-therapist
contact, whether provided in person or by telephone, mail,
or e-mail. High levels of physical activity and the consump-
tion of low-calorie, portion-controlled meals, including liq-
uid meal replacements, can also help maintain weight loss.
Additional studies are needed of the effects of macronutri-
ent content (e.g., low-fat vs. low-carbohydrate diets) on
long-term changes in weight and health. Research also is
needed on effective methods of providing comprehensive
weight loss control to the millions of Americans who need
Key words: lifestyle modification, weight loss, diet, ex-
ercise, behavior therapy
The Diabetes Prevention Program (DPP)1recently pro-
vided definitive evidence of the health benefits of lifestyle
intervention for weight control (1). This 4-year study ex-
amined ?3200 overweight or obese individuals with im-
paired glucose tolerance and found that a lifestyle interven-
tion designed to induce a 7% reduction in initial weight and
increase physical activity to 150 min/wk reduced the risk of
developing type 2 diabetes by 58% compared with placebo.
The intervention was also more effective than metformin, a
medication for type 2 diabetes (Figure 1). A Finnish study
yielded the same results: individuals who lost 4.3 kg with
diet and exercise reduced their risk of developing type 2
diabetes by 58% compared with a control group (2). These
two studies, together with trials on the management of
hypertension (3,4), leave little doubt of the efficacy of
lifestyle modification in facilitating long-term improve-
ments in weight and health.
In the DPP, lifestyle-treated participants lost ?7 kg at the
end of the 1st year and then regained ?1 kg a year in the
ensuing 3 years (Figure 2). Such weight regain is common
after behavioral treatment of obesity and has led some to
question the benefits of this approach (5). Thus, it is worth
noting that participants experienced a significant reduction
in diabetes risk, despite regaining about one-third of their
lost weight. These findings suggest, with regard to health,
that it is better to have lost and regained than never to have
lost at all (6).
This article briefly describes lifestyle modification for
obesity and reviews its short- and long-term results. Our
principal objective is to examine behavioral methods for
improving long-term weight control.
Lifestyle Modification for Weight Control
The terms lifestyle modification, behavioral treatment,
and behavioral weight control are often used interchange-
ably (7). They all encompass three principal components:
diet, exercise, and behavior therapy. The last term refers to
a set of principles and techniques for modifying diet and
exercise (7–9). It teaches patients how to achieve their
eating and exercise goals by methods such as keeping
records of their physical activity (and food intake) or mod-
ifying cues that elicit unwanted eating (e.g., the sight of
food on the kitchen counter). Lifestyle modification pro-
grams typically encourage patients to eat conventional
foods (of their liking) but to reduce their energy intake by
500 to 1000 kcal/d. This historically has been achieved by
reducing portion sizes and eliminating fat and sugar (9).
These were the general dietary goals of the DPP, although
*Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania and †Drexel University, Department of Psychology, Philadelphia,
Address correspondence to Thomas A. Wadden, PhD, University of Pennsylvania, 3535
Market Street, Philadelphia, Pennsylvania 19104.
Copyright © 2004 NAASO
1Nonstandard abbreviation: DPP, Diabetes Prevention Program.
OBESITY RESEARCH Vol. 12 Supplement December 2004151S
specific targets were given for each of the macronutrients
(including limiting the intake of saturated fat). Patients also
are encouraged to exercise 30 minutes a day, five to six
times a week. Walking, the activity most frequently recom-
mended, was prescribed in the DPP (1).
Regularly scheduled treatment visits and homework as-
signments are two critical components of lifestyle modifi-
cation (7,8). Patients usually attend treatment sessions
weekly for an initial 16 to 26 weeks. Sessions begin with a
weigh-in, followed by a review of participants’ food and
activity records. Interventionists often introduce a new topic
at each session, but the majority of time is devoted to
discussing methods to help participants adhere to their eat-
ing and activity regimens.
In academic medical centers, lifestyle modification is
typically provided to groups of 10 to 20 participants (during
60- to 90-minute sessions) by registered dietitians, psychol-
ogists, or exercise specialists (7,8). Treatment can be pro-
vided on an individual basis, as it was in the DPP, but this
is more expensive than group treatment. In addition, indi-
vidual counseling may be less effective than group care. In
a recent study, participants were selected on the basis of
whether they preferred group vs. individual treatment and
were then randomly assigned to one of four conditions:
those who preferred and received group treatment; those
who preferred individual care but received group treatment;
those who preferred and received individual treatment; or
those who preferred group care but received individual
treatment (10). As shown in Figure 3, group treatment
induced a significantly greater weight loss than individual
care after 6 months of treatment. This was true even in
patients who preferred individual treatment but were as-
signed to group treatment; they lost more weight than per-
sons who preferred individual treatment and received it. We
believe that group treatment is more effective because it
provides empathy, social support, and a healthy dose of
competition (7). Further accounts of lifestyle modification
are available (7–9), as is the protocol used in the DPP (11).
Short- and Long-Term Results of Lifestyle
Table 1 summarizes the results of lifestyle modification
from 1974 to 2002, as determined from randomized con-
Figure 1: Cumulative incidence of diabetes over a 4-year period in
participants who received placebo, metformin, or lifestyle modi-
fication (1). Reproduced with permission by the New England
Journal of Medicine.
Figure 2: Changes in weight over 4 years in participants who
received placebo, metformin, or lifestyle modification (1). Re-
printed with permission by the New England Journal of Medicine.
Figure 3: Weight loss at the end of 6 months in patients assigned
to group vs. individual treatment. Participants first were divided
into those who preferred group vs. individual care. They were then
randomly assigned to treatment, yielding four groups: preferred
group treatment and received it; desired individual treatment but
received group; preferred individual care and received it; or pre-
ferred group treatment but received individual. Data adapted from
Renjilian et al. (10).
Lifestyle Modification, Wadden, Butryn, and Byrne
152S OBESITY RESEARCH Vol. 12 Supplement December 2004
trolled trials published in four journals: Addictive Behav-
iors, Behavior Research and Therapy, Behavior Therapy,
and Journal of Consulting and Clinical Psychology. Only
studies representative of standard behavioral treatment are
included. No interventions prescribed a diet providing fewer
than 900 kcal/d (7).
The data show that patients treated by group lifestyle
modification lost ?10 kg (?10% of initial weight) in 30
weeks of treatment. In addition, ?80% of patients who
began treatment completed it. Thus, this approach yields
very favorable results as judged by criteria for success
proposed by the NIH/National Heart Lung and Blood Insti-
tute (12) and the World Health Organization (13).
A comparison of early (i.e., 1974) and more recent (1996
to 2002) studies shows that weight loss has nearly tripled
over the past 30 years as treatment duration has increased
more than 3-fold. For instance, in 1974, treatment for 8.4
weeks produced a mean loss of 3.8 kg, whereas treatment
from 1996 to 2002 averaged 31.6 weeks and induced a loss
of 10.7 kg. Although several new components (e.g., cogni-
tive restructuring, relapse prevention) have been added to
the behavioral approach since 1974, the most parsimonious
explanation for today’s greater weight loss is the longer
duration of treatment. The rate of weight loss has remained
constant at ?0.4 to 0.5 kg/wk (7).
Weight regain is a problem after virtually all dietary and
behavioral interventions for obesity (7,8,14,15). As shown
in Table 1, patients treated by group lifestyle modifica-
tion for 20 to 30 weeks regain ?30% to 35% of their lost
weight in the year after treatment. Weight regain slows
after the first year, but by 5 years, 50% or more of
patients are likely to have returned to their baseline
weight (16). This is very disheartening for patients, par-
ticularly when they have worked hard and spent substan-
tial funds to achieve their weight loss goals (17). Patients
need to know that, even with weight regain, they still may
have improved their long-term health, as suggested by
results of the DPP (1).
Contributors to Weight Regain
Remarkably little is known about factors responsible for
weight regain, despite the frequency with which this prob-
lem is observed. Contributors are likely to include compen-
satory metabolic responses to weight loss that include re-
ductions in resting energy expenditure (18) and leptin (19)
and increases in ghrelin (a gut peptide associated with
reports of hunger) (20). These physiological responses to
both energy restriction and weight loss protect humans
against the adverse effects of starvation (21). In addition,
once patients leave treatment, they are confronted daily by
an environment that explicitly encourages them to consume
large quantities of foods, high in fat and sugar (22). Weight
regain appears to be a nearly inevitable response to this
environment, as witnessed by our nation’s epidemic of
Lifestyle modification for obesity, 1974 to 2002
1974 1985 to 19871991 to 19951996 to 2002*
Number of studies
Initial weight (kg)
Length of treatment (weeks)
Weight loss (kg)
Loss per week (kg)
Length of follow-up
Loss at follow-up (kg)
All studies sampled were published in the following four journals: Addictive Behaviors, Behavior Therapy, Behavior Research and Therapy,
and Journal of Consulting and Clinical Psychology. All values, except for number of studies, are weighted means; thus, studies with larger
sample sizes had a greater impact on mean values than did studies with smaller sample sizes.
* Studies included in the 1996 to 2002 sample are found in Perri et al. (28), Wadden et al. (49), Meyers et al. (88), Fuller et al. (89), Perri
et al. (56), Harvey-Berino (90), Sbrocco et al. (91), Wing and Jeffery (92), and Ramirez and Rosen (93). Reproduced with permission by
Endocrinology and Metabolism Clinics of North America (7).
Lifestyle Modification, Wadden, Butryn, and Byrne
OBESITY RESEARCH Vol. 12 Supplement December 2004153S
Inadequate treatment also contributes to weight regain.
Short-term treatment of 16 to 26 weeks clearly is no match
for what is a chronic disorder for most obese individuals (7).
Obesity cannot be cured by 6 months of therapy, any more
than type 2 diabetes or hypertension can be cured by such a
brief intervention. The long-term results of obesity manage-
ment have begun to improve with the recognition that
obesity is a chronic disorder that, like hypertension and
diabetes, requires long-term care (24).
The remainder of this article describes interventions that
hold promise for improving long-term weight control by
facilitating long-term adherence to appropriate diet and ac-
Long-Term Behavioral Treatment
Several studies have revealed the benefits of continuing
to attend weight maintenance classes after completing an
initial 16- to 26-week weight loss program (24–27). For
example, Perri and colleagues found that individuals who
attended every-other-week group maintenance sessions for
the year after weight reduction maintained 13.0 kg of their
13.2 kg end-of-treatment weight loss, whereas those who
did not maintained only 5.7 kg of a 10.8-kg loss (27). The
benefits of extended contact are illustrated in Figure 4,
which displays the results of this study (27), as well as two
others with similar designs (28,29). In reviewing 13 studies
on this topic, Perri and Corsica found that patients who
received long-term treatment, which averaged 41 sessions
over 54 weeks, maintained 10.3 kg of their initial 10.7-kg
weight loss (24). Maintenance sessions seem to provide
many patients with the support and motivation they need to
continue to practice weight control behaviors, such as keep-
ing food records and exercising regularly (7).
Limitations of Long-Term On-Site Treatment
Despite these favorable results, long-term on-site treat-
ment has limitations. As Figure 4 shows, this approach
appears only to delay rather than to prevent weight regain.
Patients maintain their full end-of-treatment weight loss as
long as they participate in biweekly maintenance sessions.
In fact, they lose additional weight during the first 6 months
of extended treatment but regain the additional loss during
the second 6 months of therapy. Weight gain continues with
the termination of maintenance therapy.
Patients also tire of attending treatment sessions twice
monthly, and 50% eventually drop out (26,30). Reasons for
attrition are not well understood but are likely to be asso-
ciated with two factors. The first is the lack of weight loss
or other gratification after the first 6 months of maintenance
therapy (27–29). Most individuals who receive lifestyle
modification (25,26) or pharmacotherapy (31,32) cannot
lose ?15% of their initial weight, even if treated continu-
ously for 2 years or more. This barrier may be attributable
to compensatory biological responses (discussed earlier) or
to behavioral fatigue (i.e., participants tire of restricting
their food intake and exercising vigorously) (33). Weight
loss plateaus are frustrating to patients, most of who remain
obese after 1 year of treatment and continue to want to lose
25% of their initial weight, despite therapists’ efforts to
convince them otherwise (34). As shown in Table 2, main-
taining a reduced body weight requires as much (if not
more) effort as losing weight but provides few rewards (35).
Many individuals seem to conclude that the benefits of
weight maintenance—weight stability when weight loss is
desired—are not worth the costs (i.e., time, money, contin-
ued monitoring of eating and activity habits).
The second factor associated with attrition from therapy
concerns complaints that treatment is monotonous and
sometimes demoralizing (26). Patients often feel that they
do not acquire new information or skills after the first 6 to
12 months of therapy. In addition, weight maintenance
sessions give greater attention to individuals who suffer
lapses and regain weight than to persons who are successful.
Thus, group social interactions that were gratifying during
weight loss often lose their appeal during weight mainte-
nance classes (26).
As described in the next sections, the use of telephone,
mail, or e-mail could decrease the burden of participating in
weight maintenance therapy. However, additional research
is needed to determine the optimal frequency of on-site
weight maintenance visits and the benefits of using individ-
ual vs. group treatment. Study also is needed of the possible
benefits of scheduling periodic breaks in maintenance ther-
apy (36) and of increasing opportunities for learning by
introducing new lifestyle interventions or additional
treatment venues, such as a health club or an instructional
Telephone and Mail Contact
Long-term patient-provider contact may be provided by
telephone or mail. Perri and colleagues demonstrated that
Figure 4: Long-term changes in weight for patients who received
standard behavioral treatment, with or without biweekly mainte-
nance therapy. Data adapted from Perri and colleagues (27–29).
Data for week 96 are from Perri and colleagues (27,29).
Lifestyle Modification, Wadden, Butryn, and Byrne
154SOBESITY RESEARCH Vol. 12 Supplement December 2004
therapist contact by either of these modalities significantly
improved weight maintenance, compared with no further
intervention (37). When scheduling telephone calls, the
same therapist should contact the patient on each occasion.
A study in which patients were contacted by staff members
unknown to them failed to produce weight maintenance
results superior to those of a no-contact group (38).
Internet and E-Mail
More recently, investigators have explored the Internet
and e-mail as methods to provide behavioral treatment, both
short- and long-term. In an initial study, Tate and colleagues
(39) assigned participants to one of two 6-month weight-
loss programs delivered over the Internet. The educational
intervention provided a directory of Internet resources for
weight control. The behavior therapy intervention included
this component and 24 weekly lessons conducted by e-mail.
Patients submitted their self-monitoring diaries electroni-
cally and received feedback the same way. The behavior
therapy participants lost significantly more weight at 6
months (4.1 vs. 1.6 kg, respectively). In a 1-year study, Tate
and colleagues (40) randomly assigned individuals at risk
for type 2 diabetes to an Internet weight loss program or to
the same intervention with the addition of weekly behav-
ioral counseling, delivered by e-mail. Participants in the
latter group lost significantly more weight at 1 year (4.4 vs.
2.0 kg, respectively). These studies, taken together, under-
score the importance of participants keeping records of their
food intake and physical activity, as well as completing
other behavioral assignments. Educational instruction alone
is not sufficient to induce clinically significant weight loss.
Two additional studies examined the use of the Internet to
facilitate weight maintenance after participation in a tradi-
tional lifestyle modification program. Harvey-Berino and
colleagues (41) randomly assigned patients to one of three
22-week maintenance programs: an on-site therapist-led
intervention; an Internet therapist-led program; or a control
condition. Weight loss at the end of the initial 15-week
behavioral program averaged 6.5 kg. Most participants con-
tinued to lose weight during the maintenance programs, so
that total weight loss at the end of maintenance averaged
8.0 kg. There were no significant differences among the
three maintenance groups in total weight loss. However,
participants in the on-site program were more satisfied with
their treatment and attended more sessions than those in the
Internet program. In a second study from this team, partic-
ipants received one of three maintenance interventions: on-
site biweekly sessions for 12 months; on-site monthly ses-
sions for the first 6 months only; or 12 months of biweekly
Internet video and chat sessions, combined with e-mails
from a group therapist, on-line submission of self-monitor-
ing forms, and an e-mail discussion group (42). Weight loss
at the end of the initial 6-month behavioral program aver-
aged 9.5 kg. At 1-year follow-up, participants in the fre-
quent and minimal on-site treatment programs had signifi-
cantly greater total weight loss than patients in the Internet
program (10.4, 10.4, and 5.7 kg, respectively). Participants
in the Internet program attended fewer (virtual) sessions and
were less satisfied with their intervention plan than were
patients in the on-site program who had biweekly visits.
Internet-delivered interventions, for either the induction
or maintenance of weight loss, generally are not as effective
as traditional on-site programs. Nonetheless, Internet-based
behavioral programs do induce clinically significant weight
loss and could be provided to millions of overweight Amer-
Comparison of behaviors and reinforcement associated with losing weight vs. maintaining a weight loss
Weight loss Maintenance of weight loss
The goal of treatment is to lose a large amount of weight,
after a prolonged period of weight gain
The dieter’s principal strategy is to avoid eating all of the
foods that have caused the weight problem
Treatment is time-limited, usually 15 to 25 weeks
The dieter receives support from the diet program and
from family and friends
Weight loss is highly reinforcing; it is very noticeable
and pleasing to dieters and their families
Dieters do not have to exercise to lose weight
The goal of treatment is to lose small amounts
of weight, as small increases in weight occur
The dieter’s principal task is to learn to eat
troublesome foods in a controlled fashion
(mastery) and to eat new foods, low in fat and calories
Treatment is ongoing and life-long
The dieter receives little or no support from
professionals or family members
Maintenance of weight loss is not reinforcing;
dieters forget about their accomplishments,
as do their family members
Exercise appears to be critical to maintenance of weight loss
Reproduced with permission from the International Handbook of Behavior Modification and Therapy (35).
Lifestyle Modification, Wadden, Butryn, and Byrne
OBESITY RESEARCH Vol. 12 Supplement December 2004155S
icans who do not have access to treatment at an academic
medical center. Further research is likely to improve on
these initial, promising findings.
High Levels of Physical Activity
Data from case studies (43,44), correlational investiga-
tions (45), and randomized trials (46,47) all have concluded
that high levels of physical activity facilitate long-term
weight control. Findings from the National Weight Control
Registry, for example, clearly underscore this point (43).
Members of the Registry have lost an average of 32.4 kg
and maintained their loss for 5.5 years. Women report
expending ?2825 kcal/wk, the equivalent of walking
?28 miles/wk (or 75 to 90 min/d) (43).
Based on these findings, Jeffery and colleagues (47)
recently compared the benefits of low vs. high levels of
physical activity in a randomized controlled trial. Partici-
pants in the high-activity group were instructed to expend
2500 kcal/wk, whereas those in the low group were pre-
scribed a goal of 1000 kcal/wk. As shown in Figure 5,
weight loss in the two groups did not differ significantly at
the end of 6 months, during which participants attended
weekly group meetings. However, participants in the high-
activity group maintained their weight loss significantly
better than did patients in the low-activity group at both the
12- and 18-month assessments. Jakicic and colleagues (48)
similarly found, in secondary analyses of results of a ran-
domized trial, that obese individuals who exercised 200 or
more min/wk achieved significantly greater weight loss at
18 months than did persons who exercised fewer than
Mechanism of Action
The mechanisms by which exercise facilitates weight
maintenance are not well understood (49,50). The simplest
explanation is that increased physical activity helps to keep
patients in energy balance. Walking 3 to 4 miles a day may
help to compensate for occasional dietary indiscretions that
are associated with weight regain (in persons who do not
exercise regularly). Alternatively, exercise spares the loss of
fat-free mass during diet-induced weight loss (51), an oc-
currence that could help minimize undesired reductions in
resting-energy expenditure (49). Increased physical activity
also could be associated with improved mood that, in turn,
could facilitate long-term adherence to a low-calorie diet
(49). Regardless of the mechanism of action, the message is
the same: Patients should increase their physical activity by
whatever means possible.
Programmed vs. Lifestyle Activity
Patients can increase their energy expenditure in two
ways—programmed or lifestyle activity (52,53). Pro-
grammed activity (e.g., walking, biking, swimming) is typ-
ically planned and completed in a discrete period of time
(i.e., 30 to 60 minutes) at a relatively high-intensity level
(i.e., 60% to 80% of maximum heart rate). Lifestyle activity,
by contrast, involves increasing energy expenditure while
completing everyday tasks. Patients may, for example, in-
crease their lifestyle activity by parking further away from
building entrances, taking stairs rather than escalators, or
even by discarding the remote control to the television (52).
Epstein et al. (53) found that lifestyle activity was superior
to programmed exercise in facilitating the maintenance of
weight loss in obese children. Andersen and colleagues, in
a study of obese women, found that both types of activity,
when combined with a 1200 kcal/d diet, induced a loss of
?8 kg in 16 weeks (54). There was a trend (p ? 0.06) for
lifestyle activity to be associated with less weight regain
than was programmed exercise 1 year after treatment (0.1
vs. 1.6 kg, respectively). Results of this study await repli-
cation in a larger sample that includes men. Initial findings,
however, suggest that lifestyle activity is an ideal alternative
for patients who report they hate to exercise.
Long- vs. Short-Bout Activity
Jakicic and colleagues (48,55) have investigated the ef-
fects of prescribing exercise in multiple short bouts as
compared with a single long bout. In one study, all patients
were instructed to exercise for 40 min/d. Those who were
encouraged to complete their activity in multiple 10-minute
bouts exercised on more days over 20 weeks than did
patients who were encouraged to exercise in a single bout
(87.3 vs. 69.1 days, respectively) (55). There was a trend
(p ? 0.07) toward greater weight loss in participants who
exercised in multiple short bouts (8.9 vs. 6.4 kg, respec-
tively). The superiority of short bouts of exercise was not
replicated in a follow-up study of 18 months’ duration (48).
Nonetheless, the finding that multiple short bouts of activity
are as effective as one long bout should facilitate patients’
Figure 5: Weight change over 18 months in patients treated by
behavior therapy combined with low physical activity (i.e.,
1000 kcal/wk) or behavior therapy with high physical activity (i.e.,
2500 kcal/wk). Participants received weekly treatment (Tx) for the
first 6 months, which declined to twice monthly from months 7 to
12, and monthly thereafter.
Lifestyle Modification, Wadden, Butryn, and Byrne
156SOBESITY RESEARCH Vol. 12 Supplement December 2004
efforts to increase their activity. They do not need to set
aside a 30- to 60-minute block of time in which to exercise.
Several brief walks during the day are equally beneficial.
Supervised Activity and Incentives
Researchers also have studied whether increasing the
structure of physical activity (56,57) or providing incentives
(57) is associated with better exercise adherence and greater
weight loss. Perri and colleagues (56) randomized obese
patients to receive 12 months of behavioral weight control
that included on-site supervised exercise or a comparable
program of home-based activity. They found during the first
6 months that the two groups exercised approximately the
same number of minutes per week (107 to 120 minutes) and
lost comparable amounts of weight (10.6 to 10.9 kg). At 15
months, however, those who exercised at home engaged in
more minutes of activity and lost significantly more weight
than persons who exercised on-site (11.9 vs. 9.2 kg, respec-
tively). King et al. (58) obtained similar findings in an
Wing and colleagues (57) found that providing partici-
pants with a personal trainer (who met participants at home
or work and led them on a walk), in addition to having three
on-site supervised activity sessions per week, did not im-
prove weight loss over the on-site activity sessions alone. In
another study in the same article, the authors provided 24
weeks of lifestyle modification and three supervised exer-
cise sessions weekly. In addition, patients were randomized
to receive either no incentives or to be eligible for a lottery
drawing that rewarded more frequent attendance at exercise
sessions. The two groups did not differ significantly in
weight loss or exercise adherence at the end of the 24-week
Less structured exercise plans seem to facilitate long-
term adherence and weight control (53,54,56,58). Lifestyle
activity and at-home exercise potentially remove common
barriers to physical activity, such as travel time, cost, the
need for child care, or embarrassment about weight or
shape. The failure of structure and incentives to improve
exercise adherence suggests that internal motivation and
intrinsic reinforcement also may be critical to increasing
physical activity (59). Further research is needed on this
Dietary Options for Long-Term
America’s media worked overtime last year, providing
consumers daily updates on the low-fat vs. low-carbohy-
drate controversy that is still sweeping our nation (and
others). Four randomized controlled trials (published in
2003) found that dieters achieved significantly greater
short-term weight losses on a high-protein, low-carbohy-
drate diet than on a conventional, low-fat diet (15,60–62).
The single study that included a 1-year evaluation found no
differences in weight loss between the two approaches at the
end of this time (15). Long-term studies (i.e., ?2 years)
clearly are needed to assess the ultimate health benefits (and
risks) of low-carbohydrate diets. In the absence of such
data, other dietary approaches hold promise of facilitating
long-term weight control.
Findings from the National Weight Control Registry
Members of the National Weight Control Registry, de-
scribed in the previous section, clearly belong to a highly
select group (43). Investigators have not identified the spe-
cific factors that helped these individuals lose weight (and
keep it off after several previous failed attempts) (63).
Nevertheless, participants’ reports of their physical activity,
food intake, and eating habits are informative of the types of
behaviors that other obese individuals need to adopt to
achieve long-term weight control. As shown in Table 3,
women in the Registry consumed only 1296 kcal/d, and men
ate only 1724 kcal/d (43). Macronutrient analyses suggest
that these individuals ate a low-fat, high-carbohydrate diet.
In addition, they limited meals eaten out of the home,
particularly at fast food restaurants.
Obese individuals generally underestimate their food in-
take by 30% to 50% when eating a diet of conventional
foods (64). This is attributable to misjudging portion sizes,
failing to recognize hidden sources of fat or sugar, or
forgetting some foods eaten. Jeffery and Wing (65) have
shown that consuming portion-controlled servings of con-
ventional foods improves the maintenance of weight loss.
Participants who were prescribed a 1000 kcal/d diet and
were provided five prepackaged breakfasts and dinners a
week lost significantly more weight during 6 months than
patients who were prescribed the same number of calories
but consumed a diet of self-selected table foods. The con-
tinued provision of portion-controlled foods also was asso-
ciated with significantly greater weight loss at 18 months. A
follow-up study by this team showed that structure alone,
provided by detailed meal plans, was sufficient to improve
weight loss, at least in the short term (66).
Portion-controlled servings, such as frozen food entrees,
eliminate the need to weigh and measure foods, save time
planning and preparing meals, and reduce contact with
problem foods (67). To the extent that they reduce dietary
variety, portion-controlled meals also may better satisfy
appetite (68,69). A comprehensive review of 39 studies of
this issue found that reduced dietary variety was associated
with reduced food intake (70).
Liquid meal replacements are a popular form of a por-
tion-controlled diet. Shakes and meal bars provide patients
Lifestyle Modification, Wadden, Butryn, and Byrne
OBESITY RESEARCH Vol. 12 Supplement December 2004157S
a fixed quantity of food with a known calorie content (i.e.,
160 to 220 kcal/d). A meta-analysis of six randomized
controlled trials found that after 1 year of treatment, partic-
ipants who used meal replacements maintained a loss 2.4 to
3.4 kg greater than persons who consumed a diet of con-
ventional foods with the same calorie target (71). In the
most impressive study to date, Ditschuneit et al. (72) found
that patients who replaced two meals and two snacks a day
with liquid shakes (and snack bar) lost 7.8% of their initial
weight during 3 months of treatment, compared with a loss
of only 1.5% for patients who were prescribed the same
number of calories (1200–1500 kcal/d) but consumed a
self-selected diet of conventional foods. Thereafter, partic-
ipants in both groups replaced one meal and one snack a day
with a liquid shake or meal bar (73). As shown in Figure 6,
individuals in the original (3-month) meal replacement
group maintained a loss of 11.3% of initial weight 2 years
after treatment and 8.4% at a 4-year follow-up (73). Patients
who were originally treated by the conventional diet but
were switched to meal replacements maintained a loss of
3.2% of initial weight at 4 years.
These are the most successful long-term findings, to date,
for the dietary management of obesity. The study has lim-
itations, including the use of a nonrandomized design after
the first 3 months and the examination of a relatively small
sample (i.e., 100 participants). If, however, the results were
replicated in a large randomized controlled trial, they would
have major implications for the long-term management of
obesity. Studies also are needed of factors that contribute to
the apparent success of this approach, including the effects
of meal replacement on hunger and satiation (67).
As noted previously, further study is needed of the long-
term effects of high-protein, low-carbohydrate diets (15).
Similarly, research is needed on more traditional low-fat,
high-carbohydrate regimens, as consumed by members of
the National Weight Control Registry (43). In a randomized
trial, Toubro and Astrup (74) found that, after achieving an
initial weight loss of 13.6 kg, participants who were in-
structed to consume a low-fat, ad libitum carbohydrate
weight maintenance diet regained significantly less weight
than those prescribed a low-calorie weight maintenance
diet. Differences in weight regain were significant both 1
(0.3 vs. 4.1 kg regained, respectively) and 2 (5.4 vs. 11.3 kg
regained, respectively) years after initial weight loss. How-
ever, two other studies found that long-term weight loss
with a low-fat, ad libitum diet did not differ significantly
from that of a low-calorie diet (75,76).
Low-energy density diets present another option for
weight control. The underlying principle of this approach is
that the volume of food consumed, not calorie content,
influences satiety (77,78). Low-energy density diets aim to
minimize the amount of energy in a given weight (grams) of
food. Energy density can be reduced by replacing fat (i.e.,
9 kcal/d) with carbohydrate or protein (i.e., each 4 kcal/d) or
by increasing the fiber or water content in foods. Short-term
studies have shown that persons who consumed ad libitum
low-energy density diets lost a small amount of weight as a
result of consuming only ?70% of the calories as persons
Eating habits of National Weight Control
(n ? 629)
(n ? 155)
Maximum weight (kg)
Maximum BMI (kg/m2)
Current weight (kg)
Current BMI (kg/m2)
Energy intake (kcal/d)
Energy from fat (%)
Energy from protein (%)
Energy from carbohydrate
Number of meals or snacks
Number of meals at fast food
restaurants per week
Number of meals at non-fast
food restaurants per week
Data adapted from Klem et al. (43).
Figure 6: Long-term changes in weight in participants who were
instructed to replace one meal and one snack a day with shakes or
bars. During the first 3 months, patients in one group were pre-
scribed a 1200 to 1500 kcal/d diet of conventional foods. Those in
the second group had the same calorie goal but replaced two meals
and two snacks with shakes and bars. After 3 months, both groups
followed the modified meal replacement strategy described.
Lifestyle Modification, Wadden, Butryn, and Byrne
158SOBESITY RESEARCH Vol. 12 Supplement December 2004
on high-energy density diets (79). Long-term studies cur-
rently are being conducted to determine whether low-energy
density diets facilitate the maintenance of weight loss (80).
Studies also are being conducted on the glycemic index, a
classification system originally developed by Jenkins et al.
(81) to help patients with type 2 diabetes select foods that
would confer optimal control of glucose and insulin. Results
of a 1-year trial in obese adolescents without diabetes
showed promise (82).
There currently are not definitive data to recommend the
use of one dietary approach over another for long-term
weight control. The choice of a particular approach de-
pends, in large measure, on personal preference, although
the diet certainly should promote good health. The use of
portion-controlled servings, including meal replacements,
currently has the strongest evidence of long-term efficacy.
This approach focuses more on limiting energy intake than
modifying the consumption of a specific macronutrient.
This review has shown that a comprehensive program of
lifestyle modification clearly is efficacious in inducing a
loss of ?10% of initial weight and that losses of this size are
associated with significant improvements in health, as re-
vealed by the DPP (1). The NIH is conducting a follow-up
investigation to determine whether a weight loss of ?7% of
initial weight, combined with ?175 min/wk of physical
activity, will decrease morbidity and mortality in over-
weight individuals who already have type 2 diabetes (83).
Participants in the lifestyle intervention will receive a 4-year
behavioral program that incorporates many of the compo-
nents described in this review, including long-term use of a
meal replacement, monthly on-site weight maintenance vis-
its, and the prescription of both programmed and lifestyle
activity. This Look AHEAD (i.e., Action for Health in
Diabetes) study will provide the most definitive assessment,
to date, of the health consequences of intentional weight
Lifestyle modification for obesity faces several chal-
lenges. First among these is making treatment available to
the millions of Americans who need it. Most of what
investigators know about the behavioral treatment of obe-
sity comes from randomized controlled trials conducted at
academic medical centers in which experienced therapists
treat highly motivated patients. Treatment is efficacious
under these optimal circumstances (in which cost is not a
factor). Research now is needed to find effective methods of
providing treatment in primary care and community practice
(in a practical and affordable manner). Some self-help (84)
and commercial programs—particularly Weight Watchers
(85)—may be an effective means of increasing the avail-
ability of lifestyle modification.
Tackling the Toxic Environment
Far greater resources and efforts must be devoted to the
prevention of obesity if we are to halt the progression of this
epidemic, let alone reverse it (86). Our best hope for pre-
vention may lie with children (22). Efforts should be di-
rected toward improving the quality and monitoring the
quantity of meals and snacks served at schools, providing
more opportunities for physical activity at school and at
home, and educating youth about the importance of diet,
activity, and a healthy body weight (22). Ultimately, we
must tackle what Brownell (22) has referred to as a “toxic
environment” that explicitly encourages the consumption of
super-sized servings of high-fat, high-sugar foods, while
implicitly discouraging physical activity, as a result of sed-
entary work and leisure habits. Changing this environment
will require public policy initiatives, such as those that were
needed to reduce cigarette smoking and to increase seat belt
use (87). Although behavioral treatment can assist those
who already are obese, there is a pressing need for wide-
scale environmental interventions to reduce the number of
individuals who require such treatment.
Preparation of this article was supported, in part, by NIH
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